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Diversity: Women in orthopaedic surgery -a perspective from the International Orthopaedic Diversity Alliance

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  • Banff Sport Medicine
44 | JTO | Volume 08 | Issue 01 | March 2020 | boa.ac.uk
Diversity: Women in orthopaedic
surgery – a perspective from
the International Orthopaedic
Diversity Alliance
Jennifer A Green, Vivian PC Chye, Laurie A Hiemstra, Li Felländer-Tsai, Ian Incoll, Kristy Weber,
Margy Pohl, Carrie Kollias, Katre Maasalu, Magaly Iñiguez, Dana Bytyqui, Margaret Fok,
Philippe Liverneaux, Elham Hamdan, Violet Lupondo and Caroline B Hing
Leadership is the essential enabler for the four
most eective diversity initiatives:9,10
1. Communicate and embed values, behaviours
and cultural norms.
2. Ensure recruitment/promotion processes
are unbiased and involve diverse decision
makers.
3. Create working models that support males
and females with families.
4. Visible and committed leadership.
Unconscious bias and the ‘hidden’
curriculum
The past 30 years has seen progress in
uncovering the implicit biases11, which have
negative consequences for our choices of
trainees, colleagues and patient treatments12.
They underpin the ‘hidden’ curriculum13 - the
unwritten, unocial values and perspectives
that students learn14,15. In many nations the
hidden curriculum teaches that orthopaedics
is a ‘boys club’, that you cannot be a mother
and an orthopaedic surgeon and that work-life
balance is dicult. This plays an important role
in inadvertently deterring good candidates from
considering orthopaedic surgery. As an example
of unconscious bias, this article has omitted
non-binary genders. The authors acknowledge
this shortcoming.
In 2009, a study of attitudes in the UK
demonstrated that 24% of female medical
students would consider a career in
orthopaedic surgery. Female students were
more likely to be exposed to negative attitudes
against female surgeons and 62% of those
who were exposed to such attitudes wouldn’t
consider a career in orthopaedic surgery. 42%
of male surgeons had been exposed to negative
attitudes against female surgeons, including
Jennifer Green is an Orthopaedic
Surgeon in Canberra specialising in
hand and wrist Surgery, Chair of the
Australian Orthopaedic Association
(AOA) Orthopaedic Women’s Link
(OWL) Committee and one of the two
observers of the AOA Board of Directors.
She is the AOA Representative to the
Diversity Council of Australia.
Vivian Chye is Consultant
Orthopaedic Surgeon at Hospital
Kuala Lumpur Hospital, Malaysia.
Vivian is President of the
Malaysian Orthopaedic Association
and Vice President of the ASEAN
Orthopaedic Association.
T
he International Orthopaedic
Diversity Alliance (IODA) was
formed in 2019 by a network of
orthopaedic surgeons who are
advocates of cultural and gender
diversity. It promotes the sharing of information
between nations regarding strategies to improve
diversity and the inclusion of females and
minorities in orthopaedic surgery. The focus
of this article is to explore the current gender
statistics, the barriers and the advocacy eorts
towards improving gender diversity with the
evidence supporting these initiatives.
Introduction
Diversity is essential to creating strong
organisations that maximise the talents and
skills of their membership. Organisations
that are diverse are able to attract top talent,
increase innovation and exhibit a better quality
of decision making1. The critical mass for
eective diversity is 30% across the elds of
medicine, business and politics2-4. Diversity
within orthopaedics was recently addressed at
an international level5 and we aim to provide
an expanded perspective. Although females
represent >50% of medical graduates in many
nations, females still often constitute <10% of
orthopaedic surgeons, and orthopaedics remains
the least gender diverse of all surgical specialties.
The competence of females is not in question
with studies demonstrating patients of female
surgeons have fewer complications and lower
mortality6,7. Many barriers exist to increasing
the numbers of females in orthopaedics
including: gender bias; lack of exposure to
surgical specialities during training; lack of
mentorship and; lifestyle concerns8. The
international data presented provides a gender
diversity improvement framework.
Subspecialty Section
JTO | Volume 08 | Issue 01 | March 2020 | boa.ac.uk | 45
Laurie Hiemstra is an Orthopaedic
Surgeon at Ban Sport Medicine
Canada. She is a member of
many organisations including the
International Society of Arthroscopy,
Knee and Orthopedic Sports Medicine
(ISAKOS), the Arthroscopy Association
of North America (AANA), the
American Orthopedic Society of Sports
Medicine (AOSSM), and the Canadian
Orthopaedic Association (COA).
and in several USA orthopaedic programmes,
increasing diversity is taken into consideration
in the selection process with candidates who
otherwise rank equally. Many nations such
as the UK have evidence of steadily increasing
female orthopaedic applications, but this is still
signicantly less than for other specialties.
Flexibility in training and parenting
Signicant barriers are perceived to pursuing a
surgical specialty by females who want to have
a family. A recent survey of 10,000 female
medical students by the Royal Australasian
College of Surgeons (RACS) showed the main
barriers included lack of time for family and
friends, current or future children and the lack
of exibility of training21.
Similarly, a USA study of 720 students showed
that surgical work hours and lack of time for
outside interests were the greatest deterrents
to pursuing a surgical career. Female medical
students demonstrated greater concerns
regarding nding time to date, marry and
have children during residency. Female
students were more likely to perceive that
discouragement from pursuing surgical
training was based on gender, age and family
aspirations, as compared to males22.
>>
questioning of their skill and the perceived
conict between their clinical and family
responsibilities. Despite the marked gender
dierences expressed by medical students and
specialists, when patients were questioned,
89% had no gender preference
16
.
Providing opportunities for medical students
to engage with orthopaedic surgeons who are
positive role models for gender diversity is one
mechanism for changing this hidden curriculum.
Lack of female role models
Strategies to increase diversity include: early
exposure to the speciality eld; mentoring;
interaction with female specialists and; an
institutional culture supportive of females17-19.
Orthopaedic training programmes with greater
representation by female faculty have a higher
proportion of female trainees. However,
males who are good advocates and mentors
for females are equally eective. Cross-gender
mentoring is vital to achieving equity and
should be an aspiration for all males20.
Gender equity in selection processes
Gender equity in selection processes varies
between nations. In Australia, New Zealand
Li Felländer-Tsai is Professor and Chair
of Orthopaedics at Karolinska Institutet,
senior Consultant in Orthopaedic
Surgery at Karolinska University Hospital
in Stockholm, Sweden, 2nd Vice
President EFORT and Past President of
the Swedish Orthopaedic Association.
Ian Incoll is Conjoint Professor at
the University of Newcastle, Australia,
Australian clinician educator and
Orthopaedic Surgeon. He is Dean of
Education and a Past President of the
Australian Orthopaedic Association. He
was the lead developer for AOA 21, the
innovative and contemporary redesign of
Orthopaedic Surgical Training in Australia.
Table 1: Analysis of gender diversity per nation.
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46 | JTO | Volume 08 | Issue 01 | March 2020 | boa.ac.uk
Kristy Weber is the Abramson
Family Professor of Sarcoma
Care Excellence and Vice
Chair of Faculty Aairs in the
Department of Orthopaedic
Surgery at the University of
Pennsylvania. She is the Director
of the Sarcoma Program at the
Abramson Cancer Center and
currently serves as the President
of the American Academy of
Orthopaedic Surgeons.
limiting working hours and decreasing night
shifts. The Specialty Trainees of New Zealand
(STONZ) have well-established guidelines28.
Female inclusion in scientic and
educational meetings
Evidence shows that diversity at scientic
meetings leads to better science10,30,31.
Participation in scientic meetings is important for
professional development, provides opportunities
to collaborate and expand professional networks.
Convening, moderating and participating in
panels and presentations at scientic meetings
are key roles that aord recognition and
standing among orthopaedic peers.
Female surgeons are often the primary carers
in early childhood, a role that can severely
limit their participation in scientic meetings.
The availability of breastfeeding rooms and
childcare facilities at all orthopaedic meetings
would enhance their participation. A guide
with practical methods to improve diversity
and inclusion in scientic meetings provides
evidence-based methods to improve diversity
and inclusion in scientic meetings29.
Females in orthopaedic leadership roles
Females are under-represented in leadership
roles in their early career years. For orthopaedics
this includes executive and board positions
in professional associations. However, there
are currently at least four female orthopaedic
association presidents in the USA, Malaysia,
Sweden and Estonia. It is vital that more
females are mentored and sponsored into these
leadership roles. With the predominance of male
orthopaedic surgeons in leadership roles, it is
critical that males are engaged in this process.
A paper analysing the pass rate from the
American Board Examinations in Surgery
demonstrates that the examination results of
male surgical trainees are unaected by their
marital or parenthood status, and single female
surgical trainees outperform their male peers.
However, their pass rate drops below male
peers when they partner and decrease further
when they have children23.
Social policies supporting pregnancy and child-
rearing allow a greater participation of females
in the surgical workforce. Sweden and Estonia
have the highest rates of female participation in
orthopaedics and the most generous parental
leave and progressive social policies.
Pregnancy and breast feeding
There are health and safety concerns in
orthopaedics that are unique to females. The
occupational hazards of exposure to radiation and
Methyl methacrylate (MMA) in orthopaedics are
well-recognised but can be minimised. A double
layer of lead can be worn in pregnancy
24,25
. MMA
has also been shown to be feto-toxic at levels
>1,000 ppm. Appropriate use of vacuum mixing
and protective helmet systems have been shown
to minimise exposure to MMA
26
.
More insidious are the eects of long working
hours and night shifts on the health of pregnant
surgeons. In female surgeons who work more
than 60 hours per week, the odds of preterm
labour and delivery are 4.95 times higher than
average pregnant females in the USA. The risk
of complications of pregnancy are higher in
female orthopaedic surgeons (31.2%) compared
to the general population (14.5%)27. Evidence-
based policies must be instituted to protect
the well-being of pregnant surgeons, including
Margy Pohl is Clinical
Director of Orthopaedics at
Northland DHB, Whangarei,
New Zealand; a valued
member of the NZOA
Council and Chair of the
LIONZ initiative.
Carrie Kollias is
Paediatric Orthopaedic
Consultant at Royal
Children’s Hospital,
Melbourne.
Table 2: Analysis of the pass rate from the American Board Exams by gender and parity.
Subspecialty Section
JTO | Volume 08 | Issue 01 | March 2020 | boa.ac.uk | 47
Katre Maasalu MD, PhD, is an
Orthopaedic Surgeon at Tartu
University Hospital, Estonia
and President of the Estonian
Orthopaedic Association.
1999 when two other females qualied from
the National University Malaysia. In 2000,
three more female orthopaedic surgeons
graduated. Since then, there has been a
steady increase of females in the orthopaedic
postgraduate programmes.
In 2014, Dr Azlina Abbas, became the second
female President of the MOA, followed by Dr Chye
Ping Ching in 2019. In 2020, she will become the
rst female President of the ASEAN Orthopaedic
Association. Dr Sharifah Roohi shall become
the fourth female MOA President in 2020.
Dr Teresita L Altere from the Philippines qualied
as an orthopaedic surgeon in 1971, and became
the President of the Philippines Orthopaedic
Association (POA) and the rst female in Asia to
be the president of an orthopaedic association in
1986. Dr Virginia C Cabling became the second
and Dr Julyn A Aguilar became the third female
Presidents of the POA.
Australia: In 2018 the Australian Orthopaedic
Association (AOA) established a diversity
strategy to address the persisting lack of gender
diversity. The key AOA initiatives include:
Supporting females into leadership roles –
the AOA Board is now 40% female.
Advertising AOA Committee roles – 12% are
now held by female members.
Actively seeking representation of females at
AOA scientic and educational meetings with
policies to increase inclusion.
Providing childcare and breastfeeding
facilities at all AOA meetings.
Implementing a new, more exible,
competency-based training programme -
‘AOA 21’.
Engaging >150 female medical students/
junior doctors in AOA orthopaedic workshops
in 12 months.
Forming an AOA ‘Champions of Change’
working group of male diversity advocates.
Promoting females in orthopaedics through
active social media proles.
Publishing a quarterly newsletter promoting
gender diversity and inclusion.
>>
International representation of
females in orthopaedic surgery and
strategies to improve gender diversity
Strategies to improve representation of females
in orthopaedics are centred around reducing or
eliminating the known barriers. Organisations
must provide a safe, unbiased environment
and push for equity of opportunity for female
and minorities by encouraging mentorship
and role modelling. Changing the traditional
orthopaedic culture allows both genders a better
family life and will improve work-life balance.
Africa and Tanzania: According to the World
Health Organization, Africa has a predicted need
for 3.7 million health workers in order to provide
universal health care by 203032. In Tanzania
7.6% of the nation’s 118 orthopaedic surgeons
were female in 2019 and of the 51 orthopaedic
trainees, 5.8% were female33. The main focus
in the medical workforce has been to improve
the doctor-patient ratio through the increased
enrolment of medical students. The College of
Surgeons of East, Central and Southern Africa
(COSECSA) is the largest surgical training
institution in Sub-Saharan Africa. There have
been 340 surgeon graduates since 1999 and the
goal is to have 500 graduates in 2020. There
are currently 575 surgeons in training. Women
in Surgery Africa (WiSA), under the umbrella
of COSESCA, has established a mentorship
programme. The American College of Surgeons
(ACS) has provided a strong commitment to
WiSA and supports female surgical trainees
across the region.
Asia, Malaysia and the Philippines: Prior
to 2000, female orthopaedic surgeons were
unusual in Asia. The turn of the millennium
saw an increasing presence of females in
orthopaedic practice and training all over Asia.
Dr Tunku Sara Ahmad Yahaya founded the
Hand and Microsurgery Unit in the University
of Malaya in 1993. She became the rst female
President of the Malaysian Orthopaedic
Association (MOA) in 2006. She was the only
female orthopaedic surgeon in Malaysia until
Magaly Iñiguez is an
Orthopaedic Surgeon in
Chile. Magaly is Founder of
the Association of Chilean
Female Orthopaedic Surgeons,
Member of the Scientic
Committee and the Gender
and Diversity Task Force
Committee at ISAKOS.
Dana Bytyqui is an
Orthopaedic Surgeon
working in Kosovo.
Table 3: Guidelines for working whilst pregnant (New Zealand).
Subspecialty Section
48 | JTO | Volume 08 | Issue 01 | March 2020 | boa.ac.uk
Margaret Fok is currently an
Associate Consultant at the
Department of Orthopaedics and
Traumatology, Queen Mary Hospital,
Hong Kong, and an Honorary
Clinical Assistant Professor of The
University of Hong Kong.
the myths about an orthopaedic career. Each
quarterly publication of the COA highlights
a female orthopaedic surgeon to increase
awareness of females in Canadian orthopaedics.
The COA Annual Meeting has Instructional
Course Lectures on implicit bias, leadership and
mentorship, as well as burnout and physician
wellness. A ‘Mentor for the Day’ programme has
been initiated. Moderator guidelines encourage
diversity of gender, geography and age across all
panels and discourage all-male panels. Breast
feeding areas are available.
The COA is committed to advocating for
gender diversity as well as equity and inclusion
for all minorities, both visible and invisible.
Expansion of these foundational initiatives are
being planned over the coming years35.
Chile: Chile has parental leave protected for
six months. This can be taken by either parent
and is funded by the social security system.
Unfortunately, fathers represent less than 1% of
the parental leave taken in Chile. Chile also has
protected breastfeeding time until the infant
turns two years old.
In 2019, the rst meeting of Chilean female
orthopaedic surgeons took place, resulting in
the formation of the Association of Female
From 2007 to 2019, females represented
only 16.5% of Australian orthopaedic
training applicants; only 12.7% of these
females were oered an interview and 12.1%
were successful applicants. 20% of female
applicants were selected into training,
versus 28% of male applicants. A signicant
gender dierence favouring males has been
demonstrated in the selection process prior to
interview. Fortunately, the interview process
for selection during this period shows no
evidence of gender bias.
Canada: Within the Canadian Orthopaedic
Association (COA), females comprise 15.8%
of the practicing orthopaedic surgeon
membership and 25.8% of trainees. The
number of females delivering podium
presentations at the COA Annual meeting
is in keeping with the proportion of female
members in the association34.
The COA Gender-Diversity Strategic Plan
provides key strategies to advance gender
equity35. The focus has been on reducing
bias, encouraging females in leadership roles,
and facilitating mentorship. A ‘Women in
Leadership’ scholarship was introduced to
support attendance at a leadership course.
Regional sessions are given for university
and medical students in an eort to dispel
Philippe Liverneaux is Professor
of Orthopedic Surgery and Chairman
of Orthopedic and Plastic Surgery in
Strasbourg University Hospital. He is
past President of the French Society
for Hand Surgery, a member of the
French Academy of Surgeons and
cofounder of the Robotic Assisted
MicroSurgery and Endoscopic Society.
Elham Hamdan received her
medical degree from the Royal
College of Surgeons in Ireland in
1993, and subsequently completed
her orthopaedic surgery residency
at the University of Toronto in
Canada in 2001. She has also
completed fellowship training
in spine surgery, chronic pain
management and sports medicine.
Subspecialty Section
JTO | Volume 08 | Issue 01 | March 2020 | boa.ac.uk | 49
Violet Lupondo is a senior
Orthopaedic and Trauma
Surgeon in Tanzania.
70 days old, only the mother is entitled to the
parental benet but after this either parent is
entitled to the parental benet.
France: In France over the next 20 years, the
medical profession will undergo three major
changes: reducing numbers; ageing; and
feminisation36. The number of orthopaedic
surgeons has risen sharply in 30 years,
increasing from 1.44/100,000 inhabitants in
1981 to 4.3 in 2013. Between 2006 and 2019,
the
proportion of females increased from 3.3
to 7%, and is higher in younger age groups.
In 2015, there were 14%
females in the 30-34 age
group, compared to 0%
in the 65-69 age group.
In 2019, France had
248 female orthopaedic
surgeons. The proportion
is signicantly higher
in hand surgery with
155 females out of 767
members (20%) in 2020,
and 63 out of 167 junior
members (38%).
Gulf cooperating
countries and Kuwait:
Males earned surgical
qualications as early
as the 1960s, though
it was not until the
mid-1980s that women
began to receive surgical
training37. This has resulted in a gender
disparity that persists to the present day. The
low participation of females in orthopaedic
surgery can be attributed to many issues.
Female faculty members make up 10% of
Kuwait University’s Department of Surgery.
Currently, there are three female orthopaedic
surgeons in Kuwait, (data obtained directly
from the Kuwait Medical Licensing
Department) of which only one is a Kuwaiti
national. Between 2014 and 2019, ve
females have completed orthopaedic training
compared to 51 males in Kuwait.
Despite the large regional demand for more
orthopaedic surgeons, only one female
was accepted into orthopaedic residency
training in Kuwait for 2020. Prior to that
two females were accepted in orthopaedic
surgical residencies abroad and since 2014
only one other female has been accepted
into the orthopaedic residency programme
in Kuwait. Accurate data for Kuwaiti
females in residency programmes abroad
is not available, (there is no integrated data
source indicating the number of surgeons in
Kuwait orthopaedic or otherwise, therefore
data presented in this section should be
viewed as approximate estimates). There is
an identied perception that females in the
GCC are less likely to match than males in an
orthopaedic residency programme.
>>
Orthopaedic Surgeons of Chile. This is focused
on: gender equity in the selection process;
preventing gender discrimination; establishing
a supportive network for female orthopaedic
surgeons; and mentoring trainees interested in
pursuing a career in orthopaedics.
China (Hong Kong): The rst female
orthopaedic surgeon was appointed to Queen
Mary Hospital, Hong Kong, in 1993. As the
proportion of female medical students has
reached parity, there has been an increase in the
number of female orthopaedic trainees to 20%.
In Hong Kong, all orthopaedic
trainees are employed by the
Hospital Authority. There
is equal pay and parity of
treatment. All female doctors
are entitled to maternity
leave of up to 14 weeks. On
return from parental leave,
each hospital is committed
to provide a peaceful
environment for breastfeeding
but no childcare.
There is no part-time
surgical training oered by
the Hong Kong College of
Orthopaedic Surgeons. For
those who cannot full the
requirements of orthopaedic
training due to maternity
leave, additional training
time is required. Consequently, most female
orthopaedic trainees elect to have children
after completion of training.
Estonia: During the last ve years, 64% of
medical graduates have been female. Currently,
36% of orthopaedic trainees are female. The
increasing number of female orthopaedic
trainees is a reection of more generous
parental leave. One in four orthopaedic
surgeons are female and there is no unit
without a female orthopaedic surgeon. Female
orthopaedic surgeons have been working in
Estonian hospitals since the 1950s and the rst
female orthopaedic head of department was
appointed in 1964. The Estonian Orthopaedic
Society (EOS) was founded in 1970 and the rst
secretary general was female. The President of
the EOS has been a female since 2015.
Maternity leave and pregnancy policies are
dictated by national laws. Raising a child is
supported through many benets and it is
common to stay at home until the child is
at least 18 months old. It is possible to stay
at home until the child turns three years
without losing health insurance or position
of employment. Reduction of workload in
the third trimester of pregnancy is commonly
accepted. After delivery the parental benet
guarantees the previous income. The parental
benet is paid for a period of 435 days, or until
the child is 18 months old. Until the child is
Caroline Hing is an
Orthopaedic Surgeon and
Honorary Reader at St
George’s University Hospitals
NHS Foundation Trust. She
is a member of the BOA
Equality and Diversity working
group and BOA Education and
Careers Committee.
“Although diversity
strategies may vary
between nations,
the principles they
incorporate hold
true for all. Diversity
attracts the best talent
and leads to improved
decision-making
and innovation in our
organisations.”
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50 | JTO | Volume 08 | Issue 01 | March 2020 | boa.ac.uk
Subspecialty Section
Poor maternity and parental benets in
Kuwait appear to be a deterrent with the
majority of females in orthopaedic surgery
residencies in the GCC being single, (data
obtained directly from the Ministry of Health).
Kosovo: Kosovo is a small country of two
million inhabitants, only recently gaining
independence in 2008. The orthopaedic
surgery department
was established in
the 1970s. Currently,
there are 78
orthopaedic surgeons
and 12 trainees.
Only three (3.8%)
orthopaedic surgeons
are female and there
are currently no
female trainees.
Currently two of these three female
orthopaedic surgeons have leadership
positions in the Orthopaedic and
Traumatology Society. There is no xed
quota for training female surgeons but, when
candidates are considered equal, the female
candidate has priority.
New Zealand: NZ data reects striking
similarities with other Western nations.
network for all female registrars and
consultants. LIONZ organises introductory
workshops for female students led by senior
registrars and surgeons, while oering
collegiality and mentorship. These have
proven popular with students, though it is
too early to say whether they will result in
inuencing career choices.
While the NZOA
are committed to
improving diversity
and representation,
challenges arise from
having such a small
number of female
surgeons. Females
are represented
currently on the
NZOA Council and
Orthopaedic Training
Board and comprise over 20% of RACS
Examiners. As we develop a larger cohort of
female colleagues, we expect these numbers
will increase.
Sweden: In Sweden, the number of female
orthopaedic surgeons has increased during
the last 25 years. There has been an increase
from 6% females in 1995 to 17% in 2019
40
.
Currently, 35% of residents in orthopaedic
2019 data shows 4.7 % of active registered
orthopaedic surgeons are female. Currently,
18% of orthopaedic trainees are female with
numbers increasing. Selection processes have
been restructured to encourage consideration
of diversity as a factor in selecting from
candidates who rank equally. However,
numbers of females presenting for selection
to orthopaedic training remain low. Recent
NZ surveys of medical students and junior
doctors suggest that students’ perceptions
of orthopaedics, particularly as a career for
females, form a considerable barrier38,39.
Positive eorts to encourage female junior
doctors considering orthopaedics as a career
have been undertaken by LIONZ (Ladies in
Orthopaedics New Zealand). LIONZ was
established in 2017 and acts as a support
“Leadership in diversity involves engaging female medical
students, minimising unconscious bias, mentoring,
creating an environment that is inclusive of females and
providing support for those with family commitments.”
JTO | Volume 08 | Issue 01 | March 2020 | boa.ac.uk | 51
Subspecialty Section
surgery are female. This increase has been
expected in light of the increasing number of
female medical students and graduates. 56%
of graduates from Swedish medical schools
were female in 2018 and of newly accepted
medical students in 2019, 55% were female
41
.
Sweden has generous parental leave of 390
days42. Three months are available for each
parent, meaning that one parent cannot use
all parental leave. This has increased diversity
in parental leave and, in 2018, 29% of all
parental leave was used by males.
United States of America (USA): There
were 27,651 board-certied orthopaedic
surgeon members in the American Academy
of Orthopaedic Surgeons
(AAOS), of which 6% were
female, in 2019. Of the
3,963 residents in training,
15.4% were female43.
Orthopaedic surgery
in the USA has been
markedly male dominated
and gender disparity
has persisted, with the
percentage of female
orthopaedic trainees the
lowest in all elds. There
are currently less than ve
female chairs of major
orthopaedic departments.
There are, however,
numerous concurrent
eorts in the USA to
improve gender diversity:
The AAOS has
prioritised diversity
within its volunteer
structure in its 2019-
2023 Strategic Plan44,
including education
and transparency in the
application and selection process. Implicit
bias training is provided. The AAOS was led
by its rst female president in 2019, and the
AAOS Board of Directors will include 25%
females in 2020.
The Ruth Jackson Orthopaedic Society was
established in 1983 to advance the science
and practice of orthopaedic surgery among
females. The group prioritises mentoring
and professional development of females.
The Perry Initiative was founded in 2009 by
a female orthopaedic surgeon and engineers
to increase the numbers of females in the
eld45.
Nth Dimensions was founded in 2004.
Their primary mission is to provide
resources, expertise, and experience
through developing and implementing
strategic pipeline initiatives46.
better patient care. Most importantly,
working towards a fair, equitable and diverse
profession is a moral and ethical imperative
and, quite simply, the right thing to do.
n
Acknowledgements
The authors would like to give their thanks
to Michelle White for her editorial support
in the preparation of this article.
References
References can be found online at
www.boa.ac.uk/publications/JTO.
Conclusion
Although diversity
strategies may vary
between nations,
the principles they
incorporate hold true
for all. Diversity attracts the best talent
and leads to improved decision-making
and innovation in our organisations.
Generous parental entitlements and
progressive social policies are likely to be
drivers for the participation of females in
orthopaedic surgery. Leadership in diversity
involves
engaging female medical students,
minimising unconscious bias, mentoring,
creating an environment that is inclusive
of females and providing support for those
with family commitments. Enacting these
concepts should result in healthy, fullled
surgeons, a collaborative and innovative
orthopaedic community and ultimately to
... Globally, the International Orthopaedic Diversity Alliance (IODA) ranked the UK 15 th out of 31 countries for the proportion of female orthopaedic surgeons in 2019 ( Figure 2). 9 Although the number of female consultants is gradually increasing, there is no denying that orthopaedics remains a male-dominated speciality. In 2020, sing the USA National Registry, Acuña et al 10 calculated that "without major changes, sex parity in orthopaedic surgery will take more than 200 years". ...
... Across the UK, 'Hidden Curriculum' depicts orthopaedics as a rugby "boys club". 9 Ajaz et al 18 reported more than 80% of medical students heard negative comments from medical professionals about other specialties including orthopaedics. 19 These myths are often reinforced by other specialties who have no recent experience of modern orthopaedics. ...
... Providing medical students and trainees with career advice and positive role models may counteract the negative propaganda and support them in choosing their specialty. 9 The Royal College of Surgeons of England (RCSEng) recognizes this, and has free e-learning modules on unconscious bias. 22 Diversifying our organization can help identify healthcare inequalities. ...
Article
Full-text available
Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective. Cite this article: Bone Jt Open 2021;2-10:893–899.
... The issue surrounding gender disparity in T&O is not specific to the UK. In Canada, 12% of orthopaedic surgeons are women, and the figures are 6.1% in the US, 11 Causes for the underrepresentation of women in T&O have been investigated in the past, but previous studies focussed mainly on exploring factors that motivated and/or discouraged women who were already practising orthopaedic surgeons or in postgraduate training programmes. 6,8,9,12 Our study was designed to seek the reasons why graduating women choose or reject a career in T&O in comparison with their male colleagues. ...
... 21 Limiting working hours, decreasing the frequency of night shifts, wearing double layers of lead, increasing distance from the radiation source and appropriate use of vacuum mixing for methyl methacrylate are all shown to minimise the risks to a pregnant orthopaedic surgeon. 11,21 Women entering the field of orthopaedics should feel assured that evidence-based measures to protect the wellbeing of pregnant surgeons are implemented universally in all orthopaedic departments. ...
Article
Introduction Diversity in the healthcare workforce is associated with improved performance and patient-reported outcomes. Gender disparity in Trauma and Orthopaedics (T&O) is well recognised. The aim of this study was to compare factors that influence career choice in T&O between male and female final-year students. Furthermore, the trend of representation of women in T&O over the last decade was also compared with other surgical specialities. Methods An online survey of final-year students who attended nationally advertised T&O courses over a 2-year period was conducted. Data from NHS digital was obtained to assess gender diversity in T&O compared with other surgical specialities. Results A total of 414 students from 13 UK medical schools completed the questionnaire. Compared with male students (34.2%), a significantly higher proportion of women (65.8%) decided against a career in T&O, p<0.001. Factors that dissuaded a significantly higher percentage of women included gender bias, technical aspects of surgery, unsociable hours, on-call commitments, inadequate undergraduate training and interest in another specialty (p<0.05). Motivating factors for choosing a career in T&O were similar between both sexes. T&O was the surgical specialty with the lowest proportion of women at both consultant and trainee level over the last decade. Conclusion T&O remains an unpopular career choice among women. To enhance recruitment of women in T&O, future strategies should be directed toward medical students. Universities, orthopaedic departments and societies must work collaboratively to embed culture change, improve the delivery of the undergraduate curriculum, and facilitate students' exposure to operating theatres and female role models.
... The barriers identified by Canadian female orthopaedic surgeons using the GBS mirror the barriers that have been previously proposed in medicine. Globally, understanding that Canada has one of the highest percentages of female representation in orthopaedic surgery, this is particularly concerning 44 . The use of a validated outcome measure designed for female leaders lends legitimacy and gravitas to the findings of this study. ...
Article
Full-text available
Background: Only 13.6% of orthopaedic surgeons in Canada are women, even though there is nothing inherent to the practice of orthopaedic surgery that favors men over women. Clearly, there is a need to identify, define, and measure the barriers faced by women in orthopaedic surgery. Methods: An electronic survey was distributed to 330 female-identifying Canadian orthopaedic surgeons and trainees and included the validated Gender Bias Scale (GBS) and questions about career burnout. The barriers for women in Canadian orthopaedics were identified using the GBS. The relationships between the GBS and burnout were investigated. Open-text questions explored the barriers perceived by female orthopaedic surgeons. Results: The survey was completed by 220 female orthopaedic surgeons and trainees (66.7%). Five barriers to gender equity were identified from the GBS: Constrained Communication, Unequal Standards, Male Culture, Lack of Mentoring, and Workplace Harassment. Career burnout correlated with the GBS domains of Male Privilege (r = 0.215; p < 0.01), Disproportionate Constraints (r = 0.152; p < 0.05), and Devaluation (r = 0.166; p < 0.05). Five main themes emerged from the open-text responses, of which 4 linked closely to the barriers identified in the GBS. Work-life integration was also identified qualitatively as a theme, most notably the difficulty of balancing disproportionate parental and childcare responsibilities alongside career aspirations. Conclusions: In this study, 5 barriers to workplace equity for Canadian female orthopaedic surgeons were identified using the validated GBS and substantiated with qualitative assessment using a mixed-methods approach. Awareness of these barriers is a necessary step toward dismantling them and changing the prevailing culture to be fair and equitable for all. Clinical relevance: A just and equitable orthopaedic profession is imperative to have healthy and thriving surgeons who are able to provide optimal patient care.
... If this is true, why are the numbers of women in the surgical specialties, and most significantly orthopaedics, so low. The International Orthopaedic Diversity Alliance (IODA) has been collecting and publishing the numbers of female orthopaedic surgeons by country [1]. Estonia has the highest female representation at 26% but it quickly drops to below 10% and then even more quickly drops to minimal. ...
... However, as the pandemic reached its peak, younger patients than anticipated were more severely affected. Orthopaedic specialty lacks gender diversity with only 4.8% of orthopaedic surgeons in the UK being females [11,12], which theoretically means relatively higher risk for orthopaedic surgeons. In our survey, the majority of respondents were males aged 35-54. ...
Article
protective equipments (PPEs), conditions in outpatient and inpatient areas, concerns and NHS response, and effect on education and training. Design: An online questionnaire survey was distributed amongst BAME orthopaedic surgeons in the UK using various web-based platforms. The survey questionnaire consisted of 25 questions [single, multiple choice]. Conclusion: Although COVID-19 has presented a significant challenge to orthopaedic surgeons with BAME background across the UK, the response from BAME orthopaedic surgeons was contradicting the media and popular beliefs. There was no discrimination regarding the availability and use of PPEs. Orthopaedic doctors with BAME backgrounds worked hard throughout the pandemic. The majority were satisfied with the NHS response but constructively criticized it. Results: A total number of 226 orthopaedic surgeons with BAME background took part in the survey. Diabetes was the common-est comorbidity found in the cohort. Approximately a quarter of the respondents had to take an average of 12 days off work due to COVID-19 related symptoms or self-isolation due to a family member. 92% of doctors continued to work with Covid patients. Half of the surgeons reported that there was no shortage of PPEs whereas the other half reported non-availability of mainly masks in general. Just over a quarter of the surgeons had to use non-standard PPEs whilst in the operating theatre due to perceived shortage. 65 % felt the NHS response could have been better.
... However, as the pandemic reached its peak, younger patients than anticipated were more severely affected. Orthopaedic specialty lacks gender diversity with only 4.8% of orthopaedic surgeons in the UK being females [11,12], which theoretically means relatively higher risk for orthopaedic surgeons. In our survey, the majority of respondents were males aged 35-54. ...
Article
protective equipments (PPEs), conditions in outpatient and inpatient areas, concerns and NHS response, and effect on education and training. Design: An online questionnaire survey was distributed amongst BAME orthopaedic surgeons in the UK using various web-based platforms. The survey questionnaire consisted of 25 questions [single, multiple choice]. Conclusion: Although COVID-19 has presented a significant challenge to orthopaedic surgeons with BAME background across the UK, the response from BAME orthopaedic surgeons was contradicting the media and popular beliefs. There was no discrimination regarding the availability and use of PPEs. Orthopaedic doctors with BAME backgrounds worked hard throughout the pandemic. The majority were satisfied with the NHS response but constructively criticized it. Results: A total number of 226 orthopaedic surgeons with BAME background took part in the survey. Diabetes was the common-est comorbidity found in the cohort. Approximately a quarter of the respondents had to take an average of 12 days off work due to COVID-19 related symptoms or self-isolation due to a family member. 92% of doctors continued to work with Covid patients. Half of the surgeons reported that there was no shortage of PPEs whereas the other half reported non-availability of mainly masks in general. Just over a quarter of the surgeons had to use non-standard PPEs whilst in the operating theatre due to perceived shortage. 65 % felt the NHS response could have been better.
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