JPOSNA® Special Edition
2022 Annual Meeting Pre-Course on Diversity, Equity, and Inclusion
Choosing a Path Within Medicine: Addressing the Myths
Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX
Correspondence: Daniel J. Sucato, MD, MS, Chief of Staff, Texas Scottish Rite Hospital, 2222 Welborn St., Dallas, TX 75219. E-mail: [email protected]
Received: August 15, 2022; Accepted: August 15, 2022; Published: February 15, 2023
Volume 5, Number S1, February 2023
Abstract
Orthopaedic surgery remains a homogenous field. Exposing women and minorities at an early age to the field, minimizing implicit biases, having more mentors willing to support underrepresented groups, and creating an inclusive and welcoming environment are critical to enhancing the field and improving the care of our patients.
Key Concepts
- Diversity improves organizations.
- Career choices begin early, especially in orthopaedic surgery, and are in part dependent on a diverse group of mentors.
- To attract women to orthopaedics, it is important to eliminate microaggressions, create a workplace with a balanced lifestyle, and provide appropriate maternity leave policies.
- Diversity is achieved when underrepresented minorities comprise 30% of an organization, as it provides for a change in the culture of the institution.
Making a career choice is a critically important decision that is long-lasting and takes into account several factors. Ultimately, it is a personal decision for each individual. Factors that play a role in this decision include one’s interests, personality, lifestyle desired, and the likelihood of success in that career choice. One of the main factors is related to the general “phenotype” of the current role models and mentors.
So, what are some of the myths related to choosing a career in orthopaedics? Some of the answers can be found in the current profiles of many (most) orthopaedic groups in both private and academic practices in which white males dominate. It is safe to say that the traditional myths include the concepts that orthopaedic surgery is hard, physical work is better performed by men, the lifestyle is demanding and not conducive to women, orthopaedics is preferred by men, and finally, men perform better as orthopaedic surgeons than women.
For starters, it is important to clear up any potential confusion regarding gender differences in performance as an orthopaedic surgeon. A single residency program with 90 residents was studied and found no significant differences between men and women in well-accepted measures of performance. Interestingly, of the eight core competencies studied, women scored better in five of them, including patient care, professionalism, communication, practice, and system-based learning.1 Although these trends did not reach statistical significance likely due to lack of power, perhaps with a larger study, the significance could be demonstrated.
The reasons orthopaedic surgery as a career is not chosen by women are not fully known. Some answers can be found in a study by Rohde et al. who reported that women perceive challenges in having a good work/life balance in this profession as well as a general lack of strong mentors in the field.2 Further, evidence demonstrates that orthopaedic surgeons make decisions earlier to pursue this career compared to other specialties, with nearly 30% deciding prior to medical school, compared to 15% for other specialties.3 This difference in the timing of when decisions are made may play a role in the disparity of women vs. men related to the availability of similar-gendered role models at this point in their lives.
In order to achieve diversity, the work environment needs to change to include more appropriate maternity leave policies and providing the opportunity for women to take time off. Weiss and Teuscher reported that 80% of orthopaedic programs have policies lasting 4–6 weeks, but 50% of the programs require the use of paid time off (PTO).4 Additionally, 61% of programs reported no utilization of their leave policy which may reflect some of the peer pressures felt when seeking time off. These data suggest that further work is necessary to make it easier and more acceptable to take appropriate time. Medical systems/hospitals seem to lag behind other industries with paid time off for maternity leave, and it is imperative for us to catch up and provide a seamless environment for this to occur.
Another major barrier is the negative environment created by inappropriate questions posed to women with regard to child-bearing and marital status during interviews for residency and throughout medical school. Samora reported 62% of such questions were asked during the interview process. Even more concerning are the microaggressions (defined as verbal, non-verbal, or environmental slights) that continue to occur with an unacceptably high incidence of 74%.5 Although some of these microaggressions may be unintentional, it is important to recognize that these may be related to unconscious or implicit biases we all have which need to be identified and overcome. Significant work and research have occurred in this area and successfully overcoming these biases requires first, an acceptance that we all have them and acknowledge this; second, we need to encourage good practices and ongoing learning with a commitment to continuous improvement, working with good mentors to solicit feedback and track progress over time.6
Mentorship, guidance, and good counsel are some of the mainstays of making good decisions in any part of life but especially regarding career choice. It is critical that mentorship includes appropriate early timing for this and to have female and underrepresented minority mentors which lead to the opportunity for them to choose orthopaedics as a profession. Oladeji et al. reported that 96% of orthopaedic residents believed mentorship played a major role in their career choice.7 Thinking back on how we decided to pursue orthopaedics, it is safe to say that it probably started relatively early, and the mentors that served as role models looked like us. Since only 7% of orthopaedic surgeons are women, and underrepresented minorities all together make up less than 20%, this limits the opportunities for good role models for these groups. As evidence of this, minorities report less satisfaction with the quality of mentorship in residency, and women tend to pursue a mentor on their own.7
Appropriately timed and well-thought-out mentorship programs have been successful. Drs. Sravya Vajapey, Lisa Cannada, and Julie Samora reported on the success of the Ruth Jackson Orthopaedic Society in which 80% of the 81 scholarship winners either practiced orthopaedic surgery or were in an orthopaedic surgery residency program.8 Similarly, applying to an orthopaedic residency program was 51 times higher for women and 15 times higher for underrepresented minorities for those who completed the Nth Dimensions Orthopaedic Summer Internship Program. This is an 8-week program between the first and second years of medical school that includes lectures, workshops, research project presentations, ongoing mentoring, professional development, and counseling.9 At Scottish Rite, Drs. Amy McIntosh, Christine Ho, and Kirsten Tulchin-Francis have carried out the Perry initiative for over 10 years to foster women’s interest in engineering and orthopaedics beginning in high school, with a recent graduate matching in orthopaedics at Duke (Figure 1).
Figure 1. The Perry Initiative inspires young women to be leaders in the fields of orthopaedic surgery and engineering. The program targets women in high school and medical school—two critical junctures along the career pathway.

Finally, it is critically important that we recognize that diversity is not achieved by “checking the box” or having a token representative. Instead, it is having at least 30% representation to truly change the culture of the institution.10 The story of the eight-office insurance company placing a single female in each office only to have them all quit within a year illustrates this point. When they changed the program to strategically place three women in a few of the offices, it demonstrated an inclusivity that resulted in a positive change in the institutional culture, resulting in both the women blossoming and the company benefitting. I am blessed to be on an orthopaedic team that includes six amazing women and underrepresented minorities, all of whom make the team better and improve the lives of the children/families we are privileged to take care of.
In summary, diversity is critically important for the success of any organization whether in healthcare or any other enterprise. Underrepresented groups need to reach 30% to change the culture to one that is inclusive, enabling all to succeed. Currently, we are not moving at an acceptable pace to improve the inclusion of women and underrepresented minorities in orthopaedics, and we all need to look in the mirror to identify our implicit biases, to make a conscious and continuous effort to overcome these unconscious biases in our actions and in our words. Residency programs and healthcare institutions need to make the workplace an acceptable environment to balance the challenges of work and family life through appropriate work hours, timely scheduling of meetings/conferences and well-accepted maternity/family leave policies. Finally, mentorship programs need to start early. These programs will enable women and minorities who are truly interested and talented to pursue this career, and ultimately make our great profession even better.
Disclaimer
The author has no conflicts of interest to report.
References
- Pico K, Gioe TJ, Vanheest A, et al. Do men outperform women during orthopaedic residency training? Clin Orthop Relat Res. 2010;468(7):1804-1808.
- Rohde RS, Wolf JM, Adams JE. Where are the women in orthopaedic surgery? Clin Orthop Relat Res. 2016;474(9):1950-1956.
- Johnson AL, Sharma J, Chinchilli VM, et al. Why do medical students choose orthopaedics as a career? J Bone Joint Surg Am. 2012;94(11):e78.
- Weiss J, Teuscher D. What provisions do orthopaedic programs make for maternity, paternity, and adoption leave? Clin Orthop Relat Res. 2016;474(9):1945-1949.
- Balch Samora J, Heest AV, Weber K, et al. Harassment, discrimination, and bullying in orthopaedics: a work environment and culture survey. J Am Acad Orthop Surg. 2020;28(24):e1097-e1104.
- Gino F, Coffman K. Unconscious Bias Training That Works. Harvard Business Review; 2021.
- Oladeji LO, Ponce BA, Worley JR, et al. Mentorship in orthopedics: a national survey of orthopedic surgery residents. J Surg Educ. 2018;75(6):1606-1614.
- Vajapey S, Cannada LK, Samora JB. What proportion of women who received funding to attend a Ruth Jackson Orthopaedic Society meeting pursued a career in orthopaedics? Clin Orthop Relat Res. 2019;477(7):1722-1726.
- Mason BS, Ross W, Ortega G, et al. Can a strategic pipeline initiative increase the number of women and underrepresented minorities in orthopaedic surgery? Clin Orthop Relat Res. 2016;474(9):1979-1985.
- Van Heest A. Gender diversity in orthopedic surgery: we all know it’s lacking, but Why? Iowa Orthop J. 2020;40(1):1-4.