Diversity in trauma and orthopaedics: Rationale for an inclusive culture

Simon Fleming, Jennifer Green, Laurie Hiemstra, Samantha Tross and Kristy Weber on behalf of International Orthopaedic Diversity Alliance (IODA)

Simon Fleming is a Londonbased T&O registrar. He is a founding member and the trainee representative for the International Orthopaedic Diversity Alliance (IODA), on the Executive board for the NIHR Clinical Education Incubator and Associate Editor for Medical Education and The Clinical Teacher. He was previously Vice Chair of the Academy of Medical Royal Colleges Trainee Doctors’ Group (ATDG) and President of the British Orthopaedic Trainees’ Association (BOTA).

Jennifer Green is an Orthopaedic Hand & Wrist Surgeon. She is a Founding Member of IODA and a member of the Australian Orthopaedic Association (AOA) Champions of Change. She is a Past Chair of AOA Orthopaedic Women’s Link (OWL) and assisted in establishing the AOA Cultural Inclusion Working Group. Jennifer is an active member of the Australian Hand Surgery Society (AHSS) and the Asia Pacific Orthopaedic Association (APOA) Hand & Upper Limb Section. She is also the Australian Representative on the Asia Pacific Federation of Hand Surgery Societies (APFSSH).

Laurie Hiemstra is an Orthopaedic Surgeon working in Banff, Canada and a clinical Associate Professor at the University of Calgary. Laurie is on the Board of Directors of the Patellofemoral Foundation, Banff Sport Medicine Foundation, Canadian Orthopaedic Association (COA) and the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS). She is the Chair of the Gender Diversity and Inclusion Task Force for both the COA and for ISAKOS. She is a founding member of IODA and Women in Orthopaedics Worldwide (WOW). Laurie is the President Elect for the COA and will be the first female president of that organisation.

Samantha Tross is a Consultant Hip and Knee Surgeon, the current Lead Surgeon at Ealing Hospital. She is the first female of African- Caribbean origin to become a Consultant Orthopaedic Surgeon in the UK. She is an advocate for Diversity in Surgery and works with many charities and schools to improve this pipeline. She is a Trustee and founder member of the British Association of Black Surgeons and member of Cultural and Diversity Committee of the British Hip Society.

Kristy Weber is a Professor and Vice Chair of Faculty Affairs at the University of Pennsylvania (US) and Director of the Abramson Cancer Center Sarcoma Program. She has served as the president of the Musculoskeletal Tumor Society, the Ruth Jackson Orthopaedic Society and the American Academy of Orthopaedic Surgeons. She is a recognised champion of diversity and equity in the field.

The International Orthopaedic Diversity Alliance (IODA) is an orthopaedic surgeon-led, not-for-profit collaboration with a vision to unite leaders and industry to promote equity, diversity, and inclusion (EDI) in orthopaedic surgery around the globe.

IODA is supported by more than 30 past, present and future national orthopaedic association presidents. IODA members are actively driving discussions around EDI by organising symposia, creating educational webinars, collecting data and collaboratively publishing in the orthopaedic literature. IODA is focused on diversity in orthopaedics writ large, not just gender, envisioning a global culture of inclusivity, where everyone can thrive.

Orthopaedic surgery is one of the least gender and ethnically diverse medical specialties [1,2]. This lack of diversity has been recognised as a ‘critical issue’ by many national and international orthopaedic associations. Multifocused diversity strategies are being or have been established by International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS), the New Zealand, American, Australian, New Zealand, British, Canadian Orthopaedic Associations, and the American Academy of Orthopaedic Surgeons (AAOS). Women in orthopaedics initiatives have been established in the Societe Internationale de Chirurgie Orthopedique et de Traumatologie (SICOT), European Federation of National Associations of Orthopaedics and Traumatology (EFORT), European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), and the Asia Pacific Orthopaedic Association (APOA). These, along with over 40 national ‘Women in Orthopaedics’ societies and those focussing on underrepresented groups, working to address implicit biases, lack of mentorship [3], to act as role models and drive change at the leadership level [4].

Despite women representing close to 50% of medical graduates globally and an increasing percentage of practicing doctors in many nations, less than 5% of orthopaedic surgeons are female in most nations [1,2,5] . Gender bias and gender-based stereotypes in orthopaedics are pervasive, affecting women throughout their careers, from residency, to research and clinical work, to career advancement and compensation. Recruitment of qualified women into orthopaedics remains an issue, perpetuated by the negative perceptions of orthopaedic surgery as a career that have been disclosed by female medical students [6-9]. A perceived lack of mentorship remains a barrier [10]. Leadership and career advancement opportunities are less available to women with the numbers decreasing significantly as rank increases. This leads to burnout that can be more prevalent in women, especially senior women physicians [11,12]. These barriers also translate into a pay gap with female orthopaedic surgeons making less money than male surgeons for the same work [13]. Flexibility has been recognised as a necessary factor in promoting the inclusion of women in orthopaedics, many of whom train and work through their childbearing years. This includes flexibility for pregnancy and childbearing considerations, parental leave, lactation facilities, and recognition of family responsibilities. Flexibility is not a gender-specific policy. It offers significant benefits to all orthopaedic surgeons, whether its purpose be academic advancement, pursuit of a skill unrelated to orthopaedics, recovery from personal illness, or care of an unwell or elderly family member. It is critical that the promotion committees in academic departments have ways to level the playing field for women who bear a greater share of childcare and family responsibilities. In the surgical theatre, options and improvements in the ergonomics of surgical tools have enabled women to be equally effective from a technical perspective. Appropriate protective equipment such as lead vests that protect female anatomy allow a safe and equitable environment in which to practice. The male culture that exists in orthopaedics creates an unwelcoming environment for women, laying the groundwork for discrimination, harassment and bullying [14,15] .

The international data availability for racial and ethnic diversity in orthopaedics is not robust but it is widely noted that the field is also lacking in this area. It is imperative that this data is improved, be transparently available and measures put in place to counter it. In the United States and the UK, the lack of ethnic and cultural diversity in orthopaedics has been recognised [16-18]. In the United States, persons of colour (Black, LatinX, Asian) are underrepresented in surgical residency programs compared to medical school classes [19].

For African Americans 4.1% vs 13.3% and Hispanic 4.5% vs 17.6% [20]. Of practicing surgeons, in the USA, persons of colour comprise 9.9% of the workforce [21]. Within the UK, figures are similar with black surgeons comprising 2% of the consultant surgical body versus 5.2% of the medical workforce. Asians, the largest underrepresented group (URG), comprise 27.8% of the practising consultant surgeons compared with 30.2% of the medical workforce [22]. Trainees from URGs are more likely to leave or be dismissed from training programmes (17.5% vs 6.9% of all orthopaedic residents) [19]. Apart from the turnover in the workforce which has financial implications for the institution as well as individual, repeated discrimination over time is linked to increased medical co-morbidities and a lower life expectancy in African Americans [23]. URGs are also more likely to face discrimination, marginalisation, bullying, reduced confidence and a lack of career progression [19].

It is recognised that intersectionality (being a member of more than one group that is under-represented) in orthopaedic surgery compounds the barriers for entry and advancement. The specific barriers and challenges that exist for those of diverse gender identities, abilities, religion, and socio-economic status in orthopaedic surgery has yet to be fully understood.

The McKinsey group in their 2020 report based on the business sector demonstrates that organisations with greater than 30% diversity attract the top talent, are more innovative, make better decisions, and are more profitable [20]. For businesses, 36% higher returns were realised when there were high levels of ethnic diversity and 25% higher returns with increased gender diversity [22]. This highlights the financial benefits of IODA’s agenda and supports giving attention to all aspects of diversity.

For culture change to occur, there must be awareness of the disparities that exist for women, URGs and especially those for whom intersectionality is present [18] , and a desire to want change. Allies, mentors and sponsors are essential to help mitigate the barriers faced by women and URGs in orthopaedics [19,23-26]. Cultural change is advanced by increased visibility of URGs from a particular country or region on selection boards, training programs, examination boards, scientific meeting panels and with engagement with medical schools. Those with privilege in any culture can use it to increase the visibility of those underrepresented. Elimination of discrimination, bullying, and harassment will provide a safe and equitable workplace for both women and other URG’s [15,27,28]. Intentional mentorship and pipeline programmes will increase recruitment and improve retention [29,30]. Recruitment committees for new orthopaedic trainees and orthopaedic surgeons should include a diverse group of members in order to identify diverse candidates and include regular bias training [31]. The process for selecting leaders for international and national orthopaedic organisations should be critically evaluated to be sure best practices are used to mitigate against bias against candidates that don’t fit the majority culture appearance. It is also important to challenge the current organisational governance that maintains the status quo. Finally, recognition that URGs should not be treated as a homogeneous whole is important [30]. By understanding and appreciating their differences, the appropriate measures and support can be offered, where not only is recruitment a problem but also retention [19,30].

A critical factor in changing orthopaedic culture is for leaders in each country and region to model appropriate behaviour, be open to feedback, and hold others accountable for the change we need to see. It is valuable to slow down, listen, and do the work necessary to learn about the background and values of those who do not fit the historic orthopaedic surgeon stereotype. The goal is a culture of mutual respect where everyone can thrive, and where barriers specific to gender and race don’t exist and a sense of belonging is created. We enable what we tolerate. It requires courage to push for change in a traditional culture, and it is necessary.

To realise the benefits of diversity, the diverse voices in an organisation must be valued and included. Diversity is often considered as being ‘invited to the party’, inclusion is being ‘asked to dance’ and belonging ‘dancing without inhibitions’. Even nations such as Estonia who have the world’s highest representation of female orthopaedic surgeons, the percentage still does not reach the 30% required to achieve culture change and realise the greatest benefits of diversity. Most underrepresented groups in orthopaedics continue to have representation well below 30%.

In conclusion, diversity enriches our orthopaedic organisations as more voices with differing views are heard. Greater diversity leads to increased innovation, attracts the top talent to trauma and orthopaedics, and drives better decisions in governance. Successful diversity strategies include increased visibility of women and underrepresented groups in organisations, mentorship and sponsorship, increased flexibility for the workforce and mitigating unconscious bias in selection and promotion. More importantly, greater representation of women and underrepresented groups in orthopaedics is critical if the field is to better mirror the societies in which surgeons practice.

IODA acknowledges the commitment of EFORT to diversity in trauma and orthopaedics through the opportunity to publish in EFORT Open Reviews.

References

References can be found online at: www.boa.ac.uk/publications/JTO.

Please see WOW article and video on our Transient Journal celebrating and recognising pioneers in our field - the first women in orthopaedics in their country and the first women leaders of national organisations: www.boa.ac.uk/TJ-WOW.