Dr. Laurie A. Hiemstra an Associate Professor at the University of Calgary. She also leads the gender diversity program for the Canadian Orthopedic Association (COA), is one of the founding members of the International Orthopedic Diversity Alliance (IODA), chairs the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Gender Diversity Task Force and is the president-elect of the COA.

Dr. Nancy Hiasat is an MD who completed her medical education in Cyprus. She is currently completing her Orthopedics residency at Hamad Medical Corporation in Qatar.

• Orthopaedic surgery has the lowest percentage of women in residency programs among other surgical specialties


• Female medical students have negative perceptions about the field of orthopaedic surgery


• Women feel there is a lack of mentorship in orthopaedics and their main complaint is there are not many female mentors


• Gender bias is prevalent at every step of the process in becoming and being an orthopaedic surgeon – therefore, women are at a disadvantage at every stage in their career


• Men need to be part of the solution. By being an ally and being a sponsor, men will help mitigate the barriers that women face and help make an equitable profession


• There are now several initiatives from different organizations devoted to help women pursue a career in orthopaedics


• Increasing leadership and mentorship opportunities for women, along with flexibility in training, is crucial for attracting and retaining women in orthopaedic surgery


• Elimination of discrimination, bullying, and harassment are essential to provide a safe and equal workplace for women in orthopaedics and in medicine 

Orthopedic surgery has been a male-dominated field for centuries. The underrepresentation of women in orthopaedics is not unique to any specific country and is a global challenge. Even though women represent more than 50% of medical school graduates, they still represent less than 10% of orthopaedic surgeons in most countries (Exhibit 1 shows countries with the highest and lowest proportions of female orthopaedic surgeons – among only those countries that provided information to the International Orthopaedic Diversity Alliance (IODA)) (5). Orthopaedics surgery presents many complex problems, which require diversity in perspectives to generate effective and innovative solutions. Diversity in any workplace is an important asset, particularly in the medical field, as it is also required to provide appropriate care to diverse patient populations. While women have been increasingly pursuing different specialities of medicine and research over the years, this same trend has not been observed in orthopaedics. At the OE World Tour in June 2020, a session on women in orthopaedics was held which presented statistics in the field, as well as the experiences and perspectives of female orthopaedic surgeons practicing in different cultural contexts. A critical understanding of the myriad of circumstances that prevent women from pursuing a career in orthopaedic surgery is necessary to identify key areas of intervention to improve their engagement and leadership in this field of medicine in the years to come.  

The value of achieving gender equity has been acknowledged in other areas of medicine and the case of orthopaedics is no different. There is evidence indicating that diversity in an organization not only adds different perspectives for effective decision making, but also yields greater innovation and creativity, along with enhanced understanding of the populations to be served (9) (10). Many benefits have been associated with achieving gender parity – including increased patient satisfaction and patient-centered communication, as well as improved collective intelligence and performance of care teams (8) (11) (12). Specifically, it has been found that patients treated by female primary care physicians are more satisfied than those treated by male physicians, even after accounting for patient characteristics and physician practice style (13). Female physicians are also more likely to implement collaborative models of patient-physician relationship than do their male colleagues (14). Collectively, these findings suggest that female orthopaedic surgeons may also bring different attributes to patient encounters that may be beneficial, and their under-representation in orthopaedics is concerning (8). 

Although research has shown that women and men practice medicine differently, there is limited research on the differences in learning styles, development of skills, or outcomes for female and male surgeons (7). Findings from a population-based cohort study show that after accounting for patient, surgeon, and hospital characteristics, patients who were treated by female surgeons had a small but statistically significant decrease in 30-day mortality and similar surgical outcomes (length of stay, complications, and readmission), when compared to those treated by male surgeons (7). The authors, did, however, state need for further study given limitations of the observational study design which did not have information on the severity of the diseases for which surgery was performed (for example, cancer stage) or case complexity, even though procedures were matched directly. While there is need for more research to examine the surgical outcomes and mechanisms related to the gender of orthopaedic surgeons, current evidence does not support gender-based preferential selection of surgeons as the competency of female surgeons is not in question. 

A recent survey shows while most patients (83.9%) do not have any gender preferences when selecting their orthopaedic surgeon, 14.5% of patients preferred a female surgeon and 1.6% of patients preferred a male surgeon (8). Among patients who preferred a female surgeon, 89.2% of the respondents were female (8). Furthermore, female patients tended to have more of a preference for the gender of their subspecialty orthopaedic surgeons compared to male patients – where there was a preference for a male or female surgeon depending on the subspecialty (8). These gender preferences for different subspecialties may reflect the level of female and male representation in different subspecialties (e.g., hand surgery and paediatric orthopaedics have a greater female representation, where female surgeons were preferred), or the perceived stereotypes regarding the need for physical strength (8). Given most patients do not have any gender preference for their orthopaedic surgeon whereas some may have an element of bias in their preference, recruiting qualified female applicants to this field has been recommended (15). 

Importantly, being a woman has been identified as a barrier to accessing appropriate orthopaedic care (16). Results of a study published in 2008 show a man is twice more likely than a woman to be referred to a knee surgeon as well as 22 times as likely to be offered total knee arthroplasty (TKA) (17). The authors of this study provide possible explanations for the disparity in the recommendation of TKA based on patient’s gender. Physicians may have conscious discriminatory attitudes towards female patients. There is evidence indicating that some physicians do not take women’s symptoms seriously and attribute their symptoms to emotional instead of physical causes and refer women for specialty care less often than men, even in cases where women have greater level of disability (18) (19). Physicians may also have unconscious bias based on gender, where they may not refer female patients for TKA based on their own experiences or anecdotes from other physicians that indicate men benefit more from TKA than women (17). This inappropriate unconscious bias may form because women tend to receive surgery at a later stage than men, and there is risk of worse outcomes with more advanced prognosis (20) (21). Dr. Laurie A. Hiemstra, president-elect of the Canadian Orthopedic Association (COA), explains that male and female surgeons may perceive symptoms presented by male and female patients differently, which has important implications for the care patients receive. Specifically, male and female patients may present their symptoms differently, where women may be more stoic or appear to cope better with their symptoms. If the treating surgeon is male, they may not understand the nuances of the patient’s complaint and end up not referring women. For example, if a male patient can no longer work as a plumber due to knee pain, they may be more likely to be referred for a TKA than a female patient who works as a homemaker and has difficulty completing housekeeping or other unpaid labour due to knee pain – tasks which are traditionally not considered as important. Diversity in orthopaedic surgeons is essential if we are to truly understand our patients and give them good care. This is likely why women prefer a female surgeon, because they understand them, and aren’t brushed off by male surgeons. Therefore, diversity in orthopaedic surgeons is essential for good patient care.  

Women experience many more barriers than men in pursuing a career in orthopaedics. We have summarized below the evidence available on these barriers as well as insights shared by female orthopaedic surgeons at our OE World Tour (Exhibit 2). 

While increasing the representation of women in orthopaedics is not an easy task, with likely many years to go before we begin to observe widespread gender equity in this field across nations – several strategies can be implemented to achieve positive change. These include: 

1.    More opportunities for women to take leadership roles

Leadership has been described as a crucial enabler to support some of the most effective diversity initiatives. These include communicating and embedding values, behaviours, and cultural norms, ensuring recruitment and promotion processes are not biased, and creating working models that support both women and men (34). Having female leaders in the field of orthopaedics is necessary to spearhead these initiatives because not only do they bring a different perspective, but they can also make relevant recommendations based their lived experiences and those of their female peers. It is encouraging to note that some orthopaedic associations in recent years had female presidents, including the United States, Malaysia, Sweden, Estonia, and Canada (34). The importance of mentoring and sponsoring women for these leadership roles have been emphasized as they are largely occupied by male orthopaedic surgeons (34). 

2.    Greater mentorship from both female and male mentors

Mentorship from both male and female mentors are considered integral for encouraging and supporting more women to enter orthopaedics. Many orthopaedic organizations around the world right now have formal mentorship opportunities to not only allow women to learn more about orthopaedics, but also to engage in this field in various capacities, as well as receive guidance from others as needed (34). For example, the International Orthopaedic Diversity Alliance (IODA; https://www.orthopaedicdiversity.org) was recently established to improve the inclusion of women and under-represented minorities in orthopaedics (4). Among its many activities, such as advocating for diversity in orthopaedics, developing diversity strategies, sharing findings from orthopaedic diversity initiatives, mentoring women to orthopaedics is a key priority of the IODA (4). Additionally, Women in Orthopaedics Worldwide (WOW; https://wowortho.org/) has been established to improve the inclusion of women in orthopaedic surgery with the engagement and partnership of orthopaedic leaders. These leaders play a supportive role in developing societies for women in orthopaedics and encourage these societies to promote orthopaedic surgery as a career for women. 

The female orthopaedic surgeons who were guest speakers at our OE World Tour also emphasized the importance of mentors for helping them choose a career in orthopaedics and dispelling many misconceptions. For example, Dr. Wafaa Al Baluki from Oman explained that her mentors spent time to answer all her questions and gave her an insider perspective about the specialty. Through her mentorship experience, she was able to see that the lifestyle of orthopedic surgeons is not as difficult or awful as most medical students think. Seeing successful women in orthopedics, although few of them, helped her select this specialty. 

3.    Flexibility in training and work settings

Having programs and policies in place that support women in taking care of their personal life have been increasingly emphasized. This includes having strategies to allow women to have and raise children whether it is during their training or when they have transitioned to the next steps in their career. Many inclusive infrastructural changes have been suggested, including the presence of daycares and family space near women’s workplace so they can spend time with their family. There is also growing recognition that men need to play an active role to support women in their career – specifically, men need to become equal partners at home. Real allyship and gender partnership has been described as men doing a fair share of household chores, childcare, transportation for children’s activities, planning and tracking household activities, and supporting their partner’s career (36). The benefits of paternity leave have been described to prevent burnout among working mothers (37). 

4.    More opportunities to take part in scientific meetings 

Creating more opportunities for women to participate in scientific meetings not only contributes to the professional development of female orthopaedic surgeons, but achieving this diversity at scientific meetings can also lead to better science, as indicated by evidence (34). Using evidence-based methods to improve the presence of women at orthopaedic scientific meetings has been recommended (34).  

5.    Strategies to End Harassment and Bullying 

To address DBSH targeted towards women in orthopaedic surgery, the behaviours and factors that contribute to a negative workplace needs to be first identified to design appropriate mitigation strategies (22). The need for specific training and awareness programs designed for both trainees and attending surgeons has been recommended (23). These programs should not only focus on how to mentor women who are deciding whether to pursue orthopaedic surgery, but also provide guidance regarding how to appropriately mentor trainees of the opposite gender – where both the mentor and the mentee feel comfortable in their professional roles (23). Even though reports of sexual harassment are prevalent in the field of orthopaedic surgery, researchers have noted that “with an emphasis on the increase of the recruitment of women to our field through mentorship, coupled with the increase of women in leadership positions, the orthopaedic community can work towards making the specialty more inclusive” (23). A top-down approach to culture change has been proposed as a critical component for creating a more inclusive environment for all – where department and hospital leaders make a commitment to create a safe and respectful environment for all (22). The role of men has been repeatedly emphasized to become active champions of women in the workplace – please refer to this recently published editorial to review the steps men can take to make orthopaedics surgery a fairer place for women (35). 

While the field of orthopaedics is laden with many barriers for women to succeed, there are many female orthopaedic surgeons who have demonstrated not only do women belong in orthopaedics, but they can also be key leaders to move the research and practice in this field forward. The WOW has showcased female orthopaedic leaders from around the world that trainees of tomorrow can look up to. Below are spotlights of some notable female orthopaedic surgeons who have championed the place of women in this field. 

For an in-depth discussion on gender diversity in orthopaedics, please refer to our podcast with Dr. Laurie A. Hiemstra. Dr. Hiemstra is an Associate Professor at the University of Calgary. She also leads the gender diversity program for the Canadian Orthopedic Association (COA), is one of the founding members of the International Orthopedic Diversity Alliance (IODA), chairs the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Gender Diversity Task Force and is the president-elect of the COA.