Championing Women Orthopaedic Surgeons: Preparing for an Inclusive Future
September 24, 2021 | Article No. 70
Championing Women Orthopaedic Surgeons: Preparing for an Inclusive Future
September 24, 2021 | Article No. 102
Ayesha Siddiqua MSc, PhD
Mohit Bhandari MD, PhD
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
“Orthopaedics is still one of the least gender diverse medical specialties in the world with a known percentage of women ranging from approximately 1% in India, 7.6% in the USA, 17% in Sweden and the largest known number, 26.4% in Estonia.”
Orthopaedics Worldwide (2021)
“Attracting female medical students to orthopaedics and making orthopaedic subspecialties approachable for women should be a priority to ensure that the field attracts the brightest candidates, as this goal will not be possible if essentially half of the candidate pool is not interested in applying.”
Hariri et al.
“In spite of efforts to improve gender diversity in orthopedic surgery, women remain underrepresented, particularly with increasing academic rank.”
Gerull et al.
“In SBOT (Brazilian Society of Orthopaedics and Traumatology), we have 14,302 members and only 810 female members (5.6%). These figures are better than in 2018 when we had less women. Residents in Brazil are 1,967 males to 149 females. We are not different from other societies as the American Academy of Orthopedic Surgeons (AAOS) has 6.5% female members and had its first female president in 2019 while the British Orthopedic Association (BOA) elected the first female vice-president last year.”
Dr. Patricia Moraes Barros Fucs,
Consultant Paediatric Orthopaedic Surgeon, Brazil (3)
“Diversity of the health workforce is an imperative to improve healthcare equity. Evidence shows that under-represented minorities experience better health outcomes when treated by doctors who look like them. The reasons are complex and may include issues of communication, trust, representation in health organizations & unconscious bias. Orthopaedic studies have shown that men with the same degree of osteoarthritis are between 3 and 22 times as likely to be offered a knee replacement as women. Such statistics are concerning.”
Dr. Jennifer Green,
VP International Orthopaedic Diversity Alliance (4)
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 (see https://www.youtube.com/watch?v=IGS1E0WRpGE), 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.
Top 10 Countries
|Country||Population (million)||Orthopaedic surgeons (n)||Female orthopaedic surgeons (%)|
Bottom 10 Countries
|Country||Population||Orthopaedic surgeons (n)||Female orthopaedic surgeons (%)|
*Data collected from orthopaedic association of each nation. Asia-Pacific data courtesy of PC Chye. Information for not all countries was available to the International Orthopaedic Diversity Alliance.
“Ensuring gender equity in medicine is an issue of justice and rights. Having more physicians who are women and more women in health policy leadership also appears to enhance the provision of high-quality patient care. Large, well-conducted observational studies have shown that patients of female clinicians experience better quality of care for diabetes, and significantly lower rates of mortality, hospital readmissions and emergency department visits than those treated by male clinicians…reasons for this may include that women spend more time with their patients, are more patient-centred in their approach and provide more evidence-based care.”
Tricco et al.
“Fewer patients treated by female surgeons died, were readmitted to hospital, or had complications within 30 days (5810 of 52 315, 11.1%, 95% confidence interval 10.9% to 11.4%) than those treated by male surgeons (6046 of 52 315, 11.6%, 11.3% to 11.8%; adjusted odds ratio 0.96, 0.92 to 0.99, P=0.02). Patients treated by female surgeons were less likely to die within 30 days (adjusted odds ratio 0.88; 0.79 to 0.99, P=0.04), but there was no significant difference in readmissions or complications. Stratified analyses by patient, physician, and hospital characteristics did not significant modify the effect of surgeon sex on outcome.”
Wallis et al.
“When asked about the preference for the gender of their joint replacement surgeon, of the patients that did have a preference, twice as many preferred a male surgeon (6.6% vs 2.8%, respectively; p=0.24). Of the patients that had a preference, 94% were female. Conversely, when asked about the preferred gender of their hand surgeon, the majority of patients had no preference. However, of the patients that did have a preference, patients preferred female surgeons at a rate almost three times that of male surgeons, although this difference did not approach statistical significance (6.2% versus 2.2%, respectively, p=0.08). 86.7% of patients who had a preference were female.”
Dineen et al.
Why Are Women Needed in Orthopaedic Surgery?
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.
“(Findings of a survey of the American Academy of Orthopaedic Surgeons (AAOS) members show) women (81%) were more likely than men (35%) to have experienced these (discrimination, bullying, sexual harassment, and harassment) behaviors…Women were markedly more likely than men to have been subject to sexual harassment (54% versus 10%, P<0.05).”
Balch Samora et al.
“(In a survey of members of the Ruth Jackson Orthopaedic Society, a professional society for women orthopaedic surgeons) sixty-eight percent (171 of 250) of women reported having experienced sexual harassment during their orthopaedic training…(there were) no differences between current and past trainees in terms of the proportion who reported having experienced sexual harassment during residency training (59% [30 of 51] versus 71% [141 of 199], odds ratio 0.59 [95% CI 0.31 to 1.11]; p = 0.10).”
Whicker et al.
“(Findings from a survey in the UK show) only 24% of female students would consider orthopaedic surgical careers, differing significantly from male students (p = < 0.01). The reasons given included disinterest and male domination. Significantly greater female students had been exposed to negative attitudes regarding female surgeons (p = < 0.01), of which 62% would not consider surgery. Most patients (89%) had no sex-preference for orthopaedic surgeon. Seventy-five percent believed women are surgically as skilled as men and 4% of the patients stated they had more confidence in female orthopaedic surgeons compared to males. Fifty-eight percent of the surgeons had never encountered negative attitudes. Of those that had, skill and family responsibilities were questioned.”
Bucknall & Pynsent
“(Findings of a survey show) sixty-nine percent of all (medical) students and 75% of those pursuing surgery reported verbal discouragement from pursuing a surgical career. Women were significantly more likely to perceive that the verbal discouragement was based on gender (P < 0.0001), age (P < 0.0001), and family aspirations (P = 0.043) compared to men.”
Giantini Larsen et al.
“For women applying to orthopaedics, gender bias is most evident through illegal interview questions, in which women are asked such questions more often than men (such as family planning questions, asked to 61% of women versus 8% of men).”
Factors Discouraging Women from Pursuing Orthopedics
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 (see https://www.youtube.com/watch?v=IGS1E0WRpGE) (Exhibit 2).
|Discrimination, bullying, sexual harassment, harassment (DBSH)||
|Lack of female role models||
|Lack of mentorship||
|Lack of flexibility in training and parenting||
|Gender stereotypes/male bias||
“Within the Canadian Orthopaedic Association (COA), the number of female orthopaedic surgeon members is increasing, with the largest growth in the trainee category. The number of females in leadership roles and on the podium at the COA annual meeting is increasing and is consistent with the present gender diversity of the association’s membership.”
Hiemstra et al.
“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.”
Green et al.
“(Among speakers at orthopaedic surgery annual meetings) there was a positive correlation between the proportion of women in society leadership roles and the proportion of women in speaking roles (r = 0.73; p < 0.001). Societies with a stated diversity effort had more women as conference speakers; with 19% (375 of 1997) women speakers for societies with a diversity effort compared with 8% (160 of 1931) women speakers in societies without a diversity effort (OR 2.6 [95% CI 2.1 to 3.1]; p < 0.001).”
Gerull et al.
“…my mentor is one that loves to work with women because we consider them more precise and more reliable than some men, but the difference is whether your chief gives you the same opportunity to be a surgeon [as a man].”
Dr. Elena Samaila,
Orthopaedic Surgeon, Italy (33)
“Perhaps the most important responsibility falls not on women, but on men. It has been the behavior of men, and societies and organizations (yes, including journals) that are largely run by men, that has made things so difficult on women in our specialty. When it comes to matters of workplace harassment and bullying, men need to step up. Most men know that some of their peers behave badly, or worse, but choose not to act. We know right from wrong; we know what to do when we see wrong, and we need to do it. But that’s a bare minimum in terms of our responsibility here. Men need to start asking themselves hard questions about what we are or aren’t doing here, and taking affirmative steps to treat women in our specialty with greater respect. Dare yourself to ask, and answer honestly: What have you done? And, importantly, what more can you do?”
Paving the Path for Women in Orthopaedics
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 (see https://www.youtube.com/watch?v=IGS1E0WRpGE). 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).
Role Models from The Field
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 (https://www.youtube.com/watch?v=SalEZPT_qy8). Below are spotlights of some notable female orthopaedic surgeons who have championed the place of women in this field.
“As a mother, I had to become creative in how I managed the children. They were toddlers when I started orthopaedic residency, and more than once I wanted to quit. Thank God for the senior colleague who said, “Peace, in another 7 years, these children will be grown and soon they will leave you for school. Complete the training and you will be more productive when that happens.” How right he was!” (38)
Amaraegbulam, Orthopaedic Surgeon, Nigeria
“I think having it all is just amazing. I feel like I am thrilled to be able to continue what I trained intensely to do. After 14.5 years of education leading toward being an orthopaedic surgeon, I love living out my career—going into the OR, fixing people’s problems and then coming home to my husband and beautiful children.” (39)
Sutton, Orthopaedic Surgeon, United States
“I got my government job as well as admission to my orthopaedic residency after my marriage. Despite the many challenges and questions raised, I excelled in my chosen career with the support of my husband and parents. Being a sportsperson, I never had a problem with multitasking and managing pressure. In 2010, at the Annual Conference of the Indian Society, I was awarded ‘Young Scientist Investigator Award’…I have been actively involved in surgeries involving spinal trauma, llizarov, hip and knee arthroplasty and arthroscopy. I also got training in arthroscopy at several workshops at the national level. I have been recently associated with AOSpine and SICOT.”
“Break the barrier of thinking and have a new perception. Never doubt yourself. Always be ready to learn new things. Accept any challenge and try to make the best out of it.” (40)
Bhardwaj, Consultant Orthopedic Surgeon, India
“I joined the SBOT (Brazilian Society of Orthopedics and Traumatology) in 1985 after approval in the board exams to be a full member and become and examiner 5 years later. I served on several committees and joined the board in 2009. My leadership roles include Secretary General in 2012, 2nd Vice-President in 2016, 1st Vice-President in 2017 and finally President (first female President) in 2018. With a passion for pediatrics, I am a founding member of both the Brazilian Pediatric Orthopedic Society (SBOP) and the Latin America Pediatric Orthopedic Society (SLAOTI).”
“It was and still is a long journey because it is necessary to coordinate all work activities with the family and home duties. I believe we all face difficulties throughout life, although for the woman the family obligations are still greater than for the man — after all, this is part of the learning of adult life.”
“Be strong in your will to make it work. Study hard to be the best you can. Be a good doctor, not only an orthopedic surgeon. Be gentle with the patients and families, give your time and listen more. Be a good partner with your colleagues, you are different but with the same capability. Love what you do, and in your heart you will find that you belong to Orthopedics because Orthopedics doesn’t belong to you.” (3)
Moraes Barros Fucs
Consultant Pediatric Orthopaedic Surgeon, Brazil
“My career continues to go from strength to strength. I scored another first in 2018 being the first woman in Europe to perform Mako robotic hip surgery. I am currently the Lead for my department, External Examiner for the University of the West Indies Medical School in Trinidad and Associate Professor for the American University of the Caribbean. In 2019, I was invited by Mayor Sadiq Khan to give the Keynote address at the Mayor’s Black History month event.”
“For any young woman wishing to pursue a career in Orthopedics, I would greatly encourage it. It is a specialty that offers something for everyone, is constantly evolving and compatible with family life. I would recommend getting involved in surgical societies at your university, which allows you to build networks and exposes you to what the various specialties have to offer. Secure a mentor and don’t be afraid of failure or adversity. See them as opportunities to grow. Be relentless in pursuit of your goal but take time to enjoy the journey.” (41)
Consultant Hip and Knee Orthopaedic Surgeon, United Kingdom
Discussion with Dr. Laurie A. Hiemstra
For an in-depth discussion on gender diversity in orthopaedics, please refer to our podcast with Dr. Laurie A. Hiemstra (https://www.youtube.com/watch?v=JhnRr7GE1oU). 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.
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