To The Editor:
I am writing in regard to “Initial Review of Electronic Residency Application Service Charts by Orthopaedic Residency Faculty Members. Does Applicant Gender Matter?” (83-A: 65-70, Jan. 2001), by Scherl et al. The authors performed a randomized, prospective evaluation of chart reviews and concluded that there is no bias against women applicants in this portion of the process. They are to be commended for an effort to analyze possible factors in the current paucity of women in the field of orthopaedic surgery.
As pointed out by the authors, the chart-review phase primarily relies on objective information, which, although easier to study, is probably the least susceptible to bias. Additionally, although attempts were made to keep the reviewers blinded with regard to the goals of the study, performance of the chart reviews in the context of a study, with the reviewers knowing that their evaluations would be scrutinized, may have introduced bias. Also, there are many inherently more subjective steps in evaluation that may have an impact on an applicant’s success. These include the writing of the initial recommendation letters by orthopaedic mentors and the evaluation at the time of interview. Obviously, these factors are difficult, if not impossible, to study.
Unfortunately, the failure to recruit women into orthopaedic surgery continues. Although we are recruiting an increasing percentage of women into our programs, women remain one-seventh as likely as men to match into an orthopaedic program1, a percentage that has not changed significantly over the past twenty years. Given that medical school classes are now nearly 50% women, our field will not continue to benefit from recruitment of the top medical school graduates unless we are able to attract more women into the field.
Successful recruitment of women starts long before the stage of evaluation at the time of application to residency programs. The process involves making the assumption that women students rotating on our orthopaedic services are as likely as men to choose orthopaedics, including all medical students in orthopaedic service activities, counseling medical students about career choices, and providing successful role models.
The Ruth Jackson Orthopaedic Society was founded in 1983 as a support and networking group for the growing number of women in orthopaedic surgery. This society conducts scientific, educational, and charitable activities for the purpose of encouraging, promoting, and advancing the science, medical art, and practice of orthopaedic surgery among women. The mission of the Society has subsequently broadened to include concern with issues of women’s musculoskeletal health as well. To meet these goals, we have developed an extensive mentoring program. Information, in both written and video formats, about women in orthopaedics is distributed to medical schools as well as to interested female students, who are placed in contact, via phone or e-mail, with practicing female orthopaedic surgeons. The network has been highly successful; we receive inquiries via our web site, by word-of-mouth, through our Society members, and from referral sources, including the American Academy of Orthopaedic Surgeons. The Ruth Jackson Orthopaedic Society hopes to continue to work with all orthopaedic surgeons to maintain and improve the quality and diversity of those in our field.
S.A. Scherl, N.A. Lively, and M.A. Simon reply:
We appreciate Dr. Biermann’s comments. We agree that women will never approach equality in terms of their numbers in orthopaedics until substantial efforts are made to increase early, active recruitment and support of female medical students who might potentially be interested in the field. In fact, we clearly acknowledged this issue in both the introduction and the Discussion section of the paper. Moreover, although all three of the authors of our study support the Ruth Jackson Orthopaedic Society, and two of us are members, we find it ironic that membership was denied the third author because she had not entered medical school at the time of her application. She was referred to the first author through the Society’s mentoring program. Perhaps the Society should consider an additional membership category for college and graduate students in order to support women interested in pursuing careers in orthopaedics as early as possible.
However, the goal of our study was to answer a specific question—that is, do women who are committed to a career in orthopaedics receive a fair and equitable evaluation in the initial phase of formal recruitment for residency programs? This project was initiated, in part, in response to anecdotal complaints (on an Internet bulletin board for female medical students interested in orthopaedics) from women who felt that, despite exhibiting obvious interest and dedication, and having the necessary academic credentials, they were not treated fairly during the application process itself. In other words, there is a perception among potential female candidates that the playing field isn’t level, and that in itself could color a woman’s decision as to whether to apply to a program, regardless of her inherent interest in orthopaedics.
Basically, we disagree very little with the substance of Dr. Biermann’s letter, nor does she disagree with our findings. We reviewed her cited article1 and noted that there has been a slow increase in the percentage of female residents in orthopaedic surgery, from 1.2% (twenty-eight women across the country) in 1977 to 7.1% (198) in 1996. Both that small increase in percentage and the numbers of female residents have continued to increase since her study was published (the percentage was 7.2% in 1999 and 7.8% in 2000)2. Further analysis of Dr. Biermann’s data shows that the rate of increase for female residents in orthopaedic surgery is more than double that in any other field.
Thus, the rate of increase in orthopaedic surgery is higher than that in the average specialty, but orthopaedic surgery has a longer way to go. Hence the conclusion that for orthopaedic surgery to attract more women, mentoring before the junior year in medical school is imperative. Women in medical schools across the country are not encouraged to, and therefore do not, think of orthopaedic surgery as a career. The Ruth Jackson Orthopaedic Society has recognized this deficit and offers a mentoring program. If we can get women to choose a career in orthopaedic surgery, then the initial application process is not a barrier to actually obtaining a position in an orthopaedic surgery residency program. On the other hand, we don’t know if bias occurs at the interview stage of the process; because of the intrinsic difficulties of blinding a traditional face-to-face interview, we may never know.
However, the fact remains that simply obtaining interviews is the initial goal of the application process. The more interviews that a candidate obtains, the better his or her chances of ultimately matching with a residency position, and the invitations are issued on the basis of initial chart review. Furthermore, our study materials did include the texts of letters of recommendation (two per candidate), although we removed the names of the letters’ authors, so that only the content of the letters, and not their source, was used in their evaluation.
Finally, as we stated in our introduction, we are mystified that the Electronic Residency Application Service “does not keep statistics on the breakdown of successful applicants by gender”3. If this were done, it might be possible to determine whether bias exists in the interview process, since data on the gender of the applicants do exist. We challenge the Ruth Jackson Orthopaedic Society, perhaps in conjunction with the American Academy of Orthopaedic Surgeons, to influence the Electronic Residency Application Service to collect and release the breakdown of data by gender on successful applicants to orthopaedic surgery residency programs.