Where Are We Now?
In the current study, Gerull and colleagues  analyzed the gender distribution of awards granted by orthopaedic societies from 2000 to 2018 as well as the demographics of orthopaedics societies in 2018. Women received 8% (61 of 794) of all 2000 to 2018 awards, and comprised 9% (5359 of 59,597) of all 2018 society members. The authors found that women were more likely to receive “diversity” and “education” rather than “leadership” awards—in fact, 17 of the 22 society leadership awards have never been granted to a woman. Gerull and colleagues  also found that women were more likely to receive awards through a blinded versus unblinded process.
In reading this study, two things stood out: First, the tremendous amount of work required just to obtain demographic data about orthopaedic surgeons. That the authors could find no gender membership data for specialty societies before 2018 is itself noteworthy, as it illustrates a disconnect between stated interest in diversity and actions to measure and improve it. Second, the trend towards awards for diversity and education, rather than leadership categories, for women recipients is important, as it highlights how those underrepresented in certain fields may be pigeonholed into distinctive roles within that field.
With any improvement initiative, be it clinical or otherwise, we know we cannot improve what we cannot measure. The format of these commentaries directs me to ask in this section, “Where are we now?” Until now, we have never thought to obtain accurate demographics about our workforce. Thus, regarding diversity in orthopedics, we are not sure where we are.
Where Do We Need To Go?
Until recently, orthopaedics has had few mechanisms in place to capture accurately and consistently demographic information about the orthopaedic workforce and trainee population. The American Academy of Orthopaedic Surgeons (AAOS) census, collected biannually since 1985, is the only means by which researchers could obtain formal demographic data on our specialty. From 2012 to 2018, census surveys had a completion rate of only 23% to 39% from AAOS fellows . Thus, census data are only a best guess at the true makeup of the orthopaedic workforce. Yet, these are used as a basis for diversity committee work, research, and are widely publicized as fact. Residency and academic surgeon gender data are gleaned from Accreditation Council for Graduate Medical Education and Association of American Medical Colleges specialty data [4, 5]. Societies only haphazardly collect demographic data, which is evident in that only 2018 data were available for the current study. Even so, membership data may include some nonsurgeon women who are affiliate members. I asked the American Association of Hip and Knee Surgeons (AAHKS) staff for a breakdown of the 2020 women members; only 124 of AAHKS women members are surgeons, with only 65 of those being AAOS Fellows. How can we ask societies to recruit and mentor women or minority specialty surgeons into leadership roles, be unbiased in assessing them for awards, when there are no data to measure baselines or progress?
It is far from surprising that women were not selected for as many leadership awards as other awards, since women are only recently coming into leadership positions in orthopaedics. Only a handful of women have been specialty society presidents. Women are just now beginning to take on Chair roles in large academic institutions . However, this trend does demonstrate two phenomena experienced by those underrepresented in academic fields: the “minority tax,” and the “gratitude tax” .
Women and minority groups may feel isolated and experience bias. They hold the burden—the “tax”—of representing the whole of their minority group in all of their actions. These individuals are also driven by gratitude for their opportunity to have their positions. This “gratitude tax” is a deep sense of obligation to help the communities they represent. They are frequently mandated by their institution or practice to serve as mentors themselves, and to work on diversity initiatives. While these responsibilities are both important and necessary, they are labor-intensive and often detract from the time spent on specialty-focused activities. These contributions are exceptionally taxing because they are seldom regarded on an equal plane as other scholarly productivity . Hence, we see many driven, talented, women and minority surgeons focused on work, during a critical time in their professions, that may not be helpful for career advancement and recognition.
In my role as AAOS Annual Meeting Central Program Committee Chair, I recently examined the gender makeup of faculty of AAOS Annual Meeting Symposia from 2014 through 2020, and found that only “Practice Management” classification topics had consistently more than 10% faculty made of women speakers. As AAOS Annual Meeting Central Program Committee Chair, I am privy to the numbers that show other specialty classifications had occasional spikes above this, and others had no women at all on panels over this time period. The practice-management topics that featured women were mostly centered on diversity, and had, on average, lower attendance numbers than other specialty sessions.
How Do We Get There?
The AAOS Strategic Plan recognizes the importance of a workforce that is innovative, strategic, and diverse . Based on this study, and the lack of demographic information in all of orthopaedics, a simple, yet impactful change would be to ensure that meaningful gender, race, and ethnicity information are collected in a manner that can be tracked and measured for all members of orthopaedic groups. While it is cumbersome and impossible to break down every group, certain categories, such as the very broad “Asian” category, may deserve to have subcategories, and input from persons in those groups when determining these categories.
To address the issue of women and minorities being pigeonholed into diversity roles, and then having those pursuits diminished, we need to move towards a place where diversity activities are essential actions that all members of the profession perform and share. Rather than being assigned mostly diversity “work,” underrepresented individuals should be mentored and included in orthopaedic-specific academic and professional activities by all members of the profession, not just other minority members. A mindset change, where, instead of being a “diversity workforce,” established women and minority surgeons would serve as orthopaedic surgeon role models for the work they do as surgeons. For this to be effective, everyone in orthopaedics—not only women and minority surgeons—would share in the diversity and mentorship roles for those who are underrepresented in orthopaedics. Out of necessity, due to the coronavirus-2019 pandemic, we have seen a widespread use of videoconferencing, which is an outstanding means to access remote mentors while removing #MeToo concerns related to one-on-one meetings .
That diversity is part of the AAOS Strategic Plan is an important step. Use of technology to ensure that demographic data are captured for orthopaedic societies, meetings, and other entities will allow us to establish baselines and measure the effectiveness of efforts to improve diversity and inclusion. While completion is usually not mandatory, surgeons can do their part by taking the time to fill in these data when asked.
Recognition, such as the new Ruth Jackson Orthopaedic Society “He for She” award, is a way to reward diversity and mentorship efforts by those outside of minority groups . However, if mentorship is, indeed, to be shared work, a broader workforce is necessary. At the institutional and practice level, perhaps leaders should consider distribution of diversity tasks among all members of a department, rather than just the diversity members .
More broadly, this year, the AAOS Annual Meeting Committee added a statement on the application for the academic program, based on the data mentioned above about faculty from past programs: “In accordance with the Strategic Plan, the AAOS is committed to high-quality research and engaged scholarship by all Academy members. As part of this commitment, we value diversity and inclusion across our educational platforms and strongly encourage inclusion of those underrepresented in orthopaedics on your Symposia and ICL faculty” .
One intention of this action is to encourage prominent moderators who have led prior successful specialty sessions to consider inclusion of qualified, diverse faculty to these panels, and to forge new professional relationships. These same prominent people are also needed to share in the mentorship and guidance of young surgeons who are underrepresented in orthopaedics, and to model this behavior for others.
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4. Association of American Medical Colleges. ACGME residents and fellows by sex and specialty, 2017. Available at: https://www.aamc.org/data-reports/workforce/interactivedata/acgme-residents-and-fellows-sex-and-specialty-2017
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