Kris E. Radcliff MD
Associate Editor, Clinical Orthopaedics and Related Research®
CORR liaison to the J. Robert Gladden Society
“How can this occur?” conscientious orthopaedic surgeons who are involved in education and training of medical students and residents will ask themselves. “I am not a racist. My colleagues are not racists.”
When we think of racism, we tend to focus on individual racism, which includes overt acts like name-calling, workplace discrimination, and violence based on race. These acts still occur; a 9-year-old called my daughter a “nigger” the day I sat down to write this essay. Fortunately, overt racism is usually quickly condemned. But that’s not the point of the study by Poon et al. , and it's not the point of this commentary.
Instead, this study has identified structural racism, defined as “the normalization and legitimization of an array of dynamics—historical, cultural, institutional, and interpersonal—that routinely advantage Whites while producing cumulative and chronic adverse outcomes for people of color” . The key concept of structural racism is that ill intent by individuals is not necessary, and often is not present. Indeed, in structural racism, no individual needs to act overtly in a racist way for the system to produce discriminatory results.
In the context of residency applications, for example, recommendation letters, subinternship grades, and even interview experiences all are subjective. It is natural that orthopaedic surgeons will favor applicants with whom they have common background, experiences, and worldviews, and so it is not surprising for White applicants to be more likely to be selected by the mostly White community of orthopaedic surgeons. These unconscious biases exist without ill intent and are inherently unknown to the individual.
Proposed solutions to structural racism date back to the early days of the civil rights era as our country’s leaders wrestled with the differences between de jure segregation and de facto segregation. Even when de jure segregation (such as what occurred under Jim Crow laws) ended with the Civil Rights Act of 1964, de facto segregation persisted: Institutions of higher education, housing, and labor did not integrate. Ultimately, President Kennedy and President Johnson recognized that, even when legal barriers to segregation are removed, definitive, affirmative action is necessary by institutions to accomplish integration. The term “affirmative action” was derived from the active process of seeking out qualified applicants of color in higher education, housing, and work. Our leaders realized that deliberate action was necessary to overcome unconscious biases and to accomplish the goal of integration. Currently, affirmative action connotes elevating otherwise unqualified individuals to positions that they do not deserve. That is a perversion of the original intention, which was to provide an opportunity to qualified people who would be deprived because of unconscious biases.
The article by Poon and et al.  indicates that an unconscious bias exists in our residency selection process, because comparably qualified minority applicants are less likely to be selected into orthopaedic residencies than are White students. We need to take definitive, affirmative action to ensure that our selection process is equitable.
It is critical that readers and members of the orthopaedic surgical community respond to this study with openness and intellectual curiosity, not distrust and fault, but I fear this may not occur. In my experience, these conversations often cause people to feel defensive and to perceive blame. This isn’t necessary, and it’s unhelpful. As physicians, all of us are here because we want to help people. We all have performed countless, silent, unrecognized acts of kindness and benevolence for members of every race. However, as physicians, we are also trained to interpret and understand data. Obviously, the gender and racial constitutions of our specialty differ substantially from those of the populations that we serve. But despite the differences, we care for people from every racial, ethnic, and socioeconomic background; that being so, who really suffers from the racial disparity in admissions, suggested by the Poon et al. study ?
We do, and our patients do, too.
Dr. Poon’s study shows that our biases rob us of the chance to work with some of the best residency candidates whose paths we cross, based on objective parameters like United States Medical Licensing Examination (USMLE) scores, American Orthopaedic Association (AOA) scores, publications, volunteer experience, and research, and it appears that we miss the chance to work with them only because of the color of their skin. Although those involved with the selection process are well intentioned, the product of this selection process is discriminatory; that is the very definition of structural racism. And the harms of this process affect individuals far beyond those who would do the teaching and the learning; this problem harms patients, as well. There is a large body of research describing less-effective pain management, longer time to surgery, and worse surgical outcomes in underrepresented minority patients with orthopaedic diagnoses. Although the link between patient care and provider diversity is somewhat unclear, it is likely that unconscious biases and ineffective communication on the part of the doctor underlie the observed disparities. When an organization becomes more diverse, the minority constituents introduce heterogenous viewpoints that inherently challenge unconscious biases. Thus, diversity within the orthopaedic community has the potential to favorably impact patient care.
Although it is 58 years after the passage of the Civil Rights Act of 1964, we should continue to study, discuss, and explore these challenging, somewhat uncomfortable topics to ensure that our specialty continues to select bright, qualified people who represent the patient populations that we serve. The solution for structural racism is a complex, multidimensional approach focusing on leadership and mentorship that is well beyond the scope of this article. We are all leaders and mentors for trainees at every level, from pre-med college students through peers in practice. The simplest step is for all of us to invest resources into mentorship of diverse applicants and to support pipeline programs such as Nth dimension and the Perry Initiative . We should lobby our residency programs, departments, institutions, and ultimately national organizations to make efforts to support diversity at every level. We should come to see this commitment to diversity as an investment in the quality of orthopaedic care.
Seth S. Leopold MD
Editor-in-Chief, Clinical Orthopaedics and Related Research®
It would be nice to believe that orthopaedic surgeons are part of a profession that doesn’t tolerate racial inequality. Sadly, the facts do not support such a belief. A recent study from Johns Hopkins  found that even after controlling for relevant confounding variables, Black patients with hip fractures waited in the emergency room an average of 3 hours longer than did White patients for a simple radiograph. In community hospitals, that study found that time to eventual surgery was delayed more than 50% compared to White patients, again, after controlling for age, BMI, Charlson Comorbidity Index, and American Society of Anesthesiologists class. In a separate interview, the senior author of that paper gave compelling reasons why insurance type did not explain these delays .
It’s hard to escape the conclusion that systemic racism played a role in these otherwise-inexplicable findings, and results like those are hardly aberrant. To fully catalogue race-based musculoskeletal healthcare disparities would require more than a Spotlight essay. It would need a chapter, if not a book.
It appears now that our specialty may be no fairer to medical students of color  than it sometimes is to patients from underrepresented minority groups . In this month’s issue of Clinical Orthopaedics and Related Research®, a study performed by investigators from both coasts led by Selina C. Poon MD, MPH demonstrated that even after controlling for all reasonable confounding variables, students who were Asian, Black, Hispanic, or from other non-White racial or ethnic groups were substantially less likely to be admitted to an orthopaedic surgery residency program than were White students . In a glimmer of good news, women fared as well as men in this analysis, suggesting that the drivers of persistent underrepresentation of women in our specialty occurs upstream to the selection process.
I’ve written before about the complexity of studying race; Dr. Poon’s group effectively sidestepped most of the landmines I see so commonly in this kind of work [13, 14, 16]. Their study was large enough to be more than convincing; it included 10 years of data from the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners, nearly 9000 students and over 6000 admitted residents, respectively, and it included two models that captured all important metrics of academic performance.
The findings on race in this study cry out not for more study, as is so often suggested, but for immediate action by residency programs, and perhaps those entities that accredit them. If this study  isn’t already the main item on every program’s residency-selection committee agenda for this month, it needs to be—so pass it along to the people you know who need to see it. When they look it over, I hope they’ll pay particular attention to the authors’ two-pronged recommendations , which make specific suggestions both about the application process and each program’s environment. As programs make their assessments, a critical step will be to find a way for people who don’t look like those in the majority group—pale males like me, as it were—to feel comfortable pointing out the problems they see and have experienced. Helping people feel comfortable speaking freely on this topic is not easy, but it’s essential.
And when they do speak, we need to remember what James Baldwin wrote on this very topic: “Not everything that is faced can be changed, but nothing can be changed until it is faced.”
Join me in the Take 5 interview that follows with Selina C. Poon MD, MPH, MS, senior author of this important study, in which she shares her ideas on just how to just that.
Take 5 Interview with Selina C. Poon MD, MPH, MS, senior author of “Race, But Not Gender, Is Associated with Admissions into Orthopaedic Residency Programs”
Seth S. Leopold MD:Congratulations on this eye-opening but demoralizing study. I especially liked your suggestions at the end, which focus on residency programs’ selection processes, as well as whether the environments foster inclusion or exclusion. The concern, of course, is we all believe ourselves to be well intentioned and inclusive, yet the product of our selection processes has been anything but. How can those of us who’ve helped create flawed systems now somehow see the problems we’ve missed all along clearly enough to fix them?
Selina C. Poon MD, MPH: Thank you for your kind comments, Dr. Leopold. I agree with you that the results were eye-opening and unexpected. As physicians, we take care of our patients and we pride ourselves on “treating everyone the same.” But for a long time, I believe that we (orthopaedic surgeons) have been in denial about the diversity problem in our specialty. While there has been incremental progress made through the years, we remain behind almost all other specialties in medicine in terms of gender and ethnic diversity. Surgeons sometimes point to the differences in academic metrics as a justification of why there is less diversity. Our paper  shows this justification is unfounded. My team found that we are not immune to our own implicit biases. Research about the racial disparities in our medical student evaluation tools is being published [3, 4, 6, 12, 18]. Program directors and residency review committee members need to re-evaluate the tools they use, and adjust their expectations appropriately. We also need to continue the conversation about more-meaningful methods to measure the qualities we want in a resident and future colleague.
Dr. Leopold:I’m somewhat skeptical that we can bootstrap our way out of this. How, specifically, can we benchmark our progress so that it doesn’t take 5 or 10 years—more than a lifetime, to those whose careers are at stake—to see whether we’ve made a measurable difference?
Dr. Poon: Every year, the AAMC publishes data regarding the number of women and minorities in all the different subspecialties. We have had the ability to benchmark our progress for years. Unfortunately, the data do not look good. At the rate we’re now going, one study  concluded it will take orthopaedic surgery 127 years to reach gender parity with the population, while other surgical subspecialties will take anywhere from 7 years to 71 years. Minority representation in orthopaedic residency averaged 25.6% from 2006 to 2015, lower than all other surgical subspecialties. The representation of minorities in orthopaedic residencies decreased by about 32% over those 10 years .
Each program can also analyze its own historical data and find out where it stands compared to the number of students available in medical schools. If a program seeks to create change, it should evaluate the overall message it is sending to underrepresented minority applicants and what it is doing to attract applicants to their program. The data are available, we just need to pay attention to them.
Dr. Leopold:It’s clear enough why keeping some groups from succeeding in a profession would be unfair to those individuals—in this case, medical students of color. The impact of your finding, of course, may go far beyond that; for example, how might underrepresentation of racial groups influence the health of the patients whom our specialty treats, and how would we know?
Dr. Poon: As the population of the United States becomes more diverse, our patient population is becoming more diverse as well. By 2050, more than 50% of the country’s population will be non-White. Musculoskeletal concerns and problems affect everyone, and as such, orthopaedic surgeons treat a diversified population. Studies have shown that patients respond differently to physicians with whom they have some concordance (race, culture, language, gender) [5, 8, 11]. This allows for more-effective communication and strengthens the physician-patient relationship. A patient’s intention to adhere to the advice and recommendations of the physician is also greater if that patient has more of a perceived personal similarity with his or her physician [9, 21, 22]. Only time and research will tell whether this will lead to better health.
Dr. Leopold:Your study suggests that getting more women into our specialty will require us to work upstream of the selection process; but with nearly 19 men for every woman in our specialty, we know that this isn’t easy. In addition to addressing the program-level inequalities you suggested in your study, how can we work on more-effective mentorship and sponsorship for people of color, where the numbers are also small?
Dr. Poon: Visibility is one of the most important aspects of inspiration and change. Having our first woman of color Vice President will inspire many young women of color seeing others like them in leadership positions. It is important to have visible leaders in orthopaedic surgery be people of color so that young medical students and surgeons can see and be inspired to pursue a productive career in orthopaedic surgery.
This is where social media can be a powerful tool. I have expanded my professional work circle of friends through different social media platforms. There are so many strong people of color on social media, and I am learning from them and trying to amplify their messages as well. Because of travel restrictions and social-distancing rules, most of us have virtual grand rounds. One benefit of this is that it is easier to invite speakers. Reach out and invite someone who does not look like the “typical” orthopaedic surgeon (that is, a White man) to give grand rounds or invite him or her to be a part of your program or symposium. In addition, promote and amplify the message from these individuals. They have worked hard to have their voices heard. Finally, I try to work with surgeons who are minorities to broaden our professional networks. Diversifying our networks and groups of individuals that we work with can make a difference. This move allows me to continually expand my group of available people to promote and learn from.
Dr. Leopold:Let’s say you’re the program director of a large, influential residency program. What are your next two moves to remedy the inequities you uncovered in your study? OK, you just got promoted; you’re in charge at the Accreditation Council for Graduate Medical Education (ACGME). What’s your play there?
Dr. Poon: First, I would join and donate to one of the professional societies that highlight the issues facing physicians and surgeons who are minorities. This would allow me to gain an understanding of what many minority surgeons go through. I am there to learn about their perspectives, what they go through day to day and every time they walk into a professional meeting. In addition, I hope to demonstrate to my colleagues, residents, and future medical students that I am committed to learning more about this complex issue and continue to create the changes necessary to make programs more inclusive. Next, I would look to sponsor students who are minorities to come to our program for their subinternships. We can either participate in programs like Nth Dimension  or create a scholarship for students to consider and explore our program for a subinternship. It will also give our faculty an opportunity to get to know these candidates better. I know you said two moves, but here is one more, because I think this is important: I would work with the department to acknowledge the diversity work and mentorship that is already being done at my institution. Performance assessment and promotional evaluations should include any diversity efforts performed by the faculty. Creating change needs to be from the top down as well as bottom up, and everyone needs to aide in the effort.
As someone in charge of the ACGME, my focus would be to expand beyond orthopaedic surgery. I would need to know what every department is doing to try to increase diversity in their residency classes. How many students who are underrepresented minorities are invited for interviews, and how many of them are ranked in the top 10%? Once we start measuring this, I believe it will keep the issue on the minds of all program directors. In addition, I think providing a safe and inclusive learning environment for all residents should be a priority. Realizing that structural racism in the United States is present at the hospital and within residency programs, I would want to support the residents who are minorities as best I could. The micro and sometimes macro aggressions they have to experience on a daily basis are important. I’m not looking to blame or call out people, but I would like for all of us to learn as a group how we can be more inclusive and realize that our actions may create negative work and learning environments. The process to report and address any discrimination-based complaint should be clear and easily accessible to all residents and faculty. We need all programs to cultivate an environment in which trainees can raise concerns and provide feedback without fear of intimidation or retaliation. In addition, I would create a peer group for the residents who are minorities and attendings across all specialties so they can help support each other.
Dr. Leopold would like to acknowledge Montri D. Wongworawat MD, Clare M. Rimnac PhD, and Colleen E. Briars ELS for their suggestions on this important topic.
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