Blacks remain underrepresented in medicine, accounting for only 6% of medical school graduates, 4.4% of active medical residents, and 3.6% of faculty in US medical schools according to the data published by the Association American for Medical Colleges.1 2 3
Methods
Between July 1 and September 1, 2020, a 38-item, anonymous survey was distributed electronically to 455 orthopaedic surgeons practicing within the United States, who self-identify as Black (the term which encompasses African American, Caribbean-American, Black African, and Black). These individuals were identified using the J. Robert Gladden Orthopaedic Society (JRGOS) e-mail database. JRGOS is a multicultural orthopaedic organization whose mission includes increasing diversity within the profession. The survey solicited perspectives on race and racial discrimination in current orthopaedic practice and general views regarding overall perceived occupational opportunity and discrimination for Black orthopaedic surgeons in the United States. In addition, respondents were asked questions designed to categorize experiences with racial microaggressions.4 , 5 6
Survey data were collected and managed using Research Electronic Data Capture (REDCap) hosted at Prisma Health, Greenville, SC.7 8 4 4 4 , 5 5 4 , 5
POOS item scores range from 1 to 5, with higher mean scores indicating perception of better occupational opportunity for Black Americans. The PODS uses a four-point scale to rate the extent of discrimination against Black Americans in a given occupation. Higher PODS scores denote perceptions of more occupational discrimination. Mean scores on the POOS and PODS domains were compared by sex. Response frequency to the POOS and PODS domains was also reported. POOS item frequencies were combined into three categories—“agree or strongly agree,” “disagree or strongly disagree,” “neither agree nor disagree.” Finally, survey comments were reviewed for prominent themes and concepts.
This study was institutional review board exempt. Frequencies and descriptive statistics were reported. Mean POOS scores were compared between male and female respondents using an independent sample Student t -test, with a P value < 0.05 considered to be statistically significant. SPSS was used for all statistical analyses (IBM).
Results
Demographics
There were 274 self-identified Black orthopaedic surgeons who responded to the survey, yielding a 60% response rate. The most common age group was 40 to 49 years (29%), followed by 50 to 59 years (27%). Most respondents were male (215, 78.5%). There were 58 female respondents (21.2%), which accounts for a higher sex proportion than in the 2018 AAOS orthopaedic surgeon census (5.8%).2 2 2 Table 1 .
Table 1 -
Demographics and Practice Characteristics of 274 Black Orthopaedic Surgeons
Category
N (%)
Category
N (%)
Age group
69 (25.2)
Current practice typea
35 (13.2)
Sex
215 (78.5)
Geographic locationa
10 (3.8)
Affiliated with orthopaedic residency (n = 266)
108 (40.6)
National society membership
253 (92.3)
Degree of specializationa
222 (83.5)
Subspecialty interest
54 (19.7)
ENC = East North Central, ESC = East South Central; MA = Mid-Atlantic; MT = Mountain; NE = New England; PA = Pacific; SA = South Atlantic; WNC = West North Central; WSC = West South Central
a Based on AAOS Orthopaedic Surgeon 2018 census description.
Racial Microaggressions in Orthopaedic Practice
Overall, 89% of respondents experienced racial microaggressions in the workplace (Figure 1 ). The most reported microaggressions were “microinsults,” such as being confused for a nonphysician medical staff such as a nurse or physician assistant (89%) or nonmedical staff such as janitorial or dietary services (74%). “Environmental microaggressions” were experienced by 58% of respondents. Overt discriminatory statements (“microassaults”) were reported by 56% of respondents. Among all respondents, 47.1% experienced microassaults from patients and 32.3% experienced microassaults from other hospital staff including 23% reporting microassaults from peer surgeons. Microassaults from multiple sources were reported by 27.3% of all respondents. Black female orthopaedic surgeons reported higher rates of microaggressions (66% to 98%) than Black male orthopaedic surgeons (53% to 87%) across all four solicited questions.
Figure 1: Bar graph reporting responses to the 16 items of the modified Perceived Occupational Opportunity Scale (POOS) and compared by sex. ¥POOS item scores range from 1 to 5, with higher scores denoting perceptions of a more open opportunity structure. *Denotes statistically significant difference (P < 0.05).
Perceived Occupational Opportunity Scale and Perceived Occupational Discrimination Scale
On the PODS item (n = 256), 97.6% of respondents felt that Black orthopaedic surgeons in the United States face workplace discrimination, most of whom perceiving “some discrimination” (51.1%) followed by “a lot of discrimination” (27.7%). The PODS mean score was 3.02 ± 0.75 of a maximum score of 4. On the POOS, 71.1% felt that Black orthopaedic surgeons are discriminated against through hiring practices. Over 94% agreed that “racial discrimination in the workplace is a problem in the United States” (POOS item 6). However, less than 20% of respondents agreed that “the leaders of national orthopaedic organizations are trying sincerely to end racial discrimination in the workplace.” Although most of the respondents (74%) agreed that Black and White orthopaedic surgeons have good working relationships at their institution (74%), most Black orthopaedic surgeons (93% to 94%) also perceived inequalities in workplace opportunities compared with their White counterparts (POOS items 5 and 7). Responses on POOS and PODS items are reported in Table 2 . When POOS means were compared by sex, Black female orthopaedic surgeons had lower mean scores (lower perceived occupational opportunity) than Black men on all 16 items. This difference was statistically significant on 9 of 16 items (Figure 2 ).
Table 2 -
Results of Modified Perceived Occupational Opportunity Scale and Perceived Occupational Discrimination Scale Among Black Orthopaedic Surgeons (n = 257)
PODS Itema
No Discrimination, N (%)
A Little Discrimination, N (%)
Some Discrimination N (%)
A Lot of Discrimination N (%)
Overall, How Would You Rate the Extent of Occupational Discrimination Against Black Orthopaedic Surgeons? (n = 256)
6 (2.3)
49 (19.1)
131 (51.1%)
71 (27.7%)
POOS Itema
Strongly Agree or Agree, N (%)
Strongly Disagree or Disagree, N (%)
Neither Agree nor Disagree, N (%)
1. Black orthopaedic surgeons are discriminated against through hiring practices (n = 256).
182 (71.1)
32 (12.5)
42 (16.4)
2. The leaders of national orthopaedic organizations are trying sincerely to end racial discrimination in the workplace.
50 (19.5)
126 (49.0)
81 (31.5)
3. Employers go out of their way to make Black orthopaedic surgeons feel welcome.
16 (6.2)
157 (61.1)
84 (32.7)
4. Black orthopaedic surgeons are given respect from White orthopaedic surgeons and supervisors.
83 (32.3)
106 (41.2)
68 (26.5)
5. It is just as hard for White orthopaedic surgeons to get ahead as it is for Black orthopaedic surgeons.
5 (1.9)
239 (93.0)
13 (5.1)
6. Racial discrimination in the workplace is a problem in the United States
242 (94.2)
13 (5.1)
2 (0.8)
7. It is easier for White orthopaedic surgeons to get ahead than Black orthopaedic surgeons.
242 (94.2)
3 (1.2)
12 (4.7)
8. Black orthopaedic surgeons get respect and support from their supervisors.
82 (31.9)
71 (27.6)
104 (40.5)
9. Personnel decisions are primarily based on orthopaedic surgeons' training and experience rather than race.
67 (26.1)
96 (37.4)
94 (36.6)
10. Managers promote cooperation between Black orthopaedic surgeons and other racial/ethnic groups.
49 (19.1)
76 (29.6)
132 (51.4)
11. Black orthopaedic surgeons have little say in decisions that affect the functioning of their organization/place of employment.
99 (38.5)
84 (32.7)
74 (28.8)
12. There is an understanding and acceptance of cultural differences among orthopaedic surgeons of different racial/ethnic groups at my institution.
81 (31.5)
126 (49.0)
50 (19.50)
13. Non-Black orthopaedic surgeons go out of their way to make Black orthopaedic surgeons feel welcome at my institution.
47 (18.3)
131 (51.0)
79 (30.7)
POOS Itema
Strongly Agree or Agree, N (%)
Strongly Disagree or Disagree, N (%)
Neither Agree nor Disagree, N (%)
14. Extensive changes have been made to make services (resources) available to black orthopaedic surgeons at my institution.
18 (7.0)
162 (63.0)
77 (30.0)
15. Black and White orthopaedic surgeons have good working relationships at my institution.
192 (74.7)
20 (7.8)
45 (17.5)
16. Race determines who gets the most desirable work or assignments at my institution.
45 (17.5)
127 (49.4)
85 (33.1)
a Specific modifications to the POOS and PODS are italicized for each item.
Figure 2: Bar graph showing the number of respondents who indicted yes to specific questions alluding to racial microaggression experiences in the orthopaedic workplace. Report responses by sex and among all respondents.
Thematic Analysis of Respondent Comments
A thematic summary of respondent comments is found in Table 3 . Several respondents described orthopaedic surgery as a noninclusive specialty, which contributes to challenges faced as it relates to leadership, professional advancement, and networking opportunities. Respondents noted that the lack of inclusion contributed to diminished opportunity through hiring practices and subsequent practice development. Subtle and systemic discrimination was a common refrain, including greater prevalence of microaggressions over overt discrimination and lack of awareness or denial of existence of discrimination by occupational leadership. Intersectional discrimination was described by several Black female respondents who noted that it was difficult or too complex to differentiate between their experiences with race and sex discrimination.
Table 3 -
Thematic Analysis of Comments Provided by Survey Respondents
Theme 1: Lack of Inclusion by Nonminority Physicians and Leadership Affects Ability to Network, Hiring Practices, and Professional Advancement
“I think the most significant problem is the lack of advancement into leadership roles due to never really becoming a part of the “inner circle” early in your career.”
“Professional advancement is strongly influenced by your network or contacts and “who you know”…That puts African Americans at an immediate disadvantage, by virtue of how few of us there are in the profession, putting the best jobs and professional opportunities out of reach.”
“At the subspecialty level, many of the opportunities to move ahead in your discipline are dictated by your ability to network. Those networks are difficulty to penetrate unless there is a champion who advocates for the junior faculty.”
“There is a certain inside track that we are not privy to when searching for employment and thus we are not given the opportunities to even apply for those positions.”
“Usually more experienced doctors will help ‟feed” younger partners in the beginning. I'm in a large practice with very few underrepresented minorities. Over the years, I've observed a very slow response to develop the practice of minority physicians. This is confirmed when new nonminority physicians are welcomed with ample resources, patient reallocation, OR time allotment, invitation for committee positions, etc. Though not overtly obvious, it is the reason why it's hard not to check “a lot” of discrimination although the larger physician world remains oblivious to this blatant maneuvering.”
“When coming out of fellowship, I felt that there were minimal academic opportunities. I elected to go into private practice. I found limitations there as well. Some felt that I wasn't a ‟good fit” for their patient population.”
“Access to opportunities is often a reflection of who the power structure is comfortable with, which is more than likely those who look like them.”
“I do feel that my workplace, and most workplaces I am aware of, need to work on better inclusion and mentorship, particularly when I was a more junior faculty member. Even now my institution is more enthusiastic in promoting/awarding nonminority faculty.”
“I started my own practice after working five years as a minority employee in an orthopaedic private practice. The decision to start my own practice was related to perceived discrimination and perceived inability to reach my full potential in groups or practices where there was Caucasian leadership. I have definitely felt discrimination throughout my career, especially starting off. However, I feel that I have been better able to maximize my potential by eliminating racial bias within the confines of our private practice. [This] has helped create more ownership opportunities for me. These ownership opportunities did not and would not have existed as a minority employee.”
Theme 2: Racial Discrimination Is Experienced as Subtle and Systemic Rather Than Overt
“Occupational discrimination is very subtle, but it lines every phase of education and our careers.”
“There is still systemic racism ie, sometimes more subtle but just as significant, if not more so, in the careers of black orthopaedic surgeons.”
“I do feel that in orthopaedics and medicine there is a lot of unconscious and conscious bias. This affects how physicians of color are treated by colleagues and staff as well as how our patients of color are treated.”
“Discrimination at this level can be very hard to detect unless someone looking out for your well-being is honest about what is goes on.”
“Referral patterns are also impacted by race.”
“Referral bias is a big problem. If the patient is poor, hard to deal with or with multiple comorbidities or prior complications, it will be sent to a minority orthopaedic surgeon.”
“The most difficult aspect of my life was to be silent while racial injustice continues, a requirement in order to fulfil my career goals. It has undermined my achievements.”
“I try to forget negative experiences encountered as a black surgeon; memories bring up stressful feelings that I don't have time for as I'm constantly striving to be the best surgeon for my patients while regularly working to overcome subtle discrimination and racial biases in the workplace.”
“Non-Black people often disregard how Blackness affects any-and-all decisions and actions both subconsciously and consciously. The idea of trying to be “color-blind” contributes to muting our experiences. My entire existence is affected by my Blackness.”
“There is a difference between diversity and inclusion. We need both. We also need to acknowledge general racial bias in medicine as a whole. All of these issues are intertwined.
Theme 3: Discrimination Due to Both Race Versus Sex (Intersectional Discrimination) Experienced by Black Female Orthopaedic Surgeons
“For Black female orthopaedic surgeons, race versus sex discrimination can be difficult to differentiate.”
“It takes more effort overall for me to show up to work as a Black female orthopaedic surgeon compared with my other colleagues because you are not just trying to do your job, but you are also trying to combat assumptions made about you.”
“[White residents] were looked at in a different way. As a female, that was even more obvious. Not only did I experience being the only black female orthopaedic resident ever at my program, I was not viewed as equal. This continues to be a challenge even in my current workplace.”
“I definitely do not see as much discrimination since starting solo practice. Microaggressions and racial discrimination were more of an issue with prior practices. I also believe sex plays a major role in discrimination as well.”
I was never so acutely aware of my existence in society as a Black woman until I became an orthopaedic surgeon. Much of this is a by-product of having to be the ‟first” and/or ‟only” in many spaces–in residency, in fellowship, in my practice, in my state. Sometimes I am proud of this identity–out of necessity, I've perpetually aimed to not only be as good, but better than my White colleagues (male and female) and my black male colleagues. Other times–it's exhausting. Being a race AND gender ambassador in orthopaedic surgery is exhausting. No one outside of this identity can truly relate. I live under the assumption that peers, patients and staff, who do not know me well, harbor preconceived negative stereotypes of Black women. I have to put conscious effort into refuting those stereotypes. At times, that has meant not standing up for myself when I was not treated fairly, so as to not to be perceived as “difficult.” I believe that has hindered my professional advancement in different situations.
Discussion
This study is the first to survey and report the collective experiences of practicing Black surgeons, specifically Black orthopaedic surgeons in the United States. There is a lack of comparative literature evaluating the extent of discrimination perceived by underrepresented populations in orthopaedics and much supporting literature regarding discrimination in surgery is evaluated in residency populations. Although this study does not compare reported racial discrimination against other races, the results are concordant with a recent survey of 5,679 surgical residents, which reported high rates of racial discrimination among Blacks in surgical fields.9
Measuring Occupational Discrimination
On a standardized metric assessing occupational discrimination and opportunity among Black Americans, most Black orthopaedic surgeons believed that Black orthopaedic surgeons in the United States face workplace discrimination (97.6%), that there is discrimination against Black orthopaedic surgeons through hiring practices (71%), and that “it is easier for White orthopaedic surgeons to get ahead than Black orthopaedic surgeons” (94%). Only 19.5% of Black orthopaedic surgeons agreed or strongly agreed that leaders of national orthopaedic organizations are sincerely trying to end racial discrimination in the workplace. By contrast, almost 75% of respondents felt that Black and White orthopaedic surgeons have good working relationships at their institution. This discrepancy between interpersonal and institutional discrimination may point to the nuanced differences in how racial discrimination is faced by Black orthopaedic surgeons. Overt racial discrimination faced by Black orthopaedic surgeons from their peers may be less prevalent (as noted by the 23% of Black orthopaedic surgeons who reported experiencing microassaults by peer surgeons), but systemic racial bias and discrimination experienced in the workplace are described as pervasive. The high prevalence of microinsults (89%), environmental microaggressions (58%), the perception of inequity in hiring practices, career advancement, and sincerity of actions addressing racial discrimination by orthopaedic and institutional leadership noted in POOS and PODS questions as well as the thematic analysis of comments noting racial discrimination as systemic and subtle, all speak to the perception of systemic racial bias experienced by Black orthopaedic surgeons in the orthopaedic workplace.
There are very few psychometrically validated instruments that have been used to capture these feelings in an objective tool.10 - 12 13 6 6
Effect of Intersectional Discrimination
An important finding of our survey was that the effect of being both a racial and sex minority in orthopaedic surgery carried measurable consequences. There was a consistent and often, statistically significant, trend toward greater workplace discrimination and diminished occupational opportunity in orthopaedics perceived by Black women compared with Black men. Again, when comparing our results with those in other surgical specialties, the combination of female sex and minority status is shown to negatively affect the training experience of general surgery residents.14 15 16
The term “intersectionality” was first coined by Crenshaw in 1989 to describe how the exclusion of women of color from prominence in both feminist movements and civil rights movements rendered their dual identities invisible. The current survey uncovered that Black female orthopaedic surgeons reported worse scores on all POOS and PODS items compared with Black men. This difference was statistically significant on 9 of 16 items, most notably on items involving perception of respect (items 4 and 8), institutional support (items 1, 14, and 16), cultural and social acceptance (items 12 and 15), and autonomy (item 11). Furthermore, Black women answered ‟yes” more frequently to the four questions alluding to experiences with racial microaggressions than Black men. The implications of the Black female orthopaedic surgeons' perception of a less inclusive and equitable work environment likely have dire consequences both to these women personally and to the field of orthopaedic surgery. Recent literature has explored the effect of intersectionality in academic science and clinical medicine.17 - 19 20 20 20 21 , 22 23 , 24 25
Role of National Organizations in Addressing Discrimination in the Workplace
The results of this study are timely. Survey responses were collected during July and August of 2020, which corresponded with a time of notable racial unrest in the United States. Most notably, most responses were collected after several national orthopaedic organizations released official statements denouncing racism and discrimination and declaring support for antiracism initiatives.26 - 28 29
Strengths and Limitations
This study has several strengths. It is the first study to evaluate the workplace experiences of Black surgeons, specifically Black orthopaedic surgeons. Furthermore, it is the first to both quantify and qualify the experiences of racial discrimination faced in practice. We used a previously validated survey that evaluated the perception of occupational opportunity specific to Black Americans. In addition, we had a moderately high rate of return (60%) among survey respondents. It is also the first study to recount the experiences of intersectional discrimination within orthopaedic surgery, which is an area that needs additional acknowledgement and exploration.
Nonetheless, there are several limitations of this study, most notably, regarding our cohort sample. The study survey was distributed only to those who provided contact information within the JRGOS society e-mail database and who self-identified as Black. The study survey contacted 455 orthopaedic surgeons, which accounts for 79% of the AAOS census estimate of 573 Black orthopaedic surgeons in practice. Among this cohort, we achieved a respectable response rate of 60%. Black orthopaedic surgeons who did not have an available e-mail address, those who are not part of the JRGOS database, those of mixed-race who do not explicitly identify as ‟Black,” or those who declined to report race were not included. We cannot make assumptions about the workplace experiences of the 40% of orthopaedic surgeons who did not respond to the survey or the Black orthopaedic surgeons who did not receive the survey. There may be selection bias among those who did respond—meaning those who perceived racial discrimination in their practice could be more likely to speak out regarding their experiences and participate in this study. Alternatively, those who had a negative experience as a Black trainee or practicing surgeon or those who have stopped practicing orthopaedic surgery for unknown reasons (which may include discrimination) are also part of the unsampled cohort. One respondent commented, “I try to forget negative experiences encountered as a Black surgeon; memories bring up stressful feelings that I don't have time for….” It is possible that some surgeons declined to participate in the survey to avoid recounting experiences that had been distressing in the past. In addition, we did not evaluate in-depth the potential for geographic bias in the prevalence of discrimination among our cohort. Survey respondents were predominantly located in the South (50.4%) followed by Northeast (17.7%), Midwest (16.9%), and West (13.5%), which is similar to the geographic distribution of Black Americans reported in the 2010 US census (56.5% South, 17% Northeast, 17% Midwest, and 10% Northeast).30
Conclusion
Most of the Black orthopaedic surgeons surveyed agreed that racial discrimination and diminished occupational opportunity are pervasive in the workplace and reported experiencing various racial microaggressions in practice. The perception of unequal opportunity was more markedly perceived by Black female orthopaedic surgeons. Furthermore, less than 20% of respondents felt that national orthopaedic organizations are sincere in efforts to address racial discrimination in the workplace.
Critical analysis of the efficacy of institutional and national initiatives addressing inclusion and equity in the workplace for Black orthopaedic surgeons is needed. More concerted efforts to understand the experiences of Black orthopaedic surgeons, particularly Black female orthopaedic surgeons, may aid in improving the perception of orthopaedic surgery as a more equitable and inclusive surgical specialty.
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