SICOT

Why is Orthopaedic Surgery the most gender disparate field of medicine?

Emily K. Miller   Stanford, United States

While women have been health care providers for much of recorded history, they were systematically excluded from organized western medicine starting in the twelfth and thirteenth centuries [1-3]. Women started to fight their way back into medicine internationally. After the passage of the 1972 Education Amendments to the Civil Rights Act in the United States, the number of female graduates from medical schools began increasing at a steady rate [4-5].  Similar trends have followed the rise of feminist movements in many other nations, with women now forming approximately half of medical school graduates in most western countries. However, the rate of women completing orthopaedic surgery residency programs has progressed at a much slower rate, even in comparison to other surgical subspecialties [6-7]. While approximately 30% of currently active physicians are female, the percentage of female orthopaedic surgeons in the US is 5%, making it the most gender imbalanced area of medicine (below even urology with 8% and neurosurgery with 7.8%) [8]. This discrepancy becomes even more stark given that in 1970, although female representation among surgeons was <1% in all subspecialties, there was no significant discrepancy in female representation between specialties [9]. This lag in the recruitment of women into orthopaedic surgery indicates the existence of barriers to the entry of women into this field. This article focuses on these barriers and how they can be mitigated.

1. Lack of Exposure to Orthopaedic Surgery

Musculoskeletal education in medical school has historically been undervalued and limited [10]. In a 2012 survey of medical students, 75% reported having less required exposure to orthopaedic surgery in medical school compared with other specialties like otolaryngology. Required instruction in musculoskeletal medicine was associated with a 12% higher rate of application to orthopaedic surgery residency programs among all students and a 75% higher rate among women [11]. Male orthopaedic surgery applicants, compared to other from those specialties, were much more likely to cite experiences before medical school as the most influential for their decision [12]. This suggests that many orthopaedic surgery applicants had an interest in the field prior to starting medical school, which is why musculoskeletal education seems to be much more critical to encourage women to pursue orthopaedic surgery positions.

Of 267 female orthopaedic surgeons and residents who were surveyed, 85% reported having played competitive sports and 46% stated that athletics influenced their decision to enter orthopaedic surgery [13]. Women with prior athletic involvement may have more prior experience with orthopaedic surgery before medical school, making required musculoskeletal education less essential to generate interest in orthopaedics.

2. Unconscious Gender Bias

Although overt bias plays less of a role now than in the past, unconscious bias continues to be a major obstacle to women entering the field of orthopaedic surgery. While male orthopaedic surgeons may not intentionally favour male medical students, they may inherently be more likely to trust a student that seems more like them in an important way, and therefore be more likely to give that student increased responsibility in the operating room. Unconscious bias is much more difficult to tease out and identify than overt bias, but it can still impact whether a woman feels comfortable applying in orthopaedic surgery.

3. Token Minority Members

Additionally, in any field with less than 30% of a minority group, like women, any members of that group are treated as “token” members. They tend to be seen as representatives of their entire group, rather than as individuals [14]. This means that if one female resident under-performs, observers are more likely to generalize and claim that women are poor residents than they would if the resident were male. 

As minorities in orthopaedic surgery, another obstacle is lack of visibility. 30% is the threshold necessary to avoid appearing to be a male-dominated profession to outside observers [14]. In addition to making it more difficult for women to find female members, this makes female medical students look at orthopaedic surgery as a “boys’ club”, which may deter some applicants [15-17].

4. Reputation

Three common negative assumptions about orthopaedic surgery that may deter female medical students are: (1) the uncontrollable and busy lifestyle intrinsic to the specialty; (2) the necessity of enormous physical strength; and (3) the overwhelming “jock and fraternity” culture [18]. While these assumptions have some basis in fact, they tend to be grossly over-exaggerated in medical education. First, while orthopaedic surgery residency is strenuous and many subspecialties require long hours, there are also many orthopaedists with well-balanced, manageable lifestyles. Second, with new techniques and equipment, orthopaedic surgery has greatly progressed from the brute force discipline of the past and significant strength, while it may make some tasks easier, is no longer a prerequisite. However, unless female medical students work with female residents and attendings, they may never learn that many things done by brute force can also be accomplished by more technical means [13]. Finally, orthopaedic surgeons are commonly portrayed as the “dumb jocks” of medicine [19,20]. Of medical students surveyed, 54% suggested minimizing the “jock and fraternity” culture of orthopaedics as the best way to improve the attractiveness of the specialty (C. Day, unpublished survey, Harvard University, 2012). While this is still partially based in fact, many programs have much more inclusive atmospheres, especially those that already have female faculty members.  

Conclusion

The gender disparity in orthopaedic surgery has lagged behind other surgical subspecialties despite increasing percentages of female medical school graduates. This may be related to lack of required exposure to orthopedic surgery during medical school, unconscious bias, and the reputation of orthopaedic surgery for having an uncontrollable lifestyle, mandating significant physical strength, and an overwhelming “jock” culture. Increasing musculoskeletal education in medical school and increasing medical student exposure to female orthopaedic surgery faculty members could provide female students with both an introduction to orthopaedic surgery, as well as decreasing the perception of orthopaedics as a male-dominated profession and providing students with possible female role models. 

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