- Email: [email protected]
The Times, They Are A-Changing: Women Entering Academic Orthopedics Today Are Choosing Nonpediatric Fellowships at a Growing Rate
ARTICLE IN PRESS ORIGINAL REPORTS
The Times, They Are A-Changing: Women Entering Academic Orthopedics Today Are Choosing Nonpediatric Fellowships at a Growing Rate Walter Klyce, MD, Derek T. Nhan, MD, Alexandra M. Dunham, MD, Mostafa H. EL Dafrawy, MBBS, Claire Shannon, MD, and Dawn M. LaPorte, MD Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland OBJECTIVE: Pediatrics and hand surgery have historically been the orthopaedic subspecialties with the highest female representations. We sought to identify the gender distribution of orthopedic surgical faculty by subspecialty, geography, and educational background. We hypothesized that the proportion of women entering pediatric orthopaedics has decreased since 1980. DESIGN: The Accreditation Council for Graduate Medical
Education was used to generate a list of U.S. orthopedic residencies. Program websites were used to collect data regarding each faculty member’s gender, residencies, fellowships, and graduation year. t tests were used to compare quantitative data and Fisher’s exact tests to compare categorical data. Significance was defined as p < 0.05. SETTING: Publicly available data from official websites of
correlation with time was found for pediatrics as a percentage of fellowships completed by women during the same period (R2 = 0.94). CONCLUSIONS: Although pediatrics remains the most
popular fellowship for female orthopedists, women who enter academic orthopedics are increasingly choosing nonpediatric subspecialties. ( J Surg Ed 000:18. Ó 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: faculty, fellowship, gender, orthopedics,
pediatrics, specialties COMPETENCIES: Medical Knowledge, Professionalism,
Interpersonal and Communication Skills, Systems-Based Practice
U.S. orthopedic residencies. PARTICIPANTS: Of 153 residencies, 142 (93%) had accessible faculty lists. RESULTS: Of 3596 orthopedic surgeons, 7.9% were
women. Among fellowship-trained faculty, 22% of pediatric orthopedists were women compared with 7.6% of faculty in other orthopedic subspecialties (p < 0.00001). There was a significantly higher percentage of female faculty in the West (13%) than in any other U.S. census region (p < 0.001 vs. Midwest, vs. South, and vs. Northeast). A strong correlation with time was found in number of women completing fellowships other than hand or pediatrics from 1980 to 2014 (R2 = 0.95); a strong inverse Funding: No funding was received in support of this work. Each author certifies that his or her institution has waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. Correspondence: Inquiries to Dawn M. LaPorte, MD, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Suite 5252, Baltimore, MD 21287; e-mail: [email protected]
INTRODUCTION Gender distribution in medicine has undergone a marked transformation in recent decades. In 2015, 48% of medical school matriculants and 39% of faculty were women, compared with less than 10% of either in 1975.1-3 Although the influx of women in medicine represents progress, it has proceeded at different rates in different specialties, and as a result, gender continues to be highly predictive of career choice. In U.S. medical schools, pediatrics has the second-highest percentage of female residents, with 65% of pediatric residency applicants being women during the 2016 to 2017 cycle. In contrast, orthopedic surgery remains the most male-dominated field in medicine, with only 15% of orthopedic residency applicants being women in 2016 to 2017.4 Similar gender distributions are found among medical school faculty. In 2012, 51% of pediatric faculty at U.S. medical schools were women (the third-highest proportion of any
Journal of Surgical Education © 2019 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2019.12.007
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ARTICLE IN PRESS specialty) but only 15% of orthopedic faculty were women (the lowest proportion of any specialty).5 Previous studies6-13 have examined the role of gender in residency choice, but few have examined how gender is associated with fellowship choice among orthopedic surgeons. Pediatric orthopedics may represent a middle ground between the low percentage of women in orthopedic surgery and the high percentage of women in general pediatric medicine. In 2016, Cannada14 examined the relationship between gender and the orthopedic fellowship match and found that pediatric fellowships had the highest proportion of female applicants; however, this study was based on National Resident Matching Program data only from 2010 and onward. Other studies relating gender and orthopedic subspecialty have been survey-based and thus subject to potential sampling bias.11,15,16 A similar reliance on survey response is seen in the only study examining the geographic distribution of active female orthopedists in the United States; and although studies have examined the proportion of women in various orthopedic residencies, no similar study has been performed for orthopedic faculty.12,13 This topic is important because past efforts to increase the representation of underrepresented groups have had only limited success, and in order to address such issues, it is necessary to fully understand the current state of women in orthopedics.9,17-20 Additionally, past studies have demonstrated the influence role models and mentors may have on what type of fellowship-training residency graduates choose, and where they choose to practice.8,10,12,14,21,22 We hypothesized that although women comprise a disproportionate percentage of pediatric orthopedic surgeons relative to other orthopedic subspecialties, a smaller proportion of women entering academic orthopedics today are pursuing pediatric fellowships than were women 30 or more years ago. This hypothesis was informed chiefly by the increased number of fellowship options now available and by the authors’ personal observations in orthopedic surgery. Given the known popularity of hand surgery among women entering orthopedic surgery,23 chronologic data for female orthopedic hand surgeons was examined concurrently, as means of comparison. We also hypothesized that different regions of the country would have different proportions of women among their orthopedic faculty. Finally, knowing that women had made earlier forays into pediatric orthopedics compared with other orthopedic subspecialties, we hypothesized that female pediatric orthopedic faculty would have achieved greater academic success than women in other orthopedic subspecialties. Appointment to full professorship and membership in the American Academy of Orthopaedic Surgeons (AAOS) were used as metrics to test this hypothesis. To our knowledge, this is
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the first study to examine gender-based differences in fellowship choices among academic orthopedic surgeons before 2010, as well as the first nonsurvey-based study to examine the geographic distribution of women in academic orthopedics.
METHODS Faculty Data Collection The Accreditation Council for Graduate Medical Education website was queried in 2015 for all accredited U.S. orthopedic residencies, yielding 153 programs. Program websites were used to identify faculty members with appointments at each residency. Eleven programs did not provide publicly accessible lists of their orthopedic faculty members, leaving 142 residencies in the sample. From June 2015 to June 2017, faculty data were collected from each website with regard to gender; number, type, and year of academic degrees completed; number, type, and year of residencies completed. These data were updated from July 2017 to October 2017, and additional data were collected regarding and number and type of fellowships completed; academic appointment (instructor, assistant professor, associate professor, professor); and membership in the AAOS. Data unavailable on program websites were obtained from the Doximity website (www.doximity.com) or an Internet search. Doximity is the largest online social network used by U.S. medical practitioners, which includes more than 70% of U.S. physicians and has a verified membership of more than 1 million.24,25 Initial data collection yielded 3928 unique faculty members, of whom 332 were excluded for not having completed orthopedic residencies, leaving 3596 confirmed orthopedic surgeons. Four hundred ninety-four individuals for whom completion of an orthopedic fellowship could not be confirmed were excluded from subspecialty analysis (Fig. 1). Although the terms “gender” and “sex” are not synonymous, their different denotations are outside the scope of this study, and for the purposes of this paper these terms were used interchangeably. Analysis was performed only for the year 1980 and after, because the number of women in our data set who completed orthopedic training annually before 1980 was too low for analysis. Fellowship and Geographic Categories Fellowships were categorized as adult reconstruction, foot and ankle, hand, oncology, pediatric, trauma, shoulder and elbow, spine, or sports. Individuals were categorized as having completed “no fellowship” only when a program listed fellowships for other faculty but none for that member. Program locations were grouped into 7
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FIGURE 1. Flowchart of data collection. ACGME, Accreditation Council for Graduate Medical Education.
smaller regions according to those used in a previous study: Pacific, Mountain, Southwest, Midwest, Southeast, Mid-Atlantic, and Northeast.12 The 4 official U.S. census regions (West, South, Northeast, and Midwest) were used for larger comparisons. (The census’s larger divisions aggregate the aforementioned smaller regions, with the exception that Arizona and New Mexico are considered West rather than South.) Determining Gender and Graduation Year Gender was inferred by the authors using the faculty members’ full names and photographs provided on the program websites. There were no faculty members for whom gender was ambiguous. Fellowship graduation year was estimated by adding 1 year to the year of residency graduation. If only the year of medical school graduation was available, fellowship graduation year was estimated by adding 6 years. Statistical Methods Comparisons of categorical data were made using chisquared tests or the Fisher exact test when a category had fewer than 5 values. Differences between subgroups were determined using 2-tailed t tests. Significance was defined as p < 0.05. Correlations were examined using exponential regression by adherence to a parametric curve.
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RESULTS Gender Distribution Overall and by Subspecialty, Educational Background, and AAOS Membership Among 3596 orthopedic surgeons, 7.9% were women (Table 1). No differences were found between genders in completion of doctorates of osteopathic medicine or other graduate degrees, but male faculty had completed more PhDs (p = 0.03) and were more frequently members of the AAOS (p = 0.01). Data for fellowships are reported in Table 2. For faculty who had completed a fellowship, there was a significant association between gender and subspecialty, with women accounting for 22% (91/420) of all pediatric orthopedists compared with 7.6% (185/2424) of all other orthopedic subspecialists (p < 0.001). Notably, 18 of 22 oncology fellowships and 21 of 25 trauma fellowships completed by women were completed in 2000 or later. Geographic Distribution Proportions of female faculty for each geographic region are shown in Figure 2. Statistical differences between smaller regions by gender are shown in Figure 3. When comparisons were made between large U.S. census regions, the West also had significantly larger proportions
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TABLE 1. Academic and Educational Characteristics of U.S. Orthopedic Surgical Faculty From 142 Accredited Orthopedic Residencies, Stratified by Sex, as of October 2017 N (%)
Characteristic
Fellowship training Pediatrics Hand Adult reconstruction Foot and ankle Oncology Trauma Shoulder and elbow Spine Sports Academic degree MD PhD Other degree(s)* Academic rank Lecturer Assistant professor Associate professor Professor Not found AAOS membership
p Value
Women (N = 284)
Men (N = 2818)
91 (32) 58 (20) 9 (3.2)
339 (12) 351 (12) 359 (13)
19 (6.7) 22 (7.7) 27 (9.5) 9 (3.2)
170 (6.0) 124 (4.4) 309 (11) 108 (3.8)
14 (4.9) 35 (12)
348 (12) 484 (17)
277 (98) 0 (0) 14 (4.9)
2762 (98) 50 (1.8) 107 (3.4)
14 (4.9) 139 (49)
117 (4.2) 898 (32)
0.53 <0.001
54 (19)
466 (17)
0.29
36 (13) 41 (14) 161 (57)
558 (20) 779 (28) 2031 (72)
0.004
<0.001 <0.001 <0.001 0.66 0.011 0.45 0.56 <0.001 0.037 0.31 0.012 0.35
<0.001
AAOS, American Academy of Orthopaedic Surgeons. *Excluding other medical degrees (i.e., doctor of osteopathic medicine and Bachelor of Medicine and Bachelor of Surgery [MBBS]).
TABLE 2. Most Common Fellowships of 3102 Orthopedic Faculty from 142 Accredited Orthopedic Residencies, by Sex, as of October 2017 Specialty, N (%)
Completed Fellowships
Single specialty Most common Secondmost common Thirdmost common Most common dual specialties
Women (N = 285)
Men (N = 2643)
Pediatric, 90 (32) Hand, 57 (20)
Sports, 468 (18) Spine, 349 (13)
Sports, 30 (11)
Hand, 348 (13)
Pediatric and sports, 3 (33*)
Shoulder/elbow and sports, 9 (12y)
*As a percentage of all women who completed 2 fellowships (n = 9). † As a percentage of all men who completed 2 fellowships (n = 73).
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of female orthopedic surgical faculty (68/522, 13%) than did the Northeast (67/1102, 6.1%), the Midwest (68/891, 7.6%), or the South (81/1081, 7.5%) (all, p < 0.001). Changes in Proportion of Women Entering Pediatric Orthopedics A strong correlation with time was seen in total women completing fellowships other than in hand or pediatrics from 1980 to 2014 (R2 = 0.95) (Fig. 4); a strong inverse correlation with time was seen for pediatrics as a percentage of all fellowships during the same period (R2 = 0.94) (Fig. 5). Proportion Attaining Full Professorship For the 243 female faculty with a listed academic rank, those in pediatric orthopedics (12%, 10/81) had not attained full professorship at a higher rate than those in other subspecialties (15%, 24/162) (p = 0.60). This was also true when pediatric orthopedists were compared with hand surgeons (18/129 [14%] vs. 16/114 [14%], respectively; p = 0.87).
DISCUSSION Women continue to constitute a small percentage of orthopedic faculty, with a nationwide average of less than 8%, and female orthopedic surgeons hold significantly fewer PhDs and memberships in the AAOS than do their male counterparts. Pediatrics is the orthopedic subspecialty with the most female representation (21%) at U.S. residencies, and both pediatric and hand subspecialists have significantly higher female representation than do other orthopedic subspecialties. Geographically, women make up a significantly larger proportion of orthopedic faculty in the western U.S. than in the eastern U.S. Since 1980, the percentage of women completing pediatric fellowships decreased exponentially, as more women pursue other subspecialties such as orthopedic trauma and oncology. Finally, women in pediatric orthopedics have not attained full professorship at a higher rate than their nonpediatric colleagues. Our estimate of the percentage of female orthopedic faculty (8%) is lower than that found by the Association of American Medical Colleges in 2012 (15%).5 Several factors may explain this discrepancy. Importantly, we focused solely on faculty who had completed orthopedic residencies. A large number of orthopedic faculty not included in the initial 3928 faculty members were women, including primary care sports medicine physicians, physical medicine and rehabilitation physicians, and physical therapists. Likewise, 25% of the 332 faculty later excluded were women. Conversely, the Association of American Medical Colleges did not limit its census to
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FIGURE 2. Proportions of female orthopedic surgical faculty at accredited orthopedic residency programs as of October 2017, mapped by region.
orthopedic surgeons. Additionally, we were unable to obtain faculty lists from 11 of the 153 accredited programs. Given the substantial variations in gender distribution among programs, there may have been a higher percentage of women if faculty data from all 153 programs had been accessible. We believe that our finding represents an accurate approximation of the percentage
of female orthopedic surgeons teaching at U.S. residencies through 2017. The gender difference in AAOS membership likely reflects the changing demographic characteristics of orthopedic specialists over time, whereas the gender differences by PhD completion may be attributable to discrepancies in educational goals, lifestyle preferences, or other factors.
FIGURE 3. Proportions of female orthopedic surgical faculty at accredited orthopedic residency programs as of October 2017. Significant differences are indicated by brackets between regions; all other comparisons are nonsignificant.
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FIGURE 4. Number of pediatric, hand, and other orthopedic fellowships completed by female members of orthopedic faculty at 142 accredited orthopedic residencies, 1980 to 2014 (R2 = 0.95 adherence to a parametric curve, as shown by the dotted trend line).
The gender differences by geographic region were striking, with the Mid-Atlantic region having the lowest percentage of female orthopedic faculty (5.6%) and the Mountain region having the highest (18%). These
FIGURE 5. Fellowship types as a percentage of all fellowships completed by female members of orthopedic faculty at 142 accredited orthopedic residencies, 1980 to 2014 (R2 = 0.94 adherence to a parametric curve, as shown by the dotted trend line). Trauma and oncology (Onc) were chosen as representative subspecialties because they were the 2 of the subspecialties with the largest change in percentage of women during this period.
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differences remained significant when regions were compared by large U.S. census districts. The reasons for these differences are unclear. The total number of faculty in the West (522) was smaller than that in the other census regions, so it is possible that sampling error may contribute to the observed discrepancies. However, another contributor might be a regional “snowball effect,” as numerous studies have shown the strong influence a positive role model or mentor can have on a woman considering a career in orthopedic surgery, and more than half of US programs have only 1 or no women on their faculty.6,8,10,12 Amoli et al.15 found that geographic considerations and academic opportunities were more important to female pediatric orthopedic surgeons than to their male counterparts; therefore, some of the female faculty in this study may have been likelier to gravitate to institutions or regions where other women already worked. This difference may also represent factors such as regional differences in bias or academic culture, but these are outside the scope of our study. We identified notably higher proportions of female orthopedic surgeons in the Mountain and Pacific regions and somewhat lower proportions in the Northeast compared with the results of a previous study.12 This disparity may be explained in part by methodological differences (survey vs. systematic approach), as well as by our focus on academic institutions rather than all practice types. Although pediatrics still has the highest proportion of women among orthopedic fellowships, women are entering other fellowships at a much faster rate (Fig. 4), and pediatrics represents a decreasing percentage of all orthopedic fellowships completed by women (Fig. 5). The historical association between general pediatric medicine and gender is well-known; thus, some of the factors that have attracted women to general pediatrics, such as differences in workplace culture, lifestyle, patient population, and types of disorders, may apply to women entering pediatric orthopedics. We examined only formal, full-year fellowships; thus, we did not include informal fellowships that are less structured or shorter than a year. Though pediatrics and hand were the 2 most popular orthopedic fellowship types for women in the 1980s and 1990s, they were also 2 of the first fields to emerge as established subspecialties. Thus, the increasing subspecialization of orthopedics may contribute to the observed decrease in popularity of pediatric orthopedics among women, and, conversely, the increase in popularity of subspecialties such as oncology and trauma. Given the known effect that role models have on career choice, the entrance of women into these nonpediatric subspecialties may encourage more women to follow.6,8,10,12,26 In 1 study of orthopedic residency applicants, 68% of women eliminated programs
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ARTICLE IN PRESS from their consideration on the basis of a perceived gender bias, compared with less than 1% of men.26 A similar pattern may exist when female residents choose fellowship types, which would help explain why women have begun to enter nonpediatric subspecialties in considerable numbers only recently. We believe that the influx of women into nonpediatric subspecialties represents progress in these fields, rather than a decreased interest in or aversion to pediatric training, and is attributable chiefly to increasing subspecialization and the greater number of women entering the field of orthopedics. Women in pediatric orthopedics were no likelier than those in nonpediatric orthopedics to have obtained full professorship. We identified 6.1% of professors in orthopedic surgery as female compared with a study in 2006 that identified 3.8% as female;7 therefore, we believe that the number of female orthopedic professors has increased during the past decade. A 2004 study of academic general surgeons found that (1) women felt more isolated than did men, (2) women felt that career advancement opportunities were less available to them than to men, and (3) the group most likely to consider leaving academia was female assistant professors.27 Similar influences in orthopedics may explain the persistent gender gap by academic rank among U.S. orthopedic surgical faculty. The effect of gender bias on academic advancement for medical school faculty is wellestablished, and we believe that gender bias may contribute to the lack of difference we found between women attaining professorship in pediatric orthopedics versus in other subspecialties, along with gender-related differences in career goals or lifestyle.17,18,21,22,28-30 Future inquiry may also help to elucidate the challenges and professional experiences unique to women in orthopedics, which remains the most male-dominated field of medicine. One possible limitation of our study is our subjective determination of gender rather than using official reporting of male and female sex. However, we ensured internal consensus regarding each individual’s apparent gender, and we believe that these efforts minimized error. Another limitation is our focus on academic orthopedics. Because we examined only residency program faculty, our findings cannot be generalized to all practice types. Regarding academic rank, it is possible that some faculty have different appointments at multiple institutions; because we evaluated only unique individuals, our study did not capture these differences, although none was noted during analysis of the female faculty. Our reliance on program websites presents another possible limitation because there may be variation in the frequency with which these websites are updated, but we believe that the large cross section captured in this study, in addition to the updating of the
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data before analysis, overcomes this limitation, and that our findings thus represent an accurate reflection of the composition of orthopedic surgical faculty during the time period examined. We included only formal, yearlong fellowships; therefore, we cannot comment on the informal fellowship types that existed before the 1980s. Our methodology also may not fully capture individuals who completed alternate training routes, such as those who pursued fellowships after working in general practice for a year or more. Therefore, our data may overestimate the number of academic orthopedic surgeons who did not complete formal postresidency fellowships. The geographic and academic trends identified in this study have important implications for workforce planning across all fields of orthopedics. Active recruitment, role modeling, and mentoring are likely to diversify the orthopedic workforce.6,8,10,12 The chronologic trends within subspecialties suggest that as more women enter academic orthopedics, they are diversifying away from primarily pediatric fellowships.
ACKNOWLEDGMENTS We thank Anne Kuwabara, MD, and Joseph Lopez, MD, MBA, for their help generating and completing the database used in this study.
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The Times, They Are A-Changing: Women Entering Academic Orthopedics Today Are Choosing Nonpediatric Fellowships at a Growing Rate Walter Klyce, MD, Derek T. Nhan, MD, Alexandra M. Dunham, MD, Mostafa H. EL Dafrawy, MBBS, Claire Shannon, MD, and Dawn M. LaPorte, MD Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland OBJECTIVE: Pediatrics and hand surgery have historically been the orthopaedic subspecialties with the highest female representations. We sought to identify the gender distribution of orthopedic surgical faculty by subspecialty, geography, and educational background. We hypothesized that the proportion of women entering pediatric orthopaedics has decreased since 1980. DESIGN: The Accreditation Council for Graduate Medical
Education was used to generate a list of U.S. orthopedic residencies. Program websites were used to collect data regarding each faculty member’s gender, residencies, fellowships, and graduation year. t tests were used to compare quantitative data and Fisher’s exact tests to compare categorical data. Significance was defined as p < 0.05. SETTING: Publicly available data from official websites of
correlation with time was found for pediatrics as a percentage of fellowships completed by women during the same period (R2 = 0.94). CONCLUSIONS: Although pediatrics remains the most
popular fellowship for female orthopedists, women who enter academic orthopedics are increasingly choosing nonpediatric subspecialties. ( J Surg Ed 000:18. Ó 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: faculty, fellowship, gender, orthopedics,
pediatrics, specialties COMPETENCIES: Medical Knowledge, Professionalism,
Interpersonal and Communication Skills, Systems-Based Practice
U.S. orthopedic residencies. PARTICIPANTS: Of 153 residencies, 142 (93%) had accessible faculty lists. RESULTS: Of 3596 orthopedic surgeons, 7.9% were
women. Among fellowship-trained faculty, 22% of pediatric orthopedists were women compared with 7.6% of faculty in other orthopedic subspecialties (p < 0.00001). There was a significantly higher percentage of female faculty in the West (13%) than in any other U.S. census region (p < 0.001 vs. Midwest, vs. South, and vs. Northeast). A strong correlation with time was found in number of women completing fellowships other than hand or pediatrics from 1980 to 2014 (R2 = 0.95); a strong inverse Funding: No funding was received in support of this work. Each author certifies that his or her institution has waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. Correspondence: Inquiries to Dawn M. LaPorte, MD, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Suite 5252, Baltimore, MD 21287; e-mail: [email protected]
INTRODUCTION Gender distribution in medicine has undergone a marked transformation in recent decades. In 2015, 48% of medical school matriculants and 39% of faculty were women, compared with less than 10% of either in 1975.1-3 Although the influx of women in medicine represents progress, it has proceeded at different rates in different specialties, and as a result, gender continues to be highly predictive of career choice. In U.S. medical schools, pediatrics has the second-highest percentage of female residents, with 65% of pediatric residency applicants being women during the 2016 to 2017 cycle. In contrast, orthopedic surgery remains the most male-dominated field in medicine, with only 15% of orthopedic residency applicants being women in 2016 to 2017.4 Similar gender distributions are found among medical school faculty. In 2012, 51% of pediatric faculty at U.S. medical schools were women (the third-highest proportion of any
Journal of Surgical Education © 2019 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2019.12.007
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ARTICLE IN PRESS specialty) but only 15% of orthopedic faculty were women (the lowest proportion of any specialty).5 Previous studies6-13 have examined the role of gender in residency choice, but few have examined how gender is associated with fellowship choice among orthopedic surgeons. Pediatric orthopedics may represent a middle ground between the low percentage of women in orthopedic surgery and the high percentage of women in general pediatric medicine. In 2016, Cannada14 examined the relationship between gender and the orthopedic fellowship match and found that pediatric fellowships had the highest proportion of female applicants; however, this study was based on National Resident Matching Program data only from 2010 and onward. Other studies relating gender and orthopedic subspecialty have been survey-based and thus subject to potential sampling bias.11,15,16 A similar reliance on survey response is seen in the only study examining the geographic distribution of active female orthopedists in the United States; and although studies have examined the proportion of women in various orthopedic residencies, no similar study has been performed for orthopedic faculty.12,13 This topic is important because past efforts to increase the representation of underrepresented groups have had only limited success, and in order to address such issues, it is necessary to fully understand the current state of women in orthopedics.9,17-20 Additionally, past studies have demonstrated the influence role models and mentors may have on what type of fellowship-training residency graduates choose, and where they choose to practice.8,10,12,14,21,22 We hypothesized that although women comprise a disproportionate percentage of pediatric orthopedic surgeons relative to other orthopedic subspecialties, a smaller proportion of women entering academic orthopedics today are pursuing pediatric fellowships than were women 30 or more years ago. This hypothesis was informed chiefly by the increased number of fellowship options now available and by the authors’ personal observations in orthopedic surgery. Given the known popularity of hand surgery among women entering orthopedic surgery,23 chronologic data for female orthopedic hand surgeons was examined concurrently, as means of comparison. We also hypothesized that different regions of the country would have different proportions of women among their orthopedic faculty. Finally, knowing that women had made earlier forays into pediatric orthopedics compared with other orthopedic subspecialties, we hypothesized that female pediatric orthopedic faculty would have achieved greater academic success than women in other orthopedic subspecialties. Appointment to full professorship and membership in the American Academy of Orthopaedic Surgeons (AAOS) were used as metrics to test this hypothesis. To our knowledge, this is
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the first study to examine gender-based differences in fellowship choices among academic orthopedic surgeons before 2010, as well as the first nonsurvey-based study to examine the geographic distribution of women in academic orthopedics.
METHODS Faculty Data Collection The Accreditation Council for Graduate Medical Education website was queried in 2015 for all accredited U.S. orthopedic residencies, yielding 153 programs. Program websites were used to identify faculty members with appointments at each residency. Eleven programs did not provide publicly accessible lists of their orthopedic faculty members, leaving 142 residencies in the sample. From June 2015 to June 2017, faculty data were collected from each website with regard to gender; number, type, and year of academic degrees completed; number, type, and year of residencies completed. These data were updated from July 2017 to October 2017, and additional data were collected regarding and number and type of fellowships completed; academic appointment (instructor, assistant professor, associate professor, professor); and membership in the AAOS. Data unavailable on program websites were obtained from the Doximity website (www.doximity.com) or an Internet search. Doximity is the largest online social network used by U.S. medical practitioners, which includes more than 70% of U.S. physicians and has a verified membership of more than 1 million.24,25 Initial data collection yielded 3928 unique faculty members, of whom 332 were excluded for not having completed orthopedic residencies, leaving 3596 confirmed orthopedic surgeons. Four hundred ninety-four individuals for whom completion of an orthopedic fellowship could not be confirmed were excluded from subspecialty analysis (Fig. 1). Although the terms “gender” and “sex” are not synonymous, their different denotations are outside the scope of this study, and for the purposes of this paper these terms were used interchangeably. Analysis was performed only for the year 1980 and after, because the number of women in our data set who completed orthopedic training annually before 1980 was too low for analysis. Fellowship and Geographic Categories Fellowships were categorized as adult reconstruction, foot and ankle, hand, oncology, pediatric, trauma, shoulder and elbow, spine, or sports. Individuals were categorized as having completed “no fellowship” only when a program listed fellowships for other faculty but none for that member. Program locations were grouped into 7
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FIGURE 1. Flowchart of data collection. ACGME, Accreditation Council for Graduate Medical Education.
smaller regions according to those used in a previous study: Pacific, Mountain, Southwest, Midwest, Southeast, Mid-Atlantic, and Northeast.12 The 4 official U.S. census regions (West, South, Northeast, and Midwest) were used for larger comparisons. (The census’s larger divisions aggregate the aforementioned smaller regions, with the exception that Arizona and New Mexico are considered West rather than South.) Determining Gender and Graduation Year Gender was inferred by the authors using the faculty members’ full names and photographs provided on the program websites. There were no faculty members for whom gender was ambiguous. Fellowship graduation year was estimated by adding 1 year to the year of residency graduation. If only the year of medical school graduation was available, fellowship graduation year was estimated by adding 6 years. Statistical Methods Comparisons of categorical data were made using chisquared tests or the Fisher exact test when a category had fewer than 5 values. Differences between subgroups were determined using 2-tailed t tests. Significance was defined as p < 0.05. Correlations were examined using exponential regression by adherence to a parametric curve.
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RESULTS Gender Distribution Overall and by Subspecialty, Educational Background, and AAOS Membership Among 3596 orthopedic surgeons, 7.9% were women (Table 1). No differences were found between genders in completion of doctorates of osteopathic medicine or other graduate degrees, but male faculty had completed more PhDs (p = 0.03) and were more frequently members of the AAOS (p = 0.01). Data for fellowships are reported in Table 2. For faculty who had completed a fellowship, there was a significant association between gender and subspecialty, with women accounting for 22% (91/420) of all pediatric orthopedists compared with 7.6% (185/2424) of all other orthopedic subspecialists (p < 0.001). Notably, 18 of 22 oncology fellowships and 21 of 25 trauma fellowships completed by women were completed in 2000 or later. Geographic Distribution Proportions of female faculty for each geographic region are shown in Figure 2. Statistical differences between smaller regions by gender are shown in Figure 3. When comparisons were made between large U.S. census regions, the West also had significantly larger proportions
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TABLE 1. Academic and Educational Characteristics of U.S. Orthopedic Surgical Faculty From 142 Accredited Orthopedic Residencies, Stratified by Sex, as of October 2017 N (%)
Characteristic
Fellowship training Pediatrics Hand Adult reconstruction Foot and ankle Oncology Trauma Shoulder and elbow Spine Sports Academic degree MD PhD Other degree(s)* Academic rank Lecturer Assistant professor Associate professor Professor Not found AAOS membership
p Value
Women (N = 284)
Men (N = 2818)
91 (32) 58 (20) 9 (3.2)
339 (12) 351 (12) 359 (13)
19 (6.7) 22 (7.7) 27 (9.5) 9 (3.2)
170 (6.0) 124 (4.4) 309 (11) 108 (3.8)
14 (4.9) 35 (12)
348 (12) 484 (17)
277 (98) 0 (0) 14 (4.9)
2762 (98) 50 (1.8) 107 (3.4)
14 (4.9) 139 (49)
117 (4.2) 898 (32)
0.53 <0.001
54 (19)
466 (17)
0.29
36 (13) 41 (14) 161 (57)
558 (20) 779 (28) 2031 (72)
0.004
<0.001 <0.001 <0.001 0.66 0.011 0.45 0.56 <0.001 0.037 0.31 0.012 0.35
<0.001
AAOS, American Academy of Orthopaedic Surgeons. *Excluding other medical degrees (i.e., doctor of osteopathic medicine and Bachelor of Medicine and Bachelor of Surgery [MBBS]).
TABLE 2. Most Common Fellowships of 3102 Orthopedic Faculty from 142 Accredited Orthopedic Residencies, by Sex, as of October 2017 Specialty, N (%)
Completed Fellowships
Single specialty Most common Secondmost common Thirdmost common Most common dual specialties
Women (N = 285)
Men (N = 2643)
Pediatric, 90 (32) Hand, 57 (20)
Sports, 468 (18) Spine, 349 (13)
Sports, 30 (11)
Hand, 348 (13)
Pediatric and sports, 3 (33*)
Shoulder/elbow and sports, 9 (12y)
*As a percentage of all women who completed 2 fellowships (n = 9). † As a percentage of all men who completed 2 fellowships (n = 73).
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of female orthopedic surgical faculty (68/522, 13%) than did the Northeast (67/1102, 6.1%), the Midwest (68/891, 7.6%), or the South (81/1081, 7.5%) (all, p < 0.001). Changes in Proportion of Women Entering Pediatric Orthopedics A strong correlation with time was seen in total women completing fellowships other than in hand or pediatrics from 1980 to 2014 (R2 = 0.95) (Fig. 4); a strong inverse correlation with time was seen for pediatrics as a percentage of all fellowships during the same period (R2 = 0.94) (Fig. 5). Proportion Attaining Full Professorship For the 243 female faculty with a listed academic rank, those in pediatric orthopedics (12%, 10/81) had not attained full professorship at a higher rate than those in other subspecialties (15%, 24/162) (p = 0.60). This was also true when pediatric orthopedists were compared with hand surgeons (18/129 [14%] vs. 16/114 [14%], respectively; p = 0.87).
DISCUSSION Women continue to constitute a small percentage of orthopedic faculty, with a nationwide average of less than 8%, and female orthopedic surgeons hold significantly fewer PhDs and memberships in the AAOS than do their male counterparts. Pediatrics is the orthopedic subspecialty with the most female representation (21%) at U.S. residencies, and both pediatric and hand subspecialists have significantly higher female representation than do other orthopedic subspecialties. Geographically, women make up a significantly larger proportion of orthopedic faculty in the western U.S. than in the eastern U.S. Since 1980, the percentage of women completing pediatric fellowships decreased exponentially, as more women pursue other subspecialties such as orthopedic trauma and oncology. Finally, women in pediatric orthopedics have not attained full professorship at a higher rate than their nonpediatric colleagues. Our estimate of the percentage of female orthopedic faculty (8%) is lower than that found by the Association of American Medical Colleges in 2012 (15%).5 Several factors may explain this discrepancy. Importantly, we focused solely on faculty who had completed orthopedic residencies. A large number of orthopedic faculty not included in the initial 3928 faculty members were women, including primary care sports medicine physicians, physical medicine and rehabilitation physicians, and physical therapists. Likewise, 25% of the 332 faculty later excluded were women. Conversely, the Association of American Medical Colleges did not limit its census to
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FIGURE 2. Proportions of female orthopedic surgical faculty at accredited orthopedic residency programs as of October 2017, mapped by region.
orthopedic surgeons. Additionally, we were unable to obtain faculty lists from 11 of the 153 accredited programs. Given the substantial variations in gender distribution among programs, there may have been a higher percentage of women if faculty data from all 153 programs had been accessible. We believe that our finding represents an accurate approximation of the percentage
of female orthopedic surgeons teaching at U.S. residencies through 2017. The gender difference in AAOS membership likely reflects the changing demographic characteristics of orthopedic specialists over time, whereas the gender differences by PhD completion may be attributable to discrepancies in educational goals, lifestyle preferences, or other factors.
FIGURE 3. Proportions of female orthopedic surgical faculty at accredited orthopedic residency programs as of October 2017. Significant differences are indicated by brackets between regions; all other comparisons are nonsignificant.
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FIGURE 4. Number of pediatric, hand, and other orthopedic fellowships completed by female members of orthopedic faculty at 142 accredited orthopedic residencies, 1980 to 2014 (R2 = 0.95 adherence to a parametric curve, as shown by the dotted trend line).
The gender differences by geographic region were striking, with the Mid-Atlantic region having the lowest percentage of female orthopedic faculty (5.6%) and the Mountain region having the highest (18%). These
FIGURE 5. Fellowship types as a percentage of all fellowships completed by female members of orthopedic faculty at 142 accredited orthopedic residencies, 1980 to 2014 (R2 = 0.94 adherence to a parametric curve, as shown by the dotted trend line). Trauma and oncology (Onc) were chosen as representative subspecialties because they were the 2 of the subspecialties with the largest change in percentage of women during this period.
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differences remained significant when regions were compared by large U.S. census districts. The reasons for these differences are unclear. The total number of faculty in the West (522) was smaller than that in the other census regions, so it is possible that sampling error may contribute to the observed discrepancies. However, another contributor might be a regional “snowball effect,” as numerous studies have shown the strong influence a positive role model or mentor can have on a woman considering a career in orthopedic surgery, and more than half of US programs have only 1 or no women on their faculty.6,8,10,12 Amoli et al.15 found that geographic considerations and academic opportunities were more important to female pediatric orthopedic surgeons than to their male counterparts; therefore, some of the female faculty in this study may have been likelier to gravitate to institutions or regions where other women already worked. This difference may also represent factors such as regional differences in bias or academic culture, but these are outside the scope of our study. We identified notably higher proportions of female orthopedic surgeons in the Mountain and Pacific regions and somewhat lower proportions in the Northeast compared with the results of a previous study.12 This disparity may be explained in part by methodological differences (survey vs. systematic approach), as well as by our focus on academic institutions rather than all practice types. Although pediatrics still has the highest proportion of women among orthopedic fellowships, women are entering other fellowships at a much faster rate (Fig. 4), and pediatrics represents a decreasing percentage of all orthopedic fellowships completed by women (Fig. 5). The historical association between general pediatric medicine and gender is well-known; thus, some of the factors that have attracted women to general pediatrics, such as differences in workplace culture, lifestyle, patient population, and types of disorders, may apply to women entering pediatric orthopedics. We examined only formal, full-year fellowships; thus, we did not include informal fellowships that are less structured or shorter than a year. Though pediatrics and hand were the 2 most popular orthopedic fellowship types for women in the 1980s and 1990s, they were also 2 of the first fields to emerge as established subspecialties. Thus, the increasing subspecialization of orthopedics may contribute to the observed decrease in popularity of pediatric orthopedics among women, and, conversely, the increase in popularity of subspecialties such as oncology and trauma. Given the known effect that role models have on career choice, the entrance of women into these nonpediatric subspecialties may encourage more women to follow.6,8,10,12,26 In 1 study of orthopedic residency applicants, 68% of women eliminated programs
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ARTICLE IN PRESS from their consideration on the basis of a perceived gender bias, compared with less than 1% of men.26 A similar pattern may exist when female residents choose fellowship types, which would help explain why women have begun to enter nonpediatric subspecialties in considerable numbers only recently. We believe that the influx of women into nonpediatric subspecialties represents progress in these fields, rather than a decreased interest in or aversion to pediatric training, and is attributable chiefly to increasing subspecialization and the greater number of women entering the field of orthopedics. Women in pediatric orthopedics were no likelier than those in nonpediatric orthopedics to have obtained full professorship. We identified 6.1% of professors in orthopedic surgery as female compared with a study in 2006 that identified 3.8% as female;7 therefore, we believe that the number of female orthopedic professors has increased during the past decade. A 2004 study of academic general surgeons found that (1) women felt more isolated than did men, (2) women felt that career advancement opportunities were less available to them than to men, and (3) the group most likely to consider leaving academia was female assistant professors.27 Similar influences in orthopedics may explain the persistent gender gap by academic rank among U.S. orthopedic surgical faculty. The effect of gender bias on academic advancement for medical school faculty is wellestablished, and we believe that gender bias may contribute to the lack of difference we found between women attaining professorship in pediatric orthopedics versus in other subspecialties, along with gender-related differences in career goals or lifestyle.17,18,21,22,28-30 Future inquiry may also help to elucidate the challenges and professional experiences unique to women in orthopedics, which remains the most male-dominated field of medicine. One possible limitation of our study is our subjective determination of gender rather than using official reporting of male and female sex. However, we ensured internal consensus regarding each individual’s apparent gender, and we believe that these efforts minimized error. Another limitation is our focus on academic orthopedics. Because we examined only residency program faculty, our findings cannot be generalized to all practice types. Regarding academic rank, it is possible that some faculty have different appointments at multiple institutions; because we evaluated only unique individuals, our study did not capture these differences, although none was noted during analysis of the female faculty. Our reliance on program websites presents another possible limitation because there may be variation in the frequency with which these websites are updated, but we believe that the large cross section captured in this study, in addition to the updating of the
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data before analysis, overcomes this limitation, and that our findings thus represent an accurate reflection of the composition of orthopedic surgical faculty during the time period examined. We included only formal, yearlong fellowships; therefore, we cannot comment on the informal fellowship types that existed before the 1980s. Our methodology also may not fully capture individuals who completed alternate training routes, such as those who pursued fellowships after working in general practice for a year or more. Therefore, our data may overestimate the number of academic orthopedic surgeons who did not complete formal postresidency fellowships. The geographic and academic trends identified in this study have important implications for workforce planning across all fields of orthopedics. Active recruitment, role modeling, and mentoring are likely to diversify the orthopedic workforce.6,8,10,12 The chronologic trends within subspecialties suggest that as more women enter academic orthopedics, they are diversifying away from primarily pediatric fellowships.
ACKNOWLEDGMENTS We thank Anne Kuwabara, MD, and Joseph Lopez, MD, MBA, for their help generating and completing the database used in this study.
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