Abstract

Background: The field of orthopaedic surgery has experienced a surge of initiatives aimed atto enhanceing diversity and inclusion in residency programs. Organizations such as the Ruth Jackson Orthopaedic Society, the Perry Initiative, the American Association of Latino Orthopaedic Surgeons, Black Women Orthopaedic Surgeons, Nth Dimensions, Pride Ortho and the J. Robert Gladden Orthopaedic Society have been at the forefront of these efforts. Despite meaningful progress, women and underrepresented minorities continue to comprise a disproportionately small percentage of orthopaedic trainees nationwide. Increasing representation across gender, racial and socioeconomic lines is essential not only for equity but for improving the quality of patient care and fostering innovation within the field.

Methods: In this study, we reviewed national programs, institutional initiatives and published literature related to recruitment, mentorship, early pipeline exposure and residency selection processes to identify strategies most strongly correlated with improved diversity metrics.

Results: Commonly cited approaches include structured mentorship, early engagement of medical students, implicit bias training and the adoption of holistic review in orthopaedic surgery residency applicant selection.

Conclusions: We highlight recurring themes of intentional mentorship, accountability and systemic support. Continued collaboration among societies, training programs and accrediting bodies remains crucial to achieving a more inclusive and representative orthopaedic workforce.

Keywords: Diversity Initiative; Implicit Bias; Inclusion; Mentorship; Representation

Introduction

Orthopaedic surgery is one of the least diverse surgical subspecialties. Orthopaedic residents from traditionally underrepresented groups-racial and ethnic minorities, women and LGBTQ+ individuals face challenges, such as finding peers and mentors who share similar backgrounds and experiences. Challenges may persist into the residents’ tenure as attending surgeons, when they encounter a lack of diversity within the broader community of orthopaedic professionals.

According to the 2022 Physician Specialty Data Report produced by the Association of American Medical Colleges, orthopaedics lags behind other medical specialties in representation of women and racial and ethnic minorities [1]. Although women constitute 16%-33% of orthopaedic surgery residents, they comprise only 6% of practicing surgeons [2,3]. Nearly 64% of residents are white, while only 21% are Asian, 7% are Hispanic and 6% are African American [2,3]. During the past decade, the percentage of residents from underrepresented racial and ethnic minorities has remained between 8% and 10% [3]. Moreover, 2018 census data from the American Association of Orthopedic Surgeons (AAOS) revealed that only 2% of practicing orthopaedic surgeons were African American and only 2% were Hispanic/Latino [4].

Diversity in orthopaedics is vital for patient care and an inclusive work environment [5-7]. A diverse orthopaedic workforce promotes culturally competent care, thereby increasing patient trust, satisfaction and treatment adherence. Diversity promotes creativity and innovation by assembling individuals with varied perspectives, experiences and ideas, thus enhancing problem solving and the potential for developing new surgical techniques and approaches [8].

In response to the lack of diversity in orthopaedics, several organizations have made efforts to foster change. Organizations we describe in this review have spearheaded initiatives to enhance diversity in orthopaedic surgery residency programs through targeted recruitment, mentorship, early exposure pathway programs and initiatives to mitigate implicit bias in hiring and promotion.

In this clinical review, we examine the state of diversity in orthopaedic residency programs and the challenges and barriers that underrepresented groups face when entering the profession. We also highlight strategies that help create a more diverse and inclusive future in the field of orthopaedic surgery.

Underrepresentation In Residency Programs

From 2007 to 2019, the number of female applicants to orthopaedic residency programs surged by 64%, but the number of female residents grew by only 24% [9-11]. In 2020, women made up only 16% of orthopaedic residents, while they made up 33% of residents in 6 other surgical specialties: neurosurgery, ophthalmology, otolaryngology, plastic surgery, general surgery and urology [3]. Women represent 47% of the medical student population and their underrepresentation in orthopaedics suggests systemic barriers [12].

Likewise, between 2007 and 2019, there was a 26% increase in Underrepresented in Medicine (URiM) applicants but a surprising 10% decrease in URiM residents [10,13]. According to the Association of American Medical Colleges, Black orthopaedic surgery residents have never comprised more than 5% of the resident population and only 4% of orthopaedic residents identify as Hispanic, with both numbers increasing only marginally over the past 2 decades [14,15]. These imbalances extend into academic research, where 83% of orthopaedic basic science research faculty are male and 62% are Caucasian [16].

Challenges and Barriers for Underrepresented Minorities

Barriers to Entry

Diversity in orthopaedics is inhibited by structural barriers that particularly affect residents, including long hours, the need to relocate during training, training inflexibility and lack of exposure to the field [17]. Implicit bias in the selection process for training also leads to discrimination, a self-perpetuating lack of role models and consequently, a lack of diversity in the field for aspiring trainees from underrepresented groups [17,18]. A survey of directors of 75 orthopaedic surgery residency programs noted the most commonly stated barriers to increasing diversity and representation from underrepresented backgrounds were a lack of minority faculty, minority applicants being ranked highly but not matched and a lack of minority applicants [19]. Unsurprisingly, the study also found that programs with higher percentages of underrepresented minority faculty had significantly higher percentages of underrepresented minority residents and that programs participating in medical student outreach programs (e.g., Nth Dimensions and the Perry Initiative) had significantly higher percentages of underrepresented minority faculty compared to residency programs that did not participate in these programs [19].

We use “underrepresented minority” here to refer to racial and ethnic minorities and women and to LGBTQ+ individuals, who are not well represented in orthopaedics and face barriers to entry. Notably, orthopaedic surgery is more likely than other surgical fields to be perceived as less welcoming to LGBTQ+ trainees [20].

Discrimination in Training and Practice

Gender and racial discrimination pose challenges in orthopaedic surgery. Implicit favoritism by the majority and outright bias against minorities contribute to feelings of alienation and lack of support among residents, as well as practicing surgeons. A cross-sectional study reported that directors of orthopaedic surgery residency programs are predominantly white men; the lack of diversity in leadership exacerbates feelings of alienation among minority groups [21,22]. Another study described pervasive gender bias in surgery [23]. For women, bias can manifest in a hostile work environment, pressures related to motherhood and parenting and an alienating, male-centric culture. Bias is often self-sustaining, reinforcing a dominant culture that is difficult to change without targeted interventions such as pathway programs [24]. Another study reported that 81% of female orthopaedic surgeons said they had experienced discrimination, bullying and sexual or other harassment at least once in their career, a substantially higher proportion than that of their male counterparts [25]. In addition, 76% of African American surgeons reported experiencing these abuses, which may negatively affect residents’ performance and mental well-being. While underrepresented minority residents made up just 6% of orthopaedic residents in the period 2010-2020, they comprised 17.5% of residents who resigned and/or were dismissed from their residency programs during that period [19]. Literature on how discrimination affects LGBTQ+ residents within orthopaedics is lacking; most of the available studies discuss barriers to entry into the field for LGBTQ+ individuals.

Lack of Mentorship

Institutional obstacles disproportionately affect minorities in orthopaedic surgery. One major institutional barrier is the limited availability of mentors who are sensitive to the challenges that minorities face and with whom residents can identify. Effective mentorship is vital for navigating the “hidden curriculum” in medicine that is, unspoken norms, values and professional expectations specific to particular medical specialties [26]. Without appropriate guidance and professional connections, minority trainees may find it difficult to advance professionally. When their career progress is hindered, existing disparities are perpetuated unless proactive measures are taken. The literature shows a scarcity of mentorship for women [27]. Without mentorship and guidance, women may not have a roadmap to success in orthopaedics. They may also be deterred by prevailing stereotypes about the physical demands and competitive nature of the specialty [28]. These factors collectively act as implicit barriers, discouraging women from entering the field [22,25].

What Is Needed to Promote Diversity in Orthopaedic Surgery?

Despite incremental progress over the past 15 years, major ethnic and gender disparities persist in orthopaedic residency programs. To effectively promote diversity, the academic community must prioritize mentorship, recruitment and support for minority candidates across the country [13]. Although representation of women, LGBTQ+ persons and racial and ethnic minorities in orthopaedic residencies has improved, it remains lower than in other medical and surgical specialties. Interestingly, most applicants to orthopaedic surgery programs have already decided on this specialty when they enter medical school [29]. Therefore, interventions during medical school may not suffice and programs that target students at earlier stages of training are critical.

Mandatory exposure to orthopaedics during medical school positively correlates with the number of female applicants to the field [30]. Conversely, negative perceptions can deter women from choosing orthopaedic surgery. Because early exposure and access to role models can positively influence female students’ perceptions of the field, early outreach is vital. Further, combating gender bias in the application and interview process is key; 61% of women report having been asked during residency interviews inappropriate questions about their plans for starting a family, compared to 8% of men [30]. To address biases that deter women from the field, interventions are needed.

Conventional recruitment strategies for medical specialties often focus on third-year rotations, personalized mentorship and scholarships for away or visiting rotations. Our literature review suggests that targeted pipeline programs that recruit women and URiM applicants into orthopaedics could ultimately yield greater diversity in the field. The Perry Initiative, for example, has recruited more than 12,000 girls and women in high school and medical school, 20% of whom have successfully matched into orthopaedic surgery residencies [31,32].

Discussion: Successful Initiatives and Strategies to Improve Diversity

Here we discuss current initiatives aimed at improving diversity and inclusion in orthopaedic residency programs.

Pipeline and Early Exposure Programs

Nth Dimensions promotes focused professional development and enables women and URiM students to enter structured relationships with mentors [33]. Their multiphase approach starts with “bioskills” workshops and a summer internship and includes ongoing educational support and mentorship through residency. Nth Dimensions alumni experience high rates of successful matches into orthopaedic surgery residency, a retention rate of 75% and match rate of 72% across several cohorts [34]. The one-on-one mentorship of Nth Dimensions, in addition to New York University’s Summer Externship program, which has scholarships for URiM applicants, illustrate principal ways women in medical school have developed an interest in orthopaedics [30]. To address the lower rate of admission into orthopaedic residency for Asian, Black and Hispanic applicants (61%) compared to white applicants (73%), they also created programming that provides relatable role models, annual scholarships and a community that facilitates success for its scholars [35,36]. Such initiatives also challenge “stereotype threat,” the fear of confirming a perceived stereotype, which can be another barrier to entry [37].

The Ruth Jackson Orthopaedic Society offers targeted mentorship to trainees across all educational levels, from undergraduate students to residents [38]. It enables prospective mentees to request mentors who meet their specific needs, even allowing gender preferences in mentor selection [39]. Given the field’s low percentages of female faculty and residents, the ability to specify a gender preference is particularly important [40]. The effectiveness of the Society’s approach is evident: 80% of their scholarship winners from 2003 to 2016 went on to become orthopaedic surgeons [41]. The scholarship model is also used by other programs, such as the J. Robert Gladden Orthopaedic Society, Pride Ortho and the American Association of Latino Orthopaedic Surgeons, to empower those who are underrepresented in the field.

Pride Ortho, established in 2021, aims to create a community for LGBTQ+ individuals and allies in orthopaedics [42]. Its mentorship program uses a ranking system to develop a personalized experience for each mentee based on their career type, race and sexual orientation. Such personalized approaches can be effective in establishing meaningful mentor-mentee relationships in diverse settings [41].

Longitudinal Mentorship and Retention Programs

The J. Robert Gladden Orthopaedic Society focuses on addressing systemic racial disparities in orthopaedic surgery [20]. The Gladden Society offers a mentorship and professional development program to residents and medical students, as well as a program to prevent URiM attrition by enabling struggling URiM residents to address concerns about their experience early on [9]. Mentors and mentees are paired according to expressed interest in given subspecialties and geographic location. Distinctive features of the Gladden Society include its small mentor-to-mentee ratio, pairings based on age and stage of training and the opportunity to apply for research grants and traveling fellowships, regardless of stage of training.

Professional Development and Networking Initiatives

The American Association of Latin Orthopedic Surgeons has also recently initiated a mentorship program. Under the leadership of Dr. Ramon Jimenez and Cristian Escelera, the program awards scholarships for medical students from diverse backgrounds, enabling them to attend the American Academy of Orthopedic Surgeons (AAOS) annual meeting. These scholarships equip students with knowledge, resources and mentorship to enhance their applications to orthopaedic surgery residency programs. Additionally, the program covers lodging, travel and registration expenses for 13 scholars to attend the AAOS annual meeting [43]. Moving forward, the Association aims to fortify the network of Latino orthopaedic surgeons, residents and medical students, offer ongoing mentorship to its members and ensure the retention of Latino trainees within the field [43].

Affinity-Based and Community-Building Organizations

Black Women Orthopaedic Surgeons emerged from a virtual assembly of Black women in the orthopaedic field held in July 2020 amid the COVID-19 pandemic and social unrest. The meeting aimed to empower Black women orthopaedic surgeons, celebrate their achievements and offer them a supportive forum for sharing their unique experiences and challenges in a profession where they represent only 0.6% of the workforce in the US. The 2018 AAOS census highlighted this disparity, noting the overwhelming majority of more than 30,000 orthopaedic surgeons in the United States were male (94%) and white (85%), underscoring the necessity for spaces that foster representation and inclusivity. The organization’s inception marks a critical step toward addressing the lack of diversity within the specialty, providing a platform for mentorship, networking and advocacy.

Future Implications

Early interventions appear to be key in promoting diversity in orthopaedic surgery. Their principles of personalized mentorship, early exposure and long-term relationships are universally applicable and have been adopted by organizations such as the Medical Student Orthopaedic Society and social media platforms such as OrthoMentor (on Instagram) to increase access to valuable resources [44].

Conclusion

The impact of diversity in orthopaedic surgery residencies extends beyond representation, enhancing patient care, stimulating innovation and enriching the medical profession. Although historically lacking diversity, the specialty orthopaedic surgery is experiencing a major transformation. Driven in part by organizations that increase awareness of the benefits of diversity within prominent societies in our field. As a result of their efforts that increase representation of underrepresented groups in orthopaedic residencies. Their efforts are helping to ensure the recruitment and retention of orthopaedic surgeons who are more broadly reflective of the diverse patients they serve.

Conflict of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors.

Acknowledgement

None.

Data Availability Statement

Not applicable.

Ethical Statement                                                

The project did not meet the definition of human subject research under the purview of the IRB according to federal regulations and therefore, was exempt.

Informed Consent Statement

Informed consent was taken for this study.

Authors’ Contributions

JPA: conceptualization, formal analysis, writing (original draft), writing (review and editing), project administration. AHS: conceptualization, formal analysis, writing (original draft), writing (review and editing), project administration. SZ: data curation, writing (original draft). AAA: conceptualization, methodology, formal analysis, project administration. DML: conceptualization, methodology, formal analysis, project administration.

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