Diversity in orthopaedics and traumatology: a global perspective

Africa

The population of South Africa (SA) is around 57 million, with a doctor-to-patient ratio of 6:10,000, less than half the global average. The ‘brain drain’ out of SA has had an immense impact on the healthcare system, with thousands of skilled doctors (nearly half of those registered) and healthcare professionals now working abroad. Although the shortfall of BAME (black, Asian and minority ethnic) doctors has improved over the years, a 2016 study showed that only 25.85% of doctors in SA represent the black community. A recent article highlighted that 38.7% of undergraduates in South African medical schools were black, 13.4% coloured, 13.6% Indian/Asian and 33% white. ¹⁶

Australia

Aboriginal people and Torres Strait Islanders are the indigenous, First Nations peoples of Australia and comprise 3% of the population. Indigenous Australians experience higher rates of cardiovascular, respiratory and diabetic diseases as well as higher rates of trauma and considerably lower life expectancy.

The Royal Australasian College of Surgeons (RACS) is responsible for surgical training in Australia. The Australian Orthopaedic Association (AOA) is a specialty society and its members account for 20% of the 7000 surgeon and 1300 trainee members of the RACS. Australia has three indigenous surgeons and five indigenous surgical trainees; three of whom are in orthopaedic training. There are no qualified indigenous orthopaedic surgeons (RACS Indigenous Health Committee data, February 2020).

In 2019, the AOA participated in the Australian Indigenous Doctors Association (AIDA) Conference for the first time, facilitating workshops and encouraging delegates into orthopaedic surgery. An expanded involvement is planned for 2020. The indigenous orthopaedic trainees will attend the workshop as facilitators and role models for their younger colleagues.

Australian initiatives to increase the number of indigenous surgeons involve creating an ‘Indigenous Trainee Pipeline’ through career enhancement scholarships for medical students, surgical skills workshops, an annual RACS Aboriginal and Torres Strait Islander Mentoring Prize, a Surgical Trainee one-year Indigenous Scholarship and an Indigenous Surgical Trainee Selection Initiative.

New Zealand

New Zealand’s (NZ) Treaty of Waitangi mandates equal access to national resources and requires the government to ensure that Maori have at least the same level of health as non-Maori. Currently, this is not the case, with Maori having significantly worse health outcomes.

Ensuring all surgeons have an understanding of the role of whanau, Maori belief systems and values or tikanga, will likely promote changes to Maori health outcomes but improving the diversity of the medical workforce such that it is reflective of the population is also key.

Maori make up 16.5% of the NZ population but in 2015, only 6% of house officers. There are no accurate statistics regarding current numbers of Maori orthopaedic surgeons. Efforts continue to improve the diversity of the workforce in terms of ethnicity as well as gender. Greater numbers of graduating Maori medical students will help, and currently 15.5% of orthopaedic trainees are Maori.

Africa

In South Africa, gender disparity still exists despite 62.2% of medical students identifying as female. ¹⁶ SA has 1,007 registered orthopaedic surgeons but only 5% are female. The South African Orthopaedic Association (SAOA) has made efforts to increase the cultural and gender diversity of its membership to better represent its multiracial population. However, despite these efforts, some groups remain under-represented, raising awareness that combined active efforts and interventions from universities at undergraduate level, orthopaedic departments at trainee level and representative associations at all levels are still necessary, with special attention focused on the growth and development of females pursuing careers in orthopaedic surgery.

Tanzania

Tanzania is an East African nation with a population of 51 million. It faces major challenges such as poor infrastructure, low education levels, poverty, and disease including musculoskeletal injuries, contributing to high mortality and disability. Tanzania has one of the lowest physician-to-population ratios (3.1:100,000) in the world, despite the high disease burden. In 2006, only 20% of doctors practiced in the rural areas where 73% of the population live. The Tanzania Development Vision 2025 commits the nation to providing universal access to quality primary healthcare. To fulfil this vision, the government has committed to increase the health workforce to meet the population demands resulting in a 28-fold increase in medical student intake over a 24-year period (from 55 to 1580 per year). Despite this, only 7.6% of the 118 orthopaedic surgeons and 5.3% of the 51 orthopaedic trainees are female. The College of Surgeons of East, Central and Southern Africa (COSECSA) with the Tanzania Development Vision 2025 aims to increase the number of surgeons in the region. Women in Surgery Africa (WISA), under the umbrella of COSECSA, has established a mentorship programme in each of its member countries including Tanzania. The American College of Surgeons is also committed to supporting WISA and the education and training of young female surgeons.

Malawi

Currently there are 13 qualified orthopaedic surgeons in Malawi, including three women, covering a population of 17.5 million. Five are from other countries: three from within Africa, two from Europe. As of January 2020, there are five orthopaedic trainees; one is female. ¹⁹

United States of America (USA) and Canada

In 2019, 6% of the 27,651 board-certified members of the American Academy of Orthopaedic Surgeons (AAOS) and 15.4% of the 3,963 residents were female. ²⁰ There are fewer than five female chairs of major orthopaedic departments.

The American Academy of Orthopaedic Surgeons (AAOS) now has its first female President and is implementing the 2019–2023 Strategic Plan which includes greater transparency in committee appointments, diversity in committee membership and training on diversity and implicit bias for Academy leaders, volunteers, and staff. A diversity dashboard measures the key recruitment, selection, retention and culture metrics and in 2020, the Board of Directors will be 25% female. ²¹ The goals of the Ruth Jackson Orthopaedic Society, The Perry Initiative and the Nth Dimension are to increase the number of women in medicine and engineering and eliminate disparities for all communities. ^22,23 Numerous efforts are in place in North America to improve diversity. The focus has been on reducing unconscious bias, encouraging women in leadership roles, mentoring young women, engaging female medical students to consider orthopaedics, creating an environment that is inclusive of women and providing support for both men and women with family commitments. ^21–23

In Canada in 2018, 198/1659 (11.9%) of practicing orthopaedic surgeons were female and in 2019, 26% of residents or fellows were women. ²⁴ The Canadian Orthopaedic Association (COA) 2019 Gender diversity strategic plan, provides key strategies and practical actions to promote and advance gender equity within Canadian orthopaedics. ²⁵ In Canada women are now represented through the orthopaedic specialty and in their national professional organization. At the COA annual meeting the number of females on the podium is in keeping with the percentage of female members in the association. ²⁶

South America

The percentage of female trauma and orthopaedic (T&O) surgeons varies between countries. Six percent of the Chilean Society of Orthopaedics and Trauma (SCHOT) are women in contrast to 13% of trainees. In Perú, women represent 4.8% of the total registered traumatologists but less than 2% of the National Society of Orthopaedics and Trauma (SPOT).

In order to increase opportunities for and participation of women in the speciality, various initiatives have started with the first T&O women’s association founded in Chile in 2019, focussing on equal opportunities in selection processes, avoiding gender discrimination, mentoring and providing network support. Since then, other societies have been founded in Latin America, such as the Peruvian Female Orthopaedic Surgeons Society. Further efforts are aimed at promoting and increasing the participation of women in different fields of T&O and strengthening networks between Latin American countries.

Australia

In Australia, only 4.3% of orthopaedic surgeons and 15% of orthopaedic trainees are female. A recent AOA initiative has assessed the two-stage orthopaedic trainee selection process for gender bias. Initially, a score based on the applicant’s CV and training supervisors is generated, then the highest-scoring 50% are interviewed and, of these, 50% will be selected onto the training programme. Data from 2007 to 2019 showed that females represented 16.5% of applicants to orthopaedic training but only 12.1% of the successful applicants. A significant gender difference favouring male applicants was demonstrated in stage 1 of the selection process. In 2018–2019, almost 50% of the interviewers were female (compared to only 11% between 2011–2017) and this has eliminated gender bias in the interview stage of selection. As a result, the AOA is increasing the percentage of applicants that will be interviewed to more than 80% and considering interviewing all applicants with the required basic CV application criteria in the future.

In 2018, the AOA established a diversity strategy to address the persisting lack of gender diversity. Again, key initiatives included supporting females in leadership roles, improving female representation on boards, providing childcare and breastfeeding facilities, setting up workshops, championing change through male diversity advocates, providing female examples in orthopaedics on social media and publishing a quarterly newsletter promoting diversity. ^27–29

Estonia

During 2014–2019, 64% of medical graduates have been female. Currently, 36% of orthopaedic trainees are female. The increasing number of female orthopaedic trainees is a reflection of the more generous parental leave policies dictated by national laws. A reduced workload in the third trimester is accepted and after birth, parental benefits guarantee the previous income. Such benefits are paid for a period of 435 days, or until the child is 18 months old. It is possible to stay at home until the child turns three years without losing health insurance or employment. Until the child is 70 days old, only the mother is entitled to the parental benefit but after this either parent may receive it.

France

In France, there are concerns that over the next 20 years, the medical profession will be affected by reducing workforce numbers due to ageing and feminization. ³⁰ The number of orthopaedic surgeons has risen sharply in 30 years, increasing from 1.44:100,000 inhabitants in 1981 to 4.3 in 2013. Between 2006–2019, the proportion of females increased from 3.3% to 7.0%, and it is higher in younger age groups. In 2015, there were 14% females in the 30–34 age group, compared with 0% in the 65–69 age group. In 2019, France had 248 female orthopaedic surgeons. The proportion is significantly higher in hand surgery, where 20% of members and 38% of junior members are women. ³¹

Kosovo

In Kosovo, orthopaedic surgery was established as a specialty in the 1970s. Currently, there are 78 orthopaedic surgeons and 12 trainees. Only 3.8% of orthopaedic surgeons are female and there are no female trainees. However, two of these three female orthopaedic surgeons have leadership positions in the Orthopaedic and Traumatology Society. There is no fixed quota for training female surgeons but, when candidates are considered equal, the female candidate has priority. ²⁸

Sweden

Over the last 25 years, the number of female orthopaedic surgeons has increased from 6% to 17%. ³² Currently, 35% of residents are female, reflecting the increasing number of female medical students. In 2018, 56% of medical graduates were female. ³³ Sweden has generous parental leave of 390 days with three months available for each parent. This has increased diversity in parental leave and in 2018, 29% of all parental leave was used by males. ³⁴

Gulf co-operating countries (GCC) and Kuwait

It was not until the mid-1980s that women began to receive surgical training in these countries, so a significant gender disparity still persists. ³⁵ The low female participation in orthopaedic surgery can be attributed to many issues. Female faculty members make up only 10% of Kuwait University’s Department of Surgery. Currently, there are three female orthopaedic surgeons in Kuwait, but only one is a Kuwaiti national. Between 2014 and 2019, five females completed orthopaedic training in Kuwait compared with 51 males.

Despite the large regional demand for more orthopaedic surgeons, in Kuwait, only one woman was accepted into orthopaedic residency training for 2020. Accurate data for Kuwaiti females in residency programmes abroad is not available.

There is a perception that females in the GCC are less likely to match than males in an orthopaedic residency programme. Poor maternity and parental benefits in Kuwait appear to be a deterrent, with the majority of females in orthopaedic surgery residencies in the GCC being single (data from the Ministry of Health).

Hong Kong

The first female orthopaedic surgeon was appointed in 1993. As the proportion of female medical students has reached parity, the number of female orthopaedic trainees has increased to 20%. In Hong Kong, all trainees are employed by the Hospital Authority. There is equal pay and parity of treatment. All female doctors are entitled to up to 14 weeks of maternity leave and, on return, each hospital is committed to providing a space for breastfeeding. Part-time surgical training is not available. Consequently, most female orthopaedic trainees elect to have children after training has been completed. ²⁷

Asia, Malaysia and the Philippines

Prior to 2000, female orthopaedic surgeons were unusual in Asia, but the turn of the millennium saw an increasing female presence in both orthopaedic training and practice. The three female Malaysian orthopaedic surgeons in 1999 were joined in 2000 by three more female graduates from the National University of Malaysia. Since then, there has been a steady increase of females in the orthopaedic postgraduate programmes. Recent advocacy by the female Malaysian Orthopaedic Association President at Orthopaedic Association meetings throughout Asia has highlighted the issue of gender diversity in orthopaedics.

United Kingdom

In general, UK data and the initiatives developed by the British Orthopaedic Association (BOA) and the British Orthopaedic Trainee Association (BOTA) mirror those of other European and international strategies. National statistics suggest that over the last decade the number of female consultant T&O surgeons has only increased from 4% to 6%; during the same period the percentage of female trainees has doubled at the junior level (15% to 30%) and risen from 13% to 19% at registrar level. Within the BOA, 12% of consultant members are women suggesting a willingness to ‘belong’ and the percentage of ‘early years’ consultant members is rising. Twenty-eight percent of BOTA committee members are female. Some subspecialties, notably paediatric orthopaedics, are significantly more diverse at national (25% female consultants), European and international levels (Table 1) whilst others such as spinal surgery have yet to make progress. The BOA sponsors one female delegate per year in a Future Leaders Programme and is encouraging female participation in research applications.

USA

Females have been permitted to serve in permanent roles within the US Armed Forces since the Women’s Services Integration Act was passed by the United States Congress in 1948. Previously, women only served in times of war and were barred from combat roles. Since 1980, females have seen an increased role in the military, from attending US military academies starting in 1976 through the 2013 reversal of the combat exclusion policy and presently inclusion in special operations forces. Females accounted for approximately 2% of the military workforce at the end of the draft in 1973 but most recent data show that 18% of the US military officer corps is female. ³⁶

Despite females representing nearly 50% of the US medical school graduates annually in the civilian sector, in 2016, only 28.5% of military physicians were female, mirroring overall gender differences in the US military. Most of the female physicians are in the junior ranks with only 18% reaching the rank of Colonel. ³⁷

Given the smaller overall female applicant pool within military healthcare, the Department of Orthopaedics at San Antonio Military Medical Center (SAMMC) has far outpaced national US averages for female orthopaedic surgeons in training and on staff. The 2019 AAOS data showed that 6% of staff surgeons and 15% of residents were female, whilst the SAMMC Dept of Orthopaedics was represented by 26% female attendings and 23% female residents. This jumps to 30% faculty and 27% residents for the 2020–2021 academic year. Actively recruiting strong female leadership (including the first female Vice Chair) and the presence of female staff surgeons has led to a reciprocal rise in female residents via a culture that not only recruits female orthopaedic surgeons but helps with their faculty development and subsequent promotion.