Orthopedics' Unique Hurdles for Women
In her fourth year of medical school, Claudette Lajam faced a moment of truth. A burly attending orthopedic spine surgeon held up a rod cutter in one hand, a quarter-inch titanium spinal rod in the other.
"Watch me," Lajam responded. She picked up the tool and severed the rod. It wasn't easy. Her shoulder hurt for a month. It was also unnecessary, because there were ways to cut the rod that didn't require brute strength. But at least she had cleared another of the hurdles that keep orthopedic surgery a mostly male specialty.
Although Dr Lajam—now an assistant professor at New York University—won her board certification in 2009, women who have followed her into orthopedic surgery still face similar barriers.
As of 2015, only 5% of practicing orthopedists were women, the lowest percentage of any medical specialty. And that statistic appears to be changing slowly—in 2010, it was 4%.
Multiple initiatives are under way to address the problem, but leaders in the field say it will take a big effort—and perhaps a change in culture—for the specialty to approach gender balance. Much depends on this work. Not only would women enjoy the same opportunities to this rewarding career, but patients would benefit, researchers say.
Advantages to Diversifying Orthopedics
It's not that male orthopedic surgeons provide a lower quality of care to women, says Mary I. O'Connor, MD, chair of the American Academy of Orthopaedic Surgeons (AAOS) Diversity Advisory Board. And men in the profession don't consciously discriminate against women. In one survey, more than 93% of referring physicians and orthopedic surgeons say that a patient's gender doesn't affect their decision to recommend total knee arthroplasty.
"You could go see an orthopedic surgeon who is a different gender or different ethnic background and still have a great outcome," says Dr O'Connor. "But some patients prefer a doctor who looks like them and feel they can trust such an individual to a greater degree. And trust is essential for patients to be compliant with treatment recommendations."
Epidemiologists have estimated that underuse of arthroplasty is three times higher among women than among men. To explore the reasons for this finding, one team of researchers trained a man and a woman with mild osteoarthritis of the knee as standardized patients. This pair described their symptoms and histories in identical terms to 29 orthopedic surgeons. The surgeons were 22 times more likely to recommend arthroscopic knee surgery to the man than to the woman.
Further evidence for bias comes from Dr O'Connor's own research. She found that on average, women have worse function and more pain at the time of knee replacement surgery than men, and although they improve as much, they don't attain the same level of health that men enjoy after surgery.
A possible explanation for these findings is that orthopedic surgeons take women's symptoms less seriously than men's, so more damage is done by the time women get surgery.
Separate studies show that patients who can identify with their physicians' gender or ethnicity have better outcomes, compliance, trust, and communication, says Bonnie Simpson Mason, MD, a retired orthopedic surgeon and founder and executive director of Nth Dimensions Educational Solutions, an organization working to diversify medicine.
Identifying Barriers to Break Through Them
With such compelling reasons why more women should enter the field, what's keeping them out? After all, women now outnumber men in medical school.Dr Mason cites the sort of attitude that Dr Lajam encountered during her residency.
"Unfortunately, there are myths that are still perpetuated at the undergraduate and medical school level around the field being appropriate for or even open to accepting women," she says. "Traditionally, [orthopedics has] been pegged as more appropriate for the athletic, husky male."
But just how much strength is now required for the field is a matter of debate.
"Most stereotypes have some element of truth," says Lisa Lattanza, MD, a professor of orthopedics at the University of California, San Francisco, and cofounder of the Perry Initiative, which encourages young women to enter orthopedics. "There is a lot of sports medicine involved in what we do. Some, though not all, of the surgery requires a bit of strength, but not to the extent that some medical students believe it does."
And even small women can succeed, says Dr Lattanza, who was 5'4" and weighed 120 pounds in her residency. "You have to be smarter than the bone, not stronger than the bone. You use body mechanics and leverage when you need additional force."
Dr Lajam has even run into objections from patients who think she might not be strong enough to operate on them. "Usually, this is when they are sitting on the exam table, often before I examine them," she says. "I generally don't answer—I just move the exam table with them on it so I can get around to the other side of it. That usually satisfies them."
Women expressing interest in the specialty also sometimes encounter a warning that it's not conducive to raising a family. That's no more true than in any other surgical specialty, and some, including general surgery, have much higher representations of women, points out Dr Lattanza.
Yet opposition to women entering the field persists. As recently as last year, Dr Lattanza heard from a medical student who interviewed for a residency in orthopedic surgery, only to be told by the interviewing physician that the specialty was not for women.
And sexism doesn't end with board certification. Dr Lajam recalls a meeting of a department safety committee in which a colleague referred to all of the male doctors with the honorific "Doctor" followed by their last names, but he referred to Dr Lajam by her first name. When she called him out on it, he thanked her and said he hadn't been aware he was making this distinction.
In an elevator, Dr Lajam was startled when another physician said, "Nice ass." The man was a colleague of her father, a cardiothoracic surgeon, and she wanted to show him how ridiculous his comment was.
"That's very nice that you noticed it," she said. "You know, I think my father would be very proud that you think I have a nice ass. I'm going to tell him that you said that." He ran out of the elevator after her to apologize.
She advises women in the field to speak out frankly but to avoid antagonism. "You don't want to polarize people more," she says. "You try to make people see things."
Helping Female Surgeons Find Each Other
Dr Lajam has brought that approach to the Ruth Jackson Orthopaedic Society (RJOS), an organization of women orthopedic surgeons, where she is serving as president. She has focused on encouraging institutions within the field to put women in visible positions.
RJOS recently created a database matching women to their expertise within the specialty, so that event organizers can more easily find female speakers and researchers can more easily find female collaborators.
A 2015 study by members of the Musculoskeletal Tumor Society found that men publish more overall, but that the difference could be explained by academic rank, because a higher proportion of men are in more senior positions. In general orthopedic publications, women make up a proportion of authors similar to their low representation in the specialty.
The Perry Initiative, cofounded by mechanical engineer Jenni Buckley, PhD, complements the work of RJOS by hosting day-long seminars for high school girls. Participants meet female engineers and surgeons, perform mock orthopedic surgery and conduct biomechanical engineering experiments. The organization also connects medical students to mentors and peers, and introduces fracture fixation techniques and power tools.
Taking a similar approach, Nth Dimensions brings orthopedic surgeons who are women or members of ethnic minority groups into undergraduate programs and medical schools to give talks and lead workshops. It conducts internships and professional development workshops, and provides housing grants for students to attend specialty association annual meetings.
Signs of Progress, and Remaining Work
In these encounters, women in the field explain that orthopedics is one of the most enjoyable specialties in medicine because practitioners can so often help improve their patients' lives in tangible ways. "I love my job," says Dr Lajam. "I think it's very fun. Somebody comes into your office and they can't walk. You do an operation, and then they can walk."
The efforts have shown some signs of bearing fruit. In a survey of participants of the Perry Initiative medical school program, 28% matched in orthopedic residencies for 2016, almost double the 14.8% of women in US orthopedic residencies.