A recent STAT article by Usha Lee McFarling identified orthopedic surgery as “the whitest specialty.” That’s a problem many, perhaps most, orthopedic surgeons are aware of. But seeing it stated so bluntly is jolting. It’s disconcerting to think that the orthopedic community is making so little progress toward achieving the principal ideal articulated in our country’s fundamental declaration of moral values: that all people are created equal and that they have inalienable rights – in our case, that everyone, Black, brown, as well as White, has the right to the same high level of medical care.
Unfortunately, as study after study has shown, minorities do not enjoy the right to equitable care. Instead, they are subject to disparities in treatment and outcomes that speak to the prejudices that are built into the health care system and are present – sometimes consciously, but most often subconsciously – in the minds of physicians. One important contributing element to these disparities is the paucity of minority practitioners. Studies have also shown that Black patients, for example, respond better to Black physicians, who so often share a psychological and cultural sympathy unavailable to most White physicians. It’s for that reason that being identified as “the whitest specialty” is so immensely troubling.
In researching her STAT article, Ms. McFarling spoke with American Academy of Orthopaedic Surgeons leaders, practicing surgeons, residents, and med students about the dearth of minority and female orthopedic surgeons. What she heard was perplexity and frustration about why better progress hasn’t been made toward correcting the gross underrepresentation of everyone other than White men. The AAOS, she noted, was one of the first specialties to recognize the lack of diversity and over the years has put in great effort to address the problem, creating task forces, committees, and diversity awards and sponsoring conferences and discussions. Yet progress has been glacial, at best.
From her respondents, Ms. McFarling heard an array of reasons for this. Black, Hispanic, and Native American persons are underrepresented in medical schools, so the pool of potential applicants for orthopedic residencies is shallow to begin with. STEM studies are notoriously inadequate in poorer primary and secondary schools, in which so many minority students are educated. The MCAT and USMLE Step 1 test, which play a role in acceptance to residencies, have been shown to be biased. The specialty has few Black or brown role models and, consequently, few advocates and a lack of mentorship. Overt bias may be fairly rare (though microaggressions are still a common and ongoing problem), but most minority and female orthopedic surgeons feel strongly that implicit or subconscious bias is entrenched and works against acceptance to residencies, success in residencies, and advancement in the field.
One of this article’s authors (AW) saw all these factors at work as a resident, then as an admissions committee member at both Yale and Harvard. But the fact is that other medical specialties face exactly these problems and barriers, and yet have been substantially more successful in overcoming them.
What seems to be distinctive about orthopedics is that the mindset which perpetuated (and still perpetuates) In this regard, Kristy Weber, MD, the first female president of the AAOS, told Ms. McFarling that the critical first step to bringing in more women or people of color is changing the culture. There seems to be a consensus about that.
So, what does that mean, given that the AAOS has made serious efforts in that regard that have clearly been less than effective?
The answer, as we see it, is first – to not give in to frustration. The time frames involved in changing customary states of mind are typically elongated, and the deeper the habituation, the longer transformation takes. Deep changes always mean a long, hard slog. For transformations of this sort to take place, the requirements are a general agreement on the value of the transformation, exposure to the destructive consequences of the customary modus operandi, and persuasion for why change needs to happen.
In orthopedics, the first requirement has been met. The AAOS espouses diversity and inclusion as a high-level value. In terms of the second two requirements – exposure and persuasion – orthopedic surgeons have been witness to events, campaigns, conferences, et cetera. But these have not been enough, which means that efforts need to be focused, enlarged, sustained, determined, and innovative.
Does the orthopedic surgery community have the ability to do that?
The answer is: Yes, it does.
Currently the orthopedic surgeon community boasts a number of organizations, groups, and individuals pushing for change, in addition to the AAOS’s Diversity Advisory Board. The predominantly African American J. Robert Gladden Orthopaedic Society, the Ruth Jackson Orthopaedic Society of female orthopedic physicians, and the Association of Latino Orthopaedic Surgeons are all energetic advocates, as is Nth Dimensions, the Perry Initiative, and various ad hoc and individual endeavors.
These are all strong proponents for their own groups in their own way. But history has shown in so many cases that concerted rather than individual action empowers advocacy, and what orthopedic surgery needs in its current situation of gross underrepresentation of minorities and women is an enhanced campaign to raise awareness and redouble persuasion.
One of many examples of the power of collective action is the Association of Minority Health Professions Schools founded by Dr. Louis Sullivan in 1977.* Dr. Sullivan (later secretary of the Department of Health & Human Services) was at that time the founding dean of Morehouse School of Medicine. Morehouse had been launched on a shoestring and needed funding urgently. Other Black health schools, such as Meharry Medical College and Tuskegee College of Veterinary Medicine, were in even more pressing financial need. The coalition of schools that Dr. Sullivan organized became a powerful force in Congress and the National Institutes of Health, magnitudes more effective in raising funds from government and other sources than the best individual efforts of the separate institutions.
Dr. Sullivan’s association is only one of a multitude of historical examples of the effectiveness of unified action. AAOS currently has no single officer charged with bringing together the efforts of the change assets that already exist. It could, perhaps should, have someone in that position. AAOS could invest that same office with a mandate to survey the other medical specialties and bring to bear the most effective diversity, equity, and inclusion (DEI) practices in their arsenals.
Finally, despite the attention AAOS has brought to DEI needs, a look at the organization’s strategic goals, its core values, and its “key enablers” finds not a single mention of diversity or inclusion. Given the country’s current focus on the need for equality, given the poor performance of the orthopedic surgery specialty in terms of inclusion, the obvious question is: Should there not be an official declaration positing diversity as a primary AAOS desideratum?
There is recent precedent for this in the American College of Physicians/American Board of Internal Medicine’s Physician Charter on Professionalism, which includes “social justice” as a primary goal of medical practice. This highlights and reinforces the humanitarian strivings of the profession. In light of the paralysis illuminated by Ms. McFarling’s STAT article, a clear, concise declaration by the AAOS of the value and need for DEI as a central component of the organization’s values should be high on the AAOS order of business. A commitment in that form would serve as a powerful catalyst for bringing orthopedic surgery into step with its sister specialties, as well as affirming the core egalitarian principle that underlies all of medical care.
Dr. White is the Ellen and Melvin Gordon Distinguished Professor of Medical Education and Professor of Orthopedic Surgery at Harvard Medical School, Boston. Dr. Chanoff is a founding board member of the Augustus A. White III Institute for Healthcare Equity. Neither Dr. White nor Dr. Chanoff reported any conflicts of interest. A version of this article first appeared on Medscape.com.
Correction, 2/1/22: An earlier version of this article omitted the title of "Dr." before Dr. Louis Sullivan's name.