Month: April 2022

Diversity, Equality and Inclusion in Orthopaedics

The lack of diversity within the orthopaedics industry has been well documented over the past several years.

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[us_iconbox icon=”fas|fas fa-user-md-chat” style=”circle” size=”20px” iconpos=”left” title=”Contributor” title_size=”20px” title_tag=”h3″ alignment=”left” css=”%7B%22default%22%3A%7B%22font-family%22%3A%22Roboto%22%7D%7D”]Stephanie Muh, MD
Deputy Chief of Service in the Department of Orthopaedics Henry Ford Hospital West Bloomfield[/us_iconbox][us_separator]

Since the 1970s the percentage of women entering medicine has steadily increased, and currently 51% of matriculating medical students are female. The number of females entering surgical specialties has also steadily increased. While the many surgical subspecialties including neurosurgery, plastic surgery, urology, and others have seen continued growth of female surgeons, orthopaedics unfortunately has not seen the same growth.1,2,3 Orthopaedics has only seen a 2-3% increase since 1990.

Overall, orthopaedic surgery ranks last (5.8%) in the percentage of practicing female physicians, and that percentage has not dramatically changed when discussing training programs where it continues to rank last in the percentage of female residents (16% as of 2020) and underrepresented minorities (URMs)(7.7% in 2020).2,4,5,6 At the current rate of 3% growth per year, it would take 217 years to reach parity in orthopaedics.6 This reflects the lack of growth in diversity.

At the current rate of 3% growth per year, it would take 217 years to reach parity in orthopaedics.6

Of concern, recent work has identified the American Shoulder and Elbow Surgery society (ASES) as having one of the lowest percentages of female members.7 Only the scoliosis research society, the knee society, cervical spine research society, and hip society rank lower. Clearly, there is much room for improvement for inclusion with Orthopaedics as well as within our specialty. While there are many factors that influence the advancement of diversity, a few important topics will be discussed.

Why Do We Need to Improve Diversity? 

An abundance of literature demonstrates underrepresented minorities have worse outcomes compared to Caucasian patients even when accounting for socio-economic factors. Additionally, patients want to be treated by those who look like them as patient satisfaction improves with communication among people who share similar social, cultural, and linguistic experiences.2

Finally, recent evidence suggests that patients who are treated by physicians of the same race, ethnicity, cultural background, or gender feel more comfortable with their care and tend to have better outcomes.8 With 12.4% of the U.S. population identifying as African American and 51% of the population being women, clearly the orthopaedic community does not reflect the current population.

Ways to Improve Diversity 

Bias (explicit, implicit)

Bias can be both implicit and explicit through a variety of ways including personal interactions, institutional cultures, recruitment and hiring processes, as well as professional evaluation processes.9,10 All of these processes have the potential to subtly disadvantage underrepresented minorities and women.

Explicit biases are demonstrated by those who believe that women should simply not be orthopaedic surgeons because they do not possess the strength, intelligence, temperament, or other characteristics. Those are often easily identified within society. However, implicit bias, which is likely much more prevalent but difficult to identify, has been defined as a reflection of unconscious attitudes or stereotypes that affect individual decisions and actions. Correction of implicit bias centers on self-awareness of the problem and a desire for change. To improve diversity, leaders must first recognize that bias exists (often within themselves as well) and then have the desire to eliminate it. Only then can leaders work to gain “buy-in” from fellow members (partners, colleagues, and faculty).

To achieve this, bias literacy (the uncovering, defining, and understanding of implicit bias so it may be made explicit) is a necessity. The Harvard Implicit Association Tests (IAT) is a free online tool used to detect and measure implicit bias. This test should be required of all participants to evaluate bias among team members.

The hiring process is just one example of how implicit bias perpetuates the lack of diversity within our profession. Within the recruitment and evaluation process, bias tends to flourish when such processes are unstructured or informal. Additionally, evidence suggests that interviewers preferred men, Caucasian-sounding names, a lighter skin tone, taller individuals, and personality traits most associated as male attributes. To counteract this implicit bias, it has been recommended that during the recruiting process committees establish a specific set of criteria and commit to the value of credentials before evaluating individual applicants.

Mentors and Advocates 

Mentors and advocates are critical to the development and advancement of surgeons, especially in academic medicine.9 While they are often used interchangeably, and can be the same person, they are in fact two separate qualities.

A mentor is an individual who provides guidance through the process of navigating a career path from past experiences of the mentor. An advocate actively creates opportunities for promotion and progression to leadership positions are more closely tied to the concepts of advocacy and sponsorship than to mentorship.

The difference between these roles is clear: a mentor helps one think through the process of navigating his or her career, whereas an advocate is a person with influence and who creates opportunities for others toward promotion and career advancement. Women and URMs are in need of more mentors and advocates in order to improve diversity within our profession. Increasing exposure of women and URM surgeons on podiums and major speaking roles at conferences, meetings, and teaching events is just one way an advocate can help with progress.

When an audience sees a diverse faculty at events it helps cultivate the principle of being a diverse organization. It should be noted that not all mentors or advocates need to be of the same race or gender. Especially in the current state with the limited number of active female and URM surgeons, strong male leaders can provide both mentorship and act as advocates. My personal experience has seen several male orthopaedic colleagues provide crucial mentorship as well as become an advocate for my professional development.

Several organizations have been created to help address this issue (Perry Initiative, Ruth Jackson Society, J Robert Gladden Society, Orthopaedic Diversity Leadership Consortium, Nth Dimension), and evidence suggests that these organizations are making an impact. URM and women who attended a medical school at an institution with high URM and female representation on the faculty and residency were more likely to apply to orthopaedics. However, more support and recognition are necessary to continue to diversify our profession. It has also been identified that early exposure to orthopaedics has increased awareness of the specialty to women and URMs.

Many subspecialities have recently organized Diversity, Equality, and Inclusion (DEI) committees. ASES leadership organized a DEI subcommittee, and with executive board mentorship and advocacy our committee has accomplished several impressive achievements within only a few years. The list of achievements includes sponsorship of a Nth dimension summer intern in shoulder/elbow, the creation of an ASES scholars program introducing local medical students to the field of shoulder and elbow surgery, and junior resident scholarships for ASES/AAOS shoulder/elbow courses, and a medical student/resident webinar to expose the specialty of shoulder and elbow surgery to a younger group of future physicians.

The recent increased recognition regarding the need for diversity is encouraging. While recent progress is promising, there needs to be a continued long-term effort to change the culture of diversity within our specialty and orthopaedics as a whole. Without a sustained focused goal of change in culture, the progress made to date is at risk for failure.

Finally, the topic of diversity in orthopaedics should not be limited to surgeons. Diversity within our industry as well as support from staff should also be targeted. As a female surgeon, I want to also work and collaborate with companies who have demonstrated a clear dedication for improving diversity within our workforce.

The mentioned topics are just a small subset of many additional factors not mentioned in this blog post, but they are meant as a possible catalyst for discussion as well as achievable actionable items. While the overall goal is to increase membership of women and URMs, we also must be cognizant of these individuals’ qualifications and if they can uphold the standards of professional care that should be expected of every orthopaedic surgeon.

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References

  1. Poon S, Kiridly D, Mutawakkil M, Wendolowski S, Gecelter R, Kline M, Lane LB. Current Trends in Sex, Race, and Ethnic Diversity in Orthopaedic Surgery Residency. J Am Acad Orthop Surg. 2019 Aug 15;27(16):e725-e733. doi: 10.5435/JAAOS-D-18-00131. PMID: 30676512.
  2. Ramirez RN, Franklin CC. Racial Diversity in Orthopedic Surgery. Orthop Clin North Am. 2019 Jul;50(3):337-344. doi: 10.1016/j.ocl.2019.03.010. PMID: 31084836.
  3. American Association of Medical Colleges. 2020 facts: applicants and matriculants data. 2020.https://www.aamc.org/data-reports/workforce/report/physician-specialty-data-report
  4. Vij N, Singleton I, Bisht R, Lucio F, Poon S, Belthur MV. Ethnic and Sex Diversity in Academic Orthopaedic Surgery: A Cross-sectional Study. J Am Acad Orthop Surg Glob Res Rev. 2022 Mar 8;6(3):e21.00321. doi: 10.5435/JAAOSGlobal-D-21-00321. PMID: 35258489; PMCID: PMC8906469.
  5. Okike K, Phillips DP, Johnson WA, O’Connor MI. Orthopaedic Faculty and Resident Racial/Ethnic Diversity is Associated With the Orthopaedic Application Rate Among Underrepresented Minority Medical Students. J Am Acad Orthop Surg. 2020 Mar 15;28(6):241-247. doi: 10.5435/JAAOS-D-19-00076. PMID: 31305355.
  6. Haffner MR, Van BW, Wick JB, Le HV. What is the Trend in Representation of Women and Under-represented Minorities in Orthopaedic Surgery Residency? Clin Orthop Relat Res. 2021 Dec 1;479(12):2610-2617. doi: 10.1097/CORR.0000000000001881. PMID: 34180873; PMCID: PMC8726541.
  7. Saxena S, Cannada LK, Weiss JM. Does the Proportion of Women in Orthopaedic Leadership Roles Reflect the Gender Composition of Specialty Societies? Clin Orthop Relat Res. 2020 Jul;478(7):1572-1579. doi: 10.1097/CORR.0000000000000823. PMID: 31180910; PMCID: PMC7310307.
  8. Hill A, Jones D, Woodworth L. Physician-patient race-match and patient outcomes. Available at: https://papers.ssrn.com/abstract=3211276. Accessed May 5, 2020.
  9. Scerpella TA, Spiker AM, Lee CA, Mulcahey MK, Carnes ML. Next Steps: Advocating for Women in Orthopaedic Surgery. J Am Acad Orthop Surg. 2021 Nov 10. doi: 10.5435/JAAOS-D-21-00932. Epub ahead of print. PMID: 34780383.
  10. Samora JB, Ficke JR, Mehta S, Weber K. True Grit in Leadership: 2018 AOA Critical Issues Symposium Addressing Grit, Sex Inequality, and Underrepresented Minorities in Orthopaedics. J Bone Joint Surg Am. 2019 May 15;101(10):e45. doi: 10.2106/JBJS.18.01276. PMID: 31094992.
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New Study Shows No Revisions and a Low Complication Rate for Exactech’s Vantage® Total Ankle Fixed Bearing System

This study, published in Foot & Ankle Surgery: Technique, Reports & Cases in March, is the Vantage Ankle’s third outcome publication but the first for its fixed bearing total ankle arthroplasty system.

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Exactech Vantage Total Ankle

Gainesville, Fla (April 14, 2022) – Exactech, a developer and producer of innovative implants, instrumentation, and smart technologies for joint replacement surgery, announced today that an independent retrospective study reported positive two-year clinical outcomes with the Vantage Ankle Fixed Bearing System. This study, published in Foot & Ankle Surgery: Technique, Reports & Cases in March, is the Vantage Ankle’s third outcome publication but the first for its fixed bearing total ankle arthroplasty system. The prior two studies focused on its mobile bearing counterpart, which is used overseas.

The two-year minimum clinical outcome study, performed by Aaron T. Scott, MD, Matthew A. King, DPM, and Bryanna D. Vesley, DPM, at Wake Forest Baptist Medical Center in Salem, N.C., included 22 consecutive patients with an average of 24.6 months follow-up. They reported positive results and demonstrated a statistically significant reduction in pain scores, low complication rates, and a 100 percent implant survivorship at short-term follow-up.1 All surgeries were performed by Dr. Scott, an independent researcher.

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...Over the past 3.5 years, my patients have reported a high level of overall satisfaction, substantial reductions in pain severity, and functional improvement following implantation of the Vantage Ankle...
Aaron T. Scott, MDWake Forest Baptist Medical Center
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“I was initially drawn to the Exactech Vantage Total Ankle’s anatomical design of its talar component.2 Once I began using it in 2018, I was ultimately sold on the intuitive design of the instrumentation as I felt that it allowed me to maximize my efficiency in the operating room and obtain component alignment,” said Dr. Scott. “However, I have been even more impressed by our early clinical results. Over the past 3.5 years, my patients have reported a high level of overall satisfaction, substantial reductions in pain severity, and functional improvement following implantation of the Vantage Ankle.” 1

Additional findings on the Vantage Ankle System were recently published, highlighting its mobile bearing implant, which is available for use outside the United States. Both outcome studies were published in the Journal of Clinical Medicine in February 202123 and June 20213.

Both studies reported no revisions, statistically significant decreases in pain scores, and statistically significant increases in range of motion after a minimum of one-year follow-up. All surgeries for the February study were performed by Vantage Ankle design surgeon Prof. Victor Valderrabano, MD, chairman of the Swiss Ortho Center in Basel, Switzerland, while Massimiliano Mosca, MD, of Italy’s Istituto Ortopedico Rizzoli, performed the surgeries for the June study as an independent researcher.

“The Vantage Ankle Mobile Bearing System offers axial tibial fixation, a low-profile curved talus, and a mobile inlay. Because the system is designed to recreate the natural biomechanics of the ankle and foot, I believe my patients will feel like they have their natural ankle joint,” said Prof. Valderrabano. “Dr. Scott’s study is one more outcome study that validates the success of the Vantage Ankle. I trust it gives my patients quality of life and helps them get back to their desired sports activities.”

Exactech is committed to clinical research and developing innovative orthopaedic implants which deliver positive clinical outcomes that help both patients and surgeons. Two more Vantage Ankle studies are expected to be published later this year. To learn more about our full foot and ankle portfolio, visit exac.com/foot-and-ankle/.

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About Exactech

Exactech is a global medical device company that develops and markets orthopaedic implant devices, related surgical instruments and the Active Intelligence® platform of smart technologies to hospitals and physicians. Headquartered in Gainesville, Fla., Exactech markets its products in the United States, in addition to more than 30 markets in Europe, Latin America, Asia and the Pacific. Visit staging.exac.com for more information and connect with us on LinkedIn, VuMedi, YouTube, Twitter and Instagram.

  1. King M., Vesley B., Scott A. Early Outcomes with the Vantage Total Ankle Prosthesis. 2022. Foot& Ankle Surgery: Techniques, Reports & Cases. https://doi.org/10.1016/j.fastrc.2021.100121.
  2. Valderrabano V. et al. Mobile Anatomical Total Ankle Arthroplasty – Improvement of Talus Recentralization. Journal of Clinical Medicine. 2021 Feb; 10 (3):554. https://dx.doi.org/10.3390%2Fjcm10030554.
  3. Mosca M. et al. Clinical Radiographical Outcomes and Complications After a Brand-New Total Ankle Replacement Design Through an Anterior Approach: A Retrospective Short-Term Follow-Up. Journal of Clinical Medicine. 2021 Jun; 10 (11):2258. https://dx.doi.org/10.3390%2Fjcm1011225.
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Media contact

Nancy Walsh
Director, Marketing Communications
(352) 377-1140
media@exac.com