Clinical Relevance vs Statistical Significance: The Good, The Bad, and The Future of Sexual Harassment in Orthopaedic Surgery
This guest post comes from Jennifer Beck, MD.
As a female, mid-career orthopaedic surgeon, I believe I bring a unique perspective to reporting on the changes that I have witnessed over the past 15 years in academic orthopaedic surgery. It is well documented that ours is an overly White, male-dominated field, often associated with the stereotype of “dumb jock” doctors bringing locker-room humor to the operating room. Stereotypes and parodies abound on various social media platforms. Additionally, it is widely known that cultural and demographic change in orthopaedics has occurred at a pace slower than in other fields in medicine.
I must clarify that the news isn’t all bad. Traiblazing individuals including female orthopaedic department chairs (Drs. Lisa Lattanza, Susan Bukata, Michelle Caird, April Armstrong, Valerae Lewis, Leesa Galatz, and Evalina Burger) and society presidents (Drs. Kristy Weber, Lori Karol, Serena Hu, Mary O’Connor, Heather Vallier, Bess Brackett, Marybeth Ezaki, Jo Hannafin, Judy Baumhauer, Lisa Cannada) and groups like the Ruth Jackson Orthopaedic Society, SpeakUp Ortho, the International Orthopaedic Diversity Alliance, and The FORUM have created pathways for positive change in support of diversity. At a time when health care is being attacked from all sides, we must band together for change and cannot lose momentum they have created.
When reviewing statistical analysis of my clinical research, the perfectionist in me wants to achieve that elusive “statistical significance” so I can say, “Yes, there was a difference.” However, when finding nonsignificant results, I am often left wondering if they are clinically relevant or useful. At the recent 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons, Dr. Emily Whickers and colleagues presented a poster on sexual harassment in the field of orthopaedics. Based on a survey of members of the Ruth Jackson Orthopaedic Society, her group initiated their study “to better understand harassment in orthopedic medicine in light of ‘the stories that we had all heard,’” Whickers told MedPage Today.
They did not find a statistically significant decline in harassment during orthopaedic training, with 59% of the current residents reporting harassment vs 72% of the past residents; p = 0.10. How can orthopaedic surgery continue to make progress toward “significance”?
Encouragingly, the authors did find a trend that current residents felt more comfortable reporting harassment, a step toward defining and acknowledging the problems through a supportive culture. Now is the time to thoughtfully reflect on and openly discuss successful programs that have been instituted and their effect. We can learn from other’s successes, and failures.
As we do so, let’s discuss options to the 4 characteristics that contribute to this problem as reported by the National Academies of Sciences, Engineering, and Medicine:
- Male-dominated field
- Improve the pipeline of female/nonbinary, LGBTQ, and underrepresented minority members of our field through programs and organizations such as the J. Robert Gladden Society and The Perry Initiative
- Create and adequately resource diversity, equity, and inclusion committees and programs
- Appropriately promote and actively retain women (who are leaving medicine at record rates due to the COVID-19 pandemic)
- Organizational tolerance
- Decrease the prevalence of men who “fail up” in medicine
- Create pathways for reporting and evaluating sexual harassment in a safe and nonjudgmental fashion
- Create and support resources for victims of sexual harassment
- Create and enforce repercussions for offenders through education, behavior modification, and situational modification
- Absolve any sense of retaliation through the medical hierarchy
- Hierarchical and dependent relationships during surgical training
- Create an educational environment that is supportive and engaging of open conversations on critical issues and topics
- Identify and resource faculty mentors who can work with victims and perpetrators of sexual harassment
- Isolationist feelings of female residents
- See recommendations from Point 1
- Create programs focusing on the needs of female surgical trainees in all subspecialities
- Hire, promote, and retain female faculty and mentors
- Hire, promote, and retain male faculty and mentors who encourage and engage in open conversations
It is easy to become discouraged when efforts may not be producing the results as quickly as we want. But as numerous Peloton instructors say, “It’s progress, not perfection” that matters. Sexual harassment is not a one-time, one-solution fix. It’s not a checkbox on a to-do list. It’s the daily grind and grassroots cultural change, the need for program and policy creation and implementation, the constant evaluation of program efficacy, and the continued awareness of the struggle that will lead to the progress we desire for an inclusive and safe field of orthopaedic surgery.
Jennifer Beck, MD is a pediatric sports medicine surgeon at UCLA and a member of the JBJS Social Media Advisory Board. She thanks Jennifer Weiss, MD and Selina Poon, MD, both pediatric orthopaedic surgeons, for their help with initial editing of this post.
Strengthening Our Residency Programs through Robust Research
Residency training is an essential pipeline to keeping the field of orthopaedics strong. As I tell the surgeons in my department, we should always be looking for our replacement. Who is going to carry the flag of orthopaedics after our time has passed?
Research related to education and training helps guide us. Continuing a collaboration between the American Orthopaedic Association’s (AOA) Council of Orthopaedic Residency Directors (CORD) and JBJS, the top abstracts from research presented at the 2019 CORD Summer Conference are now available in an article by Weistroffer and Patt on behalf of the CORD/Academics Committee.
Ten studies are featured, with a number looking at aspects of resident screening and selection. For instance, Pacana et al. evaluated use of the standardized letter of recommendation (SLOR) form; while widely adopted, it may not be a cure-all in evaluating applicants, as most applicants were “highly ranked” or “ranked to match.” Work by Secrist et al. suggests that 59 is the number of programs that medical students should target in order to obtain 12 residency interviews (with previous work showing that the average matched applicant attends 11.5 interviews). Alpha Omega Alpha status was the strongest determinant of an applicant’s interview yield. Crawford et al. surveyed residency applicants to find out which characteristics they felt were important to success in an orthopaedic residency. Hard work, compassion, and honesty made the top-10 list each year.
The importance of diversity within orthopaedics is also echoed in the included research. It is well documented that orthopaedic surgery falls far behind other specialties in this area. Among topics explored: potential differences in descriptive terms used in letters of recommendation for male and female candidates, and perceptions of pregnancy and parenthood during residency. Illustrating the importance of exposure and access to role models in orthopaedics, Samora and Cannada found that 80% of female medical students who received a scholarship to attend the Ruth Jackson Orthopaedic Society/AAOS annual meeting eventually pursued a career in orthopaedic surgery. I agree with the authors, who stated, “We must work on diversifying our field and providing opportunities for women and underrepresented minorities to consider a career in orthopaedics.”
I know we will continue to make positive change as a profession. Moreover, I am convinced that the future of orthopaedics is strong, with many with top-notch candidates ready and able to help shape our path.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
“Inflation” and Bias in Letters of Recommendation
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to 2 recent studies in JBJS Open Access.
It’s that time of year when many of us write and review letters of recommendation (LOR) for orthopaedic residency applicants. LOR have always played a large part in the ranking and selection of applicants, and they may be weighed even more heavily during the upcoming “virtual-interview” season. Many applicants present remarkable objective measures of accomplishment, accompanied by 3 to 4 glowing LOR from colleagues. But can all these people really be that good? I am not the first to wonder whether “grade inflation” has crept into the writing of recommendation letters.
As letter writers, we fulfill two important, but potentially conflicting, roles:
- Mentors: We want to support the applicants who have worked with us.
- Colleagues: We want to be honest with our peers who are reviewing the applications.
In addition, this dynamic is now playing out in the context of our profession’s efforts to increase the racial and gender diversity of the orthopedic workforce. This begs the question as to whether there are differences in how we describe applicants based on race and gender.
To help answer that question, our research team analyzed LOR from 730 residency applications made during the 2018 match. Using text-analysis software, we examined race- and gender-based differences in the frequency of words from 5 categories:
- Agency (e.g., “assertive,” “confident,” “outspoken”)
- Communal (e.g., “careful,” “warm,” “considerate”)
- Grindstone (e.g., “dedicated,” “hardworking,” “persistent”)
- Ability (e.g., “adept,” “intelligent,” “proficient”)
- Standout (e.g., “amazing,” “exceptional,” “outstanding”)
We hypothesized that men and women would be described differently, expecting, for example, that agency terms would be used more often for describing men and communal terms more often for describing women.
Our hypothesis was almost entirely wrong. The agency, communal, grindstone, and ability words were used similarly for both male and female applicants. Standout words were used slightly (but significantly) more often in letters describing women. When comparing word usage in LOR for white candidates to those of applicants underrepresented in orthopedics, standout words were more commonly used in the former, and grindstone words were more commonly used in the latter. Interestingly, neither gender nor race word-usage differences were observed when LOR using the American Orthopaedic Association (AOA) standardized letter format were analyzed.
In a separate but related study, we looked at the scores given in each of the 9 domains of the AOA standardized letter of recommendation. These scores clustered far “to the right,” with 75% of applicants receiving a score of ≥85 in all domains. While I am certain that orthopaedic residency applicants are universally very talented all-around, this lopsided scoring distribution makes it very hard to differentiate among candidates. Furthermore, 48% of applicants were indicated as “ranked to guarantee match.” I suspect that the “ranked to guarantee match” recommendation is made more often than it should be. Again, this “inflation” makes it challenging for applicants to stand out – and may have especially important implications in this year’s virtual-interview environment.
What I take away from these two studies is that our natural tendency as orthopedic surgeons is to write effusively about our student mentees. Perhaps the differences in how we describe applicants based on their race and gender can be mitigated by using the AOA standardized letter format, but that format has a profound ceiling effect that makes it hard to discern the “cream of the crop.”
As a specialty, we are truly fortunate to have such excellent students vying to be orthopedic surgeons, and it is quite possible that nearly all of the applicants applying for our residency programs would make great orthopedic surgeons. However, it would help us to have a baseline measure of how we rate our students. Having some kind of benchmark against which to measure our past rankings and how they compare to those of our peers would help immensely.
Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.
Marian Frauenthal Sloane, MD: Ahead of Her Time
In 2016, only 6.5% of practicing orthopaedic surgeons in the US were women. By contrast, 49% of all medical students in the US are women. That apparent discrepancy has sparked concern, conversations, and action in the orthopaedic community.
The current gender imbalance in orthopaedics would be even more stark were it not for two trailblazing women who lived during the early part of the 20th century. One of them, Ruth Jackson, MD, is the well-known namesake of today’s professional society of female orthopaedic surgeons. The other, New York City orthopaedist Marian Frauenthal Sloane, MD, has endured relative obscurity, until now.
The “What’s Important” essay by Hooper at al. in the June 5, 2019 issue of The Journal of Bone & Joint Surgery profiles Dr. Frauenthal Sloane’s short but influential career as orthopaedic surgeon, researcher, author (she coauthored 2 JBJS articles in the 1930s), and teacher. Despite the long way we still have to go to achieve gender diversity in orthopaedics, the authors of this fascinating sketch conclude by saying that “without [Dr. Frauenthal Sloane’s] brief but profound influence, women orthopaedists would probably be in a very different place today.”
Read related OrthoBuzz post about diversity in orthopaedic surgery.
Webinar–Diversity in Orthopaedics: Taking Action to Drive Change
On Wednesday, November 14, 2018 at 8:00 PM EST, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from five orthopaedists with an impressive track record of success in meeting this challenge head-on:
- Regis O’Keefe, MD, PhD, FAOA
- Mary O’Connor, MD, FAOA
- Julie Samora, MD, PhD, MPH
- Kristy Weber, MD, FAOA
- Lisa Lattanza, MD, FAOA
Recognizing the lack of diversity in the profession of orthopaedics as a critical issue, this webinar is one of many AOA initiatives supporting increased diversity within the profession.
Seats are limited, so REGISTER NOW.
Nov. 14 Webinar – Diversity in Orthopaedics: Taking Action to Drive Change
On Wednesday, November 14, 2018 at 8:00 PM EST, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from five orthopaedists with an impressive track record of success in meeting this challenge head-on:
- Regis O’Keefe, MD, PhD, FAOA
- Mary O’Connor, MD, FAOA
- Julie Samora, MD, PhD, MPH
- Kristy Weber, MD, FAOA
- Lisa Lattanza, MD, FAOA
Recognizing the lack of diversity in the profession of orthopaedics as a critical issue, this webinar is one of many AOA initiatives supporting increased diversity within the profession.
Seats are limited, so REGISTER NOW.
Nov. 14 Webinar – Diversity in Orthopaedics: Taking Action to Drive Change
In many areas of the US, the orthopaedic workforce does not mirror the patient population being treated. The need for workforce diversity is more than a social concern or a “good-business” practice. Diversity, or the lack of it, directly affects the quality of patient care as well as access to care.
On Wednesday, November 14, 2018 at 8:00 PM EST,the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from four orthopaedists with an impressive track record of success in meeting this challenge head-on:
- Regis O’Keefe, MD, PhD, FAOA
- Mary O’Connor, MD, FAOA
- Julie Samora, MD, PhD, MPH
- Kristy Weber, MD, FAOA
Moderated by Lisa Lattanza, MD, Professor and Vice Chair of Diversity and Professionalism and Chief of Hand, Elbow, and Upper Extremity Surgery at UCSF, this webinar will conclude with a 15-minute Q&A session during which attendees can ask questions of the panelists.
Seats are limited, so REGISTER NOW.
Addressing the Gender Gap in Orthopaedics
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Megan Conti Mica, MD, in response to the 2018 Medscape Orthopaedist Compensation Report.
In a recently published Medscape survey looking at orthopaedic compensation, orthopods were the second-highest paid specialists overall. Despite that, only 51% of orthopaedist respondents to the Medscape survey felt they were fairly compensated. My question to you is: How fairly compensated would orthopods feel if that second-highest salary was decreased by $150,000 annually without reason?
While the reported overall wage gap between female and male physicians is more than $50,000 annually1, the Medscape survey found that the gender wage difference for orthopaedic surgeons was $143,000 annually—adding injury to insult. That annual gap would amount to $4 million of lost wages for women over a 30-year career as an orthopaedic surgeon.
Why does medicine in general and orthopaedics in particular have a gender gap? Is it because male surgeons have better outcomes than female surgeons? Not according to a 2017 study that found that patients of female surgeons experienced lower death rates, fewer complications, and fewer 30-day readmissions to the hospital, compared with patients of male surgeons.2 While I do not believe that gender alone makes one a better surgeon, I do believe that gender diversity within our field is imperative.
What is more disheartening is it seems no one with the power to make change is doing anything to close the gap. In 2009, only 4% of the AAOS fellows were female. Honestly, I cannot blame women for not trying to join the “boys club.” If someone told you that you would be a distinct minority in your profession, make less, and have to work harder, most rational human beings would find a different career. If we want more women in orthopaedics, we need to understand that the gender wage gap is just the surface of a bigger issue.
I challenge everyone (men and women) to do better. Help your female partners. Be more attentive and mentor female surgeons. Support women when they speak up, and champion for them when they don’t. The attributes that make a great orthopaedic surgeon—love of and dedication to this great specialty—are gender-neutral.
Megan Conti Mica, MD is a hand and upper-extremity surgeon at the University of Chicago Medical Center and a member of the JBJS Social Media Advisory Board.
References
- JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284
- BMJ 2017;359:j4366, Published 10 October 2017. doi: 10.1136/bmj.j4366
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