Tag Archive | gender

“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:

  1. Mentors: We want to support the applicants who have worked with us.
  2. 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:

  1. Agency (e.g., “assertive,” “confident,” “outspoken”)
  2. Communal (e.g., “careful,” “warm,” “considerate”)
  3. Grindstone (e.g., “dedicated,” “hardworking,” “persistent”)
  4. Ability (e.g., “adept,” “intelligent,” “proficient”)
  5. 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.

Addressing the Gender Gap in Orthopaedics

Female Orthos for OBuzzOrthoBuzz 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

  1. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284
  2. BMJ 2017;359:j4366, Published 10 October 2017. doi: 10.1136/bmj.j4366