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Physicians for Social Justice, Diversity and Equity: Take Action and Lead

      Abstract

      Physicians are in a position to take action and lead to actively mitigate against bias and discrimination. Social justice, diversity, and racial, gender, and SGM (sexual and gender minority) equity are sensitive issues. Few orthopaedic surgeons are minorities or female, and orthopaedic surgery is not perceived to be an inclusive specialty. This is an obstacle to equitable diverse hiring. As it takes almost 30 years to advance from preschool to orthopaedic fellowship graduation, we should advocate for educational equity beginning in early childhood. We should serve as role models for young people of all backgrounds and suggest that if they are dedicated and study hard, someday they too could become orthopaedic surgeons and researchers. Wherever possible, each of us in our own way and position should take a leadership role to resolve the disparities in our profession.
      2020, at the risk of understatement, has been a difficult year for everyone. In addition to a viral pandemic, associated restrictions, and a resultant economic collapse, challenges, crises, protests, counterprotests, and advocacy related to diversity, and racial, gender, and SGM (sexual and gender minority) equity have been front and center in the United States and globally. As editors, we feel compelled to contribute to the societal conversation regarding social justice, as related to our professional and subspecialty interest.

      What Is to Be Done?

      After substantial thought and research, our answer is “Take action and lead.”
      We respect that readers have diverse points of view; thus, we are generally careful and sparing in our use of the word “should.” Now, however, we are examining our journals (and other organizations where we hold leadership roles) with a goal of mitigating against bias and discrimination. In addition, under President Brian Cole, the Arthroscopy Association of North America has initiated a Diversity and Inclusion Task Force charged with increasing minority involvement in leadership and activities, and to ensure an inclusive environment. Thus, we assert the editorial point of view that our readers should do the same.
      Educated readers should support “egalitarianism” (social justice),
      Social justice defined
      Merriam Webster Dictionary.
      “inclusion of different types of people in a group” (diversity),
      Diversity defined
      Merriam Webster Dictionary.
      and “freedom from bias” (equity).
      Equity defined
      Merriam Webster Dictionary.
      In 2020, in some circles, these terms have become politicized; we, on the other hand, quote dictionary definitions that remain timeless.
      From our point of view, in our honored positions as orthopaedic surgeons and related researchers, it is not enough to be passively “against” discrimination or “for” diversity and equity. Each of us in our own way and unique position ought to take action against discrimination and lead in favor of diversity and equity.

      Challenging Facts

      Professionally, the specifics regarding our subspecialty illustrate our challenge. We present data reflecting the United States, and we suspect that inequities may also exist in the nations of many of our international readers.
      Only “1.5 percent of AAOS members identify as African American, 1.7 percent as Hispanic/Latino, 6.7 percent as Asian American, and .4 percent as Native American. According to 2016 data from the Accreditation Council for Graduate Medical Education (ACGME), 4 percent of orthopedic surgery residents were African American, 5.4 percent Hispanic/Latino, and 0.2 percent Native American. Meanwhile, Caucasian and Asian American surgeons were overrepresented in orthopedic residencies in comparison with the U.S. population.”
      • Boyd J.
      U of M orthopedist works to attract and retain diversity in orthopedic surgery and on the ice. Department of Orthopedic Surgery, University of Minnesota.
      Only 7.7 percent of medical students in the United States in 2016 are black “according to the Association of American Medical Colleges. That’s … short of the 13.2 percent in the general population.”
      • O’Donnell J.
      • Robinson D.
      After decades of effort, African-American enrollment in medical school still lags. USA TODAY Network.
      In addition, “[w]omen make up just 5% of the active physicians in orthopedic surgery, according to a 2015 report from the Association of American Medical Colleges. The percentage is likely to rise, but only marginally, with data showing that about 14% of orthopedic residents are women.”
      • Castellucci M.
      Women still a rarity in high-paying surgical specialties. Modern Healthcare.
      In contrast, according to 2017 data, “more than 60 percent of physicians under the age of 35 are female.… In the next-highest age bracket (35 to 44 years of age), women [comprise] 51.5 percent.… As each age bracket gets older, the percentage of female physicians drops, with 82.4 percent of physicians over the age of 65 being male.”
      • Johnson M.
      The healthcare future is female. Athena Health.
      While less data are available with regard to SGM individuals (“including those who identify as lesbian, gay, bisexual, transgender, or queer”), SGM medical trainees and practitioners rate orthopaedics as the number one least SGM-inclusive medical specialty.
      • Sitkin N.A.
      • Pachankis J.E.
      Specialty choice among sexual and gender minorities in medicine: The role of specialty prestige, perceived inclusion, and medical school climate.
      To sum up the challenging facts, relatively few orthopaedic surgeons, few orthopaedic trainees, and few American medical students are minorities. In addition, although many younger physicians are female, few orthopaedic surgeons and trainees are female. And orthopaedic surgery is not perceived to be SGM inclusive.

      The Obstacle to Diverse Hiring

      Today, we in orthopaedic education and practice who desire to hire minorities and women as associates face obstacles, because there are few minority or women orthopaedic specialists to recruit. It is plausible that orthopaedic residency training programs might stand a better chance of recruiting women, as there are an abundance of female medical students, yet the facts and due diligence suggest that few women choose orthopaedics as a specialty. Orthopaedic residency training programs desiring to recruit minorities are further limited, because relatively few medical students are minorities. Although medical schools might stand a better chance of recruiting minorities, the facts suggest that relatively few choose medicine as a profession, and due diligence suggests that “race gaps” highlight educational inequalities faced by minority students well before they can apply to medical school or even college, thus undermining their chances for academic or professional success.
      • Reeves R.V.
      • Halikias D.
      Race gaps in SAT scores highlight inequality and hinder upward mobility. Brookings.
      To again summarize, few minorities or women chose orthopaedics as a specialty, few minorities choose medicine as a profession, and minorities face educational inequality limiting their opportunity to achieve the academic success required for medical school. We thus identify two issues: choice of profession and equitable education.

      Advocate

      As we have personally experienced, it takes almost 30 years to advance from preschool to orthopaedic subspecialty fellowship graduation. As educational disparities develop early in life,
      • Reeves R.V.
      • Halikias D.
      Race gaps in SAT scores highlight inequality and hinder upward mobility. Brookings.
      society must ensure that educational equity begins in childhood. As arthroscopic surgeons and related researchers, we may believe we have little direct impact on early childhood educational equity, yet as individuals and collectively, we are influential. We should advocate, donate, volunteer, and vote. If an opportunity presents, we should take action and lead.

      Inspire

      In terms of minorities and women making a choice to pursue medicine and then orthopaedic surgery as a desired medical specialty, we wield enormous impact and a most direct influence. We must consciously change our behavior and demonstrate that we are an inclusive medical specialty. We must strive to see the potential in, and encourage, candidates of all backgrounds. We should serve as role models with the hope of narrowing the disparities among those who pursue medicine, and ultimately orthopaedics, as a career. A challenge is that in many situations, individuals are drawn to role models with whom they share similar backgrounds. But, because there are few minority or female orthopaedic surgeons, we active orthopaedists who are in the majority should support our female and minority colleagues and proactively seek out and empathetically relate to minority and female mentees. The onus is on us to overcome the barrier of being of a different background. If we succeed in this regard, we can serve as exemplars of both orthopaedic surgery and of inclusion, potentially accomplishing a pair of laudable goals. Let's go out of our way to ask medical students, as well as our younger patients, how they are doing in school, and tell those who do not share our background (as well as those who do), that medicine and orthopaedics are great professions. Let’s encourage those who seem receptive and suggest that if they are dedicated and study hard, someday they too could become orthopaedic or related surgeons or researchers.

      Do Something—Again

      A final thought: having taken the time to study these issues, and as others have observed, it is not enough to do something once and cross it off our lists. When the opportunity presents, we should take action and lead, and then we should actively look for the next opportunity and lead yet again. In our privileged positions, we should seek social justice, diversity, and equity. When we have an opportunity, we should hire as possible, advocate, and inspire.

      References

        • Social justice defined
        Merriam Webster Dictionary.
        (Available at)
        • Diversity defined
        Merriam Webster Dictionary.
        (Available at)
        • Equity defined
        Merriam Webster Dictionary.
        (Available at)
        • Boyd J.
        U of M orthopedist works to attract and retain diversity in orthopedic surgery and on the ice. Department of Orthopedic Surgery, University of Minnesota.
        (Available at)
        • O’Donnell J.
        • Robinson D.
        After decades of effort, African-American enrollment in medical school still lags. USA TODAY Network.
        (; February 28, 2019, updated March 2, 2019. Available at)
        • Castellucci M.
        Women still a rarity in high-paying surgical specialties. Modern Healthcare.
        (; July 28, 2018. Available at)
        • Johnson M.
        The healthcare future is female. Athena Health.
        (; February 14, 2018. Available at)
        • Sitkin N.A.
        • Pachankis J.E.
        Specialty choice among sexual and gender minorities in medicine: The role of specialty prestige, perceived inclusion, and medical school climate.
        LGBT Health. 2016; 3: 451-460
        • Reeves R.V.
        • Halikias D.
        Race gaps in SAT scores highlight inequality and hinder upward mobility. Brookings.
        (; February 1, 2017. Available at)