The Buzz This Week
Black physicians in the United States remain underrepresented. U.S. Census Bureau data from 2018 indicated that only 5.4% of physicians are Black but 12.8% of the population is Black. Sustained efforts in many specialties have led to increased physician diversity, and of the medical school class entering in 2019, 7.4% were Black. One specialty that has continued to struggle with diversity is orthopedics. In this field, less than 2% of surgeons are Black, just over 2% are LatinX, and less than 0.5% are Indigenous Americans. Even as medical school representation has increased, between 2002 and 2016, orthopedic residents who are people of color declined.
The lack of representation in the specialty is openly acknowledged, and has been for decades. Yet much remains the same. Some cited reasons for absence of change in the field have been:
- Representation: StatNews interviewed many physicians of color and almost all noted Black and LatinX orthopedic surgeons were non-existent in their early medical education. For many medical students of color interested in the field, the lack of representation has led to them turning their focus to other specialties instead.
- Mentorship: Without representation in the field, medical students of color have difficulty finding mentors who have had similar experiences or look like them. Mentorship in any specialty is important, but for orthopedic surgery, medical school research, orthopedic rotations, and in-person networking are all highly important for residency selection. All of these things are more difficult to achieve without a mentor.
- Culture: A survey of 274 Black orthopedic surgeons conducted in 2021 found that well over 90% of respondents felt they faced workplace discrimination, and less than 20% thought current national orthopedic leadership was genuinely trying to end it. The specialty faced another setback last year after a shared document for residency applicants had numerous hostile comments posted to it directed at women and people of color. The culture is a turnoff for many would-be residency candidates very interested in the field. In a 2011 study, there were approximately 14 white applicants for every Black and LatinX one.
Structure and Expense of Residency Application: A study published in Academic Medicine from 2014 found that most medical students spent $1,000-$5,000 on residency interviews. Prospective family medicine residents spent the least on average at $1,000-$2,000, and surgical applicants spent the most, with 20% spending over $7,000. The mean expense for orthopedic surgery residency application costs in 2020 was over $8,000. The cost differential comes from applicants applying to and interviewing with more programs due to the extremely competitive nature of the specialty and participating in more away rotations during medical school in order to have a strong application. During COVID with virtual interviews and reductions in away rotations, expenses fell to an average of $1,900, presenting an ongoing opportunity to remove the expense barrier of the application process. Additionally, orthopedic surgery residency candidates often need to start planning for their application as soon as medical school begins. Orthopedic training is often excluded from standard medical school curricula, and insider knowledge is required to be successful in applying. Data shows that between 2005 and 2014, 73% of white applicants were accepted to residency programs, while only 46% of Black applicants were.
Why It Matters
Dr. Kelechi Okoroha, an orthopedic surgeon at Mayo Clinic and an alum of the Nth Dimensions program, a non-profit founded to address the lack of diversity in orthopedic surgery (specifically women and underrepresented people of color), noted, "Our population in America is very diverse. I think our patients deserve an equally diverse group of surgeons who are each equipped naturally with different cultural competencies to help treat them. Additionally, diversity in our surgeons will help decrease some of the inequalities you see in health care and treatment of patients today."
And inequalities in orthopedics, though less often noted than many other health disparities, abound. Patients of color are significantly undertreated compared to white counterparts. Black and LatinX patients were less likely to receive knee and hip replacements, less likely to receive pain medication after orthopedic injuries, and more likely to have negative outcomes, including infection, readmission, reoperation, and even death.
Leaders of color in the field have indicated that until the specialty is more diverse, many of the disparities are likely to remain. Numerous studies have shown improved outcomes when patients of color are treated by providers of the same ethnicity. In order to treat patients of color, it will require more providers of color, who are more likely to enter the field with mentors of color. There are currently hundreds of full professors of orthopedics at medical schools across the U.S.—just 6 are Black.
The Accreditation Council for Graduate Medical Education (ACGME) may help to push the pace of increasing diversity. While no requirements exist related to diversity, changes are being planned. Dr. Eric Carson, Washington University orthopedic surgery professor and a leader in diversifying the field, has been frustrated by the speed of change but noted that now numerous programs are paying attention to diversity and taking potential new requirements seriously. NYU has one of the most diverse orthopedic surgery residency programs in the U.S., with deliberate focus and commitment to that goal. Dr. Joseph Zuckerman, chair of the orthopedics department stated, “To attract diverse trainees, programs must showcase that diversity is important.”