Male Practice: Gender Inequality in Orthopaedic Surgery

Ask the typical orthopaedic surgery residency program director about the biggest problem he faces, and you are apt to hear that he is deluged with too many applications. Still, we need to solicit even more. Specifically, we need to convince more female students to apply—even if by so doing, life gets harder for the typical program director. Here is the problem: The gender distribution of medical schools around the country is about 50/50; orthopedic residency programs, by contrast, are nearly 90% male [5]. To put this in context, the United States Senate, long celebrated as an “old boy’s club,” is only about 80% male. Gender imbalance in orthopaedic residencies seems not to be caused by overt discrimination. Female applicants are, statistically speaking, as likely to match as their male counterparts. An elegant experiment by Scherl et al. [7] detected no anti-female bias when researchers asked reviewers to rate “chart[s] from female candidate[s that were] altered into a ‘male’ version.” Rather, the problem is upstream: female students just are not applying to orthopaedic surgery. There may be good reasons why female students do not seek residency positions in orthopaedics. Applying to orthopaedic surgery often entails additional study time for the United States Medical Licensing Examination® (USMLE) Step 1, the de facto residency entrance exam, as well as a few months on the road as an auditioning student. Although this investment in human capital is substantial for all applicants, the projected return on this investment is probably higher for male students. “The return from investing in [acquiring] a skill is greater when more time is spent utilizing the skill,” Gary Becker said in his Nobel Lecture [2]. In general, male physicians work more hours per week than their female counterparts. In short, orthopaedic surgery positions are worth more to applicants who want (or are able) to work longer hours; and such applicants typically are men. The financial inefficiency of on-call duties in orthopaedic surgery may also make the field unappealing to those responsible for child care—and those responsible are typically women. (That is a positive, not a normative, statement; it describes what is, not what should be.) In my experience at a community hospital, night call duties were frequent, but emergency procedures were rare. When an orthopaedic surgeon performed an operation, it was typically a simple and less-remunerative one, such as draining a septic joint. Most nights produced little or no practice revenue. An orthopaedic surgeon who arranges for frequent child-care coverage just to cover the contingency that her presence is needed in-house will quickly veer into deficit. There is also the question of mentorship. Specifically, there are few female role models for women in orthopaedic surgery. A female medical student at Johns Hopkins School of Medicine, for instance, may believe that the femur is more interesting than the femoral artery, but still might choose to become a vascular surgeon, in part because the surgeon-in-chief at Hopkins is a vascular surgeon—and a female one at that. By comparison, orthopaedic surgery boasts few female chairpersons, and few professors overall. Similarly, my use of the pronoun “he” in the first paragraph of this essay was not accidental: most program directors are male as well. Finally, there is the issue of popular perceptions. The portrayal of the stereotypical orthopaedic surgeon as “strong as an ox and just as smart” may be a myth [8] but it is a frequently touted one just the same. Image matters. Many women who enter medical school seem to think that orthopaedic surgery requires brute strength more than anything; and even with more curricular time devoted to musculoskeletal medicine than ever before [3], there is hardly an opportunity to disabuse female students of this faulty stereotype before career choices are made. But what should really get our notice is the possibility—beyond the list of “good reasons” explaining the dearth of women in our field—of some “bad reasons.” We must ask ourselves, “Is there something rotten in the state of orthopaedics?” Is there something driving women away? I suggest that we have transitioned too slowly from the all-consuming residency and intense practice approach propounded by Halstead, (another, perhaps less-enlightened, Hopkins chief) to one more agreeable to people—male or female—whose family commitments are on par with the commitments they have made to their careers. According to the most recent American Academy of Orthopaedic Surgeons census, full-time orthopaedic surgeons on average work more than 60 hours per week; 15% of them work more than 75; and more than a few cross the 100-hour threshold. Granted, working long hours allows the surgeon to amortize fixed practice expenses over a wider base (and in turn earn a high hourly wage); but to me, working a “century week” routinely is an invitation to stress, burnout and despair [6]. Broadening our appeal to the entire medical school class may take effort, but the task is justified by self-interest. It is in our interest as a profession to have the best possible applicant pool, and right now too many top female students shun us. It is in our interest as a profession to have an adequately large applicant pool; and while there is a surplus today, declining payments for orthopaedic services may turn that on its head. Finally, it is in our interest as a profession to create working conditions that promote the flourishing of all members. Although that step will help make orthopaedics more welcoming to the women contemplating entering the field, it is also highly beneficial for those of us already here.