June 2000 Bulletin

Road to diversity tough, but possible

Chairmen tell how they’re changing orthopaedics

By Carolyn Rogers

It’s widely known that the racial and ethnic composition of the United States is shifting toward greater diversity. The U.S. Census bureau predicts that African Americans will account for 14 percent of the total population by 2030, and the Hispanic population, 19 percent. By 2050, nearly a quarter of all Americans will be of Hispanic origin.

Also well-known–at least among the members of the orthopaedic profession– is that the racial, ethnic, and gender makeup of the nation’s orthopaedic surgeons does not reflect this growing diversity.

United States medical schools are slowly beginning to reflect the country’s demographic changes, although recent repeals of affirmative action initiatives have slowed that progress. The orthopaedic profession, however, lags far behind.

Although women now make up nearly 50 percent of medical school graduating classes in the United States, a recent AAOS Diversity Committee questionnaire sent to 2,744 orthopaedic residents showed that less than 8 percent are women. And while nearly 35 percent of medical school students identified themselves as Asian, African American, Hispanic or Native American in the 1999 Association of American Medical Colleges Data Book, just 18 percent of orthopaedic residents identified themselves as such in the AAOS survey.

Reasons for including minorities in medicine go well beyond matching the statistical ratios of various U.S. population groups. Minority physicians, it is often suggested, are more likely to serve minority populations, and they relate better to patients of the same racial and ethnic background. Moreover, inclusion of minorities in medicine adheres to the principle of equal opportunity that is a fundamental right of all Americans.

While the road to diversity in orthopaedics may be uphill and strewn with obstacles, many orthopaedic residency programs in the United States are taking on the challenge and succeeding, one resident at a time.

"There’s little doubt that women, African Americans and Hispanics have fewer opportunities to enter, or once in, to become contributing members of orthopaedic programs in the United States," Henry J. Mankin, MD, former chair of the Harvard combined orthopaedic residency program, says. "The express reasons for this by faculty members sometimes sound reasonable, but on analysis all are spurious. It’s the responsibility of the chief of service and the faculty members to change this pattern and offer all individuals equal opportunity."

According to Dr. Mankin, the following factors played a role in the success that the orthopaedic department at Harvard had in creating what many consider one of the more liberally diverse programs in the United States:

"It’s not easy to convert people to accept a diversity-supporting point of view, but it can be done and, in fact, must be done." Dr. Mankin says. "Talk about it openly, discuss it at meetings, hold symposia, make people aware of each person’s needs and points of view."

During the 27 years Dr. Mankin has been associated with the Harvard orthopaedic residency program, it almost always has admitted two women and three African Americans or Hispanics annually, although he points out that these numbers should not be construed as quotas, but simply the way things turned out. This gives the Harvard program a record of selecting than 35 percent of individuals considered by some as "diverse." Dr. Mankin stresses that he and other faculty members view these residents as contributing caretakers, scholars and investigators who have helped enormously to maintain the quality and the reputation of the Harvard program.

The current orthopaedic program chair at Harvard, James Herndon, MD, continues to strive for diversity.

"First, we make every effort to interview women and minorities who apply–we usually interview five or 10 women and five or 10 minorities," Dr. Herndon says. "Secondly, in the interviewing process, we make sure to involve a black faculty member and a woman faculty member in the process. We also have our women and minority residents meet with them so they can see how people are treated fairly as adults and professionals.

"Thirdly, we have a dean, as well as CEOs of the hospitals, who are interested in maintaining diversity and who are constantly assessing what we’re doing. Every day in our environment, we’re all tuned into it as an issue, and we try to be fair."

In its upcoming class of 10 orthopaedic residents, Harvard has two women residents and one African American. The program also has Asian Americans residents and several with Indian and Hispanic backgrounds.

"We were surprised this year–out of 450 applications, just five African Americans and fewer than five women applied," Dr. Herndon says. "Orthopaedics has never done well with women, but when you look at the fact that the graduating class is now 50 percent women… well, we in orthopaedics have always prided ourselves on getting the best and the brightest. But such a small percentage of orthopaedists are women–it’s a concern. We’ve improved in the last five years, but it’s still being seen as a specialty just for big guys."

Robert D. D’Ambrosia, MD, chairman of the Louisiana State University orthopaedic residency program, states that most residency programs tend to use the same criteria for selection as admissions committees at medical schools. "They usually choose the most aggressive applicants who are the best test-takers," says Dr. D’Ambrosia, 1999 AAOS president. "Going through medical school and residency can be a most desensitizing and brutal experience. Often a certain suppression of feelings is necessary in order to function in this environment. Communication with your peer group and patients which was once considered as a frill in medical education is now emerging as an important quality in taking care of patients."

Dr. D’Ambrosia believes that in order to be sensitive and responsive to diversity issues there should be diversity in the faculty, too. "In our faculty, which includes three African Americans, one Hispanic, three Asians and one woman, the department’s biggest frustration has been the paucity of women applicants applying for orthopaedic positions.

"I think it’s a matter of keeping your mind a little more open and a little more flexible so that you’re not turned off by average standardized test scores. Minority applicants often do not do well on standardized tests so interviews and letters of application become very important. Poor standardized test-takers often need some extra work and effort on the part of our faculty, but the end result can be even more rewarding."

Dr. D’Ambrosia is proud of the program’s African American graduates. He currently has three African American orthopaedic residents from Louisiana, Florida and Pennsylvania medical schools. "All of our African American residents have had the communication skills, the motor skills, the decision-making ability and work ethic, but they’ve tended to have some difficulty with the standardized test taking. (However, he remembers a recent African American woman graduate who was AOA from her medical school and who excelled in standardized test taking.)

"With a little extra help and care from a concerned faculty we are able to polish their test-taking skills. They are then able to pass the boards and become orthopaedic surgeons that the faculty has been very proud of."

The program has not fared as well in attracting women–there are currently no female residents in the program and only one woman faculty member.

"So few women apply", Dr. D’Ambrosia says. "And those that do have chosen to go elsewhere." Two women were on his match list this year but he believes women applicants are more comfortable in an academic environment that is not in an inner city, such as the University of Michigan.

Dr. D’Ambrosia, who has been chair of the LSU orthopaedic department for 25 years, states that he and the members of his department strive to be flexible and sensitive to the issues of diversity and consider it openly in their deliberations about perspective candidates. He emphasized that choosing just AOA applicants with concrete skills who have good standardized test taking skills can be sometimes unrewarding. "We strive to have hard working, sensitive and dedicated residents with good communication skills," Dr. D’Ambrosia said. "Residents with a passion for their specialty and who know their limitations will always make excellent practicing orthopaedic surgeons."

At Tulane University in New Orleans, Louisiana, Thomas Whitecloud, MD, says, "I’ve been chair for nine years and have always emphasized diversity. I’ve actually considered female candidates and minority candidates as a different kind of a group–as a separate category. Consciously, we try to have at least one female and one African American in every class."

But he admits this doesn’t always happen. Out of 30 residents, the orthopaedic program currently has three females, one African American and one Native American.

"Four or five years ago, we had no female applicants. Now we’re interviewing 10 or 15 for each incoming class. For the last couple of years, we’ve probably gotten fewer African American applicants than women.

"I think the qualifications of African American candidates are usually not as strong as we like to see. The quality of our program has improved a great deal, so the people we bring into our program are superior candidates. That makes it harder for someone with less than sterling academic credentials to be accepted."

A program chair who is wholeheartedly committed to diversity is vital if a residency program is to achieve diversity, says Serena Hu, MD, an orthopaedic surgeon at the University of California, San Francisco (UCSF), and a member of the Academy’s Diversity Committee.

"The leadership must be supportive and willing– if the chair doesn’t support diversity, it’s not going to happen. You need to have a chair who looks at individuals and all the things that will make a good orthopaedic surgeon, rather than just at 99th percentile board scores," she adds.

UCSF program currently has three women, three African Americans, eight Asians, and one Hispanic among it 27 orthopaedic residents.

Dr. Hu believes that the UCSF program has been successful in attracting women, in part, because it has already established itself as women-friendly.

"Most women applicants would rather go to a program that’s already had several women. It breaks the ice. Plus we have six women faculty members–which is a pretty high number–who can serve as role models. There’s still a push out there for women to go into primary care, pediatrics or Ob/Gyn –it helps for them to see orthopaedic surgeons who look like themselves."

Michael Reis, MD, the UCSF orthopaedic residency program director, agrees that a diverse faculty is a draw. In addition to the department’s six women faculty members, there are also three Asian members and one Hispanic.

"The chairman, Dr. David Bradford, has been here for 10 years, and he’s made a real effort to recruit women and minorities into the faculty," Dr. Reis says. "I believe that’s been key to our success. When women or minority medical students interview here, they see that diversity for themselves. We don’t have to do anything formally to encourage them."

When presented with opportunities to interact with medical students, George Lucas, MD, program director for the orthopaedic residency program at the University of Kansas School of Medicine,Wichita, makes it a point to counsel women students that "orthopaedics is something they can do well at."

"I think it’s important, with medical school classes being 50 percent women now, that women have a wide career choice," Dr. Lucas says. "I tell them they don’t need to limit themselves to family practice or pediatrics."

That’s the first step Dr. Lucas takes in his attempt to increase the diversity of his residency program.

"Secondly, in the selection process, I will usually favor an application from a woman or a minority student," he says. "I’ve commonly invited those students to interview even though they may not have been strongest on paper. So I have a selection bias in who I invite to interview.

"My efforts in that regard have not been tremendously successful, though, because we’re here in the Midwest and our applicant pool is overwhelmingly white, Anglo-Saxon males. And Wichita is not the most exciting place, so it’s difficult to attract from outside the area. Although our training program is good, people might prefer to be in other, more attractive places."

This year, however, three out of four residents in the incoming class are minorities.

"I have an African American, a woman of Indian descent and a young man who is also of Indian descent. I hope this trend will continue in future years."

1999/2000 AAOS Diversity Committee optional background survey

The AAOS Diversity Committee distributed a survey to 2,744 orthopaedic residents during the Orthopaedic In-Training Examination (OITE), held in Nov. 1999. There were 2,341 surveys returned, resulting in a usable return rate of 85.3 percent.


Males 2,142 (92.2%)

Females 181 (7.8%)

Caucasians 1,800 (77.5%)

African American 91 (3.9%)

Native Americans 16 (0.7%)

Asian American 251 (10.8%)

Hispanics/Latino 63 (2.7%)

Other 102 (4.4%)

The four medical schools most frequently attended by female respondents to the survey are:

  • Duke University (0.3%)
  • University of Michigan (0.3%)
  • Northwestern University (0.2%)
  • University of Alabama (0.2%)

The six residency programs with the largest number of female residents are:

  • Duke University Medical School Division of Orthopaedics (0.2%)
  • Mayo Graduate School of Medicine (0.2%)
  • St. Luke’s - Roosevelt Hospital Center/Columbia University (0.2%)
  • Case Western Reserve University (0.2%)
  • Northwestern University Medical School (0.2%)
  • Ohio State University Hospital (0.2%)

The five medical schools most frequently attended by minority* respondents to this survey are:

  • Harvard Medical School (1.0%)
  • University of California at San Francisco School of Medicine (0.7%)
  • Northwestern University Medical School (0.6%)
  • University of Southern California School of Medicine (0.5%)
  • UMDNJ New Jersey Medical School (0.5%)

The six residency programs with the largest number of minority* residents are:

  • Howard University Division of Orthopaedics (0.8%)
  • Harvard Combined Residency Program (0.8%)
  • University of Puerto Rico School of Medicine (0.7%)
  • University of Southern California Orthopaedic Residency Program (0.7%)
  • Case Western Reserve University (0.5%)
  • New York University/Hospital for Joint Diseases (0.5%)

*Calculated by adding all percentages except Caucasian

See Cultural competency article

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