The following manuscript was submitted to the September 2017 Women in Medicine theme issue.

---

by Ann Joyce, PhD, William Young, EdD, and G. Douglas Letson, MD

Over the past 50 years, the demographics of medical school graduates in the United States has changed dramatically with the number of women (47%) almost equaling the number of men in 2014 (AAMC, 2014). However, the Association of American Medical Colleges (2014) reports that out of all the sub-specialties, orthopaedic surgery has the lowest proportion of female residents, instructors, assistant, associate, and full professors. The promotion of women leaders in orthopedic surgery positions within academic medicine has remained relatively unchanged (GWIMS, 2014). This study will provide a critical lens through which professionals can understand and address the needs of women in orthopaedic surgery. Additionally, this study hopes to help institutions recognize ways to create leadership programs to advance women in medicine.

The most dramatic demographic change within medical schools was the influx of women into the profession in 1970, shortly after the passage of Title IX of the Higher Education Act (England and Pierce, 1999). Yet, women continue to experience barriers and career obstacles while trying obtaining leadership positions in academic medicine, especially in the field of orthopaedic surgery (Daniels, French, Murphy and Grant, 2011).

In 1932, Ruth Jackson, MD became the first practicing female orthopedic surgeon in the United States (RJOS, retrieved February 12, 2016). She was the first woman certified by the American Board of Orthopaedic Surgery and the first woman to admitted to the American Academy of Orthopaedic Surgeons (AAOS, 2014). Despite a promising start for women in academic medicine, orthopedic surgery now lags behind all other surgical specialties in recruiting and promoting women into residency and leadership positions (Daniels, French, Murphy, and Grant, 2012).

With the continuing increase in diversity our population’s demographic profile, numerous groups have expressed a need for diversity in all realms of the medical field in the United States (Kundhal & Kundhal, 2003).  Medical schools now seek a racially, ethnically, and socio-economically diverse student population (Kundhal & Kundhal, 2003 and Daniels, French, Murphy, and Grant, 2012). This quest for diversity includes the enrollment of women.  With the changing needs of our society, it is important to recruit, retain, and promote women into leadership positions.

The findings of several research studies report a lack of women leaders in orthopaedic surgery, yet the knowledge acquired from these studies has failed to increase the number of women in this field (Bickel, et al., 2002, Daniels, et al., 2011, and Tosi and Makin, 1998). Additionally, although physicians are not trained to be leaders per se, they find themselves in leadership positions for the welfare of their patients, education of students, and social responsibility (Bachrach, 1996). Today, academic medicine needs all the leaders of all types, including the development of women leaders (Bickel et al, 2002).

Bickel et al (2002) concluded that several benefits have been observed when institutions cultivate women leaders, not only in orthopaedic surgery, but in all subspecialties. These benefits include the following: improved marketing efforts for the institution, additional healthcare provider options for patients, an increased number of role models for students and residents, enhanced institutional creativity, and an enriched institutional culture (Bickel et al., 2002). The bottom line is, institutions that recruit, retain, and promote women into leadership positions are at an advantage (Bickel et al., 2002).

A self-report survey was sent to all women in orthopaedic surgery. The survey assessed perspectives of women in orthopaedic surgery in regards to organizational culture, leadership development, challenges, diversity, gender bias, recruitment, and retainment.  An examination of the data provides insights into areas of improvement and suggestions for institutional practice. The results indicate that although institutions are making progress in some areas, there is a need for more advocacy on gender equality, pro-family policies, and employee retention. The purpose of this study is to ensure the success of women not only in orthopaedic surgery, but across all sub-specialties.

Conceptual Framework

A critical theory lens was used to focus on social issues such as inequality and power (Creswell, 2013). This study hopes to add to and to support research-based strategies that professionals can use to increase women’s leadership roles, as well as to provide information that will assist women in their efforts to transcend barriers in their profession (Cresswell, 2013). This research highlights three critical needs: the need to hear the female orthopaedic surgeon’s perspective, the need to identify policies and social support as experienced by women in academic medicine, and the need for women leaders to transcend the issue of perceived barriers that women face when pursuing promotion or tenure in orthopaedic medicine.

Research Questions

Although this study focuses on the culture of women in orthopaedic surgery, the results of this study can apply to all areas of academic medicine.  The survey targets the following areas: mentoring, gender bias, social and professional isolation, promotion, equal pay, accommodations, and recruitment. The results of the report provides information that can assist an institution in developing a foundation for the advancement of women in orthopaedic medicine.  The following research questions were placed into four categories.

1. Practices for women in orthopaedics should be implemented at the institutional level.

In what ways do female orthopaedic surgeons feel institutions support the development of women leaders?

2. Practices that women in orthopaedics medicine should consider in regards to challenges expressed throughout the profession.

In what ways do female orthopaedic surgeons feel institutions have responded to challenges for women in orthopaedics, such as mentoring for women, gender bias, social and professional isolation, promotion and equal salary, accommodations, recruitment and retainment?

3. Practices for women in orthopaedics medicine should offer guidance and support for leadership development.

In what ways do female orthopaedic surgeons feel institutions are effective at maintaining supportive environments, so that women can develop into leaders?

4. Practices for women in orthopaedic medicine should offer a work-life balance that satisfies both women’s ambition and lifestyle.

Are female orthopaedic surgeons satisfied in academic medicine?

The research questions for the study were developed based on a review of the available literature on the topic. Analysis of these questions can help an institution facilitate the development of women leaders in academic orthopaedic medicine.

Pilot Study

Prior to this study, a pilot study was conducted, which surveyed key women in orthopaedic medicine. The questions for the survey were modified from Tosi and Mankin’s (1998) Ensuring the Success of Women in Academic Orthopaedics and combined with revised questions from the University of North Carolina’s Kenan-Flagler Business School (2012) UNC’s Leadership Survey 2012: Women in Business. The two surveys were integrated and reformatted into a new survey that features leadership development for women in orthopaedic surgery.

After corrections and modifications were made to the original survey, the same participants were surveyed a second time to measure the reliability of the modified survey. The Test-Retest method was used to evaluate the stability, repeatability, and reproducibility of the survey. The same survey was given to the same participants three months apart and a paired sample t-test was conducted using SPSS software. A paired sample t-test measured the population means of two groups. A paired sample t-test was conducted to compare the first survey, which was titled the pre-test and the second survey, which was titled the post-test. The following are the results of the paired sample t-test.

Population and Sample

The data source included a self-report survey which was emailed to all known women in orthopaedic medicine. Email communication was sent to all known chairman listed with the American Academic of Orthopaedic Surgeons (AAOS) Faculty Roster Representatives. The study population included approximately 600 participants in three organizations: The Group on Women in Medicine and Science (GWIMS), Ruth Jackson Orthopaedic Society (RJOS), and American Academy of Orthopaedic Surgeons (AAOS). The survey was made available to as many women as possible in orthopaedic medicine in the United States in 2015, approximately 700 known female orthopaedic surgeons and residents.

Data Analysis

The survey was designed to provide data outcomes in regards to development, challenges, maintenance, and satisfaction of leadership programs for women in orthopaedic medicine. Each participant completed an electronic survey through Survey Monkey. The data were analyzed using descriptive statistics, mean, mode, and frequency, where appropriate for each research question. No inferential statistics were be used. If partial surveys were returned, only completed categories were used to maintain section validity and reliability.

Collection for this study occurred in two ways: (1) solicitation of study participants through referrals, also known as snowball sampling and (2) solicitation of participants through email through program directors and program coordinators. The survey was generated electronically using Survey Monkey, and was accessed through an electronic link that was provided in the email. The email contained a brief study description, IRB number, and the study link (Survey Monkey). Participants were encouraged to forward the survey link to other female orthopaedic surgeons.

Data collection occurred over the course of six (6) weeks beginning approximately July 1, 2016 ending August 15, 2016. A total of 699 participants were solicited through email. Of those, over 100 emails were returned and unusable. Identifying information was not linked to the participant survey responses. The only response rate that was verifiable for this study was the rate of return versus total number of mailed responses. There was a 19.8% response rate from participants based on the number of returned participant responses which met the number needed to achieve a power of .80. The rate of response was acceptable. The deadline for responses was approximately 45 days from the initial request. Most of the responses occurred in the second week of data collection. Approximately 120 surveys were returned, 117 surveys were usable with a response rate of 19.8%.

Results

For the purpose of this paper four tables were selected that represented the most comprehensive results of the data.  The following is quantitative statistical analysis of the data, the results of which are presented in order of the four research questions. The collected data were analyzed using descriptive statistics; frequency, mean, median, and percentages.

Demographics

In this section participants were asked their age, residency and fellowship training, academic rank, and length of time at their institution. One hundred and seventeen participants responded to the five demographic questions. Ninety-one participants (78.45%) were between the ages of 25-44. Twenty-five participants (21.55%) were over the age of 45. Seventy-seven (65.81%) participants completed an orthopaedic residency program, 40 (34.19%) had not yet completed a residency program. One-hundred and fifteen (98.29%) participants completed a fellowship, two (1.71%) had not yet completed a fellowship program. When participants were asked about their titles at their institutions, 7 (5.98%) stated they were instructor. Thirty (25.67%) participants listed they were Assistant Professors. Sixteen (13.68%) listed they were Associate Professors. Ten (8.5%) listed they were Professors and 54 (46.15%) listed Other. Participants were given an opportunity to provide additional information for the Other option. Their responses included, Associate Dean, Clinical Associate Professor, Senior Partner, staff surgeon, private practice, attending, resident or fellow. When participants were asked how long they were at their institutions, 58 (49.57%) 57 replied 1-3 years, 35 (29.91%) replied 4-7 years, 8 (6.84%) replied 8-11 years, 5 (4.27%) replied 12-15 years, and 11(9.4%) replied 16 or more years.

Research Questions Related to Leadership Development

Participants were asked four questions related to institutional culture and leadership development. The fundamental goal of this research question was to develop a knowledge base on the perceptions of women in orthopaedic surgery on leadership development within their institutions.

Table 1. Leadership Development (Section 2: Question 6)

How important do you think these characteristics are to your institution?
	Not Aware	Not important (1)	Somewhat important (2)	Very important (3)	Not Applicable	Total	Mean
Recognizing the need for developing leadership programs	3.57% 4	5.36% 6	49.11% 55	41.96% 47	.088% 1	112	2.38
Recognizing the need for increasing women leaders	4.46% 5	12.50% 14	40.18% 45	42.86% 48	.088% 1	112	2.32
Creating a new vision that includes the development of women leaders	5.36% 6	17.86% 20	43.75% 49	33.04% 37	.088% 1	112	2.16
Institutionalizing change to accomplish the vision	6.25% 7	18.75% 21	44.64% 50	30.36% 34	.088% 1	112	2.12

Note 1. N=117 and missing data =4
Note 2. The mean was calculated on the responses Not Important (1), Somewhat Important (2), and Very Important (3) only.

In response to the institutional culture of leadership development, participants indicated that leadership development is an important initiative. However, participants also indicated that institutions are progressing slowly.

Research Questions Related to Challenges for Women

Participants were asked seven questions related to challenges and barriers women experience when seeking promotion. The fundamental goal of this research question was to develop a knowledge base on the perceptions of women in orthopaedic surgery on challenges ore barriers women encountered in their careers.

Table 2. Leadership Challenges for Women (Section 3: Question 10)

How would you rate your institutions performance on the following efforts to develop women leaders?
	Poor (1)	Fair (2)	Good (3)	Excellent (4)	NA	Total	Mean
Recruitment of women	9.09% 8	29.55% 26	38.64% 34	22.73% 20	1.12% 1	88	2.75
Retaining women so they aspire to leadership levels	13.79% 12	39.08% 34	24.14% 21	22.99% 20	1.14% 1	87	2.56
Having enough women in the leadership pipeline	28.41% 25	37.50% 33	21.59% 19	12.50% 11	1.12% 1	88	2.18
Having a work-life balance that attracts women	12.79% 11	34.88% 30	43.02% 37	9.30% 8	3.37% 3	86	2.49
Accelerating the development of women with early-career high potential	20.48% 17	43.37% 36	31.33% 26	4.82% 4	6.74% 6	83	2.20
Having women develop the full range of skills necessary for promotion	15.12% 13	38.37% 33	36.05% 31	10.47% 9	3.37% 3	86	2.42

Note 1. N=117 and missing data= (28, 29, 28, 28, 28, 28)
Note 2. The mean was calculated on the responses Poor (1), Fair (2), Good (3), and Excellent (4) only.

The Challenges section was the largest section of the survey. This section addressed several sensitive issues such as institutional performance on developing women leaders, gender equity, gender bias, equal pay, social and professional isolation, accommodations for women in regards to child care, evaluation systems, transitions for working mothers, and barriers for women interested in advancing their career.  Overall, women reported a need for advocacy and engagement in all areas of this section.

Research Questions Related to Leadership Maintenance

Participants were asked three questions related to their institution’s effectiveness at maintaining supportive environments so that women can develop into leaders.

Table 3. Leadership Maintenance (Section 4: Question 19)

How do leaders in your institution perform on the following personal leadership competencies?
	Poor (1)	Fair (2)	Good (3)	Excellent (4)	N/A	Total	Mean
Communicating effectively	10.59% 9	28.24% 24	47.06% 40	14.12% 12	1.16% 1	86	2.79
Creating a culture of accountability and performance	11.76% 10	23.53% 20	47.06% 40	17.65% 15	1.16% 1	86	2.88
Being adaptive	16.67% 14	23.81% 20	44.05% 37	15.48% 13	2.33% 2	86	2.74
Developing others	14.12% 12	34.12% 29	37.65% 32	14.12% 12	1.16% 1	86	2.66
Leveraging diversity	16.05% 13	37.04% 30	35.80% 29	11.11% 9	4.71% 4	86	2.53
Creating a shared vision	14.12% 12	24.71% 21	47.06% 40	14.12% 12	1.16% 1	86	2.75

Note 1. N=117 and missing data= (30, 30, 29, 30, 27, 30).
Note 2. The mean was calculated on the responses Poor (1), Fair (2), Good (3), and Excellent (4) only.

In summary, participants rated their institutions fairly high in terms of leadership competencies. 

Research Questions Related to Satisfaction

To address this research question, participants were asked whether or not women are satisfied with other areas within their institution.  This category contained 4 sub-questions in regards to continuing education, training opportunities, vacation and personal leave, opportunities for promotion and work-life balance.

Table 4. Satisfaction (Section 5: Question 20)

	How satisfied are you with the following at your institution?
		Dissatisfied (1)	Somewhat satisfied (2)	Neutral (3)	Very satisfied (4)	N/A	Total	Mean
Continuing education and training opportunities		5.75% 5	20.69% 18	27.59% 24	45.98% 40	0.00% 0	87	3.14
The amount of vacation, sick, and personal days that I receive		4.82% 4	15.66% 13	33.73% 28	45.78% 38	4.60% 4	83	3.20
Opportunities for promotion, raises, and bonuses		16.44% 12	20.55% 15	31.51% 23	31.51% 23	16.09% 14	73	2.78
Work-life balance		13.25% 11	28.92% 24	31.33% 26	26.51% 22	3.49% 3	83	2.71

Note 1. N=117 and missing data= (30, 30, 30, 31).
Note 2. The mean was calculated on the responses Poor (1), Fair (2), Good (3), and Excellent (4) only.

The data revealed that overall participants were fairly satisfied with key factors that we commonly see with employee turnover.  

Additionally, several participants indicated that female orthopaedic surgeons are still a young group and that there still is inherent gender bias throughout the specialty. Institutional difference was a second theme throughout the open comments section. Many participants indicated they were either from a community hospital, private practice, or specialty hospital, rather than an academic institution. In the case of the former group, leadership development was stunted or did not exist as readily as it does in academic institutions. Both of these concerns may affect the findings of the survey.

Key perspectives included:

1. There is a lack of resources, opportunities, and awareness of leadership programs at the institutional level.

2. There is a need for advocacy and engagement at the institutional level for gender equality.

3. There is a need for advocacy for women in orthopaedic surgery to reduce social and professional isolation.

4. There is a need for advocacy to implement accommodations for working mothers.

5. Advancing careers and pro-family policies are an issue for both men and women.

6. Maintaining supportive environments is an important initiative and institutions are progressing slowly.

7. Participants indicated that overall they were fairly satisfied with their employee benefits.

Implications

The data analysis indicated that it is important for institutions to provide leadership programs that focus on the strategic agenda, vision, and transformational leadership for both men and women (Pennings, 2007). Leadership development programs should bring individuals from various groups and backgrounds together to share their experiences (Bolman & Deal, 2008). The physician leader is an integral part of the academic institution and more effective leaders are more productive. Implications from the research revealed the following:

1. Institutions could benefit from creating leadership development programs that incorporate health policy, business acumen, interpersonal skills, healthcare leadership, and organizational management, which could lead to more cost-effective and optimal care for patients (Satiani, 2016).

2. Institutions could benefit from creating a tool-kit for those interested in leadership that encompasses presentations and or material designed for professionals to leverage their careers.

Overall, both men and women physician leaders perform a large range of roles. They must be patient advocates, administrators, instructors, researchers, budget experts, leaders, and great clinicians. With the changing societal and cultural needs of patients (Bickel, et al, 2002), creating leadership programs and online tool-kits may offer a variety of opportunities for aspiring and practicing leaders and benefit the patient, the physician, and the institution.

Summary

Although there has been some progress in the areas of recruitment and recognizing the need for leadership development of women in orthopedic surgery, institutions need to advocate for gender equality, pro-family policies, and employee retention. As stated earlier, gender equity does not just refer to the number of women, but also their experience and perception of their environment (Boushey, 2009).  Furthermore, women attract more women, and institutions should make efforts to recruit and to retain these valued employees. In addition, data analysis suggests that women may benefit from increased opportunities for advancement in a work place that cultivates diversity.  However, few resources are available to assist institutions in training women to become leaders.

Lastly, since the inception of this study, Teuscher and Cannada (2016) reported that the number of female residents in orthopedic surgery has improved more than 40 percent over the last decade, from 67 to 105 active residents in 2015. They outlined several areas that pertain to this improvement, such as the creation of 11 subspecialty organizations, a female chairman, The Perry Initiative, mentorship, scholarships, research awards, and additional educational opportunities for young women to be exposed to orthopaedics (Teuscher and Cannada, 2016).

In conclusion, this was an investigative study with the purpose of identifying perceptions of women in orthopaedic surgery in regards to leadership development.  Although, many medical specialties show an increase in women in academic medicine, orthopaedic surgery still lags behind most specialties. Additionally, gender equity does not just refer to the number of women, but also their experience and perception of the environment (Boushey, 2009).  The study shed some light on several issues that have not been addressed before in regards to leadership development for women. A deeper analysis may be needed to develop stronger policies and practices for women leaders in academic medicine.

References

American Academy of Orthopaedic Surgeons. (Retrieved 2014, July 2). www.aaos.org.

Bachrach, D. J. (1996). Developing physician leaders in academic medical centers. Medical Group Management Journal/MGMA, 44(1), 34-8.

Bickel, J., Wara, D., Atkinson, B. F., Cohen, L. S., Dunn, M., Hostler, S., … & Stokes, E. (2002). Increasing women’s leadership in academic medicine: Report of the AAMC Project Implementation Committee. Academic Medicine, 77(10), 1043-1061.

Bolman, L. & Deal, .. Reframing Organizations, 6th Edition. Jossey Bass Publishing

Boushey, H. (2009, October). The new breadwinners. The Shriver Report: A woman’s nation changes everything. Center for American Progress, 31-67.

Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications.

Daniels, E. W., French, K., Murphy, L. A., & Grant, R. E. (2012). Has diversity increased in orthopaedic residency programs since 1995? Clinical Orthopaedics and Related Research®, 470(8), 2319-2324.

England, S. P., & Pierce Jr, R. O. (1999). Current diversity in orthopaedics, issues of race, ethnicity, and gender. Clinical Orthopaedics and Related Research®, 362, 40-43.

Group on Women in Medicine and Science. (Retrieved 2014, July 2). www.aamc.org/members/gwims/statistics/.

Kundhal, K. K., & Kundhal, P. S. (2003). Cultural diversity: An evolving challenge to physician-patient communication. JAMA, 289(1), 94-94.

Mankin, H. J. (1999). Diversity in orthopaedics. Clinical Orthopaedics and Related Research®, 362, 85-87.

Pennings, R. (2007). Transformational leadership: How do we get there. In 16th Annual Chair Academy’s International Conference, Jacksonville, FL. Retrieved from http://www.chairacademy.com/conference/2007/papers/transformational_leadership.pdf.  

Ruth Jackson Orthopaedic Society (Retrieved 2016, February 12). www.rjos.org.

Satiani, B. (2012). Business knowledge in surgeons. The American journal of surgery, 188(1), 13-16.

Teuscher, D. & Cannada, L. (2016) Women in orthopaedics: The attraction is mutual. AAOS Now. Aug 2016.

Tosi, L. L., & Mankin, H. J. (1998). Ensuring the success of women in academic orthopaedics. Clinical Orthopaedics and Related Research®, 356, 254-263.

University of North Carolina. (2012). UNC Leadership Survey 2012: Women in Business.

Image credit: Surgery Wednesday by Ryan Dickey licensed under CC BY 2.0.