Letter to the Editor: How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?

Abstract

To the Editor, As medical students at the University of Manchester in the United Kingdom (UK), we read the article, “How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?” with great interest [6]. The article conveys a poignant message; namely, that there is a perception among medical students from minority backgrounds that there is a lack of diversity within orthopaedic surgery [8]. This will undoubtedly hinder future specialty applications and diversity in the surgical workforce. It is well-documented that surgical specialties struggle with diversity, with orthopaedics being among the most affected [4]. This is an international problem; the Royal College of Surgeons of England recently commissioned and shared an independent review that highlighted ongoing issues with diversity and inclusion in surgical specialties in the UK [7]. In introducing this report, the president of the Royal College wrote, “We must stop the unacceptable behaviors, the unconscious bias, and the prejudice which prevent women and those from other ethnic backgrounds making progress in a surgical career, from joining our Council, and taking positions of leadership. I welcome the honesty of the report and the ambition and scope of its recommendations” [7]. The report followed an outcry from women and people of color in the Royal Society in the wake of elections to Society leadership that empaneled four white men who, according to the report, “seemingly came from very similar social backgrounds.” [7]. The report, which was lengthy and detailed, struck us as an honest self-assessment of a problem that has persisted for too long. In general, the study in Clinical Orthopaedics and Related Research® [6] claims that ideas towards diversity, sexism, and inclusion improved universally following an orthopaedic rotation. However, when examining the results more closely, it is evident that there remain serious issues in students’ perceptions of orthopaedic surgery and that the improvements to those perceptions were, in fact, only minor. Even after clinical rotations, scores for perception of diversity and inclusion and sexism within orthopaedics peaked at 1.5 and 2.0 (on a 5-point Likert scale from 0 to 4), respectively, for nonmajority groups, identified in the study as women, nonwhite ethnic groups, and those of nonheterosexual sexual orientation. For example, when women who described themselves as cis-gender were questioned about the diversity of orthopaedic surgery before the rotation, the mean score was only 0.71. This increased to just 1.0 post-rotation [6]. This remained worryingly low. One might expect greater increases if the specialty was truly diverse and inclusive. When questioned about this, Dr. LaPorte acknowledged the low scores and suggested that placements alone are insufficient to change perceptions. Dr. LaPorte also explained that “20% of students rotate with our orthopaedic services” [3]. A recent study in the UK showed that 80% of UK medical students have some form of orthopaedic placement [5]. This shows the large disparity in orthopaedic teaching worldwide, and given the struggles with diversity in UK orthopaedics, is in keeping with the suggestion that placements are ineffective at encouraging future participation. The effect of perceptions on future applications were also mentioned, with the idea that less diverse specialties are unattractive to all, not simply nonmajority groups [3]. On this subject, we are of the opinion that there is need for a prospective, longitudinal study similar to this one to be undertaken with a few modifications. Our proposed study would follow students who, having had an orthopaedic rotation, go on to apply for orthopaedic specialty training. In this way, we could examine whether a positive experience in medical school rotations correlates to increased applications for higher training. This would allow for further clarification of the relevance of these results and hopefully would show increased application numbers among minority groups. We conclude from this article that minority students hold strong negative perceptions of orthopaedic surgery even after the conclusion of an orthopaedic rotation. As such, greater work is required by the specialty, in collaboration with medical schools and student societies, to challenge these perceptions and improve diversity. Previous studies have suggested that the presence of role models and exposure during medical school play a key role in increasing diversity. Such programs exist but are not as widespread as necessary [1]. Flexibility in training, equal representation, and mentorship programs would also serve to drastically improve these issues [2]. There is an urgent need for further research that tests solutions to a problem that has been amply described.