Year: 2020
Type: article
Abstract: Diverse workforces and inclusive workplaces improve productivity, innovation, and overall quality-of-care for all patients,1, 2 increase public trust in medical research,3 and are generally good for business.4 Unfortunately, orthopedics lags behind other biomedical fields in the recruitment of women and underrepresented minorities into training programs and faculty ranks5-7 and focused recruitment efforts have not reduced the gender, racial, or ethnic gaps in orthopedic residency programs.7 These gaps exist among both clinical and research faculty in academic orthopedic surgery departments,8 as well as in other departments that house orthopedic researchers, such as engineering. The Orthopaedic Research Society (ORS) is in a privileged and unique position to positively influence recruitment and retention efforts because orthopedic research laboratories are often entry points for students who aspire to be scientists, engineers, physicians, and/or surgeons. As a premier orthopedic professional society, ORS has the responsibility to set cultural standards for safe and inclusive environments for all members and affiliates to implement and follow. In 2019, the president of the ORS (co-author JCI) formed a Task Force to address diversity, equity, and inclusion (DE&I) within the Society. Our charge was to recommend how the ORS can (a) increase understanding of the importance of DE&I to the ORS mission, (b) foster inclusion by promoting communication and building communities that engage underrepresented groups and the greater ORS membership, and (c) develop resources to increase the cultural competency of the global research community and ORS. For 6 months, we reviewed the current ORS diversity statement, available literature, and membership data, and discussed best practices and goals for promotion of a diverse, equitable, and inclusive culture in the ORS. In this editorial we summarize our findings and outline next steps. Human diversity is multidimensional and intersectional. Our diversity results from inborn traits, learned characteristics, and individual experiences. Inborn traits include gender identity, race, ethnicity, age, and sexual orientation (Figure 1, white ring). The next dimensional category consists of characteristics we can learn, change, or control such as language, religion, and marital/dependent status (Figure 1, purple ring). Finally, professional diversity is represented by academic credentials and work experiences (Figure 1, blue ring). The combination and intersectionality of traits and experiences make individuals unique. ORS collects information from its membership on many aspects of professional identity (eg, degree obtained, current position). In regards to other dimensions of human diversity, ORS only collects information on two gender identities (female or male) from those members who choose to disclose. Though the ORS strives to improve the inclusion of all underrepresented groups, the lack of data on any other aspect of member diversity limits our understanding of where deficiencies exist and where efforts to address them are most needed. Available gender data show that in 2018 ORS ranked third amongst 19 AAOS Board of Specialty Societies in female membership at 24.7%, trailing only the Ruth Jackson Orthopaedic Society (95.9%), which has a goal of advancing the science and practice of orthopedic surgery among women, and the American Spinal Injury Society (42.8%).5 Over a 5-year period (2015-2019), the number of ORS members identifying as female grew from 595 to 994, but the percent of female members rose just 1% during this time (from 23.5% to 24.5%). On the other hand, the number of individuals who did not report a gender identity increased from 1.8% to 13.9% between 2015 and 2016, and was 13.5% in July 2019. To understand ORS gender diversity in greater depth, the Task Force reviewed the most recent dataset (2 July 2019) and considered three categories of members (Active, Associate, and Affiliate). The Associate (mostly students/trainees) and Affiliate (eg, vendors) members have a greater percentage of women than the Active members (eg, faculty and principal investigators; Figure 2). Associate and Affiliate members were less likely to reveal a gender identity as male or female. This disparity may reflect inadequate gender identity options in surveys or beliefs by some individuals, especially younger people, that revealing a gender identity is either harmful for professional advancement or irrelevant. Membership diversity is important for the long-term success of ORS and the fields of orthopedics and musculoskeletal research. Diverse research teams are more productive and innovative, have more highly cited publications, are more equipped to solve complex problems and adapt to change, and produce more impactful, equitable, and comprehensive outcomes because their collective experiences and perspectives allow for better decision making.1, 10, 11 Diverse teams not only garner more professional success, but are also better prepared to close gaps in orthopedic healthcare outcomes for women and minoritized individuals, such as the higher risk for infections and other complications in racial and ethnic minorities after a joint replacement.12, 13 Recognition of disparities in musculoskeletal treatment of racially or ethnically diverse individuals is troublingly low among orthopedic surgeons.14 More awareness and research in these areas are essential to address such disparities in musculoskeletal and orthopedic healthcare treatments and outcomes. A more diverse and inclusive ORS community can educate and identify solutions for these problems. Medical school classes and many graduate programs in the United States are now gender-balanced and have more racial and ethnic diversity than ever. Unlike other research, medical and surgical specialties, orthopedics does not yet reflect this balance.5-7 Despite these challenges, success stories provide lessons to consider. Orthopedic departments with more diversity in their faculty have greater success in recruiting women and underrepresented minorities into training and faculty positions.15, 16 Structured programs, such as the Perry Initiative and Nth Dimension, also appear to make a difference in increasing the number of women and underrepresented minorities in orthopedic surgery.17, 18 This success indicates that mentoring matters. However, maximum benefit from diversity initiatives will not be achieved if these learners do not also see role models at orthopedic meetings, are not included in decision-making processes or leadership of professional societies, are not allowed to express their perspectives and utilize their experiences to enhance productivity, and/or feel physically or psychologically unsafe. A commitment to DE&I at ORS meetings and sponsored events is essential for providing all individuals with full access to professional development and advancement. In a competitive research environment, success in securing research funding and academic promotions requires evidence of research productivity, impact, and recognition of investigator reputation at the national and international levels. ORS meetings are a valuable platform for investigators to gain recognition and visibility for their ideas, augmenting the chance of success in future publications, grants, and promotions. Given that the success of diverse investigators improves the recruitment of diverse research and clinical trainees, as well as research and clinical outcomes, the inclusion of diverse groups in membership, leadership, and presentations at meetings of ORS is foundational to the success of diversity efforts throughout orthopedics. Inclusive environments are mosaics of individuals in which differences are celebrated and viewed as strengths, as opposed to melting pots in which assimilation is favored and biases persist. Within the ORS, the Women's Leadership Forum (WLF) has welcomed women to the field, provided a network of mentors and peers, and nominated and sponsored women for awards and podium positions as well as board/committee membership since 2005. The WLF's success is remarkable. In 2018, the ORS was one of nine orthopedic research societies (out of 23) with a greater percentage of women on the Board of Directors than in their membership (44% vs 25%).19 Over the last 25 years, the field has also seen increases in the number of women in leadership roles within the ORS, on the Editorial Board of this journal, and in women cited as first and corresponding authors in this journal.20, 21 While the WLF has developed women leaders and fostered a sense of belonging for women within the ORS, there is still much to do to advance the inclusion for all minoritized individuals in the Society. Symposia and panels composed only of men ("manels") or white individuals perpetuate the impression that women or people of color are not experts and are not welcome in the field. When women and minoritized groups are not represented on panels, other biases often emerge. For example, women are less likely to be introduced with a professional title (eg, Dr X) than male co-panelists.22 The subtle (and often unintentional) message to the woman and the audience is that she is less qualified than other panelists. These and other microaggressions, which could be intentional or unintentional, can be prevented by populating program committees with diverse members, by addressing each other with respect, and by seeking broad input from a diverse membership. Each of us can take steps to identify our own unconscious biases (as we all have them) that inadvertently prevent us from being inclusive. These actions include reviewing our contact lists, asking our colleagues for feedback, and taking online Implicit Aptitude Tests (www.implicit.harvard.edu). Awareness of personal unconscious biases is the first step to changing our behavior and becoming advocates for inclusion. The "leaky pipeline" in science is well documented, as women and underrepresented minorities are not well represented in the professoriate, C-suite, or other senior leadership positions, despite more women receiving advanced degrees.23 For example, women have comprised more than half of the class in doctoral programs in biology or biomedical sciences for well over 20 years, but the percentage of faculty positions held by women or federal research funding awarded to women are far below 50%.24 Motherhood is one of several drivers of gender imbalance at higher career levels (eg, faculty, department chairs, deans) in STEM (science, technology, engineering, and mathematics) fields. Indeed nearly twice as many new mothers as new fathers leave full-time employment after becoming parents.25 Male and female scientists share drive and capacity to excel in research careers, but our systems do not equitably support women during their transition to parenthood. Reasonable accommodations for new parents, especially new mothers, at professional meetings would address some of these concerns.25 Arrangements could include providing dependent-care travel grants, on-site lactation rooms, help with freezing and shipping of milk home, and affordable, high-quality child care. The risk of not providing these services is greater to the Society's future than potential liabilities, which can be managed with careful planning. In addition to the pressures of parenthood, unconscious bias and harassment are major factors that drive women and minoritized individuals (especially sexual and gender minorities but also racial and ethnic minorities) from STEM fields.26 Sexual harassment and coercion occur at scientific meetings and significantly decrease feelings of safety and inclusion. As many as 75% of physics undergraduates reported some form of sexual harassment while attending a scientific meeting.27 The ORS has a Code of Conduct that forbids sexual harassment at its events; however, it is likely that many instances are not reported because victims fear retaliation or believe that nothing will be done. Such demoralizing experiences may lead these individuals to leave the field, despite years of training and lifelong interests. Other forms of harassment also contribute to individuals not reaching their full potential. These include but are not limited to persistent comments about appearance or parenthood, slurs, and inappropriate touching or communications (eg, text messages). The consequences can include a reduction in the victim's sense of belonging and/or exacerbation of imposter syndrome. A consensus study of the National Academies of Science, Engineering, and Medicine concluded that professional societies have a major role in upholding behavioral standards during meetings and collaborative research events.26 Importantly, the report also concluded that professional societies can be drivers of change in the community via their capacity to educate, inform, train, codify, and reinforce cultural expectations for their field. The Task Force strongly endorses these conclusions and would like to see the ORS fulfill this responsibility. In October 2019, the ORS Board of Directors reviewed the findings from the Task Force, approved a revised Diversity and Inclusion Statement for the Society (Box 1), and formed a new DE&I committee that will further the work of the Task Force. Under the new ORS 2025 strategic plan, the Board of Directors also identified DE&I as a core value of the ORS and defined a community objective to cultivate a diverse, inclusive, and engaged ORS by increasing access and opportunities. These first steps lay the foundation for more discussions and programs to better connect ORS members to each other and to those who benefit from our work, especially patients and learners. The ORS is a dynamic scientific community that advances musculoskeletal discovery to improve health. Society activities and governance aim to engage conscientious individuals from diverse social, scientific, and professional backgrounds to achieve our goals and positively impact our community. The ORS cultivates a diverse, inclusive, and engaged community by promoting and increasing equitable access and opportunities to individuals of all races, ages, ethnicities, nationalities, gender identities, sexual orientations, abilities, incomes, religions, and all other forms of human diversity. The new DE&I Committee will monitor and prioritize issues in a rapidly changing area. Immediate needs include expanding our understanding of diversity in the ORS and increasing the diversity profile of our membership. The paucity of data on dimensions of human diversity within the ORS membership concerned the Task Force because it prevents the Society from tracking the success of new initiatives and can promote an inaccurate perception that the ORS does not value member diversity. Benefits of collecting more data include: better recognition of human diversity in the ORS; improved definition of member needs; informed ORS meeting programming; representative diversity in conference speakers, moderators, and organizers; better capabilities to evaluate how ORS demographics compare to other organizations and to the communities suffering from musculoskeletal and orthopedic conditions; and becoming a resource for members who are studying diversity at their institutions and/or recruiting new scientists or engineers. Security and privacy concerns with data collection are manageable risks with proper investments in technology, deidentification of data, and assurances that protections are in place regarding access to the data. Overall, benefits of collecting more data on the diversity and inclusion of the ORS outweigh the risks. We envision that the new DE&I committee will build on the ideas identified by the Task Force and address contemporary issues going forward. We anticipate that this committee will drive data collection efforts, monitor DE&I initiatives and progress, and organize training and educational events that celebrate and increase awareness of its important role in the Society. The new committee will also advise the presidential line, Board of Directors, programming committee and other groups and committees in ORS, including staff, for years to come. In sum, the DE&I Committee members will advocate for DE&I throughout the Society and work to identify and remove barriers (known and yet unknown) that prevent access and reduce interest in orthopedics. The ORS is poised to lead the orthopedic research community in implementing the best DE&I principles and to shape the future orthopedic workforce. Innovation, diligence and sustained commitment, including financial investments from the Society, will be required to achieve DE&I goals. ORS leaders should have competencies in these areas and promote, through words and action, the conviction that DE&I are important to the Society. Ultimately everyone is responsible for achieving DE&I in our field, not just those who are from underrepresented groups or whom we wish to recruit, retain, and assist. We encourage everyone to examine and understand how bias affects their actions and to participate in DE&I efforts within the Society. In conclusion, as the premier orthopedic research community, ORS has a responsibility to recruit, train, and retain a scientific and healthcare workforce that will discover and deliver treatments for millions of people who suffer from musculoskeletal disability across the globe. To achieve its new mission statement of accelerating musculoskeletal research to improve health, ORS must foster the best research and innovation, be as diverse as the population being served, and engage the entire workforce to deliver equitable solutions to patients. Authors are listed in alphabetical order because contributions were equal. The following authors were members of the ORS Task Force: TA, KCF, BF, KMK, KJL, XSL, DMM, RO, RMQ, MvdM, and JJW. These authors reviewed the report and provided crucial feedback: CJH, JCI, and CMR. All authors approved the manuscript.
Source: Journal of Orthopaedic Research®
DOI: 10.1002/jor.24685
Institutions: University of California, San Francisco, University of California San Francisco Medical Center, University of Illinois Chicago, Orthopaedic Research Society, Cornell University, Icahn School of Medicine at Mount Sinai, University of Michigan, Michigan Medicine, Indiana University Indianapolis, Indiana University School of Medicine, University of Pennsylvania, University of New Mexico, University of New Mexico Health Sciences Center, Temple University, Virginia Tech, Case Western Reserve University, Mayo Clinic
Language: English
Subfield: Gender Studies
Field: Social Sciences
Domain: Social Sciences
Open Access status: bronze
OpenAlex ID: W3014374854