Abstract Background Orthopaedic surgery residency has one of the lowest percentages of women (13.1%) of all primary surgical specialties. There are many possible reasons for this, including bias during the selection process. Questions/purposes We therefore asked whether performance during residency might adversely bias the selection of future female orthopaedic residents by researching whether males and females perform equally in orthopaedic surgery residency. Methods Ninety-seven residents enrolled in our residency between 1999 and 2009; six males and one female left the program, leaving 90 residents (73 males, 17 females) as the study cohort. Resident performance was compared for OITE scores, ABOS results, faculty evaluations, and in a resident graduate survey. Results Males and females had similar faculty evaluations in all ACGME competency areas. Males and females had similar mean OITE scores for Years 2–5 of residency, although males had higher mean scores at Years 3 through 5. Males and females had similar mean ABOS Part 1 scores and ABOS Part 1 pass rates; however, fewer males than females took more than one attempt to pass. Males and females had similar Part 2 pass rates or attempts. For the 45 resident graduates surveyed, females pursued fellowships equally to males, worked slightly less hours in practice, and reported higher satisfaction with their career choice. Conclusions For the 90 residents at one residency program, we observed no differences between males’ and females’ performance. Although females pursue orthopaedic residency less frequently than males, performance during residency should not bias their future selection. ------------------------------------------------------------------------------------- Results in details We observed no difference between female and male performances in any of the eight ACGME competencies as measured by faculty electronic evaluations. Although small differences were observed between females and males, there were no statistical differences in any of the ACGME competency areas or the added areas of technical skills and overall competency. The mean E-Value® rating for men and women in each of the six core American College of Graduate Medical Education competencies and the additional measures of technical skills and overall competency is displayed. OITE scores were similar between females and males in all years of residency. We observed no differences in the second, third, fourth, and fifth year scores. The mean score on the annual Orthopaedic In-Training Examination (OITE) for male and female residents in each year of training is displayed. The p values are after post hoc correction for multiple comparisons. The ABOS Part 1 scores were similar between females and males. From 1999 to 2004, the average percent correct for females was similar (p = 0.68) to that for males (75% versus 76%, respectively) and from 2005 to 2008, the average standardized score was similar (p = 0.50) for females and males (198.0 versus 203.2, respectively). Although there were no differences between females and males on the ABOS Part 1 examination, females took a greater (p = 0.05) number of attempts to pass the ABOS Part 1 exam. Three of 10 females (30%) and three of 49 males (6%) required more than one attempt to pass. There was no difference in the number of passing attempts for ABOS Part 2. The survey of our resident graduates showed no difference (p = 0.45) in the number of female (six of eight [75%]) and male residents (22 of 38 [58%]) who decided to pursue a fellowship. Four of the six women completed a hand fellowship. There were differences between females and males in hours worked per week and number of call days per month. Females on average worked fewer hours and took less calls than their male counterparts. Seventy-five percent of females and 32% of males worked between 31 and 60 hours per work week; 25% of females and 68% of males worked over 60 hours per week. No females worked over 80 hours per week, whereas 11% of males did work over 80 hours per week. Seventy-five percent of females and 29% of males took calls between zero and four times per month; 25% of females and 71% of males took calls more than five times per month (p = 0.04). In ranking their career satisfaction as orthopaedic surgeons, 100% of females and 90% of males stated they would choose orthopaedics again. A total of 63% of females and 65% of males reported being very satisfied with their careers (Table 1). Discussion Although 49.1% of medical students are female, only 13.1% of orthopaedic residents are female [6]. Female medical students are choosing other surgical specialties at substantially higher rates than orthopaedic surgery. We chose to examine performance during residency, because one possible barrier to admission of females into residency could be the perception in some orthopaedic programs that females do not perform as well as males; this does not reflect our own experience. We asked whether males and females would perform equally well during residency using different outcome measures. The study has obvious limitations. First is the issue of whether our sample is representative of other programs. The relatively high number of female residents enrolled in our program over the past 10 years (20%) may not reflect the experience of other institutions with fewer females. A multi-institutional study would be necessary to limit this concern. Second, the faculty evaluations give the most insight into performance during residency, but they remain subjective and prone to bias. However, over 40 faculty members in our program use this comprehensive electronic evaluation for all residents on all rotations and have done so for over 10 years, supporting the concept that our faculty members did not perceive a difference between male and female performance during residency. Finally, we cannot determine what deters women from entering orthopaedic surgery as a profession. We did not study the 95% of graduating females who elect other fields and have data only related to performance of those who did enter orthopaedic surgery. We can tackle the question of potential selection bias by examining the performance of those who did select orthopaedics. Other authors have examined this issue, including Scherl et al. [13] who examined the issue of possible gender bias during the interview selection process. Residency applications blinded to gender were given to blinded reviewers (program directors and department chairs); no difference in the ranking of the female and male applicants was found. This study suggests women are not discriminated against during the initial Electronic Residency Application Service chart review process; our study indicates women who are selected perform well and become competent, successful surgeons. We believe it is unlikely bias was introduced against female applicants during the interview process in our institution given our experience. The problem of small numbers of women choosing orthopaedic surgery as a career appears to begin with failure to attract female medical students to apply to orthopaedic residency programs. A number of barriers may exist for women pursuing a career in orthopaedic surgery. Several studies demonstrate early exposure has a positive correlation with matching into a surgical career [8–10, 12]. There is a lack of musculoskeletal education during medical school and orthopaedic clinical rotations are frequently not required. Unless the student is exposed to orthopaedic surgery and musculoskeletal pathology before entering medical school, an interest may never develop. Bernstein et al. showed mandatory musculoskeletal education encouraged a higher application rate to orthopaedic surgery residency, especially among females and minorities [4]. This study may indicate that men are entering medical school focusing on orthopaedic surgery, and women do not have adequate exposure during medical school to choose orthopaedic surgery as a career choice. Why are studies such as this one important to the field of orthopaedic surgery? In 2007 to 2008, women comprised 49.1% of all US medical school graduates [1]. This percentage is predicted to increase. Orthopaedic surgery remains one of the primary surgical subspecialties with the lowest percentage of female residents [5]. If the field of orthopaedic surgery wants to continue to attract and employ the “best and the brightest” students as residents, it cannot afford to only draw applicants from half of the applicant pool. The American Academy of Orthopaedic Surgeons has made gender diversity a topic of special interest. Similarly, the American Association of Neurological Surgeons has identified a major problem with recruitment of women into neurosurgery and cites obstacles such as the lack of a critical mass of female neurosurgeons in academic medicine to serve as role models, gender inequity for acceptance into residency, unfair treatment for promotion, and limited opportunities for advancement of their careers as female neurosurgeons [3]. Whether similar circumstances exist in the orthopaedic community bears scrutiny. Only 7% of orthopaedic faculty members are females, and there are only 15 females in the country who hold full professorships [11]. It is important for female residents and students to have visible examples of competent, successful female orthopaedic surgeons [2]. Our data suggest female residents perform equally to males during residency; females complete our residency program with equal frequency as males; females are equally satisfied with their career in orthopaedic surgery. Given the relatively large numbers of females in our program and similar performance in females and males we found no evidence for selection bias against females based on any perceptions of differential performance. Additional research efforts are needed to evaluate gender differences in other residency programs across the country as well as further examination of other barriers for female medical students in applying to orthopaedic surgery residency programs. Source
