The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies

Listen to Andrew Duckworth, Usman Halim,  Antonia Chen  &  Chloe Scott discuss the paper 'The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies'.

Discussed papers:
Click here to read 'The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies'

Transcript

[00:00:00] Welcome everyone to our second podcast from the month of November. I'm Andrew Duckworth and a warm welcome from your team here at The Bone & Joint Journal. A big thank you as always to our readers and listeners for their comments and support as well as to our many authors. We hope you are continuing to find our podcasts and all of our knowledge translation work to be both helpful and informative.

As we approach the end of our series for the year, we aim to have delivered and covered an exciting  and wide range of topics with our primary goal, always to improve the accessibility and visibility of the work we publish at The Journal both for you as our readers and listeners, as well as for our many authors.

For this month's highlighted study, as you know, over the next 20 to 30 minutes, we will cover a range of aspects of the chosen paper, emphasizing the important points of how the study's been put together, as well as any take home messages from the paper itself. 

So, firstly, today I have the pleasure of being joined by Mr. Usman Halim, who is the lead author for their study, entitled The prevalence and impact of gender bias and sexual discrimination in orthopedics and mitigating strategies: a systematic review, which has been published in the November edition of The BJJ. Welcome Usman and a big thank you for taking the time to join us today.

[00:01:00] Hi, thanks for having me. 

I'm also delighted to be joined by two stellar colleagues who I know will be able to give us some brilliant insights and thoughts on the important issues highlighted in this paper. Joining me here in Edinburgh is my Editorial Board colleague here at the journal, Ms Chloe. Scott. Thank you, Chloe, for joining us. It's great to have you back with us.

Thank you for asking.

Chloe and I are absolutely thrilled to be joined by our final guest all the way from Boston, the US, Dr. Antonia Chen, who is the Director of Research for arthroplasty service at the Brigham and Women's Hospital in Boston, an Associate Professor of Orthopedic Surgery at Harvard Medical School. Antonia it's such a pleasure to have you with us today. Thanks for joining us. 

I'm glad to be here. I just don't have the coolest accent in the group. 

So just maybe before we move on to your paper, just a more  sad note. I know yourself and us here at The Journal, would like to pay tribute to your co-author on this paper, Dr. Elbayouk, who was a junior colleague of yours who tragically lost his life in a car accident in October of this year.  It's very sad news to hear Usman and our condolences to your team, his colleagues and family. 

Yeah, thank you very much, Mr Duckworth. He was a fantastic [00:02:00] colleague and a real motivator for us getting this paper started and done and the real driving force behind it. And I think it was really, this paper is a Testament to, you know, what a nice person he was, but also how dedicated he was to widening participation. And he was just a real advocate of fairness in all aspects of his life. So I think myself and our co-authors really want to pay tribute to him, just express the fact that we've been very affected by his sad loss, and this is a tribute to him.

Absolutely. That is very nice words. 

So Usman,  if we move on to your paper,  the aim of the work was to identify the prevalence and impact of gender bias and sexual discrimination in orthopedic surgery and to investigate any interventions that can counter such behaviours. So Husman, if you just give us a brief introduction to the paper and really, really focus on why you chose to look at this really important topic.

Yeah, absolutely. Well gender bias and sexual discrimination is something that I personally have seen quite a bit growing up and it's something that never really sat very well with me at all. And rightly so, of course. And I was really shocked when I became a foundation year [00:03:00] one doctor and I started to see it in the workplace, which I never thought I would, if I'm honest, maybe I was perhaps a bit naive. Quite a few examples of this, but the most common ones really were when  I'd be asked about my career ambitions and say I wanted to do surgery and I would get a pat on the back and lots of encouragement. And at the same time, when my female colleagues were asked the same thing people would say, well, have you thought about doing something like general practice because it's family friendly and flexible, and perhaps it's a little thing, but it never really sat well with me and I just thought it was unfair. 

So that's really what got my mind thinking about it quite a few years ago now. And as I went through my surgical training, myself and Dr. Elbayouk, we both noticed that in orthopedic departments, there wasn't a great representation of females amongst the consultant bodies. And we were a bit puzzled as to why. And we wondered whether there was just an inherent problem within our specialty. So we wrote this paper with a goal of trying to answer that question, is there a problem in our specialty of gender bias and sexual discrimination? And if there is, are there any strategies that have been tested to try and tackle it? 

That's very interesting. So that sort of lends me to, [00:04:00] just before we move on to the paper, to maybe come to Chloe first now, before we go into the paper in more detail, can you give us a brief background, Chloe? I know, you know, the numbers well, but in terms of the numbers with regards to gender diversity in surgical specialties, but in particular in orthopedics for us in the UK.

Of course Andrew. So, NHS England actually published this data, newly annually and from the NHS England data from last year, we know that 17% of orthopedic surgeons are women  in England. Now this percentage is obviously an average. If you break it down by grade, it's apparent that although 45% of orthopedic foundation doctors are women. Which is like interns would be in the United States. This then falls sequentially at every level to 19% at registrar or resident level and only 6.7% at consultant level. And if you consider certain subspecialties like hip and knee surgery, like myself and Antonia do, [00:05:00] it's even worse. It's only  5% of hip and knee consultants are women. 

So in Scotland where we work, the numbers are quite similar to England. And I know that 25% of trainees  are now women. So whilst this does look like an improvement, and is,  and as discussed, certainly in the paper as being a positive achievement, I think it also has to be mentioned that whilst the numbers of female trainees are increasing, there's a significant loss at each level. So we've got  an apparent failure to retain women in orthopedics. And also other surgical specialties that have similar kind of backgrounds to orthopedics, similar issues of work-life balance, similar hours, similar training have made much more progress in terms of evening things up. And certainly across all surgical specialties in the UK, 15% of consultants and a third of trainees are women. So,  it appears [00:06:00] that other specialties, like general surgery, are much closer  to achieving gender parity than we are. So,  in these terms, we still have got a long way to go in orthopedics in the UK.

And they are quite stark numbers Chloe, aren't they, in terms of, not only the losses as the progression through training goes on, but also in terms of relative to the other surgical specialties. So it's not necessarily, well, it is a surgical problem, but it is particularly a problem in our specialty itself.

Antonia, if I can come to you, how does that sort of compare in the US? 

So, this is really sad to hear because you guys are way better than we are. So when it comes to the consultants, our percentage is 6.9% at the last one, so attending level for us. For the registrars it is about 14%. Now these numbers are slowly increasing across the board, which is good, but it's still very slow. And when it comes to hip and knee arthroplasty, we're at 2.3%. So these are tiny, tiny percentages. And what's hard is that our numbers are high in the United States when it comes to [00:07:00] orthopedic surgeons, but our percentages are very low. 

Now what's encouraging to Chloe's point too, is that the number of registrars are increasing. So there is a pipeline now because in order to have a higher number, as we go further down the road, in terms of attendings, you have to have a pipeline to start. That said, at each level there is attrition for a multitude  of reasons, whether it be family, whether it be choices or different areas of interest, but  it's something that's quite stark in comparison to other surgical sub-specialties. 

What's interesting to me is actually percentage wise orthopedics is the lowest out of all cases across the board when it comes to women. Neurosurgery has less number, but orthopedics has a lower percentage of women in both the registrars and attending level.

Yeah. That's really interesting  like you say,  it's that contrast with the other surgical specialties, which  it's quite profound really? Isn't it? Isn't, it almost has to be said, maybe not expected, but hoped it wouldn't be the case, but it certainly is. And I have to say it's fairly similar across the water.

So if we go on [00:08:00] to just a very briefly, I want to talk about obviously the methods of the paper, just so we know what we're talking about. And also it was a systematic review performed according to the PRISMA guidelines and you included original research papers pertaining to the prevalence and impact of gender bias and sexual discrimination, as well as any mitigation strategies that have been looked at to address these, within orthopedic surgery itself. What were your  key eligibility criteria  in addition to that and what sort of data did you try and extract from the papers? 

Yeah. Well, in addition to the key points that you mentioned regarding, papers on the prevalence or impact of gender bias or sexual discrimination or mitigating strategies. We wanted to keep it as broad as possible, really,  because we wanted to capture as much information as we could from across the world. So we didn't limit ourselves to publications from any particular country or any particular year, because we wanted to get a really good, broad overview. 

We did only look at papers in English language, and we made sure that the subjects of the papers that we included were either medical students or doctors who were either interested in orthopedics or who were pursuing an orthopedic career. We tried to maintain a degree of scientific rigor [00:09:00] by only focusing or only including papers that were classified as being part of the Oxford center for evidence-based medicine levels, one to four. So we excluded a level five papers. 

 In terms of the data extracted, well in the paper, there is quite an extensive  detailed table cause we wanted to be as transparent as possible about all the data we have collected. But the key things we looked at were the year of the study, the country in which the study was published, the nature of the design, for example, whether it was based on a survey, sample sizes were important for us, and we did clearly make reference to these in the table, the demographics of the participants of each study, whether they were students or doctors, and then  information on the prevalence of gender bias and sexual discrimination, and also an attempt to kind of quantify the, or at least qualitatively describe the impact on the participants. And finally, with respect to mitigating strategies, we referenced their design, who the recipients or the targets were of these strategies and how effective they were. 

Right. And so if we move on to what you  found , you started with [00:10:00] 570 papers that were identified and you ended up with 27 papers that you've included in the narrative review. And there were a total of 13 papers that discussed the prevalence of gender bias and sexual discrimination while 13 were related to the impact of these behaviors. And then there were six that looked at mitigating strategies. So if you could briefly summarize your findings,  there's a lot of great data in the paper itself in terms of the results  but you looked at a variety of categories and they were sort of prevalence of gender bias and sexual discrimination in the workplace and online as well, and also in job applications and then the gender distribution of the perpetrators of gender bias and sexual discrimination, and then the overall impact on workforce and job offers and salaries in academia. I know it's quite a lot of information, but just summarize what you found with regards those.

 Overall, in the majority of cases, the papers that we found showed that gender bias and sexual discrimination are common in orthopedics, whether in the UK or the USA. And it must be said at this point, I think that the vast majority of the papers came from the USA with a smaller number from the UK and Canada, [00:11:00] even less so. But in pretty much all the studies we found that females were more likely to receive bad treatment in the sense of harassment or bullying or discrimination or bias. And that's really a finding we found across the board, certainly in the workplace for example. 

In respect to job applications, there are some slightly conflicting data, but it's all from the USA but generally speaking, the findings that we found were in face-to-face interviews in the USA residency interviews, females were significantly more likely to be asked gendered questions, for example, relating to marital status or plans for having children, which I think is really unacceptable. In respect to who the perpetrators are, realistically, the vast majority of the studies are really quite implicit and didn't explicitly say who these were, but a very small number made reference to the fact that more often than not the people who code out this mistreatment within our field, but were more often than not men, as opposed to female colleagues in terms of the impact,  on for example, workforce [00:12:00] planning, job offers salaries and so on.

Generally it's the case that we found that, for example, we talk about salaries first of all. There's an interesting study in Canada, which showed that female orthopedic surgeons earn significantly less than their male counterparts. And when it's looked at on an hourly rate, it's $55 less per hour for doing exactly the same work, which is hard to get your head around actually.

 There was a very small study done in the USA, and there aren't many like it, looking at the chances of females getting jobs as a consultant or attending in comparison to their male colleagues. These specifically were females and males who've done pediatric orthopedic fellowships, and it was found to be the case that the male colleagues were significantly more likely to be offered an attending person before even completing their fellowships whereas this wasn't the case for the females. 

All in all the general gist is that  it's more difficult for females to navigate a career in orthopedics, all stages actually, which was surprising to us and really quite disheartening. 

Absolutely.  I mean, you've got a really good summary there [00:13:00] Usman, but I do encourage our listeners to go and read some of the findings of some of those papers. I think you really have to read it yourself. And some of them, like you say, are just  quite astounding really. And I suppose for want of a better word, slightly embarrassing on behalf of our specialty in some ways. And you know, within the UK, you said a recent study from 2019 found that 53% of female surgeons perceived orthopedics to be a sexist specialty. And the next one down was cardiac surgery at 13%. I mean, that is, it's hugely different, you know. It's astounding, isn't it? And the article in your results, go on like that a lot. And I know, I appreciate, like you say, a lot of these studies are from the US , but  that's a UK based study where we're from and that's  only from last year, you know, it's not like the other studies of 22 years, but that's relatively recently.

And just before we move on to, you know, the implications of it which I really want to spend quite a bit of time on what did you find with regards to sort of mitigating strategies that were reported. Yeah well, obviously I'm based in the UK and I was firstly, quite disheartened to see that [00:14:00] really no mitigation strategies have actually been tested or tried in the UK. There were a very small number they're all done in the USA, and really to summarize them, I suppose they have two general themes or had two general themes. The first was seeing whether providing female role models and mentors was helpful and certainly it seems that strategies which implement a mentorship strategy do seem to encourage more females to choose orthopedics, which is very interesting and useful information.

The other line that a lot of these strategies take is implementing educational strategies or lecture programmes to educate students at the earliest stage of their career about what life in orthopedics is really like to try and dispel some of the myths and false perceptions that people have. And so the two strategies that were most detailed in terms of the descriptions in the literature are the Perry initiative and the nth dimensions summer internship program, both of which were published in 2016 and I think there's a lot we can learn from this. 

No. I agree. And  I think with the mentorship, I think it's the same old adage, isn't it? You know, it's very hard to be what you [00:15:00] can't see or imagine. And  it's a really important  thing in this situation with those numbers that Chloe and Antonia have just mentioned, it makes it so much harder if what you want to be isn't as common. And I think that's something we really have to work on. 

And if we move on to, you know, the impact of the study, you know, it's a really powerful piece of work. There's no doubt about it. And I think it is adding to a growing body of evidence, you know, that particularly over the past couple of years, I think this is becoming more pronounced in the literature, which is a great thing. I think if anything, to increas e the awareness  of this as an issue we have to tackle and take on. And it's clear from the literature you shown that gender bias and sexual discrimination is widespread within orthopedics. The impact is significant and it affects women at all stages of their career. 

But before we move on to the implications of the work, what did you feel were the limitations of the data that's currently out there as well? Was there anything in particular you noticed or felt that we need to sort of focus on?

Yeah, I think certainly there are a few small points. The first of which is certainly that the vast majority of the data came from the USA 22 of the 27 papers were published from the [00:16:00] United States of America, with smaller amounts from the UK and Canada. So I suppose some ways that it can be applied findings as readily to the USA as we do to the UK, for example but we do have studies in the UK showing it's a big problem here as well. I think, albeit a smaller number. 

 I guess the majority of the papers were also based on surveys. And so it does bring into the question of bias, responder bias for example, and whether the figures overestimate or underestimate the actual true figures. What some might say that if you'd been a victim of gender bias or sexual discrimination you might be more likely to complain about it in the form of a study or to raise it as an issue. 

But the converse is true. For example, when we look at studies on bullying, we know that in the medical workplace, people who are bullied or harassed or undermined, they're actually deterred from reporting as an issue. And so equally we might be underestimating the significance and the prevalence of this problem. 

 I think  the majority of the data was retrospective, which also brings the possibility of bias creeping in. And lastly, I would say that, I suppose what we wanted the crux of this paper to be was to [00:17:00] inform and enlighten the orthopedic community globally about mitigating strategies. From our detailed research there are only a very small number of these, which I'd say is a limitation as well. 

Absolutely. No, absolutely. I think that's a good summary of, of where we're sort of at, with the Antonio and Chloe, if I can come back to you guys, you know, until you maybe use yourself first, you know, what, what do you feel are the key key findings of this review, particularly in relation to the data that has come from the US and do these fit with your experiences?

So I'll start because I'm from the US. And I will say that it's very interesting that, first of all this publication is something that I think we needed to put out there. And I think the key factor is that all these little publications are out and no one's actually compiled them together. And it's pretty stark when you actually put them all together to understand that this is not just a problem in one centre or one geographical region or one like an academic centre versus a community center. This happens everywhere. 

And I think we brought this to light for the American Association of Hip and Knee surgeons. We put [00:18:00] together a video and as part of  this video we had female orthopedic surgeons from throughout the world, send in comments that they received from patients, from colleagues, et cetera. And they were all gendered comments and it was astounding. I mean, we couldn't publish half the stuff that came out there just because it would be almost actually over the top. And I think as a woman, and I think Chloe can understand this as well too, it didn't really surprise me. I've definitely received these comments. I've seen others receive these comments. It's something that I think we just brush off in general. So bringing this to the forefront right now is actually pretty incredible. It's something that I just grew up with and just accepted it because as you said, orthopedics has just kind of been seen as like the male specialty. I love it as a field and my colleagues have actually all been great. So I've been really thankful to have really great colleagues. 

So I think the idea of having mentorship, on both genders are actually really key. And I look at it as mentorship, coaching and sponsorship as kind of the three main thing. So, mentorship, you see someone [00:19:00] that you can relate to.  One of my mentors, her name is Audrey Tao. She's an Asian female orthopedic surgeon who does hip and knee replacements. Now I don't have to find a mentor that looks just like me per se, but it's been wonderful actually just to have that. And I'm lucky to have that opportunity. 

That said, though, I hope it can inspire other women, but some of my greatest mentors are men and these male mentors have done nothing but support me along the way, you know, advocated for me , sometimes will coach me and tell me how to do things better. And sometimes sponsor me, you know, there's like, there's this committee that's coming out with. Why don't you do that? And that's great because that's what other people do for everyone else, regardless of gender. But because there's so few females, a lot of times they might get overlooked over sidestepped.

And we've looked at, you know, females on the podium, look at females in committees. They just republished this actually out of POSNA. So pediatric orthopedic surgeons is a huge population of women, probably 30 to 40% of that group is women. And the number of women who are in committees are percentage-wise lower, which makes sense if you give the distribution. But the [00:20:00] number of women applying for committee positions is just the same as men. 

So that's an interesting finding. You would think that whatever percentage you apply should get the percentage who gets in. So the idea is the more that we have people sponsoring one another helping one another, again, regardless of gender, just that they're really good at, but if you happen to see two equal candidates, and let's say you do increase the diversity factor and you know, sexual orientation and gender and race in anything, I think that just makes our field better. And I can just tell you from working with patients, patients identify with certain individuals better. And if we have a diversity of individuals to refer to or that they can see, that's a wonderful thing. 

Absolutely. Absolutely. And to sort of echo your comments about  the video that you mentioned at the beginning there. Right? I saw that as well, and I think it's such a powerful piece. I really do. And like you said, you and Chloe weren't particularly surprised by the comments, but it's the shock on some of your male colleagues face as they read them out, they can't quite believe it. You know,  they're stunned to silence almost at some points because of how bad some of these [00:21:00] comments are that they're having to repeat. You know, and I think it's a really powerful piece. I really do.

Chloe if I ,  come to you the same sort of question , do you feel that the key take homes maybe for us here in the UK and, and how it maybe fits into your experiences as well? 

So I can echo what Antonio said really that, I mean, this is a massively important, I think paper, mainly because it gathers all those other bits of information together and presents it as one piece and helps us really to define the size of the proble m within our specialty, which is significant. I think we can all all agree from from this. 

I think the biggest take home message that I've taken is that disappointingly, in every aspect where gender bias could be an issue.  this review has shown that there is.  And that the research base confirms that it is and that women are the victims of it.

I have to say of all the data presented,  Andrew's already highlighted one of his shockers from [00:22:00] it, one of the shocking  statements that I took from the paper was from one of the UK studies from 2009. So it was one of the older studies included in the review, but it's still only 11 years ago. And we're apparently 13% of orthopedic surgeons didn't think that women were capable of being orthopedic surgeons. And that really is absolutely terrifying. And I think it's only this as an issue in orthopedics that we can successfully implement mitigating strategies, to try and correct it.

 In terms of where the papers come from in this review, it's obvious that much of this work is being done in America and it would be nice to see more UK-based studies. I think Usman has already mentioned a couple of the strategies that they are implementing in America, which would certainly be very beneficial, I think if we use them here,  

[00:23:00] Our,  kind of the role model or mentorship programmes, like the Perry initiative and the Ruth Jackson organization, who'd been demonstrated,  in some of the studies included in this review,  to really kind of draw in more young and enthusiastic, female students into considering a career. That's not certainly what we need to do if we're going to address this inbalance. 

No. I agree, Chloe. And I think it's an interesting linking into what Antonia said before you as well, that same study from 2009, I thought it was also fascinating that said, despite this the same study found that 89% of patients had no gender preference for their orthopedic surgeon. And of the 20 patients who did have a preference, 75 actively preferred a female surgeon because they found them to be more compassionate and empathetic and had much more previous positive experience with it. Isn't it? I mean, it's just  absolutely fascinating. I think it really is really invaluable data.

If we maybe just spend a bit of time talking about the mitigating strategies Antonia, [00:24:00] obviously there's ways that we can address gender bias, such discrimination, but also I think in terms o f those fall off numbers, we were seeing, do you think there's other factors that we need to try and address? You know, maybe work-life balance. I ask you that as well, because I am under no illusion that I know American orthopedic surgeons work a lot harder than we do in the UK. Your hours are ridiculous and you never take holidays, but I think I just wonder what your feeling is about that in the US?

 Well, the good news that we take a holiday now there's nothing to do. So why take holiday? You might as well just keep working. So COVID has definitely changed that there's no doubt about it.  Conferences used to be my excuse to escape from work, but there's none of that now, either. So as you can see now I'm at work. It's interesting actually to see attrition of level of women by levels. So there's two different realms. I would say here, the first role would be academics and the second realm would be non-academics and both are equally valuable. So from an academic perspective, they look at the percentage of people who are full professors, associate assistant professors, et cetera. And the attrition by females is much [00:25:00] higher than men. And percentage-wise by the end, obviously it's much higher than a men. So from an academic perspective where you're promoted based on a few things, one, you know, teaching, conferences, international presence, national presence, committee involvement, research. Those take a lot of time. And to be perfectly honest in most facilities, those aren't compensated. So it's not compensated either one people are gonna elect to not do it which is potentially true across the board, but if they do it, they need to be given time to do it. 

So for mitigating risk factor strategies, I would say what I would recommend is either give them research time that's compensated for, if research is an area of expertise. If it's teaching, then make that a core competency of theirs. And again, compensate them for that time and make sure that they don't feel like they're torn between the two of them. The last one that you asked that was work life balance, and that affects both academic and community surgeons equally. And traditionally, the role of parenting does fall on the woman, but that's not always true if it's, and it depends on which [00:26:00] woman. Let's say it's a same-sex couple that become one of the persons on an individual is going to have to choose. And as an orthopedic surgeon that's difficult, right? It's hard to take care of a family while being on call. And it's difficult to take care of family when your patient gets a dislocation and you have to come in and take care of them. So how can we mitigate that? So we've created something called an Arthoplasty call pool here. So for example, we also have a trauma call pool, but we have arthoplasty call pool. So you don't have to be on call all the time. Right? 

So if someone is on call at that timeframe, we do include our fellows to it. And this can be true for all subspecialties. So let's say I'm going to a child's school play tonight. And my patient comes in is dislocated instead of me doing it. And I'm not on call, I can call my colleague and say, Hey, can you help me? Do you mind doing that? And so that's ways that you can actually distribute the work. And this is not just for males. This is not just for females. This can be for males too. If the male wants to go to the school play they don't have to take arthroplasty call that evening, for example, and then it more evenly distributes across the board as opposed to focusing on gender as one thing.

[00:27:00] That can be done in a community setting, that could be done in the academic setting, as long as there's parity in distribution. I think that's fair. That really comes up when it comes to pregnancy. So that's where it becomes you can't distribute to male, female, right? The female will be carrying the baby. And if the female is the one who's carrying the baby, or again, if it is the same sex, couple, it doesn't make a difference which it is, but the woman's carrying the baby and she happens to be an orthopedic surgeon, she's going to have to have some time to recover. So how do you mitigate for that? And I've seen a lot of women what they do is they take as much call as physically possible before delivering the baby, which is why I think there's a lot of premature babies out there. So they really, you know, torture themselves prior to doing so. But they want to make sure that they're not taking away time from their male colleagues. But males don't take off time for paternity leave and don't necessarily make a bad call for paternity leave. So how can you equally distribute it so that everyone across the board is getting a work-life balance? And I think that'd be helpful for all individuals. 

Definitely. Definitely. I think, I think you're right Antonia. I think, like you said, like we've, we've already highlighted in the data, there is obviously a higher percentage  of trainees in other surgical specialists. There is way to do it. There is [00:28:00] ways to balance it out and do it effectively and manage on-call and all those things.

And Chloe if I just come to you,  it's important obviously  to expose people to our, I think our brilliant specialty in many ways, a medical school and try and start it from there. Isn't it? And trying, you know that mentorship system, maybe even starting as early as that, you know, for people who are interested in not losing those people to other specialties with time.

Absolutely. Andrew. So as well as the lack of role models or lack of exposure to orthopedics and to surgery in general, there's certainly been implicated in our problem in attracting women into surgery and into orthopedics in particular. And certainly getting students early seems to be key from the US data as the Jackson organization on the Perry initiatives have shown but we also in orthopedics suffer from this kind of hidden curriculum where students and women in particular, as Usman mentioned earlier in this conversation, , women are often told that orthopedics is very physical. [00:29:00] You have to basically be kind of a rugby or a football player.  How will you cope going into it, a speciality that is so male dominated and how will you cope with the hours and all of this. So there's a lot of bad press,  that doesn't necessarily come from within orthopedics, but it comes from other specialties to which medical students are exposed.

So other clinicians, prejudices and bias often muddy the water for us before we've even met the students and a worrying development, certainly in the UK is that access to surgical specialties for medical students at a lot of UK universities  is being reduced to make way and prioritize more exposure to kind of general medical specialties in general practice. And I fear that this will make,  improving our diversity even more difficult, as it may be that you will only rotate through orthopedics, for example, if you've specifically asked [00:30:00] for it.  And I think we'll certainly miss out as a specialty,  as the research that there is on medical students suggest that their opinion of us improves when they've been exposed to us rather than getting worse. So if they're  never exposed then they never even think of it as a career, and I think that's going to be a real issue for the future. 

Yeah, no, absolutely. Yeah. Sorry. Sorry. Yeah. Carry on. 

Okay. And in terms of what what Antonia said about  work-life balance and kind of juggling careers  and parental responsibilities, it's slightly different obviously in the UK because ours are more restricted,  and parental leave is slightly better provided by the state, I suppose, than it is in America. And certainly if you look at the proportion of female orthopedic surgeons,  internationally, it does tend to be highest in countries where they've got the [00:31:00] most,  either childcare support or parental leave support so that you can share it between partners, , or so that, you know, it's built into your contract. There's no barriers to taking it other than a desire to take it, but certainly, you know, we have to make sure that flexible training is possible in orthopedics, but again, these issues about work-life balance, they don't just affect orthopedics. They affect all acute hospitals specialties, whether it's medicine, emergency medicine, other surgical specialties. And yet they seem to cope with it and seem to not be putting women off. So there's certainly more, I think, of a culture issue and I think that's what this paper really exposes. 

And I know  as we've discussed before, worklife balance is not just a female issue either. It's a male issue as well. It's become more of a balance for everybody to do that as time has [00:32:00] gone on. So I think that's a really good point. 

Just to finish off, I am just going to ask all three of you, I suppose Usman if I come back to you first, you've looked at these studies over the past 20, there was a 22 year period they came from.  Do you notice any changes over that period of time or was it, I suppose depressingly the same from 22 years ago to now in terms of the findings? 

Yeah. Well, we included studies for more years with the very idea that we might be able to draw some conclusions about changes over time. That was our goal. As it so happened, there was such heterogeneity between the different papers in terms of the methodology, populations and questions asked, that it's hard to really say quantatively that things have improved or worsened or stayed the same. But I think just from a qualitative point of view, whether the papers were published 20 years ago or one year ago, they still show an unacceptably high prevalence of gender bias and sexual discrimination. And so it's almost immaterial in a way to say it's slightly improved or slightly worse. The reality is I think we still have a big problem, whether it's the USA or the UK or Canada, [00:33:00] the problem still exists. And I think we still need to tackle it.

No, I think that's a very good point. Isn't it? It's, you know, even if it's better, it's not right yet. Isn't it? That's right. Yeah. And if I come back to Chloe and Antonia, just for your final comments maybe Chloe, you go first.  How'd you feel about the future with regards to this? You know, we obviously we have to tackle it, but do you have confidence in that and our ability to do it?

I think that the main way we tackle it is accepting that there's a problem and defining what the problem is. And I think we're well on the way to doing that at the moment. And I do think that there seems to be a real drive to close the gap if not by everybody in orthopedics, certainly by all the orthopedic societies that that I'm aware of. And everyone's coming up with a diversity strategy and a way of trying to even things up and give women more exposure, more visibility, more chances of podium, you know, more involvement in leadership roles. And I think that's really [00:34:00] important, you know. I think the societies and us in general, all of us in orthopedics, need to actively try and address these issues because if we leave it to passively correct, as has been the case previously, it'll take generations to achieve any kind of equity.

I totally agree. And Antonia, do you feel much the same? You positive about the future and we can move forward at a good pace to try and get this sorted.

I think Chloe and I on here is already a good move, I would say. So that says a lot right there. I would also say too, you know, it's one of those things where we put up the video and the first response was, Oh my gosh, I didn't know that happened. So knowledge and awareness exactly as Chloe was saying is really the first step.

And then the second question people would ask us is what do I do about this? And so, you know, maybe 10 years ago that may not have been the second question that would have been like that's horrible. And then end of conversation. Okay now it's, that's horrible. Let's make steps. Yeah. And so I think that's already a [00:35:00] change in and of itself.

I already see changes as we're increasing the number of women within the field. I would be cautioned to say, though, that just increasing the numbers is not the full answer. Right. Just because we're increasing the numbers. That's wonderful. But we want to make sure everyone feels safe, included, comfortable within the field.

And again, I think we're taking steps to that. So as long as we go across the board and make everyone feel  that just as, part of the team for the orthopedic surgery is another surgical subspecialty. That's the best out there, of course. And as we increase across the numbers across the board, it's a wonderful thing. So it's a win for everyone. I think, as we go down this path, 

Absolutely. I think that's a really  positive note for us  to finish on. So everyone, I am afraid that is all we have time for - a really enjoyable conversation and thank you to all of you for taking the time to join us today. And congratulations on a really excellent study that is without doubt, an invaluable addition to the literature in this area.

And I'm sure we'll continue to lead much discussion. And, and as we've said, action, moving forward. And to our listeners, we do hope you've enjoyed joining us. And we encourage you to share your thoughts and [00:36:00] comments through social media and a like about this very important issue. Thanks again for joining us, everyone and stay safe.