AAOS Now

Published 11/30/2019
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Stephanie S. Pearce, MD; Mary K. Mulcahey, MD, FAAOS

Women Face Challenges When Pursuing Academic Careers in Orthopaedic Surgery

Fifty-seven percent of full-time faculty positions in U.S. medical schools are held by women, which is just slightly more than the 50 percent rate of female graduates of U.S. medical schools. Yet the number of female faculty in orthopaedic surgery is much lower, at 13 percent. Several factors likely contribute to this disparity, including lack of mentors; interest in pursuing hospital-employed or private practice positions; or the specific requirements of academic employment, such as teaching responsibilities and balancing research and committee work with clinical practice.

Research

Academic medicine presents several unique challenges. As described by O. William Brown, MD, JD, there are three legs to the stool of academic medicine: “teaching, research, and clinical activity.” A recent study by Polhaus et al., evaluated sex differences in National Institutes of Health (NIH) award programs to improve diversity initiatives in the research workforce. The authors found that women and men are generally equally successful at securing NIH grants at similar career points; however, men tend to have more R01 awards than women at all points in their careers, and they tend to have more subsequent grants than women. Thus, with regard to research funding, gender disparities persist.

Maintaining a high level of research productivity while also trying to meet teaching and clinical responsibilities can be daunting, but to those who have a passion for research and clinical practice, the two can complement each other. Amy McIntosh, MD, is in academic practice at Texas Scottish Rite Hospital for Children. She said, “To succeed in academics, you have to have a curious mind.” She added that an academic orthopaedic surgeon needs the “right” partner at work—someone who is also committed to clinical or bench research. Dr. McIntosh further stated, “Having monthly meetings (brainstorming sessions) to decide which research projects are worth investing the time in,” and then “holding each other accountable, to make sure the project makes it through to final publication,” are ways she excelled in an academic career.

Committee work

Serving on committees and boards is another important aspect of academic medicine. Time spent in such roles allows one to not only broaden leadership skills but also contribute to professional societies and improve the profession as a whole. Committee work also can open doors for collaborative research. Additionally, critical networking takes place at committee meetings, allowing for long-lasting relationships and career advancement.

A challenge facing many female orthopaedic surgeons with regard to participation on committees is being selected for positions. Several recent studies have sought to identify the percentage of women in orthopaedics, in addition to the percentage of women in leadership roles. Saxena et al., analyzed all of the orthopaedic subspecialty societies that comprise the Board of Specialty Societies in terms of the percentage of female members, as well as women on their boards of directors. They found a positive correlation between the number of women in membership with an increased percentage of women on the board of directors; however, the society with the highest number of female members, the Pediatric Orthopaedic Surgeons of North America (26 percent), was not the society with the highest percentage of women on the board of directors (n = 3/20, 15 percent). The society with the highest percentage of women on the board of directors was the Orthopaedic Research Society (n = 7/16), but the overall membership was only 25 percent women. The researchers’ stated goal was to educate the orthopaedic community and be transparent regarding current societal compositions in hopes of encouraging societies to consider different ways to include more women.

Combatting and changing underrepresentation involve an understanding of leadership traits and how leaders get selected. Some traits shared by leaders include physical appearance, communication ability, intelligence, and personality. Taller and more attractive leaders are consciously/subconsciously associated with strength, which is associated with good leadership; so for women, wearing heeled shoes instead of flats and presenting with good posture may improve the perception of height and thus strength. Designated leaders speak fluently, with a confident tone, so asking questions confidently at the microphone during sessions and symposia can demonstrate communication capabilities, as well as intelligence.

Once women are nominated to committees, opportunities to display strength in communication are more frequent and can help them climb leadership ranks. Interestingly, even though being moderately more intelligent than the group is attractive, because leaders need problem-solving skills, being “exceedingly more intelligent” decreases the likelihood of being designated or recognized as a leader. Therefore, balancing intelligence without being a “know-it-all” or condescending is beneficial. Finally, extroverted, assertive, and persistent personalities help women gain positive attention by others and often are seen as attractive and signs of communication competence.

Attending meetings and conferences, introducing oneself to current leadership, expressing interest and ideas confidently, and participating in social outings associated with meetings and organizations can decrease implicit bias by increasing others’ perceptions of one’s confidence, communication skills, and leadership attributes. In turn, these small actions can aid in increased nominations to committees and leadership positions.

When choosing a committee on which to serve, focus on those that align with your interests and strengths. This will facilitate idea production and enjoyment, while also allowing committee work to overlap with research, clinical activities, and teaching endeavors.

Academic promotion

Successful academic promotion can be difficult. According to the National Academies of Sciences, Engineering, and Medicine, “Women faculty are paid less, are promoted more slowly, receive fewer honors, and hold fewer leadership positions than men.” These discrepancies do not seem to be attributed to productivity, significance of work, or any other performance measure. Instead, they are likely related to the “objective” evaluation of more senior scientists, which are often arbitrarily applied in a biased manner (often unintentionally), such as selection of those who are assertive or single-minded. Such characteristics tend to be seen as socially unacceptable traits for women compared to qualities such as flexibility, diplomacy, curiosity, motivation, and dedication.

It is important to have a clear understanding of the metrics required for academic appointment, promotion, and tenure at an individual institution.
Papaconstantinou and Vargas discuss the four most common tracks in academic medicine: clinical surgeon, clinical scholar, clinical scientist, and clinical educator. Each track has its own priorities and criteria on the promotional ladder, and they are critical for young surgeons to understand. Additionally, each institution has its own requirements and protocols for advancement, which should be taken into account when considering new career opportunities and when setting short- and long-term goals. When measurable benchmarks are written into a contract (e.g., number of publications per year), promotion to associate or full professor is less likely to be overlooked based on gender or race, even in less-than-fair environments. Fighting bias is achieved more easily with statistics and numbers; they can help set benchmarks and display qualifications that are equal to those of higher-ranking colleagues. It is important to be prepared when seeking promotion. Presenting the department chair with facts and figures regarding similarly accomplished coworkers who have previously been promoted (even if they are from other departments) can be helpful.

Salary

Previous studies have demonstrated a salary gap of > $40,000 between men and women in orthopaedics who have equivalent training, work the same number of hours, and perform the same number of cases annually. Although $40,000 may not seem like a large difference at the start of one’s career, that gap widens as raises and promotions occur over time, and the salary differential transforms into potentially delayed retirement and altered lifestyle. In fact, according to Jena et al., who analyzed sex differences in salary in U.S. public medical schools, the adjusted salaries of female full professors were comparable to those of associate male professors ($250,971 versus $247,212), despite their higher rank. Therefore, negotiating and securing salary that is more equitable to that of male counterparts is important in narrowing the gender gap and receiving equal payment for work performed.

One method of discovering disparities in pay at an individual institution is to research the publicly accessible salaries of employees. Academic institutions are public entities, and most states require open display of salaries for all employees. Similar to identifying discrepancies in promotions despite achieving required benchmarks, when a salary discrepancy is seen, bring the information to the department chair to discuss why differences may exist. The Equal Employment Opportunity Commission enforces the Equal Pay Act, which “prohibits pay discrimination based on sex.” If a true disparity is present and the department head is unwilling to have discussions and offer potential solutions, the next step is involving human resources or a labor attorney to ensure equal payment for similar work.

Work-life balance

A final challenge facing academic female orthopaedic surgeons is integrating work and family. Although this is not specific to women or academia, women face additional, unique challenges, especially balancing demands at home with clinical and research responsibilities. Finding ways to incorporate family into work and vice versa helps increase the amount of quality time spent with children and partners. Additionally, discussing priorities together with your partner and children for both work and home life can help ensure that everyone is on the same page and working toward similar goals. Having a supportive partner is critical to succeeding as a wife, mother, surgeon, and researcher. Dr. McIntosh said that the “first step” toward a successful career in academics is “finding the right partner at home. One’s husband or wife has to ‘embrace’ the child-raising responsibilities and respect one’s clinical and academic responsibilities.”

Conclusion

A career in academics necessitates commitment to research, teaching, and clinical responsibilities. To be successful in all three, female academic orthopaedic surgeons must be well organized and able to multitask. It is also important to set healthy boundaries and prioritize. Learn to say “no” and avoid overcommitment. With the right partners at home and work, a curious scientific mind, a strong work ethic, and knowledge of how to subdue and equalize disparities in the workplace, it is possible for a woman in academic orthopaedics to “have it all.”

Stephanie S. Pearce, MD, works in the Department of Orthopaedic Surgery at the University of Colorado in Aurora, Colo.

Mary K. Mulcahey, MD, FAAOS, works in the Department of Orthopaedic Surgery at Tulane University School of Medicine in New Orleans.

References

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