40 minute read
The Birmingham Orthopaedic Network – Collaboration, facilitation, empowerment
Usman Ahmed
Usman Ahmed is a Consultant Orthopaedic Surgeon with a special interest in Lower Limb Revision Arthroplasty at the Princess Royal Hospital, Telford. The Birmingham Orthopaedic Network was developed in his final year of training in Birmingham and as a BOA Clinical Leadership Fellow in 2017/18”.
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The past decade has seen a rapid growth of trainee collaboratives. The West Midlands Research Group (general surgery) led the way and demonstrated the effect of empowering driven trainees in research. Since then trainees have played a significant role in studies starting with recruitment of patients to major studies through to developing and receiving funding for trainee-led projects. This has not gone unnoticed and has the broad support of consultant and research bodies.
The Birmingham Orthopaedic Network (BON) has its roots in the traditional collaborative model but has been expanded to promote wider engagement beyond surgical trainees. In addition, the model has sought to facilitate training and education as part of a broader drive towards an improved and engaging culture.
The proposal for the BON (August 2017) initially achieved broad stakeholder support on a local and regional level. With support from the Birmingham Orthopaedic Training Programme, the Royal Orthopaedic Hospital and Health Education England. From the outset infrastructure was developed towards three strategic aims:
1. To facilitate collaborative working with robust protocols and policies to enable rapid development, assessment and implementation of audit/research projects.
2. To develop a pathway to allow medical students to actively participate on traineesupervised projects.
3. To build an educational platform.
have taken a proactive lead in national project development and implementation (DRAFFT Impact Study), been willing partners in other national projects (FEMOR study, UCES study) all of which have been presented to both national and international audiences. The medical student engagement has seen approaches from both individuals and groups of medical students to foster even closer links following the particular success of the initial cohort. The educational platform continues to grow with archived material for junior doctors and medical students serving as a precursor to wider engagement with all healthcare professionals involved in musculoskeletal care.
As a testament to its rapid growth and early successes, the BON was a finalist at the Health Service Journal Value Awards 2019 in the Training and Development Initiative category. to get involved in quality work without necessarily following the more arduous academic pathway. At a time when the NHS faces unprecedented difficulties in recruitment and retention the training and development aspect of the BON was designed to encourage and engage the surgeons of tomorrow.
Trainee collaboration has been demonstrated to be a powerful tool in clinical research. But when empowered there are very few limits to what trainees can achieve. In the current NHS the drive towards cultural improvement should include giving junior staff (in any field) encouragement to develop ideas and opportunities to implement them. As such the BON has succeeded in its key objective to facilitate and empower and will continue to do so. n
To find out more about the BON visit: https://www.bon.ac.uk.
The further expansion of the BON is intended to continue with a view to encouraging participation from anybody and everybody who has an interest in musculoskeletal health. This open policy and desire to engage and participate in projects is representative of trainee desires
Why do surgeons bother with research?
Chris Bretherton
It’s probably less carrot than stick… Our governing bodies require research output at every stage of career progression. Presumably, this is to demonstrate our ability to interpret literature and practice evidence-based healthcare. Does publishing a retrospective series of your boss’ last 20 bunion operations achieve this?
Fortunately, the BOA has helped shift the goalposts, realising that low-quality research is neither helpful to ourselves or the scientific community.
The 2018 shift in research requirements for T&O Certificate of Completion of Training (CCT) now encourages surgeons to integrate research into their every-day practice, through involvement in multicenter clinical trials. This is a more efficient method of generating highquality research in the NHS. Being a local principal investigator (PI) for a clinical trial will provide greater insight into research design and interpretation than the low-quality papers we were previously incentivised to produce.
The ‘associate PI’ scheme is a joint venture between the National Institute of Health Research (NIHR) and the Royal College of Surgeons of England. It provides guidance and accreditation for trainees wishing to contribute to NIHR research. Furthermore, trials units are making the process easier by automatically providing certificates for participant recruitment, which trainees can use as evidence towards their CCT. Trainee research collaboratives are emerging in all regions, with notable examples from Birmingham, Peninsula and Northern Deaneries. Each has its own model for encouraging research, education and mentorship. Combining their efforts, they have won major grant funding for high quality, trainee-led trials.
All in all, these changes mean that weekends spent data mining and resubmitting papers to gain CCT will soon be a thing of the past. The new incentives promote meaningful engagement in research, which equals happy surgeons and happy patients. n
What is consent?
John de Bono
The Paterson Inquiry has brought renewed scrutiny of the relationship between surgeon and patient. The fifth anniversary of the Supreme Court’s landmark decision in Montgomery is a good time to review the current state of play on the law of consent and the implications for surgeons.
John de Bono QC is a leading clinical negligence barrister practicing from Serjeants’ Inn Chambers in London.
To understand Montgomery we need to take a step back and recognise how things used to be. In what some will still regard as the good old days, it was for the surgeon rather than the patient to decide on what treatment was required. Advice was acceptable, and a surgeon was not negligent, if he acted in accordance with the practice of a reasonable body of surgeons in the same field. In practice this meant that doctors could choose how much information to give a patient and whether to give options for alternative treatments.
This approach was endorsed by Lord Diplock in Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital decided in 1985. His view was that patients might be put off by a detailed discussion of risks and it was up to a doctor to decide how much information to provide:
As an overall approach this was the highpoint of paternalism in medicine. There was also an element of snobbery in the judgment. Lord Diplock observed that if an educated patient such as a barrister or judge had any concerns about the proposed treatment he would have the ability to ask appropriate questions of his surgeon. Everyone else need not worry. Sidaway remained good law until Montgomery in 2015.
Montgomery was short (under 5ft) and had diabetes. She therefore had a 10% risk of the birth being complicated by shoulder dystocia and if that happened there was a 10% risk of serious harm to her baby, giving a one per cent overall risk of serious injury to the baby from a vaginal delivery. Her obstetrician’s preference was for a vaginal delivery. She told to the court that she believed that if offered the choice Mrs Montgomery would have opted for the caesarean section. Mrs Montgomery duly had her vaginal delivery, the baby became stuck and suffered a serious hypoxic ischaemic brain injury.
The Supreme Court accepted that the obstetrician had acted in accordance with the practice of a reasonable body of obstetricians. Moving the goalposts significantly they found that this was no longer the correct test. The question is not whether a reasonable doctor would have offered different treatment but what a reasonable patient would want to know. If there are reasonable alternative treatments then a patient is entitled to know and to make her own choice. The court held:
“The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.”
This ruling has significant implications for trauma and orthopaedic surgeons. If elective surgery goes wrong a patient can argue that they would not have had the operation had they been properly advised of alternative options. Postoperative infection following hip replacement might be a recognised non-negligent complication of surgery but a patient who was not advised of that risk or of the alternative treatment options, including not having surgery, has a prima facie case in negligence.
they decided to go ahead with surgery but on a different date the rare, non-negligent complication, would probably not have happened. Many surgeons struggle with the logic of this position, arguing that if you suffer a complication of surgery on Monday you would probably have suffered the same problem with the same operation on Tuesday. So how do surgeons protect themselves? Patients will often be convinced that there was no discussion of risks or alternatives. Surgeons need to be careful to record in a letter or the clinical notes that the patient was given a choice and what the alternatives were. Advice needs to be specific to the patient. The risks of hand surgery might be different for the pianist and the barrister. The courts have left unanswered the obvious question of the surgeon: how great a risk need be to require a mention. It is not just a question of risk but the seriousness of the consequences and the implications for a particular patient. Lawyers will tell you that consent cases used to be rare in practice. This was because even if a breach of duty was established a patient would struggle to prove what we call ‘causation’. If you give me sub-standard advice I have to prove that I would not have had the same operation with proper advice. Here too the goalposts have moved significantly in favour of the litigant. In Thefaut v Johnston, 2017, Mr Justice Green, found that a patient had not been given adequate advice about spinal surgery. Had she been properly advised she would either have not had surgery at all or would have had surgery on a different date. She was therefore entitled to damages for the disability that resulted from the otherwise nonnegligent complication of a dural breach. A claimant who suffers a non-negligent complication of elective surgery need now only prove that had they been given appropriate advice about risks or treatment options they would have delayed surgery to ‘think over’ their options. The court will find that had “The only effect that mention of risks can have on the patient’s mind, if it has any at all, can be in the direction of deterring the patient from undergoing the treatment which in the expert opinion of the doctor it is in the patient’s interest to undergo.”
Perhaps inevitably the Supreme Court kept its options open as to how great a risk need be to require a mention. It is not just a question of risk but the seriousness of the consequences and the implications for a particular patient.
In Thefaut the judge gave the following guidance for surgeons consenting patients: • The dialogue between doctor and patient must be ‘adequate’. • There must be ‘adequate time and space’ for there to have been a reasonable dialogue. • Communication must be ‘de-jargonised’. • The doctor’s duty is not fulfilled by bombarding the patient with technical information. • The routine demand of a signature on a consent form does not by itself mean anything in terms of consent. • Consent should not be taken for the first time on the day of surgery.
Of course where your patient is unconscious or exsanguinating all bets are off and the court will be quite happy for you to revert to exercising your best paternalistic judgement as to what to do. That may be some reassurance, at least to the trauma surgeon. n
Note from the Editor: A follow-up article is planned addressing how the law stands with regards to consent for the non-elective but conscious patient typically encountered in trauma practice.
Supporting orthopaedic trainees returning to training after taking time out of programme
Tricia Campbell
The orthopaedic training pathway is competitive. More trainees are seeking time out of programme to pursue interests, such as leadership, research or education. They may also have caring responsibilities or take parental or sickness leave. In order to fulfil these roles and pursue extra-curricular interests, trainees need flexibility and a certain degree of control over their working lives.
Tricia Campbell is President of the British Orthopaedic Trainee’s Association (BOTA). She is currently out of programme working as a Leadership Fellow at HEE NE (Health Education England, North East).
This flexibility has the potential to also ultimately benefit patients and create a diverse workforce of wellrounded individuals to serve our diverse patient population. Allowing trainees the flexibility to take time out of training will enable formation of a diverse workforce 1 .
To facilitate such time out of training, we need to also consider the issue of safe transition back to the clinical workplace. It can be a daunting experience for many trainees, regardless of their training level, to return to an unsupervised trauma list or a night shift in a busy major trauma centre after a period of absence. A recent survey of all General Surgery Higher Speciality trainees in the Kent, Surrey and Sussex (KSS) region identified key concerns regarding their return to training around their operative skills, confidence, worklife balance, clinical knowledge and perceptions of colleagues 2
. These findings are consistent with the results of a survey conducted by the AoMRC in 2016, which found the following specific concerns:
• Attrition of clinical knowledge and practical skills. • Expectation of immediately being able to function at pre-level when resuming work. • Working out of hours without supervision from the outset.
To support sustainable careers and wellbeing, we need to normalise time taken out of programme and ensure that surgical career progression accommodates for trainees who wish to do so. In essence, we need to ensure that trainees wishing to take time out of training are not disadvantaged by their decision. As part of the ACAS agreement in May 2016, Enhancing Junior Doctor’s Working Lives group reported the importance of providing equity to those who have had a period of absence 4
. In response to this commitment, Health Education England (HEE) have developed a programme to support trainees returning to the work place following a period of absence over three months (opt in available for those less than three months).
Trauma and Orthopaedic trainees that take up the programme are low in numbers, despite having a lot to gain from the Supported Return to Training (SuppoRTT) programme. The aim of this article is to raise awareness of the challenges that trainees face when they return to training and to highlight the support available.
The areas of concern
Orthopaedics is a craft-based specialty requiring hands on learning to gain experience and allow for training progression. The concern is that time away from the operating theatre will lead to a diminution in operative skills.
clinical and professional skills fade. They found “substantial evidence that time out of practice does impact on skills retention. Skills have been shown to decline over periods ranging from 6 to 18 months, according to a curve, with a steeper decline at the outset and a more gradual decline as time passes” 5 .
An example within the orthopaedic practice is measurement of knee and shoulder aspiration skills retention learned by simulation in medical residents between 6 to 30 months post teaching event. They found that proficiency declined over time. It was also demonstrated that an opportunity to practice similar skills in the interim can positively influence retention of a learned skill 6 .
The support available
The Supported Return to Training Programme (SuppoRTT) was developed to enhance the experience of doctors returning to clinical practice. It enables them to regain their confidence and previously required skills quickly and safely. This in turn significantly benefits patient safety and quality of care. It has been designed to be flexible
and takes into account the length of absence as well as the speciality and experience of the trainee. The programme is designed to ensure that the individual can safely and confidently return to practice 3,7 .
The SuppoRTT star (Figure 1) illustrates the HEE offering: peer-to-peer mentoring,
coaching, return to training activities, testimonials or case studies, guidance documents and
signposting of useful resources.
Figure 1: The SuppoRTT star.
SuppoRTT uptake and funding co-ordinated regionally with national HEE oversight
The delivery of the programme has regional differences but should include a series of meetings with your supervisor prior to, during and after your period of absence. The purpose of these meetings is to establish your individual needs and plan your return. This plan may include a period of enhanced supervision, supernumerary period, supervised on-calls, clinical immersion, a phased return (with or without occupational health input), workbased assessments in addition to generic return to training and specialty specific refresher courses.
Your individualised return to work requirements, as agreed with your educational supervisor or training programme director (region dependent), will be funded by the SuppoRTT Programme through the meetings via submission of forms signed by selected supervisors.
Eligibility
To be eligible for the funding, trainees must be on a training programme with a National Training Number (NTN) or accepted onto a training post due to start after their period of absence. Their absence should be over
three months in duration (although those with shorter absences may opt-in) and less than two years. All eligible trainees are encouraged to engage with the SuppoRTT programme 7 .
Education and training
There is an abundance of courses covering the generic skills trainees across all specialities may require, (see Table 1). There are also a
Generic Skills Return to Training Courses
Work life balance and managing your time effectively
Communicating with confidence
Conflict resolution and assertiveness
Dealing effectively with change
Human factors training
Building resilience
Productivity in focus
Exam game plan
Coaching and virtual coaching
Return to training cross-specialty day
Clinical leadership courses
number of specialty specific courses available. These include, GASAgain (Anaesthetics), Springboard (Medicine), Return to Clinical Practice for General Surgery (Imperial College London) and Paediatric Return to Acute Clinical Practice (Paediatrics). Various learning modalities are being utilised including simulation, clinical updates, small group learning and scenario-based discussion.
There are slight regional differences in the courses available. This often depends on local specialty focus on education and training. All regions offer training for supervisors and helps upskill them in preparation for supervising trainees returning after an absence. It can also help them deal with potential challenges and introduce them to local support and guidance.
difficulties faced by trainees transitioning back into clinical practice after a period of time out of training. We need to help these trainees during their time of need and ensure that they are not disadvantaged as a result of their decision to take time out of training.
There is support available for any trainee taking time out training. Please ensure that you contact your local HEE office for further information. n
Useful resources:
National: https://www.hee.nhs.uk/our-work/supportingdoctors-returning-training-after-time-out.
Other: https://mysupportt.com.
There is currently a lot of work being done to ensure T&O trainees can benefit from the SupoRTT programme. An orthopaedic specific return to training course is being piloted in May 2020. If you would like more information please contact the National HEE SuppoRTT Fellow (details below).
Conclusion
Increased awareness is paramount in shaping the culture around returning to training. The T&O community need to recognise the https://blog.messly.co.uk/key-resources-forjunior-doctors-returning-to-training.
https://www.bma.org.uk/advice/career/ applying-for-a-job/returning-to-clinicalpractice-after-absence/a-model-process.
National HEE SuppoRTT Fellow: Sarah Siddiqui, E-mail: searh.siddiqui@hee.nhs.uk.
References
Diversity: Women in orthopaedic surgery – a perspective from the International Orthopaedic Diversity Alliance
Jennifer A Green, Vivian PC Chye, Laurie A Hiemstra, Li Felländer-Tsai, Ian Incoll, Kristy Weber, Margy Pohl, Carrie Kollias, Katre Maasalu, Magaly Iñiguez, Dafina Bytyqui, Margaret Fok, Philippe Liverneaux, Elham Hamdan, Violet Lupondo and Caroline B Hing
Jennifer Green is an Orthopaedic Surgeon in Canberra specialising in hand and wrist Surgery, Chair of the Australian Orthopaedic Association (AOA) Orthopaedic Women’s Link (OWL) Committee and one of the two observers of the AOA Board of Directors. She is the AOA Representative to the Diversity Council of Australia.
Vivian Chye is Consultant Orthopaedic Surgeon at Hospital Kuala Lumpur Hospital, Malaysia. Vivian is President of the Malaysian Orthopaedic Association and Vice President of the ASEAN Orthopaedic Association.
The International Orthopaedic Diversity Alliance (IODA) was formed in 2019 by a network of orthopaedic surgeons who are advocates of cultural and gender diversity. It promotes the sharing of information between nations regarding strategies to improve diversity and the inclusion of females and minorities in orthopaedic surgery. The focus of this article is to explore the current gender statistics, the barriers and the advocacy efforts towards improving gender diversity with the evidence supporting these initiatives.
Introduction
Diversity is essential to creating strong organisations that maximise the talents and skills of their membership. Organisations that are diverse are able to attract top talent, increase innovation and exhibit a better quality of decision making 1
. The critical mass for effective diversity is 30% across the fields of medicine, business and politics 2-4
. Diversity within orthopaedics was recently addressed at an international level 5
and we aim to provide an expanded perspective. Although females represent >50% of medical graduates in many nations, females still often constitute <10% of orthopaedic surgeons, and orthopaedics remains the least gender diverse of all surgical specialties. Leadership is the essential enabler for the four most effective diversity initiatives: 9,10
1. Communicate and embed values, behaviours and cultural norms. 2. Ensure recruitment/promotion processes are unbiased and involve diverse decision makers. 3. Create working models that support males and females with families. 4. Visible and committed leadership.
Unconscious bias and the ‘hidden’ curriculum
The past 30 years has seen progress in uncovering the implicit biases 11
, which have negative consequences for our choices of trainees, colleagues and patient treatments 12 . They underpin the ‘hidden’ curriculum 13
- the unwritten, unofficial values and perspectives that students learn 14,15
. In many nations the hidden curriculum teaches that orthopaedics is a ‘boys club’, that you cannot be a mother and an orthopaedic surgeon and that work-life balance is difficult. This plays an important role in inadvertently deterring good candidates from considering orthopaedic surgery. As an example of unconscious bias, this article has omitted non-binary genders. The authors acknowledge this shortcoming.
The competence of females is not in question with studies demonstrating patients of female surgeons have fewer complications and lower mortality 6,7
. Many barriers exist to increasing the numbers of females in orthopaedics including: gender bias; lack of exposure to surgical specialities during training; lack of mentorship and; lifestyle concerns 8
. The international data presented provides a gender diversity improvement framework. In 2009, a study of attitudes in the UK demonstrated that 24% of female medical students would consider a career in orthopaedic surgery. Female students were more likely to be exposed to negative attitudes against female surgeons and 62% of those who were exposed to such attitudes wouldn’t consider a career in orthopaedic surgery. 42% of male surgeons had been exposed to negative attitudes against female surgeons, including
Laurie Himestra is an Orthopaedic Surgeon at Banff Sport Medicine Canada. She is a member of many organisations including the International Society of Arthroscopy, Knee and Orthopedic Sports Medicine (ISAKOS), the Arthroscopy Association of North America (AANA), the American Orthopedic Society of Sports Medicine (AOSSM), and the Canadian Orthopaedic Association (COA).
Li Felländer-Tsai is Professor and Chair of Orthopaedics at Karolinska Institutet and senior Consultant in Orthopaedic Surgery at Karolinska University Hospital in Stockholm, Sweden.
Ian Incoll is Conjoint Professor at the University of Newcastle, Australia, Australian clinician educator and Orthopaedic Surgeon. He is Dean of Education and a Past President of the Australian Orthopaedic Association. He was the lead developer for AOA 21, the innovative and contemporary redesign of Orthopaedic Surgical Training in Australia.
Table 1: Analysis of gender diversity per nation.
questioning of their skill and the perceived conflict between their clinical and family responsibilities. Despite the marked gender differences expressed by medical students and specialists, when patients were questioned, 89% had no gender preference 16 .
Providing opportunities for medical students to engage with orthopaedic surgeons who are positive role models for gender diversity is one mechanism for changing this hidden curriculum.
Lack of female role models
Strategies to increase diversity include: early exposure to the speciality field; mentoring; interaction with female specialists and; an institutional culture supportive of females 17-19 . Orthopaedic training programmes with greater representation by female faculty have a higher proportion of female trainees. However, males who are good advocates and mentors for females are equally effective. Cross-gender mentoring is vital to achieving equity and should be an aspiration for all males 20 .
Gender equity in selection processes
and in several USA orthopaedic programmes, increasing diversity is taken into consideration in the selection process with candidates who otherwise rank equally. Many nations such as the UK have evidence of steadily increasing female orthopaedic applications, but this is still significantly less than for other specialties.
Flexibility in training and parenting
Significant barriers are perceived to pursuing a surgical specialty by females who want to have a family. A recent survey of 10,000 female medical students by the Royal Australasian College of Surgeons (RACS) showed the main barriers included lack of time for family and friends, current or future children and the lack of flexibility of training 21 .
Similarly, a USA study of 720 students showed that surgical work hours and lack of time for outside interests were the greatest deterrents to pursuing a surgical career. Female medical students demonstrated greater concerns regarding finding time to date, marry and have children during residency. Female students were more likely to perceive that discouragement from pursuing surgical training was based on gender, age and family aspirations, as compared to males 22 . >>
Kristy Weber is the Abramson Family Professor of Sarcoma Care Excellence and Vice Chair of Faculty Affairs in the Department of Orthopaedic Surgery at the University of Pennsylvania. She is the Director of the Sarcoma Program at the Abramson Cancer Center and currently serves as the President of the American Academy of Orthopaedic Surgeons.
Margy Pohl is Clinical Director of Orthopaedics at Northland DHB, Whangarei, New Zealand; a valued member of the NZOA Council and Chair of the LIONZ initiative.
Carrie Kollias is Paediatric Orthopaedic Consultant at Royal Children’s Hospital, Melbourne.
Table 2: Analysis of the pass rate from the American Board Exams by gender and parity.
A paper analysing the pass rate from the American Board Examinations in Surgery demonstrates that the examination results of male surgical trainees are unaffected by their marital or parenthood status, and single female surgical trainees outperform their male peers. However, their pass rate drops below male peers when they partner and decrease further when they have children 23 .
Social policies supporting pregnancy and childrearing allow a greater participation of females in the surgical workforce. Sweden and Estonia have the highest rates of female participation in orthopaedics and the most generous parental leave and progressive social policies.
Pregnancy and breast feeding
There are health and safety concerns in orthopaedics that are unique to females. The occupational hazards of exposure to radiation and Methyl methacrylate (MMA) in orthopaedics are well-recognised but can be minimised. A double layer of lead can be worn in pregnancy 24,25
. MMA has also been shown to be feto-toxic at levels >1,000 ppm. Appropriate use of vacuum mixing and protective helmet systems have been shown to minimise exposure to MMA 26 .
More insidious are the effects of long working hours and night shifts on the health of pregnant surgeons. In female surgeons who work more than 60 hours per week, the odds of preterm labour and delivery are 4.95 times higher than average pregnant females in the USA. The risk of complications of pregnancy are higher in female orthopaedic surgeons (31.2%) compared to the general population (14.5%) 27
. Evidencebased policies must be instituted to protect the well-being of pregnant surgeons, including limiting working hours and decreasing night shifts. The Specialty Trainees of New Zealand (STONZ) have well-established guidelines 28 .
Evidence shows that diversity at scientific meetings leads to better science 10,30,31 . Participation in scientific meetings is important for professional development, provides opportunities to collaborate and expand professional networks. Convening, moderating and participating in panels and presentations at scientific meetings are key roles that afford recognition and standing among orthopaedic peers.
Female surgeons are often the primary carers in early childhood, a role that can severely limit their participation in scientific meetings. The availability of breastfeeding rooms and childcare facilities at all orthopaedic meetings would enhance their participation. A guide with practical methods to improve diversity and inclusion in scientific meetings provides evidence-based methods to improve diversity and inclusion in scientific meetings 29 .
Females in orthopaedic leadership roles
Females are under-represented in leadership roles in their early career years. For orthopaedics this includes executive and board positions in professional associations. However, there are currently at least four female orthopaedic association presidents in the USA, Malaysia, Sweden and Estonia. It is vital that more females are mentored and sponsored into these leadership roles. With the predominance of male orthopaedic surgeons in leadership roles, it is critical that males are engaged in this process.
Katre Maasalu is an Orthopaedic Surgeon at Tartu University Hospital, Estonia.
Magaly Iñiguez is an Orthopaedic Surgeon in Chile. Magaly is Founder of the Association of Chilean Female Orthopaedic Surgeons, Member of the Scientific Committee and the Gender and Diversity Task Force Committee at ISAKOS.
Dafina Bytyqui is an Orthopaedic Surgeon working in Kosovo.
Table 3: Guidelines for working whilst pregnant (New Zealand).
International representation of females in orthopaedic surgery and strategies to improve gender diversity
Strategies to improve representation of females in orthopaedics are centred around reducing or eliminating the known barriers. Organisations must provide a safe, unbiased environment and push for equity of opportunity for female and minorities by encouraging mentorship and role modelling. Changing the traditional orthopaedic culture allows both genders a better family life and will improve work-life balance.
Africa and Tanzania: According to the World Health Organization, Africa has a predicted need for 3.7 million health workers in order to provide universal health care by 2030 32
. In Tanzania 7.6% of the nation’s 118 orthopaedic surgeons were female in 2019 and of the 51 orthopaedic trainees, 5.8% were female 33
. The main focus in the medical workforce has been to improve the doctor-patient ratio through the increased enrolment of medical students. The College of Surgeons of East, Central and Southern Africa (COSECSA) is the largest surgical training institution in Sub-Saharan Africa. There have been 340 surgeon graduates since 1999 and the goal is to have 500 graduates in 2020. There are currently 575 surgeons in training. Women in Surgery Africa (WiSA), under the umbrella of COSESCA, has established a mentorship programme. The American College of Surgeons (ACS) has provided a strong commitment to WiSA and supports female surgical trainees across the region.
Asia, Malaysia and the Philippines: Prior to 2000, female orthopaedic surgeons were unusual in Asia. The turn of the millennium saw an increasing presence of females in orthopaedic practice and training all over Asia.
Dr Tunku Sara Ahmad Yahaya founded the Hand and Microsurgery Unit in the University of Malaya in 1993. She became the first female President of the Malaysian Orthopaedic Association (MOA) in 2006. She was the only female orthopaedic surgeon in Malaysia until
1999 when two other females qualified from the National University Malaysia. In 2000, three more female orthopaedic surgeons graduated. Since then, there has been a steady increase of females in the orthopaedic postgraduate programmes.
In 2014, Dr Azlina Abbas, became the second female President of the MOA, followed by Dr Chye Ping Ching in 2019. In 2020, she will become the first female President of the ASEAN Orthopaedic Association. Dr Sharifah Roohi shall become the fourth female MOA President in 2020.
Dr Teresita L Altere from the Philippines qualified as an orthopaedic surgeon in 1971, and became the President of the Philippines Orthopaedic Association (POA) and the first female in Asia to be the president of an orthopaedic association in 1986. Dr Virginia C Cabling became the second and Dr Julyn A Aguilar became the third female Presidents of the POA.
Australia: In 2018 the Australian Orthopaedic Association (AOA) established a diversity strategy to address the persisting lack of gender diversity. The key AOA initiatives include:
• Supporting females into leadership roles – the AOA Board is now 40% female. • Advertising AOA Committee roles – 12% are now held by female members. • Actively seeking representation of females at AOA scientific and educational meetings with policies to increase inclusion. • Providing childcare and breastfeeding facilities at all AOA meetings. • Implementing a new, more flexible, competency-based training programme - ‘AOA 21’. • Engaging >150 female medical students/ junior doctors in AOA orthopaedic workshops in 12 months. • Forming an AOA ‘Champions of Change’ working group of male diversity advocates. • Promoting females in orthopaedics through active social media profiles. • Publishing a quarterly newsletter promoting gender diversity and inclusion. >>
Margaret Fok is currently an Associate Consultant at the Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong, and an Honorary Clinical Assistant Professor of The University of Hong Kong.
Philippe Liverneaux is Professor of Orthopedic Surgery and Chairman of Orthopedic and Plastic Surgery in Strasbourg University Hospital. He is past President of the French Society for Hand Surgery, a member of the French Academy of Surgeons and cofounder of the Robotic Assisted MicroSurgery and Endoscopic Society.
From 2007 to 2019, females represented only 16.5% of Australian orthopaedic training applicants; only 12.7% of these females were offered an interview and 12.1% were successful applicants. 20% of female applicants were selected into training, versus 28% of male applicants. A significant gender difference favouring males has been demonstrated in the selection process prior to interview. Fortunately, the interview process for selection during this period shows no evidence of gender bias.
Canada: Within the Canadian Orthopaedic Association (COA), females comprise 15.8% of the practicing orthopaedic surgeon membership and 25.8% of trainees. The number of females delivering podium presentations at the COA Annual meeting is in keeping with the proportion of female members in the association 34 .
The COA Gender-Diversity Strategic Plan provides key strategies to advance gender equity35. The focus has been on reducing bias, encouraging females in leadership roles, and facilitating mentorship. A ‘Women in Leadership’ scholarship was introduced to support attendance at a leadership course. Regional sessions are given for university and medical students in an effort to dispel
the myths about an orthopaedic career. Each quarterly publication of the COA highlights a female orthopaedic surgeon to increase awareness of females in Canadian orthopaedics.
The COA Annual Meeting has Instructional Course Lectures on implicit bias, leadership and mentorship, as well as burnout and physician wellness. A ‘Mentor for the Day’ programme has been initiated. Moderator guidelines encourage diversity of gender, geography and age across all panels and discourage all-male panels. Breast feeding areas are available.
The COA is committed to advocating for gender diversity as well as equity and inclusion for all minorities, both visible and invisible. Expansion of these foundational initiatives are being planned over the coming years 35 .
Chile: Chile has parental leave protected for six months. This can be taken by either parent and is funded by the social security system. Unfortunately, fathers represent less than 1% of the parental leave taken in Chile. Chile also has protected breastfeeding time until the infant turns two years old.
In 2019, the first meeting of Chilean female orthopaedic surgeons took place, resulting in the formation of the Association of Female
Elham Hamdan received her medical degree from the Royal College of Surgeons in Ireland in 1993, and subsequently completed her orthopaedic surgery residency at the University of Toronto in Canada in 2001. She has also completed fellowship training in spine surgery, chronic pain management and sports medicine.
Violet Lupondo is a senior Orthopaedic and Trauma Surgeon in Tanzania.
Caroline Hing is an Orthopaedic Surgeon and Honorary Reader at St George’s University Hospitals NHS Foundation Trust. She is a member of the BOA Equality and Diversity working group and BOA Education and Careers Committee.
70 days old, only the mother is entitled to the parental benefit but after this either parent is entitled to the parental benefit. France: In France over the next 20 years, the medical profession will undergo three major changes: reducing numbers; ageing; and feminisation 36
. The number of orthopaedic surgeons has risen sharply in 30 years, increasing from 1.44/100,000 inhabitants in 1981 to 4.3 in 2013. Between 2006 and 2019, the proportion of females increased from 3.3 to 7%, and is higher in younger age groups. In 2015, there were 14% females in the 30-34 age group, compared to 0% in the 65-69 age group. In 2019, France had 248 female orthopaedic surgeons. The proportion is significantly higher in hand surgery with 155 females out of 767 members (20%) in 2020, and 63 out of 167 junior members (38%). Gulf cooperating countries and Kuwait: Males earned surgical qualifications as early as the 1960s, though it was not until the mid-1980s that women began to receive surgical training 37
. This has resulted in a gender disparity that persists to the present day. The low participation of females in orthopaedic surgery can be attributed to many issues. Female faculty members make up 10% of Kuwait University’s Department of Surgery. Currently, there are three female orthopaedic surgeons in Kuwait, (data obtained directly from the Kuwait Medical Licensing Department) of which only one is a Kuwaiti national. Between 2014 and 2019, five females have completed orthopaedic training compared to 51 males in Kuwait. Despite the large regional demand for more orthopaedic surgeons, only one female was accepted into orthopaedic residency training in Kuwait for 2020. Prior to that two females were accepted in orthopaedic surgical residencies abroad and since 2014 only one other female has been accepted into the orthopaedic residency programme in Kuwait. Accurate data for Kuwaiti females in residency programmes abroad is not available, (there is no integrated data source indicating the number of surgeons in Kuwait orthopaedic or otherwise, therefore data presented in this section should be viewed as approximate estimates). There is an identified perception that females in the GCC are less likely to match than males in an orthopaedic residency programme. >> Orthopaedic Surgeons of Chile. This is focused on: gender equity in the selection process; preventing gender discrimination; establishing a supportive network for female orthopaedic surgeons; and mentoring trainees interested in pursuing a career in orthopaedics. China (Hong Kong): The first female orthopaedic surgeon was appointed to Queen Mary Hospital, Hong Kong, in 1993. As the proportion of female medical students has reached parity, there has been an increase in the number of female orthopaedic trainees to 20%. In Hong Kong, all orthopaedic trainees are employed by the Hospital Authority. There is equal pay and parity of treatment. All female doctors are entitled to maternity leave of up to 14 weeks. On return from parental leave, each hospital is committed to provide a peaceful environment for breastfeeding but no childcare. There is no part-time surgical training offered by the Hong Kong College of Orthopaedic Surgeons. For those who cannot fulfil the requirements of orthopaedic training due to maternity leave, additional training time is required. Consequently, most female orthopaedic trainees elect to have children after completion of training. Estonia: During the last five years, 64% of medical graduates have been female. Currently, 36% of orthopaedic trainees are female. The increasing number of female orthopaedic trainees is a reflection of more generous parental leave. One in four orthopaedic surgeons are female and there is no unit without a female orthopaedic surgeon. Female orthopaedic surgeons have been working in Estonian hospitals since the 1950s and the first female orthopaedic head of department was appointed in 1964. The Estonian Orthopaedic Society (EOS) was founded in 1970 and the first secretary general was female. The President of the EOS has been a female since 2015. Maternity leave and pregnancy policies are dictated by national laws. Raising a child is supported through many benefits and it is common to stay at home until the child is at least 18 months old. It is possible to stay at home until the child turns three years without losing health insurance or position of employment. Reduction of workload in the third trimester of pregnancy is commonly accepted. After delivery the parental benefit guarantees the previous income. The parental benefit is paid for a period of 435 days, or until the child is 18 months old. Until the child is “Although diversity strategies may vary between nations, the principles they incorporate hold true for all. Diversity attracts the best talent and leads to improved decision-making and innovation in our organisations.”
Poor maternity and parental benefits in Kuwait appear to be a deterrent with the majority of females in orthopaedic surgery residencies in the GCC being single, (data obtained directly from the Ministry of Health). Kosovo: Kosovo is a small country of two million inhabitants, only recently gaining independence in 2008. The orthopaedic surgery department was established in the 1970s. Currently, there are 78 orthopaedic surgeons and 12 trainees. Only three (3.8%) orthopaedic surgeons are female and there are currently no female trainees. Currently two of these three female orthopaedic surgeons have leadership positions in the Orthopaedic and Traumatology Society. There is no fixed quota for training female surgeons but, when candidates are considered equal, the female candidate has priority. New Zealand: NZ data reflects striking similarities with other Western nations. network for all female registrars and consultants. LIONZ organises introductory workshops for female students led by senior registrars and surgeons, while offering collegiality and mentorship. These have proven popular with students, though it is too early to say whether they will result in influencing career choices.
While the NZOA are committed to improving diversity and representation, challenges arise from having such a small number of female surgeons. Females are represented currently on the NZOA Council and Orthopaedic Training Board and comprise over 20% of RACS Examiners. As we develop a larger cohort of female colleagues, we expect these numbers will increase. Sweden: In Sweden, the number of female orthopaedic surgeons has increased during the last 25 years. There has been an increase from 6% females in 1995 to 17% in 2019 40 . Currently, 35% of residents in orthopaedic 2019 data shows 4.7 % of active registered orthopaedic surgeons are female. Currently, 18% of orthopaedic trainees are female with numbers increasing. Selection processes have been restructured to encourage consideration of diversity as a factor in selecting from candidates who rank equally. However, numbers of females presenting for selection to orthopaedic training remain low. Recent NZ surveys of medical students and junior doctors suggest that students’ perceptions of orthopaedics, particularly as a career for females, form a considerable barrier 38,39 . Positive efforts to encourage female junior doctors considering orthopaedics as a career have been undertaken by LIONZ (Ladies in Orthopaedics New Zealand). LIONZ was established in 2017 and acts as a support “Leadership in diversity involves engaging female medical students, minimising unconscious bias, mentoring, creating an environment that is inclusive of females and providing support for those with family commitments.”
surgery are female. This increase has been expected in light of the increasing number of female medical students and graduates. 56% of graduates from Swedish medical schools were female in 2018 and of newly accepted medical students in 2019, 55% were female 41 .
Sweden has generous parental leave of 390 days 42
. Three months are available for each parent, meaning that one parent cannot use all parental leave. This has increased diversity in parental leave and, in 2018, 29% of all parental leave was used by males.
United States of America (USA): There were 27,651 board-certified orthopaedic surgeon members in the American Academy of Orthopaedic Surgeons (AAOS), of which 6% were female, in 2019. Of the 3,963 residents in training, 15.4% were female 43 .
Orthopaedic surgery in the USA has been markedly male dominated and gender disparity has persisted, with the percentage of female orthopaedic trainees the lowest in all fields. There are currently less than five female chairs of major orthopaedic departments. There are, however, numerous concurrent efforts in the USA to improve gender diversity:
• The AAOS has prioritised diversity within its volunteer structure in its 2019- 2023 Strategic Plan 44 , including education and transparency in the application and selection process. Implicit bias training is provided. The AAOS was led by its first female president in 2019, and the AAOS Board of Directors will include 25% females in 2020.
• The Ruth Jackson Orthopaedic Society was established in 1983 to advance the science and practice of orthopaedic surgery among females. The group prioritises mentoring and professional development of females.
• The Perry Initiative was founded in 2009 by a female orthopaedic surgeon and engineers to increase the numbers of females in the field 45 .
• Nth Dimensions was founded in 2004. Their primary mission is to provide resources, expertise, and experience through developing and implementing strategic pipeline initiatives 46 .
Conclusion
Although diversity strategies may vary between nations, the principles they incorporate hold true for all. Diversity attracts the best talent and leads to improved decision-making and innovation in our organisations. Generous parental entitlements and progressive social policies are likely to be drivers for the participation of females in orthopaedic surgery. Leadership in diversity involves engaging female medical students, minimising unconscious bias, mentoring, creating an environment that is inclusive of females and providing support for those with family commitments. Enacting these concepts should result in healthy, fulfilled surgeons, a collaborative and innovative orthopaedic community and ultimately to
better patient care. Most importantly, working towards a fair, equitable and diverse profession is a moral and ethical imperative and, quite simply, the right thing to do. n
Acknowledgements
The authors would like to give their thanks to Michelle White for her editorial support in the preparation of this article.
References
