The Association of American Medical Colleges has emphasized the growing gender, racial, and ethnic diversity among medical student applicants and matriculants, highlighting notable growth in the pool of underrepresented students. In the 2021-2022 academic year, the number of total applicants grew by 18%. The number of Black or African American students increased by 21%. Black or African American students made up 11.3% of matriculants (first-year students) in 2021, an increase from 9.5% of the previous year. The number of first-year students who were Hispanic, Latino, or of Spanish origin increased by 7.1%, and they made up 12.7% of matriculants. Furthermore, women made up 56.8% of applicants, 55.5% of matriculants, and 52.7% of total medical school enrollment.1
Despite these trends in medical education, diversity within the field of pediatric orthopaedic surgery has not been equally addressed. Poon et al2 evaluated gender, ethnic, and racial diversity across US ACGME-accredited orthopaedic subspecialty fellowship programs from the years 2006 to 2015 and found notable underrepresentation of women and minorities in these programs. Specifically, their study highlighted that women and underrepresented minorities made up a small percentage of fellows, indicating a need for increased diversity initiatives in orthopaedic subspecialties. These findings reveal that despite an increase in diversity at the medical school level, orthopaedic subspecialties have struggled to reflect this trend, suggesting potential barriers that need to be identified and addressed.
Turow and Sterling investigated the role and effect of sex and age on children's preferences for pediatricians. They found that while children did not express a strong preference for the sex of their pediatrician, parents often did, with many preferring female pediatricians for their children.3 This preference underscores the importance of having a diverse pediatric workforce that can meet the needs and preferences of diverse patient populations.
Furthermore, a notable disparity exists between the racial and ethnic diversity of American pediatricians and that of American children, with minority children being underrepresented in the pediatric workforce.4 This mismatch between the demographics of pediatricians and their patients highlights the need for strategies to increase racial and ethnic diversity among pediatricians to better reflect and serve the patient population.
Methods
Data on pediatric orthopaedic surgery fellows spanning from 2013 to 2023 were collected and analyzed to assess any trends in gender or ethnic identities. These data were collected using the Accreditation Council for Graduate Medical Education Data Resource Book and are, therefore, exempt from approval by the institutional review board because these data are publicly available. The data were acquired for the years 2013 to 2023. In this data set, individuals self-identified their race and ethnicity, which were categorized into the following groups: White, Black, Asian, Hispanic/Latino, Native Hawaiian/Pacific Islander, American Indian/Alaskan Native, multiracial, and other/unknown. The collected data were then compiled to assess any trends over the 10-year period.
Results
The total number of pediatric orthopaedic surgery fellows in the decade-long analysis was 380. Of this total number, 237 fellows (62.4%) were male, 141 (37.1%) were female, and 2 (0.53%) were not reported. Self-identified races and ethnicities of fellows were evaluated, and each group made up the following portions: 239 Whites (62.9%); 35 Asians (9.2%); 17 Hispanic, Latino, or Spanish (4.5%); 17 Black or African American (4.5%); 0 American Indian or Alaskan Native (0%); 0 Native Hawaiian or Pacific Islander (0%); 2 multiple race/ethnicity (0.53%); 32 other (8.4%); and 38 unknown (10%). The total number of fellows identifying as White was 239 (62.9%) while 141 fellows were identified as non-White (37.1%). For the years 2013 to 2019, data for the Native Hawaiian or Pacific Islander group were not available. For the years 2013 to 2020, data for the multiple race/ethnicity group were not available. Table 1 provides an overview of the compiled data of pediatric orthopaedic surgery fellows from 2013 to 2023. Figures 1–3 display the gender representation of pediatric orthopaedic fellows from 2013 to 2023, the racial and ethnic representation of pediatric orthopaedic fellows from 2013 to 2023, and the White and non-White representation of pediatric orthopaedic fellows from 2013 to 2023, respectively.
Table 1 - Number of Pediatric Orthopaedic Surgery Fellows Arranged by Race, Ethnicity, and Sex
Year | Total fellows | Male | Female | Sex not reported | White | Asian | Hispanic, Latino, or Spanish Origin | Black or African American | American Indian or Alaskan Native | Native Hawaiian/Pacific Islander | Multiple Race/Ethnicity | Other | Unknown |
2013-2014 | 39 | 24 | 15 | 27 | 2 | 2 | 2 | 0 | 0a | 0b | 3 | 3 | |
2014-2015 | 39 | 26 | 13 | 25 | 3 | 1 | 1 | 0 | 0a | 0b | 7 | 2 | |
2015-2016 | 43 | 21 | 22 | 31 | 2 | 0 | 3 | 0 | 0a | 0b | 2 | 5 | |
2016-2017 | 38 | 21 | 17 | 28 | 2 | 0 | 0 | 0 | 0a | 0b | 3 | 5 | |
2017-2018 | 39 | 25 | 14 | 19 | 7 | 0 | 2 | 0 | 0a | 0b | 7 | 4 | |
2018-2019 | 37 | 24 | 13 | 23 | 2 | 0 | 3 | 0 | 0a | 0b | 3 | 6 | |
2019-2020 | 37 | 27 | 10 | 26 | 2 | 2 | 0 | 0 | 0 | 0b | 4 | 3 | |
2020-2021 | 34 | 20 | 14 | 18 | 5 | 4 | 2 | 0 | 0 | 2 | 0 | 3 | |
2021-2022 | 35 | 26 | 8 | 1 | 20 | 6 | 3 | 3 | 0 | 0 | 0 | 0 | 3 |
2022-2023 | 39 | 23 | 15 | 1 | 22 | 4 | 5 | 1 | 0 | 0 | 0 | 3 | 4 |
Total | 380 | 237 | 141 | 2 | 239 | 35 | 17 | 17 | 0 | 0 | 2 | 32 | 38 |
Percentage | 100 | 62.4 | 37.1 | 0.53 | 62.9 | 9.2 | 4.5 | 4.5 | 0 | 0 | 0.53 | 8.4 | 10 |
aData for the Native Hawaiian/Pacific Islander group were not collected from 2013 to 2019. bData for the multiple race/ethnicity group were not collected from 2013 to 2020.
Discussion
The analysis of pediatric orthopaedic surgery fellows from 2013 to 2023 reveals notable gender and racial disparities within the field. Of the 380 fellows analyzed, 62.4% were male and 37.1% were female, indicating a persistent gender imbalance. This gender disparity aligns with findings in other subspecialties of orthopaedic surgery and underscores the need for targeted efforts to recruit and retain more female fellows in pediatric orthopaedics.5
Racial and ethnic diversity among pediatric orthopaedic surgery fellows also remains limited. This lack of diversity is concerning, given the increasingly diverse patient population in the United States.6 Samora highlights the importance of a more diverse healthcare workforce because patient satisfaction and care are influenced by the diversity of providers. According to Samora, diversity within the healthcare workforce leads to better communication, increased patient satisfaction, improved care, and reduced healthcare disparities. Furthermore, Samora underscores the importance of pipeline programs that foster early exposure to medical specialties for underrepresented groups. These programs have been effective in attracting women and minorities to the field, showcasing the need for proactive and continuous recruitment and mentorship initiatives to address these disparities.7
Caregiver satisfaction in pediatric orthopaedics is influenced by factors such as demographics, health literacy, wait time, and physician empathy.8 Efforts to increase diversity in orthopaedic surgery have shown some progress but remain insufficient. Tran et al discussed various outreach and support programs designed to promote diversity within orthopaedic surgery. These programs, which include mentorship, scholarships, and targeted recruitment efforts, are essential for addressing the current disparities and fostering an inclusive environment. These diversity initiatives have been shown to positively affect medical students' perception of inclusivity in the field. However, the slow pace of change suggests that more robust and sustained initiatives are required.9
The presence of mentors who exemplify a particular specialty can inspire students to pursue similar paths. For example, exposure to faculty members who are actively engaged in a specialty can enhance students' interest and understanding of that field.10 Increasing the visibility of diverse role models in pediatric orthopaedics could potentially attract a more diverse group of applicants to the specialty. In addition, the representation of minority groups within orthopaedic surgery residency programs has been linked to broader trends in the medical field. Okike et al11 noted that residency programs with higher minority representation tend to attract more diverse applicants, suggesting a positive feedback loop that could be leveraged to enhance diversity in pediatric orthopaedics.
The disparity in racial and ethnic representation among pediatric orthopaedic surgery fellows is a reflection of broader issues within medical education and the healthcare system. Building on the work of Ramirez and Franklin,12 it is evident that barriers such as implicit bias, lack of mentorship, and financial challenges markedly hinder minority representation in orthopaedic surgery. To address these barriers, initiatives such as the Perry initiative and the Ruth Jackson Orthopedic Society (RJOS) should be expanded. The Perry initiative, for example, focuses on mentoring and inspiring young women interested in orthopaedic surgery while RJOS provides resources and networking opportunities for women in orthopaedics. These efforts could be adapted to address racial and ethnic disparities more directly, offering targeted mentorship and scholarship opportunities for underrepresented minority groups.
Conclusion
While there have been some strides toward increasing diversity in medical education, notable gaps remain in pediatric orthopaedic surgery. To address these gaps, it is essential to implement systemic changes that include pipeline programs, targeted mentorship initiatives, and partnerships with established organizations such as the Perry initiative and RJOS. In addition, integrating these efforts into residency and fellowship programs could help create a more inclusive and diverse workforce that better reflects the patient populations served. This diversity is not only a matter of equity but also essential for providing culturally competent care to the diverse patient populations that pediatric orthopaedic surgeons serve.
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