To The Editor:
I am writing in regard to "Initial Review of Electronic
Residency Application Service Charts by Orthopaedic Residency Faculty
Members. Does Applicant Gender Matter?" (83-A: 65-70, Jan.
2001), by Scherl et al. The authors performed a randomized, prospective
evaluation of chart reviews and concluded that there is no bias
against women applicants in this portion of the process. They are
to be commended for an effort to analyze possible factors in the
current paucity of women in the field of orthopaedic surgery.
As pointed out by the authors, the chart-review phase primarily
relies on objective information, which, although easier to study,
is probably the least susceptible to bias. Additionally, although
attempts were made to keep the reviewers blinded with regard to
the goals of the study, performance of the chart reviews in the
context of a study, with the reviewers knowing that their evaluations
would be scrutinized, may have introduced bias. Also, there are many
inherently more subjective steps in evaluation that may have an
impact on an applicant’s success. These include the writing
of the initial recommendation letters by orthopaedic mentors and
the evaluation at the time of interview. Obviously, these factors
are difficult, if not impossible, to study.
Unfortunately, the failure to recruit women into orthopaedic
surgery continues. Although we are recruiting an increasing percentage
of women into our programs, women remain one-seventh as likely as
men to match into an orthopaedic program1,
a percentage that has not changed significantly over the past twenty
years. Given that medical school classes are now nearly 50% women,
our field will not continue to benefit from recruitment of the top
medical school graduates unless we are able to attract more women
into the field.
Successful recruitment of women starts long before the stage
of evaluation at the time of application to residency programs.
The process involves making the assumption that women students rotating
on our orthopaedic services are as likely as men to choose orthopaedics,
including all medical students in orthopaedic service activities,
counseling medical students about career choices, and providing
successful role models.
The Ruth Jackson Orthopaedic Society was founded in 1983 as a
support and networking group for the growing number of women in
orthopaedic surgery. This society conducts scientific, educational,
and charitable activities for the purpose of encouraging, promoting, and
advancing the science, medical art, and practice of orthopaedic
surgery among women. The mission of the Society has subsequently
broadened to include concern with issues of women’s musculoskeletal
health as well. To meet these goals, we have developed an extensive
mentoring program. Information, in both written and video formats, about
women in orthopaedics is distributed to medical schools as well
as to interested female students, who are placed in contact, via
phone or e-mail, with practicing female orthopaedic surgeons. The
network has been highly successful; we receive inquiries via our web
site, by word-of-mouth, through our Society members, and from referral sources,
including the American Academy of Orthopaedic Surgeons. The Ruth
Jackson Orthopaedic Society hopes to continue to work with all orthopaedic
surgeons to maintain and improve the quality and diversity of those
in our field.
S.A. Scherl, N.A. Lively, and M.A. Simon reply:
We appreciate Dr. Biermann’s comments. We agree that
women will never approach equality in terms of their numbers in
orthopaedics until substantial efforts are made to increase early, active
recruitment and support of female medical students who might potentially
be interested in the field. In fact, we clearly acknowledged this issue
in both the introduction and the Discussion section of the paper.
Moreover, although all three of the authors of our study support
the Ruth Jackson Orthopaedic Society, and two of us are members,
we find it ironic that membership was denied the third author because
she had not entered medical school at the time of her application. She
was referred to the first author through the Society’s
mentoring program. Perhaps the Society should consider an additional
membership category for college and graduate students in order to
support women interested in pursuing careers in orthopaedics as
early as possible.
However, the goal of our study was to answer a specific question—that
is, do women who are committed to a career in orthopaedics receive
a fair and equitable evaluation in the initial phase of formal recruitment
for residency programs? This project was initiated, in part, in
response to anecdotal complaints (on an Internet bulletin board
for female medical students interested in orthopaedics) from women
who felt that, despite exhibiting obvious interest and dedication,
and having the necessary academic credentials, they were not treated
fairly during the application process itself. In other words, there
is a perception among potential female candidates that the playing
field isn’t level, and that in itself could color a woman’s decision
as to whether to apply to a program, regardless of her inherent
interest in orthopaedics.
Basically, we disagree very little with the substance of Dr.
Biermann’s letter, nor does she disagree with our findings. We
reviewed her cited article1 and
noted that there has been a slow increase in the percentage of female residents
in orthopaedic surgery, from 1.2% (twenty-eight women across
the country) in 1977 to 7.1% (198) in 1996. Both that small
increase in percentage and the numbers of female residents have
continued to increase since her study was published (the percentage was
7.2% in 1999 and 7.8% in 2000)2.
Further analysis of Dr. Biermann’s data shows that the
rate of increase for female residents in orthopaedic surgery is
more than double that in any other field.
Thus, the rate of increase in orthopaedic surgery is higher than
that in the average specialty, but orthopaedic surgery has a longer
way to go. Hence the conclusion that for orthopaedic surgery to
attract more women, mentoring before the junior year in medical
school is imperative. Women in medical schools across the country
are not encouraged to, and therefore do not, think of orthopaedic
surgery as a career. The Ruth Jackson Orthopaedic Society has recognized
this deficit and offers a mentoring program. If we can get women
to choose a career in orthopaedic surgery, then the initial application
process is not a barrier to actually obtaining a position in an
orthopaedic surgery residency program. On the other hand, we don’t
know if bias occurs at the interview stage of the process; because
of the intrinsic difficulties of blinding a traditional face-to-face interview,
we may never know.
However, the fact remains that simply obtaining interviews is
the initial goal of the application process. The more interviews
that a candidate obtains, the better his or her chances of ultimately matching
with a residency position, and the invitations are issued on the
basis of initial chart review. Furthermore, our study materials
did include the texts of letters of recommendation (two per candidate),
although we removed the names of the letters’ authors,
so that only the content of the letters, and not their source, was
used in their evaluation.
Finally, as we stated in our introduction, we are mystified that
the Electronic Residency Application Service "does not
keep statistics on the breakdown of successful applicants by gender"3. If this were done, it might be possible to
determine whether bias exists in the interview process, since data
on the gender of the applicants do exist. We challenge the Ruth
Jackson Orthopaedic Society, perhaps in conjunction with the American
Academy of Orthopaedic Surgeons, to influence the Electronic Residency
Application Service to collect and release the breakdown of data
by gender on successful applicants to orthopaedic surgery residency
programs.