Hold the door open: The road to a culture of inclusion

‘You must be the change you wish to see in the world’-Mahatma Gandhi The mission statement of ISAKOS is to ‘advance the worldwide exchange and dissemination of education, research and patient care in arthroscopy, knee surgery, and orthopaedic sports medicine’. True to this mandate, ISAKOS has been dedicated to geographic diversity for the last 26 years and currently includes members from over 90 countries. In the substantial effort to ensure ethnic/geographic diversity, was something overlooked? The answer is . . . we were missing the women. As the world has embraced the value of diversity in the last decade, the lack of female participation in ISAKOS has been increasingly obvious. With forward-looking leadership however, a dedicated and intentional effort to improve gender diversity within the organisation has developed during the last several years. One might ask: is gender diversity really an issue? Don't we just want the best candidates? In many countries, gender parity has been reached in medical school with 50% or more of students identifying as female. If this is true, why are the numbers of women in the surgical specialties, and most significantly orthopaedics, so low. The International Orthopaedic Diversity Alliance (IODA) has been collecting and publishing the numbers of female orthopaedic surgeons by country [[1]Green J. Chye V. Hiemstra L. et al.Diversity: women in orthopaedic surgery - a perspective from the International Orthopaedic Diversity Alliance.J Orthop Trauma. 2020; 8: 44-51https://www.boa.ac.uk/asset/A24EAD71-AD82-4E23-98EFACF343CBD015/Google Scholar]. Estonia has the highest female representation at 26% but it quickly drops to below 10% and then even more quickly drops to minimal. The heat map from 2021 tells the story (Fig. 1). There are a paucity of green countries (> 20% female), however, the lack of data (white) in so many countries is especially concerning. Our lack of information in this area suggests a degree of apathy towards the issue. How can there be change if we don't have the data on the current state of affairs? The question remains: why are there so few women in orthopaedics? There is nothing inherent to the specialty of orthopaedic surgery that favours men over women. Women have the skills, the strength, and the intelligence to be excellent physicians and surgeons. So where are all the women? That answer is complex and is rooted in the history and tradition of medicine, a world made by and for men. That the current medical system is broken is becoming more evident. Higher rates of burnout and suicide have been recorded in physicians compared to non-physicians and these are more significant in women than in men [[2]Templeton K. Bernstein C.A. Sukhera J. et al.Gender-based differences in burnout: issue faced by women physicians. National Academy of Medicine, Washington, DC2019https://nam.edu/wp-content/uploads/2019/05/Gender-Based-Differences-in-Burnout.pdfGoogle Scholar]. These data are based on information prior to the COVID pandemic, a crisis that has had a heavier toll on women [[3]Guerrina R. Borisch B. Callahan L.F. Howick J. Register J.-Y. Mobasheri A. Health and gender inequalities of the COVID-19 pandemic: adverse impacts on women's health, wealth and social welfare.Front Global Women's Health. 2021; https://doi.org/10.3389/fgwh.2021.670310Crossref Scopus (8) Google Scholar]. In contrast, the research overwhelmingly shows that diverse groups are more successful and happier. Since we are in medicine to serve a diverse patient population, a diverse group of caregivers will be able to provide comprehensive and appropriate care. So, the case for gender diversity is not difficult to make, it is the same as the case for ethnic diversity, or diversity based on ability, sexual preference, or any other intersectionality. So, how do we make things better? The first step is recognising that there is a problem that has roots both in our organisational systems as well in the culture of our profession. Efforts need to be focused on improving the system to reduce bias and discrimination so that opportunities are equitable and fair for all. At the same time, grass roots cultural change needs to occur, making ours a culture of respect, equity and inclusion. From above and from below, labouring together for a common goal is necessary. Advocacy initiatives for gender equity are increasing in number. Many national orthopaedic organisations have ‘women in orthopaedics’ groups where female-identifying orthopaedic surgeons can network and support each other and advocate for gender equity within their country. These efforts are supported on a global level by organisations such as IODA (orthodiversity.org) and Women in Orthopaedics Worldwide (wowortho.org). Within many national organisations, efforts are ongoing to increase the numbers of women applying for orthopaedics with sessions for high school, university, and medical students promoting interest in the profession. The barriers that exist for women in the profession of orthopaedics are being identified, verified, and quantified allowing for programs and efforts to be focussed on dismantling these barriers. For example, lack of mentorship has been repeatedly stated as a significant problem for female surgeons. Intentional mentorship and leadership programs are improving the lack of inclusion of women in these often ad-hoc relationships. Research into referral patterns and pay gaps between male and female surgeons will work to improve the organisational barriers that lead to inequity between the sexes. Improvements in culture that allow for parental leave for both sexes, emphasise wellness and physician health all work to level the playing field. Finally, bullying and harassment are directed overwhelmingly at women. Addressing egregious and unacceptable behaviour at all levels will go long way to changing the culture in surgery and orthopaedics to one of respect and inclusion.‘All I'm askin’, Is for a little respect’- Aretha Franklin 1967 There is evidence that these efforts are helping but the change is slow. Promotion of women within orthopaedics to positions of leadership is at an all-time high with the USA, Australia, Malaysia, Austria, UK, Canada, Sweden, and Norway all seeing female National Association presidents in 2021–2022. National societies such as the Orthopaedic Associations of Australia, USA, UK, and Canada all have diversity strategies. International societies such as ISAKOS have made gender diversity an advocacy priority. Educational sessions and webinars on diversity and managing the challenges for women in orthopaedics are ongoing as joint efforts between many of these organisations. Although systemic organisational change needs to happen to ensure that everyone has equal opportunity, things must also change in the grass roots. The culture in orthopaedics and surgery needs to be one of respect and inclusion. To change this culture, first we need to understand our privilege. Privilege is the power and comfort you have when you look like everyone else in the room. It is often not noticeable to those who have it, but very obvious to those who don't. Privilege is a product of the power imbalances in our world. In medicine, men, and especially white men, have privilege. Patients and nurses rarely question their title or their authority. Career advancement opportunities are more plentiful, mentorship opportunities more available, reference letters have stronger positive language, research grants are larger [4Brown M.A. Erdman M.K. Munger A.M. Miller A.N. Despite growing number of women surgeons, authorship gender disparity in orthopaedic literature persists over 30 years.Clin Orthop Relat Res. 2020; 478 (In eng): 1542-1552https://doi.org/10.1097/CORR.0000000000000849Crossref PubMed Scopus (43) Google Scholar, 5Hoof M.A. Sommi C. Meyer L.E. Bird M.L. Brown S.M. Mulcahey M.K. Gender-related differences in research productivity, position, and advancement among academic orthopaedic faculty within the United States.J Am Acad Orthop Surg. 2020; 28 (In eng): 893-899https://doi.org/10.5435/JAAOS-D-19-00408Crossref PubMed Scopus (28) Google Scholar, 6Halim U.A. Elbayouk A. Ali A.M. Cullen C.M. Javed S. The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies.Bone Joint J. 2020; 102-B (In eng): 1446-1456https://doi.org/10.1302/0301-620X.102B11.BJJ-2020-0982.R1Crossref Scopus (9) Google Scholar]. All of these things are achievable for women, or those with intersectionality, but because of the historical systems that are in place, each step to achieve these things is more difficult. If we understand our own privilege, it becomes easier to understand from where everyone is coming. If we understand our own privilege, we can use that privilege to help others. This is the concept of allyship. Being an ally requires being deliberate and intentional about how you use your privilege to stand up for others who may not have the advantage that you enjoy. Being an ally means being proactive and using your power to amplify the voices of those who are marginalised in our culture. An excellent example of this is speaking out when you hear things said that shouldn't be said. The old adage fits ‘If you see something, say something’. We must be crystal clear about what kinds of behaviours we are not willing to tolerate. Studies have shown that standing by while inappropriate things are said or done is harmful both to the person at the receiving end but also for the person witnessing the behaviour [[7]Sprigg C.A. Niven K. Dawson J. Farley S. Armitage C.J. Witnessing workplace bullying and employee well-being: a two-wave field study.J Occup Health Psychol. 2019; 24 (In eng): 286-296https://doi.org/10.1037/ocp0000137Crossref Scopus (44) Google Scholar]. Saying nothing, being a bystander, gives tacit approval to this behaviour. Speaking up, being an upstander, is the most effective way to make change. It lets people know that certain behaviours are not okay. It also lets the person being treated poorly know they have your support. Another way to be an ally and to help rebalance the scales is to use your privilege to champion someone. Suggest someone for a stretch assignment, support and show up for people, and use your influence to move them up the ladder. Look around you. Is anyone being left behind? Are you taking up too much space in the conversation? Check in on people. Let them know you are thinking about them. Listen to them. To those who may be marginalised, knowing that someone cares and is there for them is a big deal. At the end of the day, men benefit as much as women by being an ally. Studies have shown that allyship leads to better physical and mental health, developing more authentic relationships, being seen as a better leader…. and the satisfaction of being a person that does the right thing. Want to be a better ally? Take the allyship challenge, lean into the discomfort and make the world a better place.The allyship challenge1.Listen to a podcast on allyship2.Intentionally acknowledge a female co-worker on an accomplishment or success.3.Be an upstander, speak up when someone makes a derogatory or sexist comment.4.Ask a colleague who you don't know well to join you for coffee and get to know them – listen to them and question them. Learn about their challenges.5.Recommend a woman or under-represented colleague for a stretch assignment or learning opportunity.6.Refuse to participate on an all-male panel.7.Send texts to three people you have trained to check in with how they are doing.8.Send texts to three people who have been your ally in the past to let them know that you are thinking of them and appreciated their support.9.Say something positive or promoting about a woman or under-represented colleague to one of your other co-workers.10.Think about how you can be an ally at home.11.Ask someone how they are doing. Like, really how they are doing. Listen and ask questions. How someone else experiences something may not be the same as you experienced it.‘there are those that push the door open and there are those that hold the door open. I like to be the door holder, letting in as many people as I can… push your privilege to bring other people opportunity’.- Colm McCarthy, Canadian orthopaedic surgeon [[8]Baedke L. The growth edge.in: McCarthy C. Opening and holding the door for others. 2020Google Scholar]. 1.Listen to a podcast on allyship2.Intentionally acknowledge a female co-worker on an accomplishment or success.3.Be an upstander, speak up when someone makes a derogatory or sexist comment.4.Ask a colleague who you don't know well to join you for coffee and get to know them – listen to them and question them. Learn about their challenges.5.Recommend a woman or under-represented colleague for a stretch assignment or learning opportunity.6.Refuse to participate on an all-male panel.7.Send texts to three people you have trained to check in with how they are doing.8.Send texts to three people who have been your ally in the past to let them know that you are thinking of them and appreciated their support.9.Say something positive or promoting about a woman or under-represented colleague to one of your other co-workers.10.Think about how you can be an ally at home.11.Ask someone how they are doing. Like, really how they are doing. Listen and ask questions. How someone else experiences something may not be the same as you experienced it. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Laurie Hiemstra reports a relationship with International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine that includes: board membership. Elizabeth Arendt reports a relationship with Journal of ISAKOS that includes: board membership.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.