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When I was a medical student interviewing for an orthopaedic residency, I was asked—as a final question—what I thought the most-serious problem was with our specialty. Since I was not yet in the specialty, it seemed immodest to try to answer, so I tried to wiggle out of the awkward situation I found myself in. No luck; my inquisitor did not relent. I told him that I thought that it helped neither the specialty nor the patients it treats if we systematically exclude half of the good ideas that might be available. He asked me to clarify. I said that I thought it was bad for medicine, bad for the subspecialty I wanted to enter, and bad for people with musculoskeletal injuries and diseases that there weren’t more women orthopaedic surgeons. As it turned out, no women graduated from that program in the 5 years I was there. I don’t mention this to criticize the program; after all, my interview answer didn’t disqualify me, there were women fellows during my time there, and this was more than 25 years ago. Very few women applied to orthopaedic programs then. That troubled me at the time, but even more troubling is how little our specialty has changed in the nearly three decades since. Orthopaedic surgery remains the specialty with the lowest proportion of women (lagging behind neurosurgery and thoracic surgery); only 6.5% of American Academy of Orthopaedic Surgeons members are women, and fewer than 1% of women residents are training in orthopaedic surgery (525 of 57,130), a proportion that has not changed during the last decade, and an obvious imbalance given that about half of all medical students are women [8, 26]. From the mid-80s through the early 2000s, the proportion of women entering orthopaedic surgery hardly changed, even as it increased steadily in obstetrics, ophthalmology, general surgery, and otolaryngology [2], and the proportion of women in our specialty has barely increased (by only 3%, from 11% to 14%) in the decade or so from 2006 to 2017 [8]. A woman is more likely to lead one of the nation’s 50 largest police departments [1] than an orthopaedic department [8]. The general consensus seems to be that exposure to the specialty—good mentorship—would be key both to encouraging more women to enter the specialty, and to ensuring the career advancement of those women already on the team [23, 26]. And career advancement is particularly important given how few have reached the pinnacles of the profession, at least as defined by membership in exclusive societies (fewer than 1% of the members of the Hip Society and the Knee Society are women), or employment as department chairs (only one in 2016) [8]. The lack of women in those societies and roles is not because of a lack of ability. It is caused, at least in part, by a lack of imagination and vision among the members of our specialty's exclusive societies, who remain mostly men, and who may not be as willing as they should to see women colleagues as leaders. Solving this calls for structural solutions at every level: Departments should commit to inviting more women to speak at grand rounds, and to find ways to make their training programs more attractive to women; selective specialty societies may need a broader definition of achievement; and medical schools might look for ways to expose a wider range of students to all specialties, including those specialties that have historically fallen far short of any reasonable gender balance. Mentorship is a key ingredient to career success for all young professionals. But since nearly 19 out of 20 potential mentors in our specialty are men [8], young women in orthopaedic surgery and those considering it may find that mentorship needs to come from more-senior men in the profession. But fallout from the #MeToo movement—which has empowered women and exposed the degree of persistent, widespread sexual abuse and harassment that remains in the workplace—has made it harder rather than easier for women professionals in business to find men to support their careers [29]. Apparently, many businessmen are declining to mentor women because they fear unsubstantiated accusations of sexual harassment being perceived as credible in the era of #MeToo. Inexcusably, the same phenomenon appears to have taken root in medicine [24, 28]. What does it mean that those in positions of power and—at least in our own specialty—the gender that represents the overwhelming majority of those senior enough to offer mentorship, suddenly are afraid? More importantly, how can we improve upon the gender imbalance that has existed in our specialty for as long as we have been keeping statistics? Responses vary widely, from those who say that men’s fear in this setting is disproportionate to objective reality [28], to those who are influenced by the “Pence Effect,” named for US Vice President Mike Pence, who has said he avoids dining alone with any woman other than his wife [29]. Some evidence can be mustered in support of both of those positions. On one hand, sexual harassment—up to and including sexual bribery—remains a regular part of the working landscape even for high-achieving women in medicine [15]. On the other hand, fearful men might point to results from one large survey, which found that about 5% of women in the workplace report that they would “always” perceive a man asking a woman to lunch in the workplace as a form of sexual harassment [16]. If this is accurate, men offering women the same kinds of informal, one-on-one career support they routinely offer other men may be gambling with their own careers. I believe most of us appreciate that the reality here is complicated and nuanced. Most of us recognize that women should be heard and believed. We know false accusations of harassment or rape are extremely rare [9, 20]. We find the increased focus on the topic in the wake of #MeToo has made it harder for men to know how to interact with women in the workplace [14]. And we realize that for too long, women who made allegations were not believed (or worse), but we also can see that failing to provide accused men a fair process is itself deeply unjust [10, 22, 25]. Regardless, we can make our specialty a great deal more welcoming to women, and we should. Many men in our specialty attribute their career successes to the influence of personal, generous, one-on-one mentorship from more-senior men [5, 6, 18, 30]. I know that I do [17]. It would simply be wrong for men not to provide women in our specialty—and, as importantly, women who may wish to enter our specialty but are as-yet undecided—with these same opportunities. Academic institutions and private-practice groups alike should create formal, structured mentorship, sponsorship, and career-development programs to increase the opportunities available to women physicians [3]. Universities and corporations see the “business case” for diversity and have taken steps to support it as a goal [7, 12, 19, 27]; our specialty should, too. Having said that, I think such corporate recommendations are insufficient. Each of us has an individual responsibility: If a panel discussion, course faculty, hospital workgroup, search committee, or academic department is not representative, we need to ask why, and what we can do—as an individual on that team—to fix it. Perhaps most importantly, it would pervert justice if men were to use the #MeToo movement to excuse the denial of opportunities to women, as appears to be happening [24, 28, 29]. But as someone who has never experienced the kind of discrimination, harassment, or assault that many women have, my views—and my words—fall short. So I’ll end by offering the last word to five women who have opined thoughtfully on these topics in the last few months: Prudence L. Gourguechon MD Past President of the American Psychoanalytic Association I still contend men don’t have to be afraid. They can still be sexual people. They don’t have to stop mentoring women. They don’t have to be like Mike Pence and have a chaperone at dinner. Just remember why women are working, what they can contribute and don’t be a jerk [13]. Alicia Glen New York City Deputy Mayor for Housing and Economic Development, and colleagues Men in these firms [those mentioned in the earlier Bloomberg article [29]] should be required to break bread with female colleagues—especially the up-and-coming ones of whom the men in the article were so afraid. Because so many major career conversations take place during casual interactions like grabbing a coffee or a beer or going to karaoke, it has never been more important to ensure women are “in the room where it happens” … These tips won’t just help firms avoid harassment complaints—they’ll help with business outcomes, too. If men at Wall Street firms are incapable of the simple act of having dinner alone with a woman without making fools of themselves, then those men pose a financial and cultural liability to the company. Would you trust a man who doesn’t trust himself to be alone with a woman with millions of dollars in investments or leading a major business division? [11]. Claudette Lajam MD Past President of the Ruth Jackson Orthopaedic Society When you’re putting a panel together to do a lecture or a course, you think about your friends—people you know. If you don’t know any women, you’re not going to put a woman on it [21]. Stephanie E. Waggel MD Psychiatrist and creator ofwww.ImproveMedicalCulture.com When I was in residency, an attending whom I viewed as a role model asked me to go to a bar across the street with him during my lunch break. Using my past experiences with male educators as a guide, I was apprehensive to accept. I recalled a time during medical school when a fellow invited me for lunch. After that, he frequently contacted me outside of work. If I ignored him, he made life insufferable for me on rounds the next day, which affected my evaluations. I did not want a repeat of this. Later, I discovered that the attending asked another resident to the same lunch. I was relieved. In order to have avoided my initial fears, he could have had a conversation with me explaining that another resident was invited, that the lunch was strictly work-related, and that it would be perfectly acceptable if I declined … A man may think that if he has to explain his intentions, it would suggest that his intentions were questionable in the first place. [Even so, that would be] a much better solution than ending mentoring entirely [31]. Julie Story Byerley MD, MPH Vice Dean for Education and Chief Education Officer for the University of North Carolina School of Medicine They [the men who have mentored the writer] demonstrate exemplary professional behavior during and outside of the work day, never compromised by alcohol consumption or flirtatious interactions. Second, they always behave comfortably but as if others are watching, demonstrating integrity. Third, though they have warm personalities, they refrain from physical touch except in larger social settings where they may give hugs in greeting. They never mention anything about my appearance or the appearance of others, and they avoid generalizing comments about gender. They text me important or urgent things, and sometimes just very funny things, but never anything I wouldn’t share with my husband or their wives. I know I am “in the club” because of their warmth and friendship as well as the content of our conversations, but I do not perceive their “club” as a stereotypical “boys’ club” where I am not welcome. Most importantly, my male mentors have chosen to speak up to support women while other men have chosen to sit quietly or, worse, offend [4].
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