Sex Disparities Among Fellowship Program Directors in Orthopaedic Surgery.

Background: Women are underrepresented in the orthopaedic surgery workforce in the U.S. The purpose of this study was to elucidate the representation of women among fellowship program directors (PDs) in orthopaedic surgery.

Methods: This was a retrospective cohort study of fellowship PDs in orthopaedic surgery during the 2022 to 2023 academic year. Academic, training, and demographic characteristics were collected from internet-based resources. Participation-to-prevalence ratios (PPRs) were calculated for both men and women. A PPR of <0.8 indicated underrepresentation and a PPR of >1.2 indicated overrepresentation. Bivariate analyses were utilized to assess the correlation between sex diversity and geographic region and between sex diversity and Accreditation Council for Graduate Medical Education (ACGME)-accreditation status. The relationship between the median annual salary and the sex diversity of each orthopaedic subspecialty was analyzed with use of the Pearson correlation coefficient.

Results: This study included 600 fellowship PDs, 40 (6.7%) of whom were women. In total, 24.5% of the fellowship PDs were assistant professors (8.8% women versus 91.2% men, p < 0.001); 26.2% were associate professors (9.6% women versus 90.4% men, p < 0.001); 36.8% were full professors (4.5% women versus 95.5% men, p < 0.001); and 12.5% were unranked (2.7% women versus 97.3% men, p < 0.001). The representation of women increased with academic rank, as reflected in their prevalence at the assistant (PPR = 0.67), associate (PPR = 0.77), and full professor (PPR = 0.80) levels. Among the orthopaedic subspecialties, musculoskeletal oncology (19.0%), pediatric orthopaedics (14.6%), and hand surgery (12.6%) had the highest proportions of women fellowship PDs. PPRs were lowest for orthopaedic sports medicine (PPR = 0.35), shoulder and elbow (PPR = 0.45), and adult reconstruction (PPR = 0.52). Women PDs had equitable representation in musculoskeletal oncology (PPR = 1.17), hand surgery (PPR = 1.02), foot and ankle (PPR = 0.84), and orthopaedic trauma (PPR = 0.80). Median subspecialty compensation was negatively correlated with the prevalence of women among fellowship PDs (r = -0.70, p = 0.036). Geographic region was not associated with sex diversity (p = 0.434), but programs with ACGME accreditation had significantly more women fellowship PDs than those without (11.0% versus 3.9%, p < 0.001).

Conclusions: Women are underrepresented among orthopaedic fellowship PDs, especially in certain subspecialties (orthopaedic sports medicine, shoulder and elbow, and adult reconstruction). More research is needed to understand the barriers that impact the representation of women among leadership positions in orthopaedic surgery.

Clinical relevance: Greater sex diversity among fellowship PDs may help to increase the recruitment of women into orthopaedic subspecialties. The equitable consideration of orthopaedic surgeons from all backgrounds for leadership positions can increase workforce diversity, which may improve the vitality of the orthopaedic community.