Gender Biases in Orthopedics

Did you know orthopedics has the lowest percentage of women residents of all specialties? In this podcast, Dr Nicholas Bertha sheds light how gender inequality in orthopedic surgery is real and well-documented.

Nicholas Bertha, MD, is an orthopedic surgeon in the department of orthopedics at the Penn State Health Milton S Hershey Medical Center in Hershey, Pennsylvania.

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Transcript:

Any views and opinions expressed are those of the authors and/or participants, and do not necessarily reflect the views, policy, or position of the Rheumatology and Arthritis Learning Network or HMP Global, its employees and affiliates.

RALN:

Welcome to this podcast from the Rheumatology and Arthritis Learning Network. I'm your host, Priyam Vora, and today we are talking to Dr. Nicholas Bertha. Dr. Bertha is an Orthopedic Surgeon in the Department of Orthopedics at the Penn State Health Milton S Hershey Medical Center in Hershey, USA. We are going discuss his research on how patient and specialty driven biases in orthopedics affect outcomes. Thank you for joining us today.

I understand that orthopedic surgery is historically a male dominant specialty with very few female residents and faculty. Is that what prompted your research?

Dr. Nicholas Bertha:

Yeah, so that was definitely one of the driving factors of our research. Historically, as you said, orthopedics has been very male dominated and that's not just for the number of residents in the attendings, but also as you kind of look into the leadership positions, they have very historically been all male dominated. So we wanted to take a look in conjunction with some other research that's previously been done looking at female representation orthopedics, and we wanted to look at something a little bit different than just the standard numbers of residents, attendings that are female. But we wanted to look as well as how the implicit or explicit biases of other providers plays a role into whether or not there are providers referring more patients to male providers or to female providers based on those historical stereotypes.

Priyam Vora:

All right, so would you describe your study?

Dr. Nicholas Bertha:

Yeah, so we looked at two different subspecialties of orthopedics specifically, which was our shoulder and elbow group and our joints, our adult reconstructive group. And the reason we picked those two groups to look at was that we had both male and female representation in both those groups and we felt that their subspecialties were primarily elective procedures, meaning that patients and other referring providers would typically be selecting who they wanted to see. Obviously there are some patients that they'll just see whoever, but you actually have more of a say, so unlike something like trauma where you're just kind of dealt the hand that you're given. So once we had selected the patient groups that we wanted, or excuse me, the attending groups that we wanted to look at, we analyzed over the course of a calendar year the number of patients that they saw and all the new patients that they had seen in that year.

And then we actually looked at who the referring provider was as that information was typically provided to us. And we also looked to see whether or not the patients specifically had requested certain providers. So by looking at that, we could see whether or not the referring providers, the male or female referring providers, were referring more to male or female orthopedic surgeons. And we're also looking at whether or not the patients were also having a bias in selecting the providers as well.

So when we looked at that, we actually did find, we looked at over 2000 new patients between these groups, and we did indeed find that there was a bias that was actually towards the referring providers referring more patients to male providers than to female providers respectively. Similar with the patient referrals, excuse me, similar to the patient selection of attendings where they tended to select more male providers again than females. So we thought that this was interesting because while we know that there's an under-representation of females in the specialty, we know that when we're looking at that group, you would think that there would be a pretty similar referral pattern amongst them, but indeed it was different. So even as physicians, there is a bias that we have, whether it's implicitly or explicitly of selecting who we want to send our patients to.

RALN:

Okay. So your article mentions that previous studies have shown that patient preferences most often relate to the surgeon's age, race, and or religion. And in subspecialties, other than orthopedics, when female patients had a gender preference, they overwhelmingly preferred a female surgeon. Did you find this to be the case in orthopedics too? And if not, is it due to the fact that they simply haven't encountered a female orthopedic surgeon?

Dr. Nicholas Bertha:

Yeah, so actually we did not find the same thing that they had found in other surgical groups, where the female patients had preferred females. We actually found that a lot of the females were requesting male providers and that's definitely one of our theories that they just haven't encountered other female orthopedic surgeons. And that's maybe likely just because there is such a high prevalence of males in the specialty. So that is definitely very possible. I think another thing that kind of plays into this as well, there's a lot of other factors that can play a role, reputation or years that are in the general area and so on and so forth. So there are some undermining things that can change this data. But with that being said, we have some of our female providers that have been here for a very long time and have a great reputation and so on and so forth, and that disparity was still present. So it's interesting. It's not definitive, proved by the statistics, but there's definitely a correlation there.

RALN:

I see. So during your research, did anything particular strike out regarding the referral biases across various demographic differences such as age, gender, race, or socioeconomic factors?

Dr. Nicholas Bertha:

So we tried taking a closer look specifically at the socioeconomic factors as well as the geographic area that they're being referred from. That's one of our hypotheses as well, is that there may be a difference based on those things specifically whether you're in an urban or a rural setting. And that perceptions of certain providers may be different based upon that, and that can be based again, just strictly upon the folks that are there or a general trend in the mentality of that whole region.

Now mind you, our study again only took place in one specific region in the United States. It definitely could have a similar impact in other areas, and I think that that's something that'd be really interesting to see. Unfortunately, just with the amount of patients that we had, and it wasn't an overly diverse population to be able to get a great idea of whether or not there was truly a difference based on race or some of those other socioeconomic factors. So I think it's a great question. I think that it's something that needs to be continued to be looked at, but we don't quite have an answer to yet.

Priyam Vora:

Okay. Maybe it's beyond the purview of this research, but I was just curious, you think this kind of bias or disparity is occurring in only orthopedics or other medical specialties too?

Dr. Nicholas Bertha:

So I think that this, while it's very prevalent in orthopedics just because of it's so male dominated, I do think that this is something that is occurring in other specialties as well. There's some data that shows from the ENT surgeons as well, that there are a lack of females in leadership positions. While there is a slightly higher rate of females actually practicing ENT than there is orthopedics, there's still that disparity. And I think that again, whether it's someone purposely referring to males just because that's who they referred to prior or they don't want to refer to females or what have you, but I do think that this is something that probably happens all over because I think that everyone has their biases to some extent. And I think as we've seen in years past, this is something that has not totally shifted yet and it's definitely still not a total equivalence between males and females when it comes to representation in medicine.

Priyam Vora:

Right. I know you touched upon this, but I'm just asking again so that our listeners can hear this. In all the research that you have done, what do you think affects a patient's bias in choosing a male surgeon as opposed to a female surgeon? I know you spoke about reputation and competency a bit, but...

Dr. Nicholas Bertha:

Yeah. So while I do think all those things matter and it does play a role, I do think that the historic representation in medicine being a male dominated field really, especially in the older population, shifts patient's perspectives as to who they want their providers to be. It is not uncommon for our female providers to walk into a patient room and that the patient thinks that they're not the doctor. They're either the nurse or a physician assistant or something other along the lines other than the physician. So I think that because of that history, I think that some people have more trust into the male physicians, whether rightly or wrongly, just because that's what they think medicine is and they think that that's just what it's been for a long time. So I think hopefully this research will bring some light to that, that this is still an issue and that this is something that needs to be addressed and we need to continue to work to equally represent both groups in medicine and show that females are just as competent if not more competent than their male colleagues.

RALN:

You actually answered my next question where I was going to ask you what do you hope to achieve with this study? So thank you. Last question, do you have any plans to expand this to a broader study?

Dr. Nicholas Bertha:

So we'd like to see a longer duration of our patient population. That's the one thing that we wanted to see first, is if we can have a portion longer than one year where we can see more data sets that can provide us a little more insight. The biggest thing from that is if we were able to see if there really is a difference between different races or different socioeconomic groups that are preferring one provider over the other. And I think that that is something we are trying to work at and trying to figure out how we can adequately do, because it's challenging, especially in this area, to be able to break things up and say, well, this is an urban area, or this patient came from an urban setting versus a rural setting. But I think that it's an important question because this is something that needs to be addressed and we can target to specific areas that really have a more larger under-representation of female providers.

The other thing that I really would like to see is whether or not this holds true in other countries around the world. Everyone has different perspectives based on their cultural norms. And again, like I said earlier, this is a study based strictly in one isolated center in the United States, and you may very well see different cultural norms in Europe or in Asia. And I think that that would be very interesting to see because I think that we can draw attention to the fact that this is really a global problem and not just something that's in the United States, or we may find that it's the opposite. We may find it's something that's really just in the United States. I think that's unlikely. I think that this is probably something that is global and that is something that is not just an isolated problem, but I do think it's important that we continue to expand these studies and draw more attention to what's going on with this.

RALN:

Okay, thank you. Any last thoughts? Anything you want to add maybe I forgot to ask?

Dr. Nicholas Bertha:

No, like I said, I think the big thing is just drawing attention to the fact that even though we've really tried to strive towards gaining a greater equality in male and female providers, there's still biases that's going on amongst patients to female providers and biases from other providers to female providers. And I think it's really important that when we are referring patients, that we really should be looking at the objective facts and looking at who really is the best provider for that patient, who's going to be able to take care of that patient to the most highest standard of quality that we can. So I think that that's going to be something that's really important as we move forward in the future. I'll look forward to seeing what happens.

RALN:

Thank you so much for taking the time to talk to us. Once again for our listeners. That was Dr. Nicholas Bertha explaining how recent trends in new patient referrals have consistently reflected gender biases in orthopedics. Thank you, Dr. Bertha.

Dr. Nicholas Bertha:

Thank you so much for having me today. It was a pleasure talking with you. I look forward to it again, maybe in the future.

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