Despite Growing Number of Women Surgeons, Authorship Gender Disparity in Orthopaedic Literature Persists Over 30 Years

Abstract

Background: The most recent demographic data reveal that only 6.5% of practicing orthopaedic surgeons are women, and as far as we know, only two women have held chair positions in academic orthopaedic programs in the United States. Furthermore, orthopaedic surgery is the least gender-diverse speciality recognized by the Accreditation Council for Graduate Medical Education. The factors that contribute to the lack of gender diversity in orthopaedics remain ill-defined. A lag in publication productivity may be a barrier to career advancement for women orthopaedic surgeons, but this has not been well studied.

Questions/purposes: (1) What is the proportion of orthopaedic studies published in six major orthopaedic journals by women first or senior authors from 1987 to 2017? (2) Did men and women orthopaedic surgeons publish in equal proportions during the study period (measured in 5-year intervals)? (3) Are there differences in the characteristics (such as study type or subject focus) of orthopaedic publications authored by women and those authored by men? (4) Has the increased proportion of practicing women orthopaedic surgeons been matched by an equal increase in authorship by women orthopaedic surgeons during the study timeframe?

Methods: A cross-sectional analysis was designed to characterize trends in authorship of orthopaedic studies by women over time. All publications from the first issue of each of six major orthopaedic journals were evaluated at seven time points (1987, 1992, 1997, 2002, 2007, 2012, and 2017). Characteristics of each first and senior author (including gender, academic degree, and specialty), and study category of each publication were collected. Articles for which this information was not available were excluded (35 of 1073, or 3.3% of published studies, no difference in proportion of excluded studies between journals). The proportions of women and men authors were compared at the seven time points and for six study categories (basic science, case report/technique article, clinical medicine, economics/practice management, editorial content [including true editorials, letters to the editor, commentaries, and book reviews] and review/meta-analysis) using a Fisher's exact test or chi-squared analysis. We compared the rates of change of women authorship, practicing women orthopaedic surgeons, and women orthopaedic residents during the study period using an ANOVA and Tukey's honestly significant difference (HSD) post-hoc test with Cohen's D measure of effect size.

Results: From 1987 to 2017, only 1.7% (15 of 880) of senior authors and 4.4% (46 of 1038) of first authors of orthopaedic publications were women orthopaedic surgeons. Based on population proportions (that is, percent of practicing women orthopaedic surgeons compared with men), the proportion of women senior authors was less than would be expected at each time point after 1987 compared with men. There were no differences between the types of studies authored by women or men. Finally, during the study period, the rate of growth of women senior authorship was less than the rates of growth of both practicing women orthopaedic surgeons (d = 5.3, 95% CI, 4.8-5.6; p = 0.023) and women first authorship (d = -4.3, 95% CI -4.6 to -3.6, p = 0.030; estimated mean 3.3, p = 0.013).

Conclusions: Women orthopaedic surgeons published a small proportion of academic orthopaedic research from 1987 to 2017, and women senior authors consistently published less than would be expected based on their population proportion compared with men orthopaedic surgeons. Furthermore, the growth of practicing women orthopaedic surgeons has not been matched by growth in senior authorship by women over the same timeframe.

Clinical relevance: This discrepancy warrants further exploration because a low rate of publication may negatively impact the career advancement of women orthopaedic surgeons and contribute to the overall lack of gender diversity in orthopaedics. We suggest that journals and publishers review their editorial processes to ensure blinding of author names during peer review and editorial decision-making, and to disclose those review processes to authors. We also suggest that institutions encourage women trainees and junior faculty to participate in mentorship programs and specialty societies that promote academic productivity.

Fig. 1

This figure details the growth of practicing women orthopaedic surgeons versus women orthopaedic first and senior authorship from 1987 to 2017. *Indicates that the rate of growth of women orthopaedic senior authorship was less than that of practicing women orthopaedic surgeons (d = 5.3, 95% confidence interval [CI], 4.8-5.6; p = 0.023) and of women orthopaedic surgeon first authorship (d = -4.3, 95% CI -4.6 to -3.6; p = 0.030); pooled estimated mean for comparison was 3.3, p = 0.014). %W Ortho = the proportion of practicing women orthopaedic surgeons, slope of best fit line, m = 0.84; %W Ortho 1^st = the proportion of women orthopaedic surgeon first authors, slope of best fist line, m = 0.93; %W Ortho Sr = the proportion of women orthopaedic surgeon senior authors, slope of best fit line, m = 0.25.

Fig. 2

This figure details the growth of women orthopaedic first and senior authorship versus practicing women orthopaedic surgeons and women orthopaedic residents from 2007 to 2017. *Indicates that the rate of growth of women orthopaedic residents was more than that of both women orthopaedic first authorship (d = -7.5, 95% confidence interval [CI], -8.7 to -5.9; p = 0.008) and of women orthopaedic surgeon senior authorship (d = -11, 95% CI, -13 to -9.7; p = 0.001); pooled estimated mean for comparison was 7.3, p = 0.001). %W Ortho = the proportion of practicing women orthopaedic surgeons, slope of best fit line, m = 0.64; %W Ortho 1^st = the proportion of women orthopaedic surgeon first authors, slope of best fist line, m = 0.79; %W Ortho Sr = the proportion of women orthopaedic surgeon senior authors, slope of best fit line, m = 0.23; %W Resident = the proportion of women orthopaedic residents, slope of best fit line, m = 2.5.

Fig. 3

This figure demonstrates the change in the proportion of (A) women who were first authors and (B) women who were senior authors between 1987 and 2017, by journal. By journal, there were no differences in the proportion of women who were first authors (pooled mean 0.075, p = 0.435), or senior authors (pooled mean 0.018, p = 0.472). JBJS = Journal of Bone and Joint Surgery; JOT = Journal of Trauma; Arthroplasty = Journal of Arthroplasty; AJSM = American Journal of Sports Medicine; JHS = Journal of Hand Surgery; JPO = Journal of Pediatric Orthopaedics.