Addressing the Leadership Gap: A Systematic Review of Asian American Underrepresentation in Orthopaedic Surgery

Abstract

Background: While Asian American individuals are well represented in medical schools in the United States, their advancement to senior positions within the field of orthopaedic surgery is disproportionately low. This underrepresentation not only limits diversity in leadership but also constrains the development of people-centred systems that reflect the needs of an increasingly diverse patient population. Objectives: This study systematically examines Asian American representation across the orthopaedic surgery professional pipeline, focusing on disparities between training-level representation and advancement into both faculty and leadership positions., and framing these gaps as a health equity concern. Methods: A comprehensive literature search for peer-reviewed original research articles was conducted via PubMed, EBSCO Open Research, Wiley Online Library, Google Scholar, and ScienceDirect. The potential articles were screened against prespecified eligibility criteria, and risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). Data were then systematically extracted and analysed. Results: This analysis included 20 research articles investigating Asian American representation in orthopaedic surgery. The results demonstrated an underrepresentation of Asian Americans in orthopaedic leadership positions despite improvements in training programme representation with subspecialty clustering in adult reconstruction and spine. Asian American surgeons were less likely to occupy academic and leadership roles than their non-Asian American peers. Across studies, underrepresentation was consistently observed, with effect size estimates indicating a substantial disparity (e.g., pooled risk difference = 0.19; 95% CI [0.12, 0.28]) in those studies reporting comparative outcomes. Similarly, while Asian Americans in residency programmes increased, this growth did not translate proportionally to faculty advancement. In contrast, Asian women face compounded barriers, particularly in subspecialties like spine surgery. These inequities undermine workforce inclusivity and may reduce cultural and linguistic concordance with patients. Conclusions: Despite having strong representation in orthopaedic training programmes, Asian Americans are disproportionately absent from leadership positions. This poses a challenge to equity in surgical education and patient-centred care. To promote equity in leadership, focused mentorship, clear promotion processes, and institutional reform are necessary to address structural barriers to career advancement, this will reflect the diversity of both the workforce and populations served.

Keywords: AAPI; Asian American; orthopaedic surgery; professional development; workforce disparities.

Figure 1

PRISMA flow diagram [1].