Orthopedic surgeons pride themselves on fixing things. Can they fix their own field’s lack of diversity?

This is part two of a STAT investigation on the lack of diversity in orthopedic surgery. For part one, click here.

Just last month, spine surgeon Shaina Lipa tweeted that she is the first Black woman orthopedic surgeon to be hired by any Harvard hospital. It was a signal event, but one long overdue, and it highlights the stunning lack of progress made to diversify American medicine’s whitest specialty: Even today, being a Black, brown, or Native American orthopedic surgeon can still mean being a “first” or an “only” in hospitals, residency programs, private practices, and faculty meetings.

The lack of diversity, which has persisted despite decades of attempts to change it, raises what many call the billion-dollar question: Will orthopedic surgery, a field known for fixing broken people, ever be able to fix itself?

STAT reported Monday that in orthopedics, fewer than 2% of practitioners are Black, just 2.2% are Hispanic, and 0.4% are Native American. The field remains 85% white and overwhelmingly male, demographics that have not changed appreciably even as the rest of medicine has become far more diverse.

With the numbers currently so small, people interviewed for this series say these racial demographics will be nearly impossible to change without focused, intentional, and consistent effort across the field, from medical schools and hospitals to residency training programs — and it will require buy-in and hard work from the field’s white majority, who hold the power and almost all the leadership positions.

“We are desperate for white male advocates in orthopedics,” said Gabriella E. Ode, a Black orthopedic surgeon and clinical assistant professor at the University of South Carolina School of Medicine who has researched the root causes of the lack of diversity in her field. “They need to have skin in the game.”

There was a time and a place Black orthopedic surgeons weren’t so alone. It was about 20 years ago at the University of Virginia, when the orthopedics department was led by a Black man — Cato Laurencin, an acclaimed surgeon, scientist, and inventor — while another Black male orthopedic surgeon, Eric Carson, assisted.

In just a short time, residents of color were flocking to train at the program, which Carson said had previously trained just a handful of Black residents. “People were asking, ‘What are you doing to recruit?’” said Carson, now a professor of orthopedic surgery at Washington University School of Medicine in St. Louis. “But we weren’t doing anything. People just wanted to be around people who look like them and where they felt safe.”

Erica Taylor was one of those people. “It was important to go to a program that would not be so shocked by me that they would not be able to train me,” she said in explaining why she applied to UVA’s residency program. With a Black chair in her corner, she said, succeeding “boiled down to papers, writing, experience, science, not the fact I was a woman or Black.”

Taylor’s residency class called themselves “the Fab Five,” and included, at a time when the specialty was nearly 90% white male, not a single white male. Four trainees were Black, one was a white woman — and not everyone at the university was rooting for them.

“They did not expect our class to do well. They wondered who would get fired first,” recalled Taylor, now chief of surgery at Duke Raleigh Hospital. “Well, everyone went on to do well.” One former resident is now vice chair of his orthopedics department; others are senior surgeons at major orthopedics practices.

But the utopia fell apart after Laurencin departed to become dean of the University of Connecticut School of Medicine and Carson no longer felt supported. Carson eventually moved to his current position in St. Louis, where he said he feels tremendous support from his chair  — and the residency program has become markedly more diverse.

The story shows what a difference having people of color in leadership positions can make in offsetting structural racism in academic and medical settings, but also highlights the fragility of such gains.

Sustained change, many in the field say, will require change at the top, specifically more faculty leaders of color in orthopedics. Studies show women are more likely to enter programs with women faculty; the same is true for people of color. But a new analysis by Charles Day, professor and executive vice chair of orthopedic surgery at Henry Ford Health Systems in Detroit, shows just 2.6% of orthopedic surgery academic faculty are Black and just 2% are Hispanic. Of hundreds of full professors of orthopedics, Carson said, just six are Black.

Day’s analysis found orthopedics had the lowest percentage of non-white faculty, program directors, or chairs of any specialty he analyzed, including neurosurgery, otolaryngology, and general surgery. The problem may be worse in orthopedics but extends to other specialties as well. “The current leadership in academic medicine across the board continues to lack representation,” Day said. “That’s one of the key variables if we are going to effect systematic change.”

There are some positive signs. This year, a record 17 Black women matched into orthopedics. It’s an astonishing number given that only about 100 of the nation’s 30,000 orthopedic surgeons are Black women, said Letitia Bradford, an orthopedic surgeon in New Mexico who directs a mentoring program for students from underrepresented groups interested in orthopedics. It’s unclear what led to the increased numbers. Some say it may show that residency programs are finally taking diversity more seriously or that the virtual interview platform ushered in by the pandemic allowed more Black and brown candidates to apply and also shine during interviews because they felt more comfortable.

Many see hope in the upcoming generation of orthopedic surgeons, people like fourth-year Emory School of Medicine student Akin Ojemakinde, who refuses to accept the status quo and will demand training, and a field, that is inclusive and diverse. ”I’d be hesitant to go to a program that doesn’t have any diversity or recent history of training African Americans. That’s a red flag,” he said. “It’s 2021. You don’t want to be the first anymore. At this point, it’s unacceptable.”

Or like Temi Ogunleye, who refuses to take no for an answer. Ogunleye played high school and college football in Texas and grew obsessed with orthopedics after watching the ACL repair of his roommate, who went on to play professionally. “I saw the impact that surgery had on the quality of his life,” he said. “I knew at 19 years old I was going to be an orthopedic surgeon.”

But the odds were stacked against him. He attended an osteopathic medical school so new it was still being built when he applied. He didn’t belong to the Alpha Omega Alpha medical student honor society. He didn’t have the highest score on the Step 1 test taken by aspiring residents. Even his mentors said he had very little chance of matching into an orthopedic residency. He didn’t care. Despite being told not to bother, he took a year off of medical school to do orthopedics research at the University of Minnesota.

Not only did Ogunleye match into orthopedics, he was selected by an excellent program at the University of Washington. He’s thrilled. And he says other Black and brown medical students who want to enter the field — he knows a number who did not apply because they were afraid they’d never match — should not give up. “You miss 100% of shots you don’t take,” he said.

For all the successes this year, many orthopedic surgeons concerned about diversity worry that the number of candidates of color is still far too low and any uptick could be temporary.

The Accreditation Council for Graduate Medical Education recently added diversity to its residency-program requirements, but the system moves slowly. The ACGME does not yet require programs to show they have actually increased the diversity of their classes, just to show they are creating a plan to do so. Because of this, dozens of programs, many that have never trained a Black person, are now reaching out to Carson.

“All of the sudden everyone wants to call me because it checks a box,” he said. While the slow pace is frustrating, Carson is happy to see some action. Programs are taking the diversity requirements seriously, he said, because they know that if they don’t show actual progress, they could be sanctioned in coming years by the ACGME, which would be detrimental to their programs.

A solution that is already making a difference is an intensive mentoring program for medical students from underrepresented racial and ethnic groups. Called Nth Dimensions, it was founded by Black orthopedic surgeon Bonnie Simpson Mason in 2004. The program is highly successful; in the past five years, 92% of those going through the program have matched in orthopedics. (The average match rate for the specialty is about 75%.)

One current mentee is Alison Lewis, a Black second-year medical student from rural southwest Georgia who has dreamed of being a doctor since elementary school. During college, she shadowed doctors at the hospital where her father is a radiation therapist, and fell in love with orthopedics while working as an X-ray technologist.

But she had never seen a Black orthopedic surgeon until she reached medical school. As an Nth Dimensions scholar, Lewis is conducting research with one mentor while getting support and advice from many others, who are mostly Black and brown doctors. “They are being honest with us about where the stats lie,” she said. “They talk about racial things they’ve experienced. They’re not sugar-coating anything.”

Lewis is realistic, but confident. “I’ve now seen enough people who look like me to know this is doable,” she said. “They told us we’re slowly but surely changing orthopedics.”

As important as it’s been for students like Lewis, Nth Dimensions is small — the program takes between 25 and 30 students a year — and competition to enter is steep. And while white surgeons act as mentors too, the time-intensive program relies largely on time donated by the field’s smattering of Black and Hispanic surgeons.

More mentoring can only accomplish so much unless the rules for who gets into residency programs change, say those pushing to diversify the field. They say that will only happen if the structure that has allowed a white male stranglehold in orthopedics is dismantled. One solution: Give residency applicants credit for attributes correlating to success in medicine that candidates from groups underrepresented in medicine often have in abundance — grit, resilience, and “distance traveled.”

Such changes, however, could result in some white candidates, perhaps even the sons and daughters of fellow orthopedic surgeons, not getting chosen. “It gets very real when you’re talking about actual applicants,” said Day. “Who’s going to be brave enough to make these changes?”

It might be Lisa Lattanza. Once a physical therapist for professional athletes, Lattanza pursued medical school in the 1990s at the urging of her mentor, pioneering female orthopedic surgeon Jacquelin Perry. (Lattanza later co-founded the Perry Initiative to help support women interested in orthopedics.) In 2019, Lattanza, who is white, became chair of the Yale Department of Orthopedics and Rehabilitation, one of the first women to ever hold such a role.

One of the first things Lattanza did was shake up the selection process for residents, adding points for grit, diversity, and resilience, attributes thought to improve success within orthopedics. “We’re not just saying, you get more points because you’re a woman or a minority,” she said. “We’re weighting things toward people who have a more interesting story, a different path.” The changes instantly altered rankings of candidates and led to a more diverse residency class, she said.

There was pushback, of course, but Lattanza, who is openly gay, has stopped letting that get to her. “I spent the first part of my career trying to fit in. That’s a horrible way to live your life,” she said. Early on, she said, “you weren’t allowed to say things like, ‘It’s the culture,’ because the men just shut down. They didn’t want to hear it.” Now, in her work to support both women and people of color, Lattanza has stopped worrying about what people think. “You know, I’m exhausted by this,” she said. “Let’s stop trying to make the people who are causing the problem comfortable.”

Another person making positive changes is Joseph D. Zuckerman, a former president of the American Academy of Orthopaedic Surgeons (AAOS) who runs one of the country’s largest and most diverse residency programs at the NYU Grossman School of Medicine. Of the program’s 70 residents, 14% are Black.

Keys to his program’s success, he said, are numbers, money, and a commitment to diversity not only from the top, but from those at all levels of the program. First, he said, programs need to have trainees and faculty of color in order to attract other trainees. “If you’re African American and you don’t see any African American faculty or residents, is that where you want to train?” he asked.

To attract diverse trainees, he said, programs must showcase that diversity is important. For 15 years, he said, NYU has regularly sent Black orthopedics faculty members to demonstrate sawing bones and simulated knee replacements at meetings of the Student National Medical Association, an organization for medical students from underrepresented groups. (NYU picked up the tab for doing so after the AAOS cut the program from its budget, he said.) His program also reserves several spots in its summer internship program for medical students from underrepresented communities; many later apply to be residents.

The success didn’t happen overnight. The program has had a DEI committee since 2010 and faculty have engaged in extensive bias training. “Even in an enlightened community, you have to work hard to offset racism,” said Zuckerman, who is white.

That hard work, however, is being done by only a minority of programs. Most orthopedics programs haven’t even taken the simple step of posting diversity, equity, and inclusion information on their websites. A recent analysis of all active residency program websites found less than 30% contained such information. Actively recruiting diverse candidates is another solution, but 32% of programs do not attempt to recruit candidates from underrepresented communities.

Other solutions seem relatively straightforward. One is to add a required musculoskeletal rotation or curriculum — literally take the skeleton out of the closet — at all medical schools so more students are exposed to the specifics of not just anatomy but the workings of the musculoskeletal system and how to examine painful knees, shoulders, and backs. One study found this sharply increased the number of women and students of color who applied to orthopedics.

Following criticism from orthopedic surgeons of color that they felt invisible in the AAOS’ public-facing materials and outreach, the group is creating videos highlighting the work of these surgeons on its website, Orthoinfo, that millions visit each year for medical information. “We want to create a visual as a role model,” said Daniel Guy, a Georgia orthopedic surgeon who is the academy’s president. He said AAOS is also tracking demographic data of all residents and fellows in orthopedics, in addition to collecting racial and ethnic data through its regular membership census. “You have to measure where you are,” Guy said.

Those trying to change the field teeter between optimism and despair. Some say the racial reckoning that followed the pandemic and the murder of George Floyd has cast such a bright spotlight onto racism in society and medicine that the lack of diversity in orthopedics can no longer be ignored. Others fear the commitment will wane — orthopedic surgeons are not known for their patience — long before the meager numbers change significantly. But all agree that change is needed.

“This is a no-brainer. It’s a desirable thing for all concerned,” said Augustus White III, a Black orthopedic surgeon who broke many color barriers throughout his long career and at 85, has left the operating room but is still battling health disparities through the Augustus White III Institute for Healthcare Equity in Boston. “Orthopedics has to do better.”

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.