A Shadow of Doubt: Is There Implicit Bias Among Orthopaedic Surgery Faculty and Residents Regarding Race and Gender?

BACKGROUND: Orthopaedic surgery continues to be one of the least diverse medical specialties. Recently, increasing emphasis has been placed on improving diversity in the medical field, which includes the need to better understand existing biases. Despite this, only about 6% of orthopaedic surgeons are women and 0.3% are Black. Addressing diversity, in part, requires a better understanding of existing biases. Most universities and residency programs have statements and policies against discrimination that seek to eliminate explicit biases. However, unconscious biases might negatively impact the selection, training, and career advancement of women and minorities who are underrepresented in orthopaedic surgery. Although this is difficult to measure, the Implicit Association Test (IAT) by Project Implicit might be useful to identify and measure levels of unconscious bias among orthopaedic surgeons, providing opportunities for additional interventions to improve diversity in this field. QUESTIONS/PURPOSES: (1) Do orthopaedic surgeons demonstrate implicit biases related to race and gender roles? (2) Are certain demographic characteristics (age, gender, race or ethnicity, or geographic location) or program characteristics (geographic location or size of program) associated with the presence of implicit biases? (3) Do the implicit biases of orthopaedic surgeons differ from those of other healthcare providers or the general population? METHODS: A cross-sectional study of implicit bias among orthopaedic surgeons was performed using the IAT from Project Implicit. The IAT is a computerized test that measures the time required to associate words or pictures with attributes, with faster or slower response times suggesting the ease or difficulty of associating the items. Although concerns have been raised recently about the validity and utility of the IAT, we believed it was the right study instrument to help identify the slight hesitation that can imply differences between inclusion and exclusion of a person. We used two IATs, one for Black and White race and one for gender, career, and family roles. We invited a consortium of researchers from United States and Canadian orthopaedic residency programs. Researchers at 34 programs agreed to distribute the invitation via email to their faculty, residents, and fellows for a total of 1484 invitees. Twenty-eight percent (419) of orthopaedic surgeons and trainees completed the survey. The respondents were 45% (186) residents, 55% (228) faculty, and one fellow. To evaluate response biases, the respondent population was compared with that of the American Academy of Orthopaedic Surgeons census. Responses were reported as D-scores based on response times for associations. D-scores were categorized as showing strong (≥ 0.65), moderate (≥ 0.35 to < 0.65), or slight (≥ 0.15 to < 0.35) associations. For a frame of reference, orthopaedic surgeons' mean IAT scores were compared with historical scores of other self-identified healthcare providers and that of the general population. Mean D-scores were analyzed with the Kruskal-Wallis test to determine whether demographic characteristics were associated with differences in D-scores. Bonferroni correction was applied, and p values less than 0.0056 were considered statistically significant. RESULTS: Overall, the mean IAT D-scores of orthopaedic surgeons indicated a slight preference for White people (0.29 ± 0.4) and a slight association of men with career (0.24 ± 0.3), with a normal distribution. Hence, most respondents' scores indicated slight preferences, but strong preferences for White race were noted in 27% (112 of 419) of respondents. There was a strong association of women with family and home and an association of men with work or career in 14% (60 of 419). These preferences generally did not correlate with the demographic, geographic, and program variables that were analyzed, except for a stronger association of women with family and home among women respondents. There were no differences in race IAT D-scores between orthopaedic surgeons and other healthcare providers and the general population. Gender-career IAT D-scores associating women with family and home were slightly lower among orthopaedic surgeons (0.24 ± 0.3) than among the general population (0.32 ± 0.4; p < 0.001) and other healthcare professionals (0.34 ± 0.4; p < 0.001). All of these values are in the slight preference range. CONCLUSION: Orthopaedic surgeons demonstrated slight preferences for White people, and there was a tendency to associate women with career and family on IATs, regardless of demographic and program characteristics, similar to others in healthcare and the general population. Given the similarity of scores with those in other, more diverse areas of medicine, unconscious biases alone do not explain the relative lack of diversity in orthopaedic surgery. CLINICAL RELEVANCE: Implicit biases only explain a small portion of the lack of progress in improving diversity, equity, inclusion, and belonging in our workforce and resolving healthcare disparities. Other causes including explicit biases, an unwelcoming culture, and perceptions of our specialty should be examined. Remedies including engagement of students and mentorship throughout training and early career should be sought.

Addressing Burnout Among Women Residents: Results from Focus Group Discussions.

Introduction: Physician burnout has been described as more common among women than men. Even if there are no gender-based differences in prevalence, risk factors, such as work/home integration/conflict and gendered biases, likely differ. Prior administrations of an annual resident wellness survey at a single urban academic institution confirmed that rates of burnout were higher among women, especially during the PGY-2 year. Methods: A series of focus groups of PGY-3 women residents across specialties were organized in 2019 at a single urban academic medical center. Given the number of participants, demographics were not collected to maintain participant anonymity. The moderator for all groups used a discussion guide consisting of eight open-ended questions based on a review of the literature. Results: Ten residents agreed to participate in one of four hour-long focus group discussions. While the residents identified some factors that were not gender-specific, they also discussed issues that they faced as women in medicine, including needing to work harder to prove themselves and unconscious gendered biases from faculty and patients. The residents thought that their well-being would be improved if their training programs better understood the experiences and needs of women residents and recommended a series of interventions, including improved mentoring and networking opportunities. Conclusions: Interventions to improve well-being need to consider gender-based differences. While mentoring and networking can help all residents, these may be especially useful for women and should be considered as a component of an overarching plan to improve diversity, equity, inclusion, and belonging.

Managing Post-Operative Pain in Orthopedic Patients: An International Comparison.

Introduction: Opioids play a crucial role in post-operative pain management in America, but not in some other countries. We sought to determine if a discrepancy in opioid use between the United States (U.S.) and Romania, a country that administers opioids in a conservative fashion, would show in subjective pain control differences. Methods: Between May 23, 2019, and November 23, 2019, 244 Romanian patients and 184 American patients underwent total hip arthroplasty or the surgical treatment of the following fractures: bimalleolar ankle, distal radius, femoral neck, intertrochanteric, and tibial-fibular. Opioid and non-opioid analgesic medication use and subjective pain scores during the first and second 24 hours after surgery were analyzed. Results: Subjective pain scores for the first 24 hours were higher among patients in Romania compared to the U.S. (p < 0.0001), but Romanians reported lower pain scores than U.S. patients in the second 24-hours (p < 0.0001). The quantity of opioids given to U.S. patients did not differ significantly based on sex (p = 0.4258) or age (p = 0.0975). However, females reported higher pain scores than male patients following the studied procedures (p = 0.0181). No sex-based differences in pain scores were noted among Romanian patients. Conclusions: Higher pain scores in American females, despite equivalent amounts of narcotics to their male counterparts, and the absence of a difference in Romanians suggested that the current American post-operative pain regimen may be tailored to the needs of male patients. In addition, it pointed to the impacts of gender, compared to sex, in pain experiences. Future research should look for the safest, most efficacious pain regimen suitable for all patients.

Interpersonal Interactions and Biases in Orthopaedic Surgery Residency: Do Experiences Differ Based on Gender?

BACKGROUND: Women residents are underrepresented in orthopaedic surgery. The causes of the deficit of women in orthopaedic surgery are multifactorial, but by identifying the perceptions of women in orthopaedic residency training and comparing them with the perceptions of men, we can improve our understanding of ways to enhance the recruitment of qualified and diverse candidates. QUESTIONS/PURPOSES: (1) What differences exist in the perceived experiences of residents identifying as women and men regarding professional, social, and personal interactions during residency training? (2) Are there differences in the percentage of women and men residents who have experienced harassment or discrimination in preresidency interviews, and are there differences in the type of harassment or discrimination experienced? METHODS: A survey was generated using Academy of Critical Care: Development, Evaluation, and Methodology guidelines. Two focus groups with seven attending orthopaedic surgeons who participate in the Collaborative Orthopaedic Education Research Group and who are experts on gender diversity in orthopaedics were held to improve survey validity. The survey included binary-response, Likert, and free-text questions on the perception of professional, social, and personal interactions held by the resident being surveyed. The questions focused on a respondent's perception of interactions with staff members, patients, resident colleagues, and attending surgeons, as well as sexual harassment. Program directors at 10 selected Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic residency programs that participate in the Collaborative Orthopaedic Education Research Group shared the survey with residents at their institutions. There were 95 programs in the Collaborative Orthopaedic Education Research Group at the time this survey was distributed. In this program, directors or other interested teaching faculty in orthopaedic residency programs voluntarily participate to discuss and develop quality research on resident and fellow education. These 95 programs account for 46% of the ACGME-accredited programs in the United States at the time the survey was created and distributed. The 10 residency programs had a total of 232 enrolled residents; 15% (34) identified as women. This gender distribution models the national sample of orthopaedic residents. Survey reliability was assessed by calculating the Cronbach alpha after determining the variance in each relevant (nondemographic) survey item. The final survey was found to have excellent internal reliability (alpha = 0.95). Responses from residents identifying as women and those identifying as men were compared using Fisher exact tests for all categorical data, and two-tailed independent t-tests were used for all continuous data. Differences in each survey category (professional interactions, social interactions, personal interactions, and sexual harassment in preresidency interview experiences) were calculated. RESULTS: Women reported experiencing microaggressions (left undefined to the survey respondent, but generally considered to be subtle, stunning, often automatic, and nonverbal exchanges that are "put downs") at work more frequently than men did (40% [six of 15] versus 5% [four of 74]; p < 0.001). Specifically, women perceived being interrupted (53% [eight of 15] versus 5% [four of 75]); p < 0.001) by men colleagues, called by their first name (67% [10 of 15] versus 4% [3 of 72]; p < 0.001), and given administrative tasks (27% [four of 15] versus 1% [one of 75]; p = 0.004) more often than men. More women than men perceived that patients (33% [five of 15] versus 0 of 74 [0%]; p < 0.001) and hospital staff (27% [four of 15] versus 7% [five of 74]; p = 0.01) respected their opinion less than that of men. More women than men perceived that group humor negatively targeted their gender (47% [seven of 15] versus 1% [one of 75]; p < 0.001) and that criticism of their surgical skill was based on their gender rather than their ability (33% [five of 15] versus 5% [four of 78]; p = 0.005). In residency or subinternship interviews, 20% of women reported experiencing sexual harassment as defined by a listing of known types of harassment in the question stem, compared with 0% of men (p = 0.004). Women reported harassment in the form of verbal remarks of a sexual nature and obscene images in the workplace, whereas men did not report any form of harassment during interviews. CONCLUSION: These findings suggest that the greatest discrepancies in the perceived experiences of women and men residents lie in professional interactions, and women residents are more likely to experience sexual harassment and disparaging humor than men residents. CLINICAL RELEVANCE: Addressing these discrepancies, particularly in the professional setting, will help to create a more inclusive work environment and attract more women to orthopaedic surgery. Annual distribution of the survey used in this study by program directors to residents in their programs can help to identify discrepant perceptions that, coupled with the collection of objective data, can be targeted for improvement.

Sex-Based Differences in Outcomes After Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Systematic Review.

Background: While sex-based differences in outcomes after hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) are often recorded, no studies have been dedicated to analyzing the literature as a whole. Purpose: To investigate whether sex is a predictor of outcomes in studies evaluating hip arthroscopic surgery for FAIS. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Embase, Cochrane, Ovid, and PubMed Central databases for English-language studies that evaluated sex-specific outcomes in human populations. The search terms used were as follows: ("Hip Arthroscopy") AND ("Femoroacetabular Impingement" OR "FAI") AND ("Sex" OR "Gender" OR "Male" OR "Female"). Studies with evidence levels 2 through 4 were included. The studies were then screened, followed by data extraction. Modified Harris Hip Score (mHHS) outcomes and return-to-sport (RTS) rates were recorded. These were analyzed using random-effects meta-analysis. Heterogeneity was calculated using the I 2 statistic. Results: Of 256 full-text articles screened, 48 articles were included in this analysis; of these, 14 studies (29%) concluded that female sex was a negative predictor of postoperative outcomes, while 6 studies (13%) found female sex to be positive predictor. The remaining 28 studies (58%) found no sex-based differences in postoperative outcomes. Of 7 studies (416 male and 519 female) included in the mHHS analysis, 2 studies concluded that male patients had significantly higher postoperative mHHS scores. Of 6 studies (502 male and 396 female) included in the RTS analysis, 1 study concluded that male patients had a significantly higher RTS rate. Conclusion: Almost one-third of the included studies determined that female sex was a negative predictor of postoperative outcomes, 13% found female sex to be a positive predictor, and 58% found no sex-based differences. Our study illustrates an insufficiency of high-level evidence supporting sex-specific differences in outcomes after hip arthroscopic surgery, but findings indicated that the postoperative mHHS score and RTS rate may be influenced by sex.

Tranexamic acid improves early postoperative mobilization in cancer patients undergoing endoprosthetic reconstruction.

BACKGROUND AND OBJECTIVES: Tranexamic acid (TXA) has been shown to decrease perioperative blood loss, transfusions, and cost in patients undergoing resection of aggressive bone tumors and endoprosthetic reconstruction. This study explored the effect of TXA administration on postoperative mobilization in these patients. METHODS: This study included 126 patients who underwent resection of an aggressive bone tumor and endoprosthetic reconstruction; 61 patients in the TXA cohort and 65 patients in the non-TXA cohort. Postoperative physical therapy (PT) and occupational therapy notes were reviewed; patient ambulation distance and duration of therapies were recorded. RESULTS: Patients in the TXA cohort ambulated further on all postoperative days, which was significant on postoperative Day 1 (POD1) (p = 0.002) and postoperative Day 2 (POD2) (p < 0.001). The TXA cohort ambulated 85% further per PT session 87.7 versus 47.4 ft (p < 0.001) and participated 14% longer, 36.1 versus 31.7 min (p < 0.001). Multivariate analysis identified a significant inverse association between postoperative hospitalization length and POD1, POD2, postoperative Day 3, and total ambulation (p < 0.001). Blood transfusion was independently associated with a 1.5 day increase in postoperative hospitalization (95% confidence interval: 0.64-2.5; p < 0.001). CONCLUSIONS: TXA administration was associated with increased postoperative ambulation and endurance. Increased postoperative ambulation was associated with decreased length of stay and increased likelihood to discharge home.

Tranexamic Acid in Patients With Cancer Undergoing Endoprosthetic Reconstruction: A Cost Analysis.

INTRODUCTION: Tranexamic acid (TXA) decreases blood loss, perioperative transfusion rates, and cost in total hip and total knee arthroplasty. In a previous study, topical TXA decreased both perioperative blood loss and transfusions in patients undergoing resection of aggressive bone tumors and endoprosthetic reconstruction. The purpose of this study was to explore the cost effectiveness of TXA in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction, assessing transfusion cost, TXA administration cost, postoperative hospitalization cost, posthospital disposition, and 30-day readmissions. METHODS: This study included 126 patients who underwent resection of an aggressive bone tumor and endoprosthetic resection at a single academic medical center; 61 patients in the TXA cohort and 65 patients in the non-TXA cohort. The cost of 1 unit of packed red blood cells, not including administration or complications, was estimated at our institution. The cost of hospitalization was estimated for lodging and basic care. The cost of TXA was $55 per patient. Patients were followed up for 30 days to identify hospital readmissions. RESULTS: Patients in the TXA cohort experienced a TXA and blood transfusion cost reduction of $155.88 per patient (P = 0.007). Proximal femur replacement patients experienced a $282.05 transfusion cost reduction (P = 0.008), whereas distal femur replacement patients only experienced a transfusion cost reduction of $32.64 (P = 0.43). An average hospital admission cost reduction of $5,072.23 per patient (P < 0.001) was associated with TXA use. Proximal femur replacement patients who received TXA experienced a hospital cost reduction of $5,728.38 (P < 0.001), whereas distal femur replacement patients experienced a reduction of $3,724.90 (P = 0.01). No differences between the cohorts were identified in discharge to home (P = 0.37) or readmissions (P = 0.77). DISCUSSION: TXA administration is cost effective in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction through reducing both perioperative transfusion rates and postoperative hospitalization. LEVEL OF EVIDENCE: III-Retrospective Cohort Study.

Bone mineral density surveillance for childhood, adolescent, and young adult cancer survivors: evidence-based recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group.

Childhood, adolescent, and young adult cancer survivors are at increased risk of reduced bone mineral density. Clinical practice surveillance guidelines are important for timely diagnosis and treatment of these survivors, which could improve bone mineral density parameters and prevent fragility fractures. Discordances across current late effects guidelines necessitated international harmonisation of recommendations for bone mineral density surveillance. The International Late Effects of Childhood Cancer Guideline Harmonization Group therefore established a panel of 36 experts from ten countries, representing a range of relevant medical specialties. The evidence of risk factors for very low and low bone mineral density and fractures, surveillance modality, timing of bone mineral density surveillance, and treatment of very low and low bone mineral density were evaluated and critically appraised, and harmonised recommendations for childhood, adolescent, and young adult cancer survivors were formulated. We graded the recommendations based on the quality of evidence and balance between potential benefits and harms. Bone mineral density surveillance is recommended for survivors treated with cranial or craniospinal radiotherapy and is reasonable for survivors treated with total body irradiation. Due to insufficient evidence, no recommendation can be formulated for or against bone mineral density surveillance for survivors treated with corticosteroids. This surveillance decision should be made by the survivor and health-care provider together, after careful consideration of the potential harms and benefits and additional risk factors. We recommend to carry out bone mineral density surveillance using dual-energy x-ray absorptiometry at entry into long-term follow-up, and if normal (Z-score > -1), repeat when the survivor is aged 25 years. Between these measurements and thereafter, surveillance should be done as clinically indicated. These recommendations facilitate evidence-based care for childhood, adolescent, and young adult cancer survivors internationally.

ABCs of Pain: A Functional Scale Measuring Perioperative Pain in Total Hip Arthroplasty Patients.

INTRODUCTION: Functional pain assessments are critical in total hip arthroplasty. This pilot study investigated a novel functional pain scale-the Activity-Based Checks of Pain (ABCs)-and its correlations with the 0 to 10 numeric rating scale (NRS) and outpatient milligram of morphine equivalents (MMEs) prescribed and needed in the first 2 weeks after total hip arthroplasty. METHODS: ABCs and NRS were collected at the baseline, inpatient, and 2-week follow-up. Primary outcome metrics were needed for pain medication at the time of pain scale completion, MMEs prescribed at discharge, and MMEs taken. Individual ABC functions and composite score were analyzed using Spearman rho and Mann-Whitney U tests. RESULTS: ABC and NRS scores were greatest preoperatively (n = 39). At each stage, the ABCs correlated with the NRS (ρ = 0.450, P < 0.01; ρ = 0.402, P < 0.05; and ρ = 0.563, P < 0.01). ABC or NRS scores did not correlate with MMEs prescribed. Last in-house NRS correlated with MMEs taken postoperatively (r = 0.571, P < 0.01). Specific ABCs functions-"sitting up" (ρ = 0.418, P < 0.01), "walking in room" (ρ = 0.353, P < 0.05), and "walking outside room" (ρ = 0.362, P < 0.05)-on the day of discharge correlated with MMEs taken. CONCLUSION: ABCs scale correlates with NRS. Neither scale correlated with MMEs prescribed at discharge, suggesting pain is undervalued in analgesic planning. Clinicians should assess pain with functions found to correlate with MMEs taken-"sitting up," "walking in room," and "walking outside room."