Diversity-inclusion gap in orthopedic surgery: a nationwide cross-sectional survey among Dutch surgeons and residents

Technical Summary: Diversity-Inclusion Gap in Orthopedic Surgery

Problem Statement
Orthopedic surgery remains one of the least diverse medical specialties globally, with women and individuals from ethnic minority backgrounds consistently underrepresented. While efforts to increase diversity are ongoing, there is a critical lack of understanding regarding the underlying mechanisms driving this lag, particularly within postgraduate medical training. Existing literature often focuses on gender and ethnicity but lacks data on other diversity characteristics (e.g., sexual orientation, religion, disability) and fails to capture the perspectives of the younger generation of trainees. Furthermore, negative perceptions of work culture, including masculine stereotypes, lack of role models, and discrimination, may deter candidates. This study addresses the "leaky pipeline" phenomenon by investigating whether increased diversity among trainees coincides with a more inclusive work culture or if a "diversity-inclusion gap" exists.

Methodology
The study employed a nationwide cross-sectional survey design targeting Dutch orthopedic surgeons, residents, and residents not-in-training (junior doctors not yet enrolled in residency programs).

• Participants: A total of 509 participants met inclusion criteria: 322 surgeons, 121 residents, and 66 residents not-in-training. Data was collected in September and October 2024 via the Dutch Orthopedic Society (NOV).
• Instrument: A 42-item questionnaire was co-developed with the NOV Culture and Diversity Committee. It assessed:
  • Diversity Characteristics: Gender, ethnicity, cultural identity, religion, sexual orientation, and disability.
  • Work Culture Perceptions: Four scales measuring the atmosphere of the learning climate (adapted from SPEED), work-home balance, equity and inclusion at the workplace, and discrimination.
  • Satisfaction: A six-item scale measuring satisfaction with diversity and inclusion at departmental and national levels.
• Analysis: Statistical analyses included Chi-square tests for diversity prevalence, ANOVA for comparing work culture perceptions across groups, and independent-samples t-tests for comparing participants with and without diversity characteristics. Effect sizes (Cramer's V, Eta-squared, Cohen's d) were calculated.

Key Results

• Diversity Prevalence: Diversity was significantly higher among residents and residents not-in-training compared to established surgeons. Specifically, the prevalence of female gender, non-European ethnicity, and non-heterosexual orientation was lower among surgeons. Overall diversity (having at least one characteristic) was 26.6% for surgeons, 47.1% for residents, and 57.6% for residents not-in-training.
• Work Culture Perceptions: Despite higher diversity, residents and residents not-in-training reported significantly less positive perceptions of work culture compared to surgeons. Surgeons reported higher scores for the atmosphere of the learning climate, equity and inclusion at the workplace, and lower levels of perceived discrimination.
• Diversity-Inclusion Gap: Participants with at least one diversity characteristic reported significantly less positive perceptions of the learning climate, work-home balance, and equity/inclusion, and reported higher levels of perceived discrimination compared to those without such characteristics.
• Satisfaction: Surgeons expressed higher satisfaction with diversity and inclusion efforts than residents and residents not-in-training. Similarly, participants with diversity characteristics reported lower satisfaction than those without.
• Gender Specifics: When gender was excluded from the definition of diversity, differences in work-home balance perceptions between groups disappeared, suggesting that work-home balance challenges are primarily driven by gender dynamics. However, differences in learning climate, equity, and discrimination persisted.

Key Contributions

• Identification of the "Diversity-Inclusion Gap": The study provides empirical evidence that greater diversity within a group (residents) does not automatically correlate with more positive perceptions of inclusion or satisfaction.
• Broadened Scope of Diversity: Unlike previous studies focusing primarily on gender and ethnicity, this research incorporates sexual orientation, religion, cultural identity, and disability, offering a more comprehensive view of diversity in orthopedic surgery.
• Stratified Perspectives: By distinguishing between surgeons, residents, and residents not-in-training, the study highlights a generational and hierarchical disconnect, where senior surgeons perceive the environment more positively than their trainees.
• Focus on "Residents Not-in-Training": The inclusion of junior doctors not yet in residency programs offers insight into early career attrition risks and the "leaky pipeline" at the entry stage.

Significance and Claims
The authors claim that their findings highlight a critical need to shift focus from mere representation to fostering an inclusive work culture. The study concludes that the "diversity-inclusion gap" suggests that increasing the number of diverse individuals does not automatically resolve issues of belonging or equity.

The paper posits that:

1. Representation is insufficient: Simply increasing diversity numbers without addressing the underlying work culture may lead to dissatisfaction and attrition among diverse trainees.
2. Perception Discrepancy: Clinical teachers (surgeons) may not fully recognize the challenges faced by diverse trainees, as they report more positive perceptions of the environment.
3. Strategic Recommendations: The authors recommend involving residents and residents not-in-training in the development of diversity and inclusion strategies (co-creation) to ensure interventions are effective. They also suggest increasing transparency in selection processes to mitigate bias and self-selection, and enhancing faculty development to address implicit bias and improve mentorship.

The study acknowledges limitations, including potential selection bias due to response rates, the self-reported nature of disability data, and the use of a newly developed (though literature-informed) questionnaire. Nevertheless, it serves as a foundational step in understanding the complex relationship between diversity and inclusion in postgraduate orthopedic training.