today is really going to look at the numbers. So particularly for female and minority team orthopedic surgeons, what are the odds and why does it matter? So these are my disclosures, not relevant to this talk. But in terms of outlines, we're going to talk about the demographics and the leaky pipeline and where there are gaps in representation in sports medicine, and also why that representation matters. So briefly, let's start with the big numbers. So the US population right now is 50-50 male-female, 65% white, and 35% persons of color. But it's important to note, by 2050, it's actually going to shift, and it'll be about 54% persons of color in the US. In terms of our medical students, in terms of how difficult it is to get into medical school, there's a 36% acceptance rate, so about 22,000 medical students matriculate each year, of which, actually, for the last three years, the majority of medical students have been female. And by race, the numbers have actually improved in the last few years to be a little bit closer to the US population, but we're still lagging behind in terms of our underrepresented minority population representation. Now, when we get to orthopedics, and Dr. Poon has so astutely brought this up in her talk, this is where the wheels fall off a little bit, and the leaky pipeline becomes very prevalent. Overall, the acceptance rate has been 69%, of which 868 in the last 10 years were women, compared to 53, over 5,300 were men. And then when it comes to diversity, in particular, black, Hispanic, and other underrepresented minority applicants have lower odds of admissions in orthopedic residency compared with white applicants, and that's even after controlling for academic metrics, like Dr. Poon had mentioned, such as AOA status, STEP scores, volunteer experience, et cetera. And so when we look at the numbers in the long term, we really, even amongst minority orthopedic surgeons, we've not cracked this 10% barrier. And actually, those numbers have dropped in the last 10 years significantly, from 9.3 to, on average, about 5.9 in the 2017 year. And amongst female orthopedic surgeons, it's very clear where that pipeline continues to leak and leak. And you can see that from medical students, where over half of the medical students are coming through amongst orthopedic residents in 2019, it was 15%. Amongst AOA fellows, it was 7%. And you can see exactly how stagnant that line is, where we haven't even cracked the barrier of 20%, even though we make up over half of those in the medical field right now. So let's look at the active orthopedic surgeons. The majority remain male, 92%, 85% white. So that's 7% female, 15% persons of color. And then when we look a little bit more into the sports medicine numbers, sports medicine is one of the most prevalent fields in orthopedics, making it up about 18% of all orthopedic surgeons, even amongst female AOSSM representation, really make 6.5%. And then even when we're looking at sports leadership, so our division chiefs, 96% male, 4% female, 14% persons of color. And our sports fellowship directors, 99% male, and 1% female, and 9% persons of color. So let's compare this to our athlete population. So amongst NCAA athletes, so all comers, all three divisions, still a majority male, but a Title IX keeps us at least 44% in terms of women. The majority are white across all three divisions. But if you look a little bit closer at our Division I athletes, in particular our fields that are feed-ins to professional sports, you'll see that the majority are persons of color, particularly in football, basketball, and women's basketball. Now when we look at our professional athletes, then there is an even greater predominance of persons of color, NBA leading the way with 75%, followed by NFL at 73%. And even women's NBA is at 83%. So compare that to the numbers that I showed earlier. So 7% female orthopedic surgeons, 15% persons of color. And just looking at our NCAA populations, 44% female, 30% students of color. So the gap continues to widen in terms of representation amongst our patient population. And then if we look a little bit closer at our D1 and pro team physicians, when we look at it from a gender standpoint, female orthopedic surgeons as team physicians, the most predominant is in the WNBA. But even with 83% persons of color and 100% women, only 45% representation of women. And then a precipitous drop off in terms of NBA and NFL. And in our Power Five conferences, I found the stat fascinating. Team orthopedic surgeons are almost 1,500 times more likely to identify as male. And there are overall only 18 team physicians overall who are identified as female orthopedic surgeons. Head team physicians, if we're digging even a little bit deeper into the leadership within sports, 1,100 NCAA institutions, over 1,100 head team physicians, only 11% are female, 129. And again, this includes orthopedic surgeons and primary care. Now, if we're looking at orthopedic team physicians, then it drops off even more. So amongst head team physicians in the NCAA Division I, there are four female head team physicians in orthopedics. From a gender standpoint, even looking at the professional level, again, looking at the AOSSM representation of 6.5%, which is still quite low, even lower when it comes to our professional team physicians, 4% overall, three of which are in the WNBA, 13 overall amongst all the team sports, of which there are 336 teams that this is included in this analysis. And in terms of pro head team physicians, so looking at both race and gender, 96% male, 85% white, secondary just to black physicians at 5.8%. And in terms of by the teams, NBA has the highest representation. Again, these are teams that are over 75% persons of color and at the highest representation, we still only are at 23%, while the NFL is at the lowest representation and that's at just under 12%. And I'd be remiss if I didn't mention that much of this is echoed in the leadership within pro sports as well, where there's significant racial disparities both in the head coaches of color as well as general management within these divisions. So why does this matter? It matters because representation is necessary to stem our failures as physicians in the patient athlete agency. So in terms of our failures in patient agency for race, what we do know is that black patients are significantly less likely than white patients to receive pain medicine for extremity fractures, despite similar pain scores. And this landmark study by Hoffman in 2016 noted when they surveyed first year medical students and residents found that 40% of first year medical students believes that black people have thicker skin, 25% of residents believe that as well. And actually even 7% of them have surveyed, thought that black people have less sensitive nerve endings. And even at the professional, on the sports level, so D1 college athletic medical staff assume black athletes feel less pain than white athletes. And that assumption is mitigated by a perception of socioeconomic status, meaning that if the medical staff assumes that their black athlete had a lower socioeconomic status, they also assumed that they had less pain. And really, one of the failings in particular is NFL, just only a few years ago, halted what's called race norming, which was used to calculate payouts for CTE injury in players, and assumed that black players had lower, basically cognitive function, so they should have lower payout from any deficits related to CTE. In terms of gender, these issues continue to be pervasive. So if you've ever heard of the term medical gaslighting, I would look it up. It's basically, the concept is that females and persons of color consistently are having their symptoms dismissed by medical providers, particularly for women, due to perception of so-called hysteria, so that it's all in their head. And the UN has actually found that almost 90% of both men and women globally are biased against women. And we see that in our care of our patients as well. So women are less likely, just like in the persons of color to receive analgesia, are less likely to receive opiates, despite similar pain scores for acute abdominal pain. In the orthopedic world, male patients are referred to orthopedic surgeons 35% more often than female patients. And I would be remiss if I didn't mention how much public scandals regarding sexual abuse of our female athletes has eroded the trust of sports medicine providers in our community. And certainly challenges and biases faced by our black female athletes remains unquantified by prevalent, both in their medical care and in their perception and treatment. So ultimately, what we know is that a lack of physician agency contributes to mistrust among our athletes. And in particular, that's why representation is important. So in summary, female and minority orthopedic surgeons remain historically underrepresented. That underrepresentation is magnified at the NCAA and pro team level where women and minority athletes are highly prevalent. And at the same time, minority representation and female representation amongst our staff may help rebuild and maintain that relationship of trust between team physicians and athletes. Thank you.

demographics

representation gaps

orthopedic surgery

female surgeons

minority surgeons