Sage Journals: Discover world-class research

Abstract

Background:

Despite the increased percentage of women in medical school and in orthopaedic residency programs, the percentage of women pursuing careers in sports medicine has only increased 3% over the past decade.

Purpose:

To investigate the experiences and perceptions of female orthopaedic surgeons about sports medicine, identifying factors influencing career interest in this surgical subspecialty.

Study Design:

Cross-sectional study.

Methods:

A mixed-methods approach, combining an online survey and qualitative interviews, was utilized to compare the clinical experiences and personal perceptions of women in orthopaedic sports medicine with women in other orthopaedic subspecialties. Surveys were distributed to members of the Ruth Jackson Orthopaedic Society and the Women in Orthopaedics online forum. Descriptive statistics from the survey were compiled, with chi-square and 2-sample t test used to compare categorical and continuous variables. Purposive sampling was used to select interview participants from survey respondents to ensure diverse perspectives were collected. Interviews were conducted via video conferencing using a semistructured interview guide, and qualitative data were analyzed using grounded theory methods to develop a model of women’s interest in sports medicine careers.

Results:

Of the 162 online survey respondents, there were no significant differences between sports- and non–sports trained respondents regarding years in practice (P = .32) and personal athletic participation (P = .39). Among the 158 respondents who completed the entire survey, 76% (n = 120) perceived sex discrimination from various sources during their clinical training, with no significant difference in perceived sex discrimination between sports- and non–sports trained respondents (P = .07). Interviews with 22 women revealed that perceived athletic identity, timing of clinical exposure, and features within the scope of practice and cultural considerations all influenced career decision making.

Conclusion:

This study provides an analysis of women’s exposure to sports medicine, revealing perceived sex discrimination from multiple sources during their clinical training. Such discrimination, however, does not directly affect their decision to pursue a career in sports medicine and is comparable with women across orthopaedics in general. Factors influencing women’s career decision making in sports medicine include the scope of practice and cultural considerations. These data may serve as the foundation to increase women’s representation within sports medicine. Future research comparing the perception of bias and discrimination rates among men within sports medicine and comparison studies with other orthopaedic specialties are necessary to provide additional context to the current trends within women throughout orthopaedics.

Keywords

education female athlete sex equity women career development

Despite the rapid increase in the proportion of female athletes participating in collegiate and high school athletics since the passage of Title IX in 1972, the change in sex composition of orthopaedic surgeons providing medical care to athletes has been negligible.^22,23 Current statistics from the Association of American Medical Colleges report that despite increased athletic participation, admission into and completion of medical school, and matriculation into orthopaedic surgery residency programs, the proportion of female sports medicine physicians remains less than 10%.³ Women’s representation is even less prevalent among team physicians at the collegiate and professional levels.^24,28,37

Meanwhile, previous investigations have demonstrated that female orthopaedic patients, regardless of athletic participation, prefer to have surgeons who are women.^4,11 Similarly, recent studies across multiple surgical specialties suggest that surgical outcomes in terms of readmission, death, and complications are less likely for female patients treated by a female surgeon.^35,36 The reasons for these findings are multifactorial and may include more meticulous patient selection in elective surgeries, and enhanced physician-patient interactions and relationships due to perceptions of shared identity, although the exact cause for these findings continues to be investigated.

Although there remains a noticeable disparity in female representation in athletics and female orthopaedic sports medicine surgeons,^3,22,23 reasons for this discrepancy have yet to be identified. Unlike other subspecialties, initiatives to increase diversity throughout orthopaedics have not produced a trickle-down effect in sports medicine.^21,27,34 Orthopaedic trauma and hand surgery have shown substantial growth in the representation of female fellows over the past 15 years, with increases of 18.5% and 10%, respectively.^29,30 In contrast, data from the Accreditation Council for Graduate Medical Education reveal only marginal gains in sports medicine, where the proportion of female sports medicine fellows rose from 6.4% in 2007 to a peak of 12.7% in 2018.^1,2 Similarly, the overall percentage of female sports medicine surgeons within the AOSSM has minimally increased from 5.3% in 2014 to 8.7% in 2024.⁷

Currently, the factors influencing a female orthopaedic surgery resident’s decision to pursue or not pursue a career in sports medicine remain unknown. The purpose of our study was to investigate the experiences and perceptions of female orthopaedic surgeons about sports medicine, identifying factors influencing career interest in this surgical subspecialty. We hypothesized that women who did not pursue a fellowship in sports medicine would report more experiences of perceived discrimination. Moreover, we hypothesized that women’s perceptions of belonging and fit would contribute significantly when deciding to pursue a career in sports medicine.

Methods

A mixed-methods design was used to better understand women’s personal perceptions of their experiences within sports medicine. Mixed-methods study designs blend qualitative and quantitative methods with the goal of strengthening our understanding of data through interpreting data through multiple analytic approaches.³¹ Specifically, we used a qualitative follow-up model design in which a principally quantitative study was followed by a smaller qualitative study with the goal of helping to evaluate and interpret results of the quantitative study.¹⁰ The quantitative component was composed of an online survey, while the qualitative component was organized on semistructured interviews. Ethical approval was obtained by the institutional review board at the senior author’s (M.V.S.) institution.

Throughout the study, the topic of discrimination was addressed. The study focused on participants’ self-reported perceptions of discrimination, regardless of external validation or further investigation of individual experiences.

Survey Methods and Analysis

Members of the research team developed a 30-item nonvalidated survey adapted from similar studies to assess female orthopaedic surgeons’ experiences in and perceptions of sports medicine (Supplement 1, available separately).^18,19 Demographic data including subspecialty training, years in practice, ethnicity, practice setting, and previous personal experience as an athlete were collected. Additional questions determined participants’ perceptions of bias and belonging within sports medicine and whether they experienced perceived discrimination during clinical training in sports medicine.

The survey was electronically distributed to 422 members of Ruth Jackson Orthopaedic Society (RJOS) and Women in Orthopaedics (WIO), a private online group of 1874 female orthopaedic surgeons and trainees. The survey was accessible from May 2022 to July 2022. Participants were eligible to participate if they identified as female and had completed an orthopaedic surgery residency program. Current orthopaedic residents were excluded. Access to the survey was made available via email attachment for RJOS members and an online link for WIO members. Respondents were asked to complete the survey once to avoid duplicate responses. Participation in the anonymous survey was voluntary.

Survey responses were collected and managed using REDCap electronic data capture tools hosted at Washington University in St. Louis.^15,16 Descriptive statistics were calculated and reported for all continuous variables. Percentiles and sample sizes were reported for all categorical variables. Pearson chi-square test was used to compare categorical variables, and Student t test was used to compare continuous variables. Statistical analysis was performed using IBM SPSS (Version 29.0). Statistical significance was set at P < .05.

Interview Methods and Analysis

Sampling for qualitative interviews was conducted using purposive sampling techniques, specifically maximal variation and snowball techniques, in which the authors purposively selected participants with the goal of obtaining a sample of women with various academic ranks, subspecialties, demographic characteristics, and impressions of sports medicine.^25,26 A purposive, as opposed to a random (probabilistic), sampling strategy was chosen because purposive sampling tends to yield richer data while maximizing efficiency and resource utilization.^9,25,26 Interviews were conducted until thematic saturation was achieved. Thematic saturation is defined by Urquhart³³ as “the point in coding when you find that no new codes occur in the data. There are mounting instances of the same codes, but no new ones.” Thematic saturation was achieved after 22 interviews.

Interviews were conducted in a semistructured format following an interview guide that was informed by the survey responses and iteratively refined over several interviews (Supplement 2, available separately). Semistructured interviewing involves using predetermined questions in a flexible and conversational formation to encourage participants to provide in-depth responses and personal perspective while allowing the interviewer to expand upon interesting areas as the conversation evolves.⁹ All interviews were conducted by 2 authors (N.M.E. and K.M.G.), both women and both senior residents in orthopaedic surgery. All interviews were conducted on Zoom from September 2022 to July 2023. Participants provided verbal consent to participate. Consent for the conversation to be audio recorded was obtained at the start of each interview. Each audio recording was then transcribed and reviewed for accuracy. Any potentially identifiable information (eg, institution names or names of colleagues) was removed. The deidentified transcript was then uploaded into Dedoose (Version 9.0) for analysis.

Data were analyzed using grounded theory methodology to create a theoretical framework of factors important to women considering a career in orthopaedic sports medicine. Grounded theory is an inductive approach for data analysis that seeks to generate theory directly from the data rather than attempting to fit data into a preexisting model; analysis took place over 3 steps: (1) coding raw data, (2) categorizing and combining data into themes, and (3) forming a conceptual model based on the themes.^8,13,26 The 2 authors independently read and coded all transcripts, and any coding discrepancies were resolved through consensus. The authors (N.M.E. and K.M.G.) met after coding every 5 transcripts to iteratively refine the codebook and discuss the emerging theory. Each coder wrote frequent memos during the coding process to continually refine the theory and raise insights about the data.⁸

The quotes provided throughout the article were selected to provide representative examples of theoretical concepts in our study. Interview quotes are coded as sports (S) versus nonsports (NS) and years in practice (0-5, 5-15, or 15+), and these codes are denoted after each quote throughout.

Results

Survey Results

A total of 162 women completed the online survey. Of the 162 women, 158 completed all questions. Additionally, 22 women (11 sports medicine fellowship-trained orthopaedic surgeons and 11 non–sports trained orthopaedic surgeons) were interviewed. Demographic characteristics of survey respondents are presented in Table 1, and demographic characteristics of interview participants are presented in Appendix Table A1.

Table 1

Demographic Characteristics (N = 162)

Demographics	n (%)
Subspecialty training
Sports medicine	57 (35.2)
Pediatrics	36 (22.2)
Hand	23 (14.2)
Trauma	14 (8.6)
Foot and ankle	13 (8.0)
Reconstruction/total joints	13 (8.0)
None	7 (4.3)
Shoulder and elbow	6 (3.7)
Oncology	5 (3.1)
Spine	4 (2.5)
Other (pediatric hand surgery)	1 (0.6)
Race
White/Caucasian	130 (80.2)
Asian/Asian American	16 (9.9)
Black/African American	11 (6.8)
Hispanic/Latino	9 (5.6)
Other	3 (1.9)
Practice level
Current fellow	11 (6.8)
<1 y	3 (1.9)
1-5 y	40 (24.7)
6-10 y	33 (20.4)
11-15 y	28 (17.3)
16-20 y	14 (8.6)
>20 y	32 (19.8)
Participation as an athlete
Collegiate	80 (49.4)
High school	56 (34.6)
None	25 (15.4)
Most common played sport
Basketball	80 (49.4)
Soccer	25 (15.4)
Track and field	22 (13.6)
Swimming and diving	20 (12.3)
Volleyball	18 (11.1)
Tennis	13 (8.0)
Cross-country	12 (7.4)
Softball	11 (6.8)
Golf	1 (0.6)
Other	1 (0.6)

A total of 35.2% (57/162) of participants had completed a fellowship in orthopaedic sports medicine; 40 of the 162 participants (24.7%) had been in practice for 1 to 5 years. Additionally, 84% (136/162) of all respondents participated in high school or collegiate athletics, with 49.4% (80/162) participating in collegiate athletics. The most frequently reported sport played was basketball (49.4%; n = 80), followed by soccer (15.4%; n = 25) and track and field (13.6%; n = 22) (Table 1).

No significant differences between women who completed a sports medicine fellowship and those in other orthopaedic subspecialties were appreciated based on years in practice (odds ratio [OR], 0.72; 95% CI, 0.37-1.38; P = .32), duration of sports medicine clinical experience in residency (OR, 0.7; 95% CI, 0.35-1.3; P = .24), or personal participation as an athlete (OR, 1.5; 95% CI, 0.59-3.87; P = .39) (Table 2).

Table 2

Sports Fellowship Trained Versus Non–Sports Fellowship Trained Survey Respondents ^a

	Sports Medicine Fellowship(n = 57)	Non–Sports Medicine Fellowship(n = 105)	Odds Ratio (95% CI)	P
Years in practice			0.72 (0.37-1.38)	.32
<10 years	34 (60)	53 (50)
≥10 years	23 (40)	50 (48)
Participation as an athlete			1.51 (0.59-3.87)	.39
Yes	50 (88)	85 (81)
No	7 (12)	18 (17)

Data are presented as n (%) unless otherwise indicated.

Overall, 70% of survey respondents reported a personal perception of sex bias within sports medicine.

A total of 160 respondents completed questions about experiences of perceived discrimination. Perceived discrimination based on sex occurring more than once yearly during their sports medicine clinical experiences was reported in 76% (120/158) of respondents (Table 3). Of those facing perceived sex discrimination, 75% reported attending physicians as a source (90/120), 71% reported patients (85/120), 56% reported support staff (67/120), and 40% reported residents or fellows (48/120). No significant difference was appreciated between sports-trained versus non–sports trained women in experiencing perceived sex discrimination (OR, 2.1; 95% CI, 0.92-4.9; P = .07).

Table 3

Perceived Discrimination Based on Type

Perceived Discrimination Type		n (%)		Odds Ratio (95% CI); P
Any discrimination (n = 162)	Respondents	124 (77)
Any discrimination (n = 162)		Sports Medicine Fellowship	Non–Sports Medicine Fellowship
Sex discrimination (n = 158)	Respondents	57	101	2.1 (0.92-4.9); .07
Sex discrimination (n = 158)	Never	9 (16)	29 (29)	2.1 (0.92-4.9); .07
	A few times a year	26 (46)	46 (46)
	A few times a month or more	22 (39)	26 (26)
Discrimination based on pregnancy or child care (n = 153)	Respondents	54	99	4.0 (1.97-8.07); <.001
Discrimination based on pregnancy or child care (n = 153)	Never	23 (43)	73 (74)	4.0 (1.97-8.07); <.001
	A few times a year	24 (44)	15 (15)
	A few times a month or more	7 (13)	11 (11)
Physical abuse (n = 158)	Respondents	57	101	0.58 (0.59-5.74); .64
	Never	56 (98)	98 (97)	0.58 (0.59-5.74); .64
	A few times a year	0 (0)	2 (2)
	A few times a month or more	1 (2)	1 (1)
Verbal or emotional abuse (n = 159)	Respondents	57	102	2.16 (1.10-4.23); .001
Verbal or emotional abuse (n = 159)	Never	30 (53)	72 (71)	2.16 (1.10-4.23); .001
	A few times a year	22 (39)	18 (18)
	A few times a month or more	5 (9)	12 (12)
Sexual harassment (n = 159)	Respondents	57	102	1.36 (0.68-2.72); .38
Sexual harassment (n = 159)	Never	37 (65)	73 (72)	1.36 (0.68-2.72); .38
	A few times a year	18 (32)	21 (21)
	A few times a month or more	2 (4)	8 (8)

Overall, 37% (57/153) of respondents reported perceived discrimination based on family planning, while 36% (57/159) faced verbal or emotional abuse. Sports fellowship–trained participants reported significantly more discrimination due to pregnancy and child care expectations and more verbal/emotional abuse compared with their non–sports trained counterparts (P < .001 vs P = .001) (Table 3). Of those reporting perceived discrimination based on family planning, 81% (46/57) reported attending physicians as the source. In cases of verbal or emotional abuse, 77% (44/57) cited attending physicians as the source, 35% (20/57) cited patients, 30% (17/57) cited support staff, and 28% (16/57) cited residents or fellows. Sexual harassment occurring more than once yearly during sports medicine clinical experiences was reported in 31% (49/159) of respondents. Of those reporting sexual harassment, 55% (27/49) cited an attending physician as the source, 39% (19/49) cited patients or support staff, and 12% (6/49) cited residents or fellows. No significant difference between sports-trained versus non–sports trained women regarding sexual harassment was appreciated (OR, 1.36; 95% CI, 0.68-2.72; P = .38).

Qualitative Results

Overall Model Framework

Our qualitative analysis culminated in creation of a conceptual model of women’s interest in sports medicine careers. The overall model framework is outlined in Figure 1 and described in detail in the subsequent paragraphs. In the model, women’s self-identity is important in making career decisions. For women deciding whether to choose a career in orthopaedic sports medicine, their self-identity was typically framed around their personal experience as an athlete or lack thereof. During these sports medicine experiences, factors that contributed to women’s overall perception of the field included (1) their interest in the clinical scope of practice within sports medicine and (2) the culture within sports medicine. Women acknowledged both positive and negative aspects within the sports medicine scope of practice and culture, which drove their overall clinical interest and sense of belonging in sports, respectively. Taken together, women’s clinical interest and sense of belonging ultimately affected their desire to pursue a career in sports medicine.

Figure 1.

Framework for factors influencing the decision to pursue a career in orthopaedic sports medicine.

Self-Identity

Individuals tended to frame their self-identity in the context of their identity as an athlete or lack thereof. Some participants remarked upon their personal involvement as an athlete, previous experiences as an athletic trainer, or enjoyment of sports and athletics when describing their interest in pursuing a career in orthopaedic sports medicine. Non–sports medicine fellowship trained respondents referred to an overall lack of interest in sports or an early interest in sports with a later deterring factor. For example, 1 non–sports medicine fellowship trained survey respondent stated, “I went into medicine and into ortho specifically to become an orthopaedic sports surgeon, after tearing both ACLs in my teenage years” (NS, 5-15).

Exposure

Participants identified various periods of exposure to sports medicine. Many referenced early experiences in athletic training and clinical rotations during medical school or residency that affected their decision. A sports medicine fellowship–trained respondent described the effect of a shadowing experience during high school: “I've always been interested in sports medicine since that was the original shadowing experience back when I was 13 or 14” (S, 0-5).

Scope of Practice

The scope of practice within sports medicine encompassed multiple domains, particularly the surgeries unique to sports medicine, team coverage, the patient population, and lifestyle (Table 4). Depending on an individual's perspective, these factors were seen as either attractive or deterring. Overall, women who pursued a sports medicine fellowship saw the scope of practice as an attractive component of sports medicine, whereas those who chose other subspecialties did not.

Table 4

Scope of Practice Factors ^a

Factor	Positive	Negative
Surgery	“What do you want your main surgery to be? And I was like, I like knee scopes, 20-minute meniscectomies sound great.” (S, 0-5)	“I don't like the surgeries they do, being under water, or tying knots in cold water.” (Survey short-answer response)
Surgery	“I was very interested in learning arthroscopic skills for my practice since I saw such potential in these surgical techniques” (Survey short-answer response)	“The big thing about sports for me is that I never liked scoping. I felt like it was one of those things where I was never good at it. And then I never had opportunities really to get better at it. And so, I still hate it.” (NS, 0-5)
Team coverage	“As a kid, that was my dream. I want to be a professional sports team, team doctor … Like, for me, I grew up around Boston, so I want to be the Red Sox team doc. That was the dream, the goal.” (S, 5-15)	“I did not want to go to high school or college games during my free time.” (Survey short-answer response)
Team coverage	“… with the different team [coverage], I felt no disadvantage there because I was a female. So, I was welcomed into an NHL locker room because I was with my attending. So, they really opened those doors there.” (S, 0-5)
Patient population	“I was really interested in the concept of treating injured athletes or even injured recreational athletes, whatever level, and getting them back to activity.” (S, 15+)	“I don't care about sports and my answer for a lot of things is “well if it hurts don't do it,” and that's not the answer most of these patients want to hear.” (NS, 0-5)
Patient population	“I thought it was fun. I thought it was engaging people are healthy. They want to get better. A very neat kind of niche, right?” (NS, 15+)	“I found it hard to manage the expectations of young athletes.” – (Survey short-answer response)
Lifestyle	“I think lifestyle is a big [positive factor] in terms of the elective nature of a sports practice and what that means for how much time you're spending at work and how late you may be there…And that basically comes down to the work-life balance side of things…[I wanted a specialty] that would allow for a little bit more balance.” (S, 0-5)	“It's very time consuming to cover a team. The actual clinic time can be definitely made into a pretty standard work week, as close as orthopaedic surgeons get outside of hand surgery. But I do think team coverage is just very time consuming with very little monetary reward from it.” (S, 5-15)
Lifestyle	“One of the stereotypes associated with a sports practice would be it's a little bit more lifestyle friendly. Some people are potentially more likely to have families or enjoy their marathons and skiing and outside hobbies.” (NS, 0-5)	“With the sports side there is more of the coverage stuff. So you have to really think if you want to be on the sidelines on your weekends because it does add extra to it.” (S, 0-5)

Years in practice are noted in brackets after each quote: 0-5, 5-15, or 15+. NHL, National Hockey League; NS, nonsports; S, sports.

Culture

The culture of sports medicine was composed of multiple factors, including perceived stereotypes, mentorship, sex bias, and departmental environment (Table 5). Again, these factors were perceived as positive or negative based on individual experiences and perspectives. For those in other subspecialties, these factors held more negative connotations and deterred their overall interest in the field. Unlike findings within the scope of practice, female sports medicine surgeons stated that in some instances they endorsed negative features of the culture but were defiant of these features because of their overall interest.

Table 5

Cultural Factors ^a

Factor	Positive	Negative
Stereotypes	“We had male surgeons, we had female surgeons, we had … people who embraced all different types of sports, including some non-traditional sports at the time … So because of the wide definition of sports and the interaction with people like all over the world in sports medicine, I did never feel like there was a stereotype for sports medicine” (NS, 15+)	“When you think of a sports medicine surgeon … you're thinking these people that played football or played big sports” (NS, 15+)
Stereotypes		“I think probably the biggest [barrier] is stereotypes. We don't see women … on podiums, we don't see them publishing research. And so, it's that kind of fear of being the other” (NS, 0-5)
Mentorship	“[My attending] taught me [being the first woman] didn’t matter I had women every step of the way in my residency program - above me, below me. So it didn't cross my mind ever.” (S, 10-15)	“Mainly feeling that I did not have the support of my attendings so would not match / would not match well” (Survey short-answer response)
Sex bias	“A lot of the athletes, they don't care, what they just care is that they're getting taken care of.” (S, 0-5)	“I think there is that just societal expectations [male athletes] don't expect. They would assume I was the primary care sports fellow; they would not assume that I was the surgical fellow.” (S, 15+)
		“The male athletic trainer walks over and is like, she's doing all the right things… it took that male voice to make this father who had no medical training, trust me.” (S, 0-5)
		“I definitely had negative experiences with OR administrators, mostly females that it was definitely a clear power struggle with the staff in the OR… your perception from ancillary staff is totally different being a woman.” (S, 5-15)
Department environment	“I was never treated anything different. And that culture came from top down.” (S, 5-15)	“There was a spot open for the local team and I voiced interest, I was basically told [by division leadership] that I couldn't do it because I'm a woman… It was very evident that there was going to be a glass ceiling for me as a woman.” (S, 5-15)
Department environment	“There were some programs where they were really not excited about the concept [of training a woman] and then there were other programs where it just wasn’t an issue…I gravitated to that because I just didn't feel like I needed to be defined as a female surgeon. I felt that I was a surgeon and like everybody else and I should be more evaluated based on merit and activity and scholarship skills than compared to what I look like. (NS, 15+)

Years in practice are noted in brackets after each quote: 0-5, 5-15, or 15+. NS, nonsports; S, sports.

Suggestions to Improve Diversity and Inclusion in Orthopaedic Sports Medicine

Participants had numerous suggestions to improve the diversity of orthopaedic sports medicine at various points within our conceptual framework. Representative quotations of these suggestions are included in Appendix Table A2. Participants emphasized the importance of exposure to sports medicine, both in investing in early pipeline programs for aspiring physicians and in increasing opportunities for female trainees to participate in sports society meetings such as the AOSSM.

To improve factors within the scope of practice, participants suggested that programs help residents hone their arthroscopy skills so that a lack of comfort with arthroscopy did not deter interested residents. While challenges and comfort with arthroscopy are not exclusive to female residents, arthroscopy alone represented a major concern for many women considering sports medicine as a career. Participants also emphasized the importance of team coverage as a sports medicine physician and of an increase in the variety of sports and athletes discussed at meetings to include women’s sports. Suggestions for changing the culture of sports medicine coalesced around normalizing diversity within sports medicine divisions; investing in allyship and mentorship of female physicians; hiring inclusive leaders; and improving women’s professional visibility as professional team physicians, conference speakers, and society leaders.

Discussion

The results of this study demonstrate that women, regardless of their interest, face perceived discrimination during clinical experiences in sports medicine. Thematic analysis of qualitative data resulted in the development of a conceptual framework to describe how female orthopaedic residents are influenced in their decision making regarding a career in sports medicine.

Within our quantitative analysis, no significant differences were appreciated regarding the likelihood of women specializing in sports medicine based on their experience levels or involvement in athletics. A total of 76% of all respondents reported experiencing sex discrimination, with 37% reporting discrimination based on family planning, 36% reporting verbal or emotional abuse, and 31% reporting sexual harassment during their sports medicine clinical rotations. Our research model assessed participants’ self-reported experiences of discrimination, abuse, and harassment. No definition of “discrimination,” “abuse,” or “harassment” was provided in this study, as the goal was to identify exposure perceived during training. Self-reported perceptions of discrimination and mistreatment have been routinely used in assessment of resident mistreatment and workplace safety and were therefore used as the basis of our qualitative analysis.^6,18

When compared with respondents in other surgical specialties, 65% of female general surgery residents in a 2021 study reported experiencing sex discrimination throughout their training.¹⁷ Within orthopaedics as a whole, these results are comparable with the study performed by Gerull et al.¹² Specifically, 18% of female orthopaedic residents reported pregnancy or child care discrimination, 32% reported sexual harassment, 37% reported verbal or emotional abuse, and 84% reported sex discrimination during their residency. As such, there remains a high incidence of discrimination not exclusive to women in orthopaedic sports medicine but rather in all fields of orthopaedics and surgery that warrant further study to identify modifiable methods in culture, training, and behavior to minimize sex discrimination for future trainees.

Our qualitative findings provided the foundation for creation of a framework that offers areas for modifiable actions to increase the proportion of female orthopaedic residents specializing in sports medicine. Programs such as Nth Dimensions and Perry Initiative demonstrate that early exposure opportunities increase orthopaedic interest among women and students who are underrepresented in medicine.^5,20,21,34 Similarly, newer programs, such as the National Football League’s Diversity in Sports Medicine Pipeline Initiative, aim to increase diversity in sports medicine by offering clinical exposure to URiM students from Historically Black Colleges and Universities.¹⁴ Using these programs as a guide, sports medicine leaders can implement additional programs targeting women at the undergraduate and medical school levels for early exposure opportunities. Additionally, increasing and improving residents’ exposure to team coverage opportunities offers a chance to expand their insights to the realities of a career in sports medicine through interactions with athletic trainers, coaches, athletes, and families outside of clinics. This also helps residents gain an understanding of belonging in sports medicine and helps to counteract sex bias from nonphysician sources such as athletes, parents, coaches, and athletic training staff. Research by Tsukahara et al³² highlights that female sports medicine providers face higher rates of disrespect and are more frequently sexually harassed by athletes, coaches, and athletic trainers compared with their male colleagues during team coverage. Particularly during team coverage opportunities, these biases should be addressed in an effort to create a respectful and equitable learning environment for all trainees. As women’s exposure to sports medicine and interest in surgical procedures improves, surgeons within the field can continue to improve women’s experiences by normalizing the inclusion of women in clinical, leadership, and professional team coverage roles.

Limitations

Limitations to this study include those intrinsic to electronically distributed surveys. Many women are members of both RJOS and the WIO online forum, and the WIO forum includes current trainees, fellows, and attendings. The survey was sent electronically to 422 members of RJOS and all attendings or fellows and was shared via the WIO online forum. We were unable to determine which members within the WIO were eligible to participate based on level of training, and thus we were unable to calculate an overall response rate. During survey distribution, it was also emphasized to participants that only a single survey should be completed to avoid duplicate responses. Participation in the study could be a result of response bias, as women who have experienced a disproportionate amount of positive or negative experience may been more motivated to respond. Additionally, a small proportion of survey respondents did not complete all questions, leading to missing data for certain topics. The findings for each topic were therefore based solely on responses from surveys with data for that individual topic. Interviews were conducted by 2 female members of the research team, potentially introducing confirmation bias. To mitigate this, a reflexive review was employed during qualitative analysis to minimize researcher bias in data interpretation.²⁶ A final limitation of the current study was lack of comparison with the predominantly male experience within sports medicine or women’s experiences in other orthopaedic subspecialties. While this study identified factors in sports medicine that influence women, these factors may not be exclusive to women and therefore may be inherent to sports medicine experiences regardless of sex. Additionally, these factors may similarly influence decision making for other orthopaedic subspecialties; however, this was outside the scope of the current study. Future research to compare the experiences of women in sports with their male counterparts and women pursuing other orthopaedic subspecialties may be beneficial to assess if these factors are unique to women’s experiences in sports medicine.

Despite these limitations, this study is the first of its kind to report factors that may influence women selecting careers in sports medicine.

Conclusion

This study provides analysis of women’s exposure to sports medicine, revealing perceived sex discrimination from multiple sources during their clinical training. Such discrimination, however, does not directly affect their decision to pursue a career in sports medicine and is comparable with women across orthopaedics in general. Factors influencing women’s career decision making in sports medicine include the scope of practice and cultural considerations. These data may serve as foundations to increase women’s representation within sports medicine. Future research comparing the perceptions of bias and discrimination rates among men within sports medicine and comparison studies with other orthopaedic specialties are necessary to provide additional context to the current trends among women throughout orthopaedics.

Supplemental Material

sj-pdf-1-ojs-10.1177_23259671251352193 – Supplemental material for Factors That Influence Female Orthopaedic Surgeons’ Decision to Pursue a Career in Sports Medicine: A Mixed-Methods Study

Supplemental material, sj-pdf-1-ojs-10.1177_23259671251352193 for Factors That Influence Female Orthopaedic Surgeons’ Decision to Pursue a Career in Sports Medicine: A Mixed-Methods Study by Nichelle M. Enata, Katherine M. Gerull, Ahmed Hanafy, Mary K. Mulcahey, Derrick M. Knapik and Matthew V. Smith in Orthopaedic Journal of Sports Medicine

Supplemental Material

sj-pdf-2-ojs-10.1177_23259671251352193 – Supplemental material for Factors That Influence Female Orthopaedic Surgeons’ Decision to Pursue a Career in Sports Medicine: A Mixed-Methods Study

Supplemental material, sj-pdf-2-ojs-10.1177_23259671251352193 for Factors That Influence Female Orthopaedic Surgeons’ Decision to Pursue a Career in Sports Medicine: A Mixed-Methods Study by Nichelle M. Enata, Katherine M. Gerull, Ahmed Hanafy, Mary K. Mulcahey, Derrick M. Knapik and Matthew V. Smith in Orthopaedic Journal of Sports Medicine

Footnotes

Appendix

Appendix Table A2

Suggestions for Improving Diversity and Inclusion Within Orthopaedic Sports Medicine ^a

Domain	Quotes
Exposure
Investing in pipeline programs and early exposure	“I think a lot of what Nth Dimensions is doing, and a lot of the other programs that target exposure to young people, and then encourage and mentor people to go through the MCAT, to interview for residencies, to have mock interviews… is probably, one of the slowest ways to increase diversity in the field, but it’s also probably one of the best ways to do it.” – [NS, 15+]
Investing in pipeline programs and early exposure	“I think it has to start in high school for people to be interested [in medicine] and go into college with that expectation and then from college to go into medicine in general and then in medical school to recruit into orthopedics and then in orthopedics to recruit into sports.” – [S, 15+]
Increasing opportunities for female trainees to participate in sports society meetings	“I think just having societies that provide opportunities for women interested in sports…giving out awards for trainees or other sorts of funding support definitely helps for opportunities for external validation and recognition, as well as actual funds to participate in some of these things.” – [S, 5-15]
Scope of Practice
Making arthroscopy skills more accessible	“And for the people who do think they're interested [in sports], I think arthroscopy skills are kind of the defining point of whether you can do this or not. Finding opportunities, whether that's resident courses or simulation labs to get better at that so you don't have that barrier.” – [S, 0-5]
Decreasing barriers for women as team physicians	“I think over the years they realized, just like with the sports media, you can't exclude women in the locker room. If you're going to have interviews in the locker room, you have to allow both the men and the women journalists in there. And [it should be the] same thing for the medicine staff. I think they figured out…maybe we shouldn't be doing all of these things in the locker room. Maybe we should have a place for the media. Maybe we should have a training facility or access point outside of the locker room.” – [S, 15+]
Decreasing barriers for women as team physicians	“My attendings thought, “Oh, she's female and she's expressed interest in female sports. We're going to give her these things. Yes, I’m interested in female sports. But not at the loss of maybe other opportunities that other people then get that I don’t.” – [S, 0-5]
Expanding the scope of sports conference topics	“I always see football [discussed at] medical conferences, I don't see gymnastics…or female athletes [discussed at] conferences. So those would be things that would draw [new people.] Recognizing that there's more than just football.” – [S, 5-15]
Culture
Normalizing diversity	“I think where they have normalized it, where the expectation is we're going to have a diversity of backgrounds – diversity of genders, races, religions, just a diverse population or it's as diverse as we can get, and that still fits within what our culture is.” – [S, 15+]
Investing in mentorship and allyship	“It’s going be all about mentors. Whether they be women or men…I think that's really what it's going to take, leaders in the field, whether it be women or men that are welcoming to women.” – [NS, 15+]
Investing in mentorship and allyship	“I was welcomed into an NHL locker room because I was with Dr. ___. So he really opened those doors there.” – [S, 0-5]
Inclusive leadership	“I think if you create the culture of family, you create the culture of inclusivity, but by treating your faculty with respect that trickles down.” – [S, 5-15]
Visibility
Increasing diversity of professional team physicians	“I think what people envision as team doctors are what they see in the newspapers and on the field in NFL, NHL, MLB. And there's a few token females and a few token non-white people in those roles, but primarily it's older white men. So I think that has to change to get the trickle down.” – [S, 0-5]
Improving the diversity of conference speakers	“I think that most of the national organizations could do a better job of making sure that the people who are standing up giving the talks and being on panels are more diverse.” – [S, 5-15]
Improving the diversity of conference speakers	“Let's not just have a special session where we just have the female docs do it. Let's have a general session. And you know what? There is a qualified [woman] physician, you just may not know them.” – [S, 15+]
Diversifying society leadership	“When there's opportunity to join a AAOS committee or a committee under one of your subspecialties to just apply and see what happens because you might be able to get a spot on a committee. And then they get to know you and then you have some decision-making power. You have some influence in that space. So I kind of think it's incumbent upon us to try to find where we can be in some of these spaces so that we can influence people's thoughts.” – [NS, 15+]
Diversifying society leadership	“Part of why I am on that committee is because one of the women in my sports medicine group was like, hey, I'm on [this committee] and we're really trying to make a concerted effort to have more diversity of people on the committee itself. She was really encouraging people to apply so that there can be a diversity of opinions.” – [S, 15+]

Years in practice are noted in brackets after each quote: 0-5, 5-15, or 15+. AAOS, American Academy of Orthopaedic Surgeons; MCAT, Medical College Admission Test; MLB, Major League Baseball; NFL, National Football League; NHL, National Hockey League; NS, nonsports; S, sports.

Final revision submitted February 27, 2025; accepted March 17, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: N.M.E. has received support for education from Elite Orthopedics LLC. K.M.G. has received support for education from Elite Orthopedics LLC and research support from Orthopedic Research and Education Foundation. M.K.M. has received nonconsulting fees from Arthrex Inc and support for education from Alon Medical Technology and Arthrex Inc. D.M.K. has served as faculty/speaker for Synthes GmbH and has received travel and lodging from Synthes GmbH; support for education from Elite Orthopedics LLC, Arthrex Inc, Midwest Associates, and Smith & Nephew; a grant from Medical Device Business Services Inc and Arthrex Inc; and honoraria from Encore Medical LP. M.V.S. has received support for education from Elite Orthopedics LLC and Arthrex Inc, travel and lodging from Medical Device Business Services Inc, and nonconsulting fees from Arthrex Inc. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was obtained from the Washington University in St Louis Institutional Review Board (IRB #202203021).

ORCID iD

Nichelle M. Enata

Supplemental Material

Supplemental material for this article is available at

References

Accreditation Council for Graduate Medical Education. ACGME Data Resource Book, Academic Year 2007-2008. ACGME; 2008. Accessed June 11, 2024. https://www.acgme.org/globalassets/pfassets/publicationsbooks/2007_2008_ana_ana_current_acgme_databook.pdf

Accreditation Council for Graduate Medical Education. ACGME Data Resource Book, Academic Year 2018-2019. ACGME; 2019. Accessed June 11, 2024. https://www.acgme.org/globalassets/pfassets/publicationsbooks/2018-2019_acgme_databook_document.pdf

Association of American Medical Colleges. Active Physicians by Sex and Specialty, 2022. Accessed May 22, 2024. https://www.aamc.org/data-reports/workforce/data/active-physicians-sex-specialty-2021

Beck

West

Jackson

Willimon

Busch

Christino

MA.

Gender and socioeconomic factors affect adolescent patient and guardian preferences in sports medicine physician characteristics and medical decision making. J Am Acad Orthop Surg Glob Res Rev. 2021;5(5):e21.00069. doi:10.5435/JAAOSGlobal-D-21-00069

Buckley

Dearolf

Lattanza

The Perry initiative: building the pipeline for women in orthopaedics. J Am Acad Orthop Surg. 2022;30(8):358-363.

Burkard

Boticki

Madson

MB.

Workplace discrimination, prejudice, and diversity measurement: a review of instrumentation. J Career Assess. 2002;10(3):343-361.

Chu

DeCampos

Alberton

Ireland

ML.

Sports Medicine Update: Advancing Women in Orthopaedics Through Partnership. AOSSM. 2024. Accessed June 10, 2024. https://www.sportsmed.org/membership/sports-medicine-update/spring-2024/advancing-women-in-orthopaedics-through-partnership

Corbin

Strauss

Grounded theory research: procedures, canons, and evaluative criteria. Qual Sociol. 1990;13(1):3-21.

Cresswell

Plano Clark

VL.

Designing and Conducting Mixed Method Research. 2nd ed. SAGE Publications; 2011.

10.

Creswell

Zhang

The application of mixed methods designs to trauma research. J Trauma Stress. 2009;22(6):612-621.

11.

Dineen

Patterson

JMM

Eskildsen

, et al. Gender preferences of patients when selecting orthopaedic providers. Iowa Orthop J. 2019;39(1):203-210.

12.

Gerull

Klein

Miller

Cipriano

CA.

Do women and minority orthopaedic residents report experiencing worse well-being and more mistreatment than their peers?

Clin Orthop Rel Res. 2024;482(8):1325-1337.

13.

Glaser

Strauss

AL.

The Discovery of Grounded Theory: Strategies for Qualitative Research. Routledge; 2017.

14.

Grant

Weiss

Weir

. NFL launches initiative to increase diversity in sports medicine. Accessed January 15, 2024. NFL.com. https://www.nfl.com/playerhealthandsafety/resources/press-releases/nfl-launches-initiative-to-increase-diversity-in-sports-medicine

15.

Harris

Taylor

Minor

, et al; REDCap Consortium. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208.

16.

Harris

Taylor

Thielke

Payne

Gonzalez

Conde

JG.

Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.

17.

Y-Y

Ellis

Hewitt

, et al. Discrimination, abuse, harassment, and burnout in surgical residency training. N Engl J Med. 2019;381(18):1741-1752.

18.

Lall

Bilimoria

, et al. Prevalence of discrimination, abuse, and harassment in emergency medicine residency training in the US. JAMA Network Open. 2021;4(8):e2121706-e2121706.

19.

Lieberman

Gerull

Chen

, et al. Factors that influence orthopedic women residents’ selection of adult reconstruction. J Arthroplasty. 2023;38(9):1877-1884.

20.

Mason

Ross

Jr Bradford

Nth Dimensions evolution, impact, and recommendations for equity practices in orthopaedics. J Am Acad Orthop Surg. 2022;30(8):350-357.

21.

Mason

Ross

Ortega

Chambers

Parks

ML.

Can a strategic pipeline initiative increase the number of women and underrepresented minorities in orthopaedic surgery?

Clin Orthop Rel Res. 2016;474:1979-1985.

22.

National Collegiate Athletic Association. NCAA Sports Sponsorship and Participation Rates Report. Accessed June 11, 2024. https://ncaaorg.s3.amazonaws.com/research/sportpart/2023RES_SportsSponsorshipParticipationRatesReport.pdf

23.

National Federation of State High School Associations. 2018-19 High School Athletics Participation Survey 2018-2019. Accessed June 3, 2024. https://www.nfhs.org/media/7212351/2022-23_participation_survey.pdf

24.

O'Reilly

Day

Cates

Baron

Glass

Westermann

. Female team physician representation in professional and collegiate athletics. Am J Sports Med. 2020;48(3):739-743.

25.

Palinkas

Horwitz

Green

Wisdom

Duan

Hoagwood

Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and policy in mental health and mental health services research. 2015;42:533-544.

26.

Patton

MQ.

Qualitative Research & Evaluation Methods: Integrating Theory and Practice. SAGE Publications; 2014.

27.

Poon

Kiridly

Mutawakkil

, et al. Current trends in sex, race, and ethnic diversity in orthopaedic surgery residency. J Am Acad Orthop Surg. 2019;27(16):e725-e733.

28.

Schick

Chandler

Kasprow

, et al. Gender disparities among professional team sports medicine physicians. Clin J Sport Med. 2023;33(6):648-651.

29.

Shittu

Murdock

Destine

, et al. Trends in racial, ethnic, and gender diversity among hand surgery fellows from 2007 to 2021. J Hand Surg. 2025;50(1):98.e1-98.e8.

30.

Silvestre

Kermanshahi

Ahn

Harris

Dehghan

Factors associated with increased sex diversity in orthopaedic trauma association-accredited fellowship training. J Am Acad Orthop Surg. Published online December 10, 2024.

31.

Tolley

Ulin

Mack

Robinson

Succop

. Designing the Study. In: Qualitative Methods in Public Health: a field guide for applied research. 2nd ed. New York: John Wiley & Sons, 2016, 45-84.

32.

Tsukahara

Novak

Takei

, et al. Gender bias in sports medicine: an international assessment of sports medicine physicians’ perceptions of their interactions with athletes, coaches, athletic trainers and other physicians. Br J Sports Med. 2022;56(17):961-969.

33.

Urquhart

. Grounded Theory for Qualitative Research: A Practical Guide. 2nd ed. London: SAGE Publications, Ltd., 2022.

34.

van Niekerk

O'Mara

Kha

, et al. Strengthening the pipeline: promoting diversity into orthopedic surgery. Clin Sports Med. 2024;43(2):253-270.

35.

Wallis

Jerath

Aminoltejari

, et al. Surgeon sex and long-term postoperative outcomes among patients undergoing common surgeries. JAMA Surg. 2023;158(11):1185-1194.

36.

Wallis

CJD

Jerath

Coburn

, et al. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surg. 2022;157(2):146-156.

37.

Whitaker

Sachdeva

Nyland

Hartley

Gender diversity in sports medicine: current trends. Arthrosc Sports Med Rehabil. 2023;5(4):100735.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.05 MB

0.07 MB