02 Mar 2020

Volume 8 Issue 1

From the Executive Editor

Now go back and look at the front cover. Who is scrubbing up? Man or woman? If a man, did you presume them to be a surgeon or a nurse? If a woman, a surgeon or a nurse?

Now look at ourselves; the T&O establishment does not exhibit great diversity. Currently the BOA has no women elected trustees (we believe there have only ever been three), the FRCS (T&O) has few women examiners, at the Congress in 2019 the number of ‘Manels’ (men only panels) was noted and criticised. Whilst there is change in our world of T&O practice, this is gradual. Much of this issue is themed to tie in with International Women’s Day, and to celebrate and champion female surgeons across the globe. We debated how to encourage readers to actually read the section on diversity, and in particular what to put on the front cover. A collage of women surgeons, whilst straightforward, would I feared (as a grey haired white male) appeal primarily to the converted. Whereas ‘the anonymous person scrubbing’ was placed front and centre to entice all of us to briefly consider our own assumptions and then perhaps, be persuaded to read the many relevant articles in this issue. We cannot control everything, but all of us can and should aim to play our part in creating an environment where medical students, juniors and consultants have no barriers, either real or perceived to a full career in T&O Surgery, apart from the need to demonstrate sufficient ability, aptitude and enthusiasm.

However diverse the T&O workforce may be it will have to comes to terms with and negotiate a changing landscape. The changes for the requirements of a trainee are introduced in ‘Implementation of the new T&O curriculum’ (page 24). The article on the National Orthopaedic Alliance (page 29) gives background to an organisation of which we may have heard and indeed which affects us but of which most of us have little or no understanding. We are not just affected by our own parochial organisational changes but those to the law in general, John de Bono asks ‘What is consent?’, and so should we. Whilst
this article relates primarily to elective practice the awkward issue of consent in non-elective work will be dealt with in a future issue.

The issue includes a letter to the editor on page 23, in this case relating to supracondylar fractures. We do not get many letters, I am hoping this is because they have not been encouraged rather than a lack of interest. However, with an online facility for the JTO we are in a position to publish a precis in the printed version and the full letter online; correspondence is now welcome.

This issue of JTO and a significant component of the agenda outlined by Don McBride in his ‘From the President’ relates to diversity. How this is manifest in opportunities for women is often used as a barometer for diversity in general as this is readily measured. However, career progress based on ability, aptitude and enthusiasm should apply to all.

Bob Handley, Vice President Elect


Subspecialty Section


Should women do orthopaedics? A topic explored at the Future Women of Orthopaedics event at St George’s University of London

1.         Miller EK, LaPorte DM. Barriers to Women Entering the Field of Orthopedic Surgery. Orthopedics. 2015;38(9):530-3.

2.         Rohde RS, Wolf JM, Adams JE. Where Are the Women in Orthopaedic Surgery? Clin Orthop Relat Res. 2016;474(9):1950-6.

3.         Bellini MI, Graham Y, Hayes C, Zakeri R, Parks R, Papalois V. A woman's place is in theatre: women's perceptions and experiences of working in surgery from the Association of Surgeons of Great Britain and Ireland women in surgery working group. BMJ Open. 2019;9(1):e024349.

4.         O'Connor MI. Medical School Experiences Shape Women Students' Interest in Orthopaedic Surgery. Clin Orthop Relat Res. 2016;474(9):1967-72.

5.         Harrington MA, Rankin EA, Ladd AL, Mason BS. The Orthopaedic Workforce Is Not as Diverse as the Population It Serves: Where Are the Minorities and the Women?: AOA Critical Issues Symposium. J Bone Joint Surg Am. 2019;101(8):e31.

6.         Moberly T. Number of women entering medical school rises after decade of decline. BMJ. 2018;360:k254.

7.         NHS Digital (2019). HCHS doctors by specialty group, specialty, grade and gender, Sept 2009 to March 2019 AH2736. Available from: https://digital.nhs.uk/data-and-information/find-data-and-publications/supplementary-information/2019-supplementary-information-files/hchs-doctors-by-specialty-grade-and-gender-sept-2009-to-march-2019-ah2736. Accessed February 2020.

8.         Neumayer L, Freischlag J, Levinson W. Demographics of today's woman surgeon. Bull Am Coll Surg. 1994;79(2):28-33.

9.         Hill JF, Yule A, Zurakowski D, Day CS. Residents' perceptions of sex diversity in orthopaedic surgery. J Bone Joint Surg Am. 2013;95(19):e1441-6.

10.        Meredyth N. Cute Little Hands. Ann Surg. 2019;270(6).

11.        National Confidential Enquiry into Outcome and Death (1997). Who operates when? A Report by the National Confidential Enquiry into Perioperative Deaths 1 April 1995 to 31 March 1996. Available from: https://www.ncepod.org.uk/1995_6.html. Accessed February 2020.

12.        Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82(11):1040-8.

Improving the undergraduate Trauma and Orthopaedic experience. Adoption of a modern teaching approach

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  2. Royal College of Surgeons (2016). Avoiding unconscious bias: A guide for surgeons. Available at: https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/avoiding-unconscious-bias. Accessed February 2020.
  3. Harden RM. What is a spiral curriculum? Medical Teacher. 1999;21(2):141-3.
  4. British Orthopaedic Association (2014). BOA Trauma and Orthopaedic Undergraduate Syllabus. Available at: https://www.boa.ac.uk/learning-and-events/medical-students/boa-trauma-and-orthopaedic-undergraduate-syllabus.html. Accessed February 2020.
  5. Prober CG, Heath C. Lecture halls without lectures—a proposal for medical education. N Engl J Med. 2012;366(18):1657-9. 
  6. McLaughlin JE, Roth MT, Glatt DM, Gharkholonarehe N, Davidson CA, Griffin LM. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. 2014;89(2):236-43. 

Less than full time training: Being a parent and an orthopaedic trainee

  1. Bellini MI, Graham Y, Hayes C, Zakeri R, Parks R, Papalois V. A woman's place is in theatre: women's perceptions and experiences of working in surgery from the Association of Surgeons of Great Britain and Ireland women in surgery working group. BMJ Open. 2019;9(1):e024349.
  2. Conference of Postgraduate Medical Deans (2018). The Gold Guide - A Reference Guide for Postgraduate Specialty Training in the UK. 7th ed. Available at: https://www.copmed.org.uk/images/docs/gold_guide_7th_edition/The_Gold_Guide_7th_Edition_January__2018.pdf. Accessed February 2020.
  3. NHS Health Education England (2018). Supported Return to Training 2018. Available at: https://www.hee.nhs.uk/our-work/supporting-doctors-returning-training-after-time-out. Accessed February 2020.
  4. British Medical Association (2019). Less than full time training (LTFT) forum. Available at: https://www.bma.org.uk/collective-voice/committees/junior-doctors-committee/ltft-forum. Accessed February 2020.
  5. Stack SW, McKinney CM, Spiekerman C, Best JA. Childbearing and maternity leave in residency: determinants and well-being outcomes. Postgrad Med J. 2018;94(1118):694-9.
  6. Acai A, Steyn C, Reid SE, Sonnadara RR. A solution to gender inequity in surgery? Better caregiving policies. Can J Surg. 2018;61(1):6-7.

Supporting orthopaedic trainees returning to training after taking time out of programme

  1. General Medical Council (2017). Adapting for the future: a plan for improving the flexibility of UK postgraduate medical training. Available at: https://www.gmc-uk.org/-/media/documents/adapting-for-the-future-a-plan-to-improve-postgrad-med-training-flexibility_pdf-69842348.pdf. Accessed Feburary 2020.
  2. S Williams, VA Bowbrick, S Chan. Return to work for higher surgical trainees: a deanery perspective. Bulletin of the Royal College of Surgeons, 2020.
  3. Academy of Royal Colleges. Return to Practice Guidance (2012) and Return to Practice Guidance Revision (2017). Available at: https://www.aomrc.org.uk/wp-content/uploads/2016/04/Return_to_practice_0412.pdf and https://www.aomrc.org.uk/wp-content/uploads/2017/06/Return_to_Practice_guidance_2017_Revison_0617-2.pdf. Accessed February 2020.
  4. NHS Health Education England (2016). Enhancing Junior Doctor’s Working Lives - A progress report Available at: https://www.hee.nhs.uk/sites/default/files/documents/Enhancing%20junior%20doctors%20working%20lives%20-%20a%20progress%20report.pdf. Accessed February 2020.
  5. General Medical Council (2014). Skills fade literature review. Avaialble online at: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/skills-fade-literature-review. Acessed February 2020.
  6. Preisner R, Jasti H, Elnicki M, Jeong K. Impact of web-based review on long-term retention of simulation-acquired knee and shoulder aspiration and injection skills. J Grad Med Educ. 2012;4(4):460-6.
  7. NHS Health Education England (2018). Supported Return to Training. Available at: https://www.hee.nhs.uk/sites/default/files/documents/Supported%20Return%20to%20Training.pdf

Diversity: Women in orthopaedic surgery – a perspective from the International Orthopaedic Diversity Alliance

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  5. Emery SE, Carousel Presidents. Diversity in Orthopaedic Surgery: International Perspectives: AOA Critical Issues. J Bone Joint Surg Am. 2019;101(21):e113
  6. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med. 2017;177(2):206-13.
  7. Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ. 2017;10;359:j4366.
  8. Miller EK, LaPorte DM. Barriers to women entering the field of orthopedic surgery. Orthopedics. 2015;38(9):530-3. 
  9. Nielsen MW, Alegria S, Börjeson L, Etzkowitz H, Falk-Krzesinski HJ, Joshi A, et al. Opinion: Gender diversity leads to better science. Proc Natl Acad Sci USA. 2017;114(8):1740-2.
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  11. Salles A, Awad M, Goldin L, Krus K, Lee JV, Schwabe MT, Lai CK. Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons. JAMA Netw Open. 2019;2(7):e196545.
  12. Sabin JA, Greenwald A. The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions: Pain, Urinary Tract Infection, Attention Deficit Hyperactivity Disorder, and Asthma. Am J Public Health. 2012;102(5):988-95.
  13. O'Connor MI. Equity360: Gender, Race, and Ethnicity-The Business Case for Diversity. Clin Orthop Relat Res. 2019;477(5):948-51.
  14. Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403-7.
  15. Gofton W, Regehr G. What we don’t know we are teaching. Unveiling the Hidden Curriculum. Clin Orthop Relat Res. 2006;449:20-7.
  16. Bucknall B, Pynsent PB. Sex and the orthopaedic surgeon: a survey of patient, medical student and male orthopaedic surgeon attitudes towards female orthopaedic surgeons. Surgeon. 2009;7(2):89-95.
  17. Van Heest AE, Fishman F, Agel J. A 5-Year Update on the Uneven Distribution of Women in Orthopaedic Surgery Residency Training Programs in the United States. J Bone Joint Surg Am. 2016;98(15):e64.
  18. Sobel AD, Cox RM, Ashinsky B, Eberson CP, Mulcahey MK. Analysis of Factors Related to the Sex Diversity of Orthopaedic Residency Programs in the United States. J Bone Joint Surg Am. 2018;100(11):e79.
  19. Auseon AJ, Kolibash AJ Jr, Capers Q. Successful efforts to increase diversity in a cardiology fellowship training program. J Grad Med Educ. 2013;5(3):481-5.
  20. Johnson WB, Smith D. 2016. Athena rising: How and why men should mentor women. Brookline, MA: Bibliomotion, 2016.
  21. Jones M. RACS Breaking Barriers Developing Drivers for Female Surgeons Survey. Available at: umbraco.surgeons.org/media/3647/racs-breaking-barriers-developing-drivers.pdf. Accessed January 2020.
  22. Giantini Larsen AM, Pories S, Parangi S Roberston FC. Barriers to Pursuing a Career in Surgery. Ann Surg, 2019, [Epub ahead of print].
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  24. Uzoigwe CE, Middleton RG. Occupational radiation exposure and pregnancy in orthopaedics. J Bone Joint Surg Br 2012;94(1):23-7.
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  26. Downes J, Rauk PN, Vanheest AE. Occupational hazards for pregnant or lactating women in the orthopaedic operating room. Acad J Am Orthop Surg. 2014;22(5):326-32.
  27. Hamilton AR, Tyson MD, Braga JA, Lerner LB. Childbearing and pregnancy characteristics of female orthopedic surgeons. J Bone Joint Surg Am. 2012;94(11):e77.
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