As medicine aims to close diversity gaps, orthopedic surgery is an outlier

Erica Taylor has a pedigree seemingly built for orthopedic surgery. She comes from National Football League royalty — her father, Hall of Fame receiver Charley Taylor, played 13 seasons with Washington’s football team — and she has degrees from a top-notch biomedical engineering program at the University of Virginia and one of the nation’s best medical schools, Duke. Spending every other childhood Sunday seeing doctors in action on gridiron sidelines, she’d wanted to be an orthopedic surgeon since she was 15.

So as a sophomore, Taylor asked to meet with a local orthopedic surgeon about the field. He enthusiastically agreed. But when she arrived, his demeanor changed. “He said, ‘Oh, you’re Erica,’ and for 20 minutes proceeded to tell me that orthopedics was too hard and most people like me go into family medicine or maybe OB-GYN,” said Taylor, who is Black. “I remember walking to the elevator with tears in my eyes. It was my first wake-up call that there were different rules for different people.”

Taylor had grown up with people wanting her to succeed. “That was not necessarily the case in ortho,” she told STAT. “I had to decide: Was this going to stop me, or was I going to use it as fuel?” She chose fuel. Now a hand surgeon, she is not only the first Black female orthopedic surgeon at Duke Health, she’s also chief of surgery at Duke Raleigh Hospital.

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Taylor is a rarity — but so is any Black, Hispanic, or Native American orthopedic surgeon. While medicine as a whole, and even other elite specialties like dermatology, thoracic surgery, and otolaryngology, has begun to increase the number of people of color in its ranks, orthopedics’ numbers have barely budged. Less than 2% of those practicing in the field are Black, just 2.2% are Hispanic, and 0.4% are Native American. Even Asian American physicians, a group considered overrepresented in medicine, are much scarcer in orthopedics, making up just 6.7% of these specialists.

The numbers in orthopedics are woefully low in part because there are few candidates of color to begin with: Black, Hispanic, and Native American students are underrepresented in medical school. But an investigation by STAT shows the shallow pool of potential orthopedic surgeons from communities of color gets further winnowed at almost every stage: Aspiring orthopedists from these groups are less likely to apply to the specialty, less likely to be accepted into residency programs, and if they are, less likely to finish their training. The pipeline is not only narrow, it’s full of leaks.

To help understand the reasons behind these persistent disparities, STAT spoke to dozens of orthopedic surgeons, from presidents of the American Academy of Orthopedic Surgeons (AAOS) and department chairs to residents and medical students who hope one day to enter the field. Their comments revealed perplexity, anger, and frustration. Some see hopeful signs of change, but others said they fear that orthopedics may never become appreciably more diverse.

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It’s not that the field’s leaders aren’t aware of the problem. Orthopedics, the branch of surgery that deals with sports injuries and musculoskeletal trauma, degeneration, and tumors, was one of the first medical specialties to openly acknowledge its diversity issues decades ago. Prompted by one of their own, Augustus White III — a barrier-breaking physician who was Stanford’s first Black medical student, Yale’s first Black orthopedic resident and professor of medicine, and Harvard’s first Black teaching hospital department chief — leaders of the AAOS have, since the 1980s, created task forces, held discussions, and awarded those in its ranks who pushed diversity efforts.

But all the talk and honors have barely moved the needle. In some respects, and despite the current national focus on diversity, the picture is worse today. The racial and ethnic diversity of orthopedics residency programs has consistently been the lowest of any specialty, and the number of orthopedics residents from groups underrepresented in medicine fell between 2002 and 2016 even as their percentages among medical students increased. The number of U.S. orthopedics residency programs without a single trainee from one of these groups increased from 40 in 2002 to 60 in 2016.

“If you see the pattern for so many years across the board, there’s something systemic,” said Charles Day, an Asian American professor and executive vice chair of orthopedic surgery at Henry Ford Health System in Detroit, who has written numerous articles documenting the lack of diversity in his field.

Many orthopedic surgeons of color say they feel abandoned by their field’s white majority. They say there has been a failure of leadership and an “outsourcing” of diversity efforts to Black and brown orthopedic surgeons who are already pushed to their limits. The orthopedics academy’s leadership has “made it clear to me this is not something they want to address,” said Eric Carson of the Washington University School of Medicine in St. Louis, a Black orthopedic surgeon who heads a group working to increase diversity in the field.

Frustration boiled over in June 2020, when a coalition of 80 Black and brown members of the American Academy of Orthopedic Surgeons, calling themselves “Concerned Faces of Orthopedics,” sent a letter of no confidence to the group’s president complaining that AAOS leadership demonstrated “diversity doesn’t matter.” They cited the demotion of the group’s diversity advisory board to a committee that no longer reported directly to the academy’s board of directors; not spending adequate resources on diversity pipeline programs; its refusal to hire a diversity officer or consultant; and the choice of an “all-male and overwhelming white” group as a nominating committee to appoint new board members and future presidents.

The group’s current president, Daniel K. Guy, a white orthopedic surgeon from Georgia, told STAT that the AAOS was acutely aware of the diversity problems and was working to address them, but that he disagreed with some criticisms in the letter. He said that he was in close contact with the diversity advisory board and that the board was doing the work of a chief diversity officer, making that position unnecessary. The advisory board, led by a Black orthopedic surgeon from Texas, is creating new initiatives that will be announced shortly, including supporting pipeline programs. He said the nominating committee was elected by the group’s members, not its leaders, but that leadership was doing whatever it could to put surgeons of color into important volunteer and committee positions. The 17-member board of directors, he noted, includes six members from groups underrepresented in medicine and five women.

“No one is going to put us as the poster child for diversity, but we are heading in the right direction,” Guy said. “The perception may be that we don’t care, but we do care and we want to make it better. We are listening, I can promise you that.”

To Carson, who points to more urgent and effective efforts to promote diversity taken by the American College of Surgeons, the work of the orthopedics academy is simply not enough. The disconnect mirrors the exasperation that mires discussion of racism in many sectors; white people who could drive change, said Carson, often can’t see the white privilege that surrounds them or understand how much work it will take to dismantle racism. “The majority of my colleagues,” said Carson, who has been held at gunpoint by police several times, “do not understand what it’s like to be Black.”

The field was roiled again just last month after anonymous racist and misogynist comments were left on a popular shared document where medical students each year pool information and tips about the upcoming “match,” the make-or-break process used to fill residency slots. Some crudely worded comments asked whether female applicants were single or willing to sleep around, and others mocked students with social media accounts that embraced diversity and pushed back against the “white bro” culture of orthopedics.

Despite quick statements of condemnation from many orthopedics societies, they were unable to identify or punish the culprits given the anonymous nature of the crowdsourced document. The blatant hostility directed at women and people of color left some students questioning their decision to choose orthopedics and others concerned that the people who posted the vitriol would become future colleagues. “Is the culture changing? Yes, but only very slowly,” said Katy Garcia, a Latina medical student applying to match in orthopedics who spoke out about the document after being personally targeted. “I guarantee I would not pursue orthopedics if I didn’t absolutely love it.”

While orthopedics may suffer from a lack of diversity in extremis — it’s also overwhelmingly male — those who have studied the field say its largely white demographics are a microcosm of the entrenched and often invisible structural racism and implicit bias that runs throughout medicine — preventing change and locking into place barriers to more equitable workplaces and health care systems.

To look at the demographics visually — charts of flat lines showing no increase in Black orthopedic surgeons over decades, or pie charts that don’t bother to include Native American orthopedic surgeons because there are so few — is to see inscribed into data the fallout of racism in our society that stretches back to slavery and colonialism. These numbers flow directly from the 1910 Flexner report on medical education in the U.S., which led to the shuttering of many Black medical schools that might have trained specialists and recommended Black physicians focus not on surgery but hygiene, as well as from a system that still struggles to collect proper ethnicity data of patients.

That’s not to say that orthopedics can’t address the reasons it remains medicine’s whitest specialty. And if it does, and makes real progress, it could point the way for the rest of medicine. In a highly competitive profession that prides itself on being able to fix things, and fix them quickly, the persistent lack of diversity is dispiriting. Said Kanu Okike, a mixed-race orthopedic surgeon in Hawaii who trained as a resident with White at Harvard and has studied the issue: “At this point in time, it’s a problem some would say is embarrassing.”

It’s more than just embarrassing. The diversity problem in orthopedics has real consequences for people’s health, contributing to inequities in patient care. Such disparities are glaringly obvious in areas like maternal mortality, heart disease, and colon cancer. But orthopedics has its own set of deeply ingrained, and literally painful, disparities: Patients of color are less likely to receive knee and hip replacements or care for hip fractures than white patients and appear more likely to die of surgical complications if they do. Black and Hispanic patients are half as likely to be given pain medication after suffering agonizing long bone fractures, or wait twice as long for pain medication if they do get it.

There’s only one orthopedic surgery Black patients are more likely to receive than white patients: the amputation of feet and legs due to diabetes and vascular disease.

Such disparities hit home for Okike, who had long heard stories about how gracefully his Nigerian grandmother had performed traditional Igbo dances. But as a child growing up in Massachusetts, he only knew a woman who suffered such terrible mobility issues she spent two decades keeping mainly to bed, needing help to walk just a few steps. When Okike tracked down her X-rays recently, as he described in a recent editorial in the Journal of Bone and Joint Surgery where he is now deputy editor for health disparities, he discovered her issue was something that could have been easily treated: knee arthritis.

These health disparities, say many in the field, are unlikely to be remedied until orthopedics is more diverse. Physicians from historically disenfranchised communities are more likely than white physicians to work in medically underserved areas. And they can often better gain the trust of their patients because of shared culture, language, and experiences. Studies show that Black and brown patients, whether they are undergoing cancer treatment or giving birth, are more satisfied with the care they receive and fare better when treated by doctors of their own race or ethnicity. “When it comes to tackling health disparities,” said Henry Ford Health System’s Day, “the elephant in the room is the disparity in provider representation.”

The lack of diversity is painfully obvious to patients as well. When one of her family members needed a serious operation recently, Angela Byars-Winston, a professor of medicine at the University of Wisconsin who is Black, scoured the internet looking for expert orthopedic surgeons who could provide a second opinion. She was struck that nearly all of them were white. “Really,” she told STAT, “there’s hardly anyone that looks like us? In the whole country?”

There’s another problem — not measured in deaths or wait times, but in the crushed dreams and broken plans of medical students who aspire to a career in orthopedics but find the path blocked. It’s hard for anyone to make it in orthopedics, which is consistently ranked (along with plastic surgery) as one of the most lucrative and competitive specialties in medicine: Orthopedic surgeons earn on average $511,000 a year, nearly twice as much as their colleagues in primary care. Many white candidates wash out of the field as well. Still, statistics show that, at every level, the road is more difficult for Black and brown candidates.

It may not be understandable to those outside the field, but orthopedics grabs some people, even obsesses them, and doesn’t let go. For many it’s a dream born young, something they’ve known they wanted since they became geekily fascinated with bones and muscles or the complexity of the human hand in fifth grade. Many were young athletes who got hooked, filled with relief and gratitude, after having a torn ACL repaired by a surgeon. For others it’s the thrill and immediate gratification of hands-on procedures where they replace a hip or hammer a “nail,” as orthopedists call medical rods, into a femur and see a patient stand up and walk.

For Garcia, a medical student at Texas Tech University Health Sciences Center hoping to match into orthopedics next year, it’s all three. “I love, love, love it,” she said. Garcia grew up in a tight-knit Mexican American community in the Rio Grande Valley of Texas and first encountered an orthopedic surgeon (who was white) when she blew out her knee after falling 10 feet during a cheerleading stunt at Stanford University.

“I love this and I was afraid to say it because I knew I did not fit in,” Garcia said. “There’s the mold of the tall, white, burly, male orthopedic surgeon and then you have me, 5’2” and a cheerleader.”

For Gbolabo Sokunbi, a Black spine surgeon at the top-ranked Hospital for Special Surgery in New York, it was the night he spent as a medical student shadowing a senior orthopedic surgery resident in the ER. “We were up all night. Car accidents. Gunshot wounds. Setting broken bones. Most people who are up all night are not excited, but I was,” he said. “That night, orthopedics chose me.”

But it doesn’t choose everyone. The obstacles begin almost immediately in medical school, or before, as soon as people mention their interest. The majority of orthopedic surgeons of color interviewed for this article were superstar academics and hard workers, some of them the children of physicians and graduates of elite private high schools. Others overcame childhoods in poverty, lackluster education, or foster care to become high-achieving medical students with the highest of USMLE Step 1 test scores, which are used by residency program directors to screen applicants. Despite their success and keen interest in orthopedics, most said they were repeatedly discouraged from entering the field.

“I was asked if I was strong enough. I was asked if I was smart enough,” said Letitia Bradford, a Black orthopedic surgeon in New Mexico who earned high honors at the University of California, Berkeley, and attended UCSF’s prestigious medical school. “Once I was told, ‘Your people really need pediatricians and family practitioners.’ I said, ‘That’s fascinating, but I think my people need surgeons too.’” She now directs Nth Dimensions, the premier program supporting students from underrepresented groups who want to enter orthopedics.

When Gabriella E. Ode, a Black orthopedic surgeon and clinical assistant professor at the University of South Carolina School of Medicine Greenville, told her medical school instructors and fellow students she was interested in orthopedics, she got push back. “It was always, ‘Oh honey, you don’t want to do that. You don’t look like an orthopedic surgeon,’” said Ode, who analyzed the roots of the field’s diversity problems in a recent series of papers. “That’s one of those first doors that gets slammed in people’s faces. They say you don’t fit into this world. People internalize that.“

For each surgeon like Bradford and Ode who leapt over numerous hurdles to succeed, many others did not. Nearly every person interviewed for this article said they knew a number of Black or brown physicians who had fallen out of orthopedics somewhere along the way. STAT reached out to a number of people who had been dismissed from or quit their orthopedics residency, but all declined to speak, not wanting to dredge up the painful episodes or discuss what feels like a major failure.

“You say, ‘What happened to that person?’ They don’t stay in communication because there’s shame and guilt. It’s like getting kicked out of a club,” said Ode. “The hard part is the people who really loved orthopedics and fell off. … Someone killed that joy. Someone did that. Somebody took that away from them.”

Jevere Howell, a graduate of the University Pennsylvania’s medical school who’d played sports all his life and returned home to the U.S. Virgin Islands each summer to work with an orthopedic surgeon, thought orthopedics seemed a great fit. He was told by the orthopedics chairman at his prestigious medical school that he’d be very competitive for a residency slot. But he didn’t match. He returned to the chairman looking for guidance after the disheartening news, but said he got a chilly reception.

Howell had to scramble; most coveted positions in other specialities were full. Luckily, anesthesiology — a rotation he’d done and liked — offered him a spot. He’s now an anesthesiologist in a large private practice in Houston, subspecializes in interesting hands-on procedures like regional nerve blocks, and has a great life. Years later, he’s not sitting around obsessing about orthopedics, but sometimes wonders why his plans were derailed.

He initially chalked up not matching to the competitive nature of orthopedics, but now sees things differently. He learned later that residency programs had broken the rules by calling other students to encourage them to rank their programs highly to increase the odds of matching into those programs.

“That notoriously happens in orthopedics and it really unbalances the system,” said Howell, adding that he was urged to boost his chances by lying and telling every program they were his top choice, but refused. “At the time, it didn’t go into my head that race was a factor. … But it would be foolish to think that race didn’t play into it either overtly or implicitly.”

Some in orthopedics have thrown up their hands, saying their field can’t be expected to fix societal problems, like weak early STEM education, poorer schools in many communities of color, or lack of access to resources that propel richer students into medical school. It’s true there’s a shallow pool to draw from because Black, Hispanic, and Native American students remain underrepresented in medical school; the gap is especially wide for men, who account for most applicants to orthopedics programs. (The number of Black men in medical school has actually fallen in recent decades.) But that’s not the whole story. Medicine has grown far more diverse in recent decades, as have some elite subspecialties. So what’s the problem with orthopedics?

The most overt problem may be representation. Many people interviewed for this article said they hadn’t seen or met a single Black or Latinx orthopedic surgeon until well into their medical education. “How do you even know you’d be interested if you don’t see someone that looks like you?” said Ode.

Often a single interaction with someone of the same race can be what makes the difference. During Sokunbi’s galvanizing night in the ER attending to gunshot wounds and broken bones, the talented resident he shadowed was Black. “It’s icing on the cake when someone looks like you,” he said.

Akin Ojemakinde, a Black fourth-year medical student at Emory, was able to shadow a Black orthopedic surgeon at Howard. “Having a one-on-one connection with someone that looks like me makes it easier to envision myself in ortho,” he said. “It made me think it was something I could actually do.”

Holly Pilson, an assistant professor of orthopedic surgery at the Wake Forest School of Medicine, has yet to meet another Native American orthopedic surgeon in person. “I often ponder how I got here,” said Pilson, who grew up with four brothers in rural North Carolina playing sports on co-ed teams with boys. “It never occurred to me that I couldn’t do things boys did, because I always had,” she said. Now, she’s the first of her Lumbee Tribe — the ninth-largest in the U.S. — to become an orthopedic surgeon.

Native physicians are often encouraged to enter primary instead of specialty care so they can address the high rates of diabetes and high blood pressure in their communities, but Pilson said a major structural and financial issue also holds Native Americans back from fields like orthopedics: Indian Health Service scholarships for medical students are mainly focused on those who pursue primary care. Other medical school loan forgiveness programs, including the National Health Service Corps Loan Repayment, are restricted to primary care physicians.

Lately, Pilson has been scouring the country for other Native American orthopedic surgeons with hopes of starting an organization for networking and mentoring students, but it’s a very short list. Said Pilson: “I can count them on one hand.”

The lack of representation leads to another problem: the lack of mentorship. Mentors are especially important in orthopedics, which, while not quite a secret society, requires a huge amount of insider knowledge to succeed. Matching in orthopedics often requires not only knowing how to study and do well on tests (something common to many specialties) but also conducting orthopedic research during medical school and spending several “away rotations” at different orthopedics programs because musculoskeletal care is not always included in medical school curricula and because in-person networking helps with being selected for residency programs, said Ode.

It’s a rigorous path many candidates start almost as soon as they enter medical school — if they know they need to. “There is a whole hidden curriculum,” said Bradford. “It’s like you’re playing a game without knowing the rules.” This knowledge gap is one of the barriers Nth Dimensions and the American Association of  Latino Orthopaedic Surgeons try to address with mentoring.

That insider how-to is often passed through families; it’s not surprising that orthopedics is a legacy field. Said Milton Little, a Black orthopedic surgeon at Cedars-Sinai who directs the Los Angeles hospital’s orthopedics trauma fellowship: “The number of people we interview that are the son or daughter or niece or nephew of an orthopedic surgeon is ridiculous.”

Sokunbi, the New York spine surgeon, didn’t decide on orthopedics until his third year of medical school and was told outright that it was too late. “I didn’t know all the little tricks, the art of test taking. I didn’t know you needed a head start. Unless you have a mentor, or a mom or dad who was an orthopedic surgeon, you wouldn’t know this,” he said, adding that he succeeded only by putting in a ridiculous amount of hard work. “The reality is if people look like you, they are more likely to tell you these things, to help you. Are you structurally disadvantaged because of the system? Yes.”

It was once standard practice for some orthopedics residency programs to take medical students coming for interviews to strip clubs to socialize. While that stopped about a decade ago, the clubby, jock culture of orthopedics remains and can leave many applicants feeling they do not fit in. “You go for cocktails and dinner in a roomful of white men and hear banter like, ‘You play lacrosse, too? Cool.’ To be honest, you’re surrounded by white men flirting with other white men,” said Ode.

That culture, a consequence of the white male dominance of the specialty, is another reason orthopedics may entice fewer applicants of color than other specialties. In his 2011 study, Day found there were 13.5 white applicants for each Black one and 14 white applicants for every Hispanic one, a mismatch far higher than that in general surgery.

The disparaging comments on this fall’s shared document for potential orthopedics trainees shows how deeply ingrained a frat-boy mentality remains woven through the field. Break rooms often feature weight benches, and golf and drinking outings are common, as is off-color banter and sexual innuendo in the operating room.

Kristy L. Weber, an orthopedic surgeon at Penn Medicine who in 2019 served as the first female president of the AAOS, said changing this culture, not just increasing numbers, is a critical first step for the field before more women or people of color will want to enter. “Why would you apply,” she asked, “if you don’t feel welcome?”

Looking at the narrow path women have forged in orthopedics can be instructive — and worrisome. Though half of medical students graduating today are women, they make up just 8.5% of practicing orthopedic surgeons and 14% of residents. A recent study suggested it will take more than 200 years for orthopedics to reach gender parity. For underrepresented racial and ethnic groups, it could be centuries more.

Not being able to match into any of the roughly 160 U.S. orthopedics residency programs is one of the biggest roadblocks for these candidates. Between 2005 and 2014, 73% of white applicants were accepted by orthopedics residencies, compared with 46% of Black applicants.

One of those not accepted, despite having a father and a brother who practice family medicine, was Uche Ononuju, who graduated from the Wayne State University School of Medicine in 2020. Ononuju matched into orthopedics on her second attempt, but only after applying to 95 programs and contacting more than 60 people on med Twitter to find advocates. “Had I not been that persistent,” she said. “I would not have matched.”

Joel Boyd, a Black adjunct assistant professor of orthopedic surgery at the University of Minnesota Medical School who has been a head team physician in both the NHL and NFL, said that in 30 years, he has yet to train a Black sports medicine fellow, and that probably won’t change until the selection process does.

“I know this department inside and out and I’d say no one is consciously biased. The problem is, it’s set up so it doesn’t happen. Unless someone says we are going to diversify our class and be intentional about it, that’s the only way it happens,” he said. “I’m only one vote.”

Many say bias is baked into the selection process, starting with test scores. Candidates are ranked using the USMLE Step 1, a grueling, nearly eight-hour test that covers, basically, the entirety of medicine. Studying for it is like drinking from a firehose.

Studies show that Step 1 scores are biased against non-white candidates, and critics argue that the scores are not good predictors of a student’s future prowess as a physician. High scores can require expensive tutoring, something that isn’t possible for all candidates. “People say, ‘Well, they just don’t have the scores,’” said Ode. “That’s an easy way to sink someone.”

In an effort to level the playing field, the test next year is moving to a pass/fail outcome, which may eradicate some disparities. But it could usher in others. Program directors are grappling with how they will screen hundreds of applicants. Will they look instead at scores on the MCAT medical school admissions test, which are similarly problematic, or rely on orthopedic colleagues calling to praise the best candidates? “If you’re Black and don’t have access to resources or networks,” asked Bradford, “who’s going to make that call for you?”

Studies show other common selection criteria, including letters of recommendation and membership in the Alpha Omega Alpha medical honors society, may be biased as well. A 2017 analysis controlling for test scores, research productivity, community service, and leadership ability, showed Black medical students were far less likely to be members of the honor society. Letters of recommendation are another problem: A 2017 analysis showed white medical students were more often described as “exceptional,” “best,” or “outstanding,” while Black students were more often described as “competent.”

The expense of applying can be another handicap. Candidates seeking orthopedics residencies can spend up to to $10,000 on applications and travel costs for interviews and away rotations, far more than those seeking to enter primary care residencies. (The fact that interviews have been virtual for two years because of the Covid-19 pandemic, and therefore both cheaper and less socially ostracizing, may be one factor increasing the number of Black and brown applicants to the field.)

Finding a residency spot is not a problem for top applicants, whether they be people of color or white. But it’s harder for still-excellent but middle-tier candidates whose selection can depend on subjective criteria where implicit bias can play a role. Those who take part in selecting residents say bias is rarely overt, but can be pervasive. “You hear things like ‘That person is not necessarily a good fit,’ or ‘I’m not sure we can train this person,’” said Little. “For a field that’s very white male-centric, it’s hard to fit in.”

The scrutiny of candidates of color is clearly higher, he said. Constantly hovering in the background is the issue of what will happen if a “first” or “only” candidate doesn’t succeed. “It can’t be someone that’s just OK,” he said. “You find yourself looking for Jackie Robinson everyday.”

Just 5% of orthopedic residents are Black, but data that St. Louis surgeon Carson has been analyzing show that in 2015, they made up 43% of residents who were fired or dismissed, far more than in any other specialty. For many in the field, such numbers are an uncomfortable echo of the nation’s criminal justice system, where a minority population makes up the majority of those who are jailed.

“I’ve watched a few [Black] co-residents go through this. Every single thing they do is documented so they can be fired,” said Taylor. “They say, ‘She showed up late again.’ ‘She was eating breakfast during conference.’ But others do that too.”

Successfully completing an orthopedic residency is difficult for everyone, whether white or Black or Latinx. Little, at Cedars-Sinai, said residents of color have very little margin for error. Many are afraid to report instances of racism for fear they will be the ones disciplined. They are also some of the most vulnerable. “Unless you’re coming from money, have someone who’s going to back you, or have a lawyer, it’s hard to fight,” he said.

Carson is often the first person a Black or Hispanic resident will call when they’re in trouble. “I’m what they call the Olivia Pope of orthopedics,” he said, referring to the fictional political fixer from the television program “Scandal.” “I come in at the last minute and try to save the day.”

He wears a lot of hats. In addition to being a Washington University professor, he is chief of the orthopedic service at the local Veterans Affairs hospital and a team physician for the U.S. Rowing Program. But a major focus of his work, as president of the J. Robert Gladden Orthopaedic Society, is diversity, and understanding why people of color are at higher risk of quitting or being fired from orthopedics residencies.

Carson, who sometimes tears up discussing the careers of residents he could not save, has seen the phenomenon enough to give it a name: “the death spiral.” He says the root cause is being a person of color in a system that is not supportive who starts to question themself, make mistakes, feel ashamed, does not reach out for help, and then starts being questioned by their attending, or supervisory, physicians. “Medicine is hard,” he said. “It’s easy to lose your confidence.”

For physicians of color who thread the needle — finish their residencies and fellowships, pass their board exams, and enter orthopedics — the problems don’t necessarily stop. In a 2020 survey Ode and others conducted of more than half of the country’s 573 Black orthopedic surgeons, 94% said racial discrimination was a problem in their work environment and many said they thought it played a role in blocking their advancement. Almost all reported they were routinely confused with non-medical staff. “I get that all the time, people saying, ‘You’re the doctor?’” said Ode. “Patients hand me food or bedpans. When I explain a surgery, they say, ‘When is the surgeon coming in?’ They can’t even process it. They can’t compute that this Black woman in front of them is a surgeon.”

Every orthopedic surgeon of color has stories like this. For Sokunbi, it was being handed car keys by a fellow surgeon who mistook him for a parking valet. For Little, it was a patient who said he reminded them of their chocolate lab. For Boyd, it was the 80-year-old knee replacement patient who, thinking it was a compliment, said: “Your people must be proud of you.”

In the survey, overt racial discrimination was reported by just 23%, but almost all felt they faced discrimination in hiring and believed it was easier for white orthopedic surgeons to advance. “There is a certain inside track that we are not privy to when searching for employment and thus we are not given the opportunity to even apply for these positions,” one respondent wrote.

Even as a handful of Black and brown orthopedic surgeons have reached positions of leadership at their universities and hospitals, some areas remain off-limits, or perhaps just not worth the fight. Many have eschewed working in academic medicine, and Taylor, despite her deep love of football and sport, ended up not choosing sports orthopedics after all. “I saw an upward battle,” she said, “that, quite honestly, I didn’t want to fight.”

One job considered the pinnacle of orthopedic success — being a professional sports team physician — remains almost entirely the domain of white physicians, despite the fact that many of these teams’ athletes are Black or brown. An analysis published this year found that nearly all team physicians in the NBA, NFL, NHL, MLS, and MLB were male and 84.5% were white. (8.4% were Asian; 5.8% were Black; 1.3% were Hispanic.)

Boyd is one of the few Black orthopedic surgeons who has served as a team physician in the NFL, and also in one of the whitest of sports, ice hockey. He served for 18 years as the team physician for the Minnesota Wild and as head physician for USA Hockey in the 1998 Nagano games. (He grew fascinated with hockey after watching Washington Capitals games featuring Mike Marston, one of the NHL’s few Black players; the obsession now runs in the family.)

In many ways, the route to being a team physician echoes the challenges of Black and brown medical students trying to enter orthopedics today: It means crashing an all-white party, which Boyd literally did to meet the hockey team owner he wanted to work for. “I don’t belong to any of the clubs that the guys who own the team belong to. How do I get an audience?” he said. “The only physicians they’ve known are all white.”

This story has been updated to explain that the anonymous nature of the crowdsourced document prevented orthopedics societies from identifying the people who left racist and misogynist comments on the document used by medical students interested in applying for orthopedics residencies.

Coming tomorrow: How — and if — orthopedics can fix its lack of diversity.

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.