Academic, leadership, and demographic characteristics of orthopaedic arthroplasty leadership: a 2022 cross-sectional study

Introduction

Central to the preservation and restoration of native joints, arthroplasty divisions are integral to orthopaedic care that sustains active lifestyles and maximizes patients’ quality of life. Advanced training in orthopaedic surgery has become increasingly common (1), with 97% of orthopaedic residents planning on participating in a fellowship program in 2020 (2). Among orthopaedic subspecialties, adult reconstruction has had the greatest increase in fellowship participation since 2010, reflecting the growing complexity and specialization required to manage degenerative joint disease (3). This trend parallels the substantial rise in total hip and knee arthroplasty procedures over recent decades (4). The number of individuals living with a total joint replacement has risen steadily in the United States and is projected to continue increasing through 2030 and beyond (5). Although fellowship and residency positions remain capped, the increasing clinical demand underscores the importance of strong leadership within arthroplasty divisions to optimize training efficiency, surgical quality, patient outcomes and the development of skilled future arthroplasty surgeons.

Many physicians aspire to leadership roles throughout their academic careers, though only a minority ultimately attain such positions. In orthopaedic surgery, most practicing surgeons work in private practice or healthcare systems without trainees, making leadership roles limited to a subset of academic orthopaedic surgeons. Factors influencing selection for these positions may include academic productivity, mentorship ability, interpersonal skills, institutional loyalty, leadership experience, and commitment to advancing patient care. Previous studies have analyzed leadership across orthopaedic subspecialties to identify demographic and academic trends among program leaders (6-10). While these studies have laid a strong foundation, there remains a paucity of data comparing leadership characteristics across several types of leadership roles within adult reconstruction.

As such, the purpose of this study was to identify and evaluate common demographic and academic characteristics among both Fellowship Directors (FDs) and Division Chiefs (DCs) within orthopaedic arthroplasty divisions in the United States. By delineating pathways that current leaders have taken, we aim to inform aspiring trainees and junior faculty on qualities and experiences conductive to leadership development. Additionally, given the clinical importance of leadership roles on surgical training, institutional culture, and ultimately patient care, identifying potential disparities among current leaders may help institutions design initiatives that promote diversity and equity in leadership selection.

We hypothesize that the majority of orthopaedic surgery arthroplasty FDs and DCs will consist of white males who have an academic background within a limited range of adult reconstruction fellowship programs in the country. We also hypothesize that a substantial number of FDs and DCs will demonstrate institutional loyalty, having completed fellowship or practiced for extended periods at their current institutions. We present this article in accordance with the STROBE reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-59/rc).

Methods

The American Medical Association’s FREIDA database (11) was used to find residency programs, FDs, and DCs. The Adult Reconstruction Fellowship Match Program list of the American Association of Hip and Knee Surgeons (AAHKS) for 2021–2022 was reviewed to compile a comprehensive list of all adult reconstruction fellowships in the United States (accessed May 2022) (12). From each program, data was collected on all FDs that were listed, in addition to any DC if available, that were found on their respective websites. AAHKS FD listings were cross-referenced with program website listings to ensure accuracy and that all leadership roles were updated properly. Next, demographic, academic, and professional background data were extracted from program websites, online CVs, and personal webpages to assess the academic and leadership characteristics of each individual. Data were cross verified across the multiple publicly available sources to minimize discrepancies. If all the information needed was not present from one of these sources, Doximity (13) and personal LinkedIn (14) profile pages were used to obtain information. All data were collected in 2022 at the end of the 2021–2022 fellowship cycle to ensure consistency and temporal accuracy. Missing or unverifiable data were recorded as “not reported” and excluded from the corresponding analyses. As only publicly available information was used, this study was exempt from Institutional Review Board approval. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Data that was obtained on each orthopaedic arthroplasty FD and DC included sex, race/ethnicity, age, academic rank, additional leadership position(s), additional degree(s), fellowship institution, years since completion of fellowship, years at current institution, years in current role, and size of current institution departments. The authors identified and selected sex and race based on web-based profile searches and the last name. Additionally, profile pictures of each FD and DC were used to help confirm sex and ethnicity. The Forebears website was cross-referenced to help ensure accuracy of ethnicity (15). The Healthgrades website was used to determine each FD and DC’s age (16). Patient satisfaction was measured using a variety of review-based websites [Healthgrades (16), Vitals (17), and Google Reviews (18)].

The Scopus database was used to gather Hirsch indices (h-index) and total number of publications (19). The h-index was introduced by Jorge E. Hirsch in 2005 as a means to assess quality of scholarly contributions and complement straightforward numerical metrics, such as total number of publications (20). The h-index mathematically adjusts for both quality and quantity by calculating the number of publications (h) that have attained at least h citations each (20). For example, an author with an h-index of 10 would have 10 published papers that have been cited at least ten times each. Likewise, an author who has 20 publications each of which has attained at least 15 citations will have the h-index of 15.

ResearchGate (RG) was used to gather RG scores and ResearchGate interest (RI) scores (21). RG is a rapidly expanding social networking website aimed to help researchers identify potential research collaborations and share recent publications. RG and RI scores are emerging metrics used similarly to the h-index to measure research quality and productivity. The website assigns each researcher an RG score that is calculated based on both the number of publications and the amount of positive feedback about each publication within the RG community. Although currently underutilized to date, we believe that the RG score may potentially be a reliable proxy of academic productivity and research quality when reviewing a researcher being considered for academic promotion.

Statistical analysis

The primary analyses in this study were descriptive, summarizing demographic, academic, and leadership characteristics of orthopaedic arthroplasty FD and DCs. Statistical analysis included the calculation of Pearson correlation coefficients and was performed using Microsoft Excel (Version 16.68; Microsoft, Redmond, WA). The correlation coefficients calculated in this analysis were interpreted according to Mukaka’s guide on correlation coefficient interpretation in medical research settings (22). Correlation coefficient values of less than 0.4, 0.4 to 0.7, 0.7 to 0.9, and greater than 0.9 are suggestive of weak, moderate, strong, and very strong positive correlations, respectively (23). H-index was compared between surgeons with the title of FD, DC, or those who held both positions. An analysis of variance (ANOVA) test was used to compare the three groups with post hoc analysis performed using Tukey’s honestly significant difference test. A two-sided alpha value of 0.05 was used to determine statistical significance.

Results

There were 116 FDs and 77 DCs from 137 orthopaedic arthroplasty divisions included. 169 surgeons were identified as an FD, DC or both. Of these, 20 were co-FDs and 22 were both FD and DC. One hundred and six institutions offered an arthroplasty fellowship program. Overall, 98.2% were males (Table 1). The majority of surgeons were Caucasian (83.4%), followed by 11.2% Asian, 3.6% Hispanic, and 1.8% African American. Average age was 52.7 years, years since fellowship graduation was 18.1, years at current institution was 13.8, and years in current role was 9.7.

The average number of faculty in each arthroplasty division and entire orthopaedic department was 8 and 54, respectively. Sixty-eight of the FDs/DCs held additional leadership positions within their division, the orthopaedics department, or the hospital. Of these, 22.9% were chairperson, 22.9% vice-chairperson, 50% director or associate director, and 10% residency program director (Table 2). Thirty FDs/DCs had additional graduate degrees (10 PhD, 10 MS, 4 MBA, 1 MAS, 1 MEng, 1 MPH, 1 MPT, 1 JD, 1 RPh) (Table 2).

Eight arthroplasty fellowship programs produced at least 8 current FDs/DCs (Figure 1). The fellowship programs that graduated the most FDs and DCs were Massachusetts General Hospital [17], Hospital for Special Surgery [17] and Mayo Clinic [13] (Figure 1).

Figure 1 Fellowships that graduated the most FDs and DCs. DCs, Division Chiefs; FDs, Fellowship Directors.

Average h-index, RG, and RI scores were 16.9, 27.6, and 1,309.5, respectively (Table 1). Most FDs and DCs had an h-index <15 (Figure 2). The 10 FDs/DCs with the highest academic productivity were noted (Table 3). On average, they had a Scopus h-index of 60.4 (8.82) and 293.3 (89.44) publications. The most productive FD/DC had a Scopus h-index of 74, while the 10th most productive had a Scopus h-index of 47. Average h-index increased from FD to DC to the both groups, but was not found to be significantly different (Table 4).

Figure 2 H-index of FDs and DCs. DCs, Division Chiefs; FDs, Fellowship Directors.

Overall, 29.6% of surgeons were full Professor, 26.6% Associate Professor, and 23.1% Assistant Professor. H-index was compared between Assistant Professors, Associate Professors, and Professors. Of the 169 surgeons identified, 35 did not have an academic rank listed and were excluded from this portion of the study. The correlation between professorship and h-index was found to be 0.46 (Table 5). This corresponds to a moderate positive correlation (22).

Discussion

Current literature evaluating academic, demographic, and leadership characteristics of orthopaedic surgery arthroplasty FDs and DCs is limited. Our study is the first to examine these characteristics in both roles. We found a pronounced lack of diversity in arthroplasty leadership, with 98.2% of FDs and DCs being male and 83.4% being White, which is consistent with prior reports of sex and racial imbalances in orthopaedic surgery (6-10,24-27). Arthroplasty leadership demonstrated substantial experience, with an average 18.1 years since fellowship completion and 9.7 years in their respective leadership roles, along with institutional loyalty averaging 13.8 years at their current institution. Many held additional graduate degrees and occupied other leadership positions within their departments or hospitals. Moreover, a small number of fellowship programs produced a disproportionately high number of current leaders, and research productivity was moderately correlated with professorship. These findings highlight the need for continued concerted efforts to broaden representation within orthopaedic surgery arthroplasty leadership.

First, the majority of orthopaedic arthroplasty FDs and DCs were found to be male and Caucasian. As racial and ethnic diversity in the U.S. patient population continues to increase (28), the need for diverse physician leadership is crucial. Diverse leadership teams offer a broader range of perspectives and experiences, enhancing decision-making, patient outcomes, and institutional effectiveness (25). Furthermore, diversity in leadership is critical for addressing health disparities and ensuring equitable care for all patients (25). The underrepresentation of women and minority groups in leadership roles in orthopaedic arthroplasty may be due to several factors (10). First, implicit bias may influence selection processes for leadership positions (29,30). Implicit bias can lead to discrimination in hiring and promotion decisions, and it may be contributing to the underrepresentation of women and minority groups in leadership roles in orthopaedic arthroplasty (29,30). Second, lack of mentorship and visible role models may deter women and minority groups from pursuing leadership positions (26,31-35). Third, work-life balance concerns and subspecialty selection patterns may influence career trajectories and timing to leadership (10,36). Finally, although female representation in orthopaedic programs increased in the last two decades, it takes a substantial amount of time for surgeons to be competitive for a leadership position which may not have passed yet (27).

Although most arthroplasty leadership were White, the racial distribution of current arthroplasty FDs and DCs in our 2022 cohort (83.4% White, 11.2% Asian, 3.6% Hispanic, 1.8% African American) is broadly similar to the demographic of all orthopaedic surgeons reported by AAOS in 2018, where 84% of surgeons identified as Caucasian, 6.7% as Asian, 2.2% as Hispanic/Latino, and 1.9% as African American (37). This suggests that the racial representation among current leaders may in part reflect the existing demographic makeup of the orthopaedic workforce. Importantly, the mean time since fellowship completion among leaders was 18.1 years, indicating that the current leadership cohort largely represents surgeons trained nearly two decades ago; therefore, cross-sectional comparisons to contemporary trainee demographics may not fully capture more recent increases in diversity among medical students and residency applicants. Our findings indicate a notable and persistent gender imbalance while suggesting a more nuanced interpretation of racial representation that warrants longitudinal study.

Efforts to increase diversity in orthopaedic arthroplasty leadership are needed to ensure that patient care and outcomes are not adversely affected by the lack of diversity in leadership positions. Targeted recruitment and structured mentorship remain important strategies to accelerate the translation of trainee diversity into future leadership representation. Outreach and mentorship programs, such as the Perry Initiative and Nth Dimensions, have been shown to positively influence interest in orthopaedic surgery among underrepresented groups and increase the amount of students both applying into and entering orthopaedic surgery (38,39). Associations such as the Ruth Jackson Orthopaedic Society (RJOS), the J. Robert Gladden Orthopaedic Society, and the American Association of Latino Orthopedic Surgeons have been established to support women and minority groups throughout their careers in orthopaedic surgery, with one of the goals being to increase their representation in leadership positions.

The average h-index of 16.9 is consistent with previous studies in orthopaedics (6-9) and indicates that most FDs and DCs have made a significant impact in their field, although the majority had an h-index of less than 15. Similarly, the average RG score of 27.6 and RI score of 1,309.5 suggest that these leaders are actively engaged in research and publication activities. However, it is worth noting that these metrics alone do not necessarily reflect the quality or impact of a researcher’s work, and there may be other factors that contribute to a leader’s success in their role. For example, leadership skills, mentorship abilities, and administrative expertise may be equally important for a successful FD or DC. Future studies should explore these factors in greater detail to better understand the qualities that make a successful leader in orthopaedic arthroplasty.

There was a moderate correlation between academic rank and h-index. Full Professors had an average h-index of 26.5, while Assistant Professors had an average h-index of 8.9. This suggests that academic rank and research productivity may be closely related, and that individuals who achieve higher academic ranks have a greater impact on the field of orthopaedics through their research contributions. Furthermore, the correlation between academic rank and h-index is an important consideration for individuals seeking to advance in academic orthopaedics. Institutions may consider an individual’s research productivity and impact when making decisions about promotions and tenure, and individuals may need to prioritize research activities to achieve higher academic ranks.

Another important finding of this study is the identification of specific fellowship programs that play an important role in producing future arthroplasty leaders. Massachusetts General Hospital, Hospital for Special Surgery, and Mayo Clinic were the programs most likely to produce future FDs and DCs. It is unclear whether these fellowship programs inherently attract great applicants who intend on becoming future leaders or whether the fellowship program creates future leaders through their training, resources, and prestige (40). This information is valuable for trainees who are interested in pursuing leadership positions in arthroplasty and can help guide their decisions about where to pursue fellowship training. These fellowship institutions can increase diversity of future arthroplasty leadership by making a conscious effort to increase diversity among their recruits for fellowship.

This study also provides insight into the career trajectories of FDs and DCs in arthroplasty. The average time since fellowship graduation was 18.1 years, indicating that these leaders have significant experience in the field. The average time in their current role was 9.7 years, suggesting that turnover among FDs and DCs is relatively low. These findings are important for trainees who are considering a career in academic orthopaedics and can provide guidance for their long-term career planning. In addition to their roles as FDs and DCs, many arthroplasty leaders in this study held additional leadership positions within their institutions. Of the 169 FDs and DCs, 68 (40.2%) held additional leadership positions including 32 (18.9%) who served as Department Chair or Vice-Chair. This highlights the significant influence these individuals have on their respective departments and the broader field of orthopaedics, further emphasizing the importance of increasing diversity of arthroplasty leadership.

It is worth noting that this study has several limitations that should be taken into consideration when interpreting the results. First, our study was limited to academic orthopaedic arthroplasty programs in the United States, and therefore the findings may not be generalizable to other subspecialties or to non-academic settings. Second, our cross-sectional study collected data from publicly available sources such as program websites and personal profiles and may not accurately reflect the complete career histories of FDs and DCs, their qualifications at the time of appointment to their leadership position, or all demographic details. Patient satisfaction data obtained from online review platforms are inherently subject to selection and reporting bias, as such reviews may not be accurately reflective of clinical performance. Further, we were unable to locate every DC associated with every academic orthopaedic program due to lack of this information on their respective websites. Third, we identified race/ethnicity using the country of origin of the last name of the FD/DC, which may lead to the reported races in this study to be different from the self-identified race by individual FDs/DCs. However, in order to minimize this limitation, we used profile pictures to help confirm FD/DC ethnicity. Finally, our analysis was limited by unequal sample sizes between FDs, DCs, and dual-role holders, as well as variability in patient satisfaction data obtained from different online review platforms, which are inherently unstandardized and subject to reporting bias.

While this current study provides insight into the demographic, educational, and scholarly characteristics of FDs and DCs within orthopaedic arthroplasty, several unaddressed questions remain regarding whether leading fellowship programs produce leaders by attracting high-potential applicants or through superior training, how non-academic qualities such as mentorship and administrative skills influence leadership selection, and the long-term impact of diversity initiatives on representation in leadership. Future studies should aim to address these questions to better delineate the factors that shape leadership development and promote diversity within academic orthopaedic surgery.

Conclusions

This is the first study that provides insight into the demographic, educational, and scholarly characteristics of both FDs and DCs in orthopaedic arthroplasty programs in the United States. There is a lack of diversity among arthroplasty leadership, with most FDs and DCs being White males. While racial representation among current leaders approximates contemporary AAOS membership, a pronounced gender disparity persists; greater efforts to increase diversity in arthroplasty leadership are needed. A large proportion of FDs and DCs hold additional leadership positions, demonstrating their role in shaping the future of orthopaedic surgery. Moreover, we found a moderate correlation between professorship and h-index, indicating that academic rank and promotion may be related to scholarly productivity. Finally, our findings highlight the importance of specific fellowship programs in producing future arthroplasty leaders, with many leaders graduating from a select few institutions. Assessing the qualities and characteristics of leadership allows for better career advisement and the establishment of pathways for those seeking leadership positions in the future. In addition, there needs to be a concerted effort to support and encourage trainees of diverse backgrounds to seek out these roles if there is truly a desire to diversify arthroplasty leadership. Widening diversity recruitment efforts by these fellowship institutions and establishing outreach and mentorship programs, such as the Perry Initiative and RJOS, are ways to improve diversity in future orthopaedic arthroplasty leadership.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-59/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-59/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-59/coif). X.L. is a paid consultant and receives royalties from FH Ortho. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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