EDITORIAL

 

Embracing diversity and inclusion in orthopaedic surgery in South Africa: a path forward to become 'stronger together'

 

 

Phakamani G Mthethwa

Department of Orthopaedic Surgery, University of KwaZulu-Natal, Nelson R Mandela School of Medicine, Durban, KwaZulu-Natal, South Africa

 

 

 

 

Where are we now?

Undoubtedly, our Springbok rugby team, guided by their inspirational leaders Rassie Erasmus and Siya Kolisi, is our proud example of a winning South African team. Spearheading the Rugby World Cup final in 2023 to beat our traditional rivals, the All Blacks, and win the Webb Ellis Cup for the fourth time, was no child's play. Seizing the lead by a one-point margin from extremely strong opposition in the dying seconds of the game wasn't good for supporters' heart health! President Ramaphosa, in a viral social media video, was heard saying in isiZulu, 'inhliziyo yami chishe yama' - loosely translated as 'my heart almost stopped'. Turning the game around required team dedication, cohesion, confidence in the abilities of fellow players, and absolute commitment. The success after a hard-fought win was celebrated by people of diverse backgrounds, races, colours, shapes, sizes and skills. The necessity for diversity and inclusion within the South African Rugby Board (SARB) rankings has become increasingly evident. Historically, during the apartheid era, the SARB predominantly represented white individuals, neglecting the participation and representation of minority groups. At that time, rugby governing bodies aligned with specific racial groups, further exacerbating the divide. Today, the challenge of building a unified and competitive team, such as the Springboks, has been a significant task for the SARB. This journey toward inclusivity strengthens the team and reflects South African society's rich diversity.

The South African Constitution's second chapter - The Bill of Rights, The Employment Equity Act and Promotion of Equality and Prevention of Unfair Discrimination Act - prohibits any form of unfair discrimination by the State or any person, including juristic persons (companies) on most of the bases or grounds listed above.¹ In line with this, the diversity portfolio is the brainchild of the South African Orthopaedic Association (SAOA), and its current and past presidents are addressing the importance of the journey of diversity needed in our orthopaedic society. In 2024, the portfolio aligned with the national development plan to benefit the members and South Africans.

Traditionally, orthopaedics has been perceived as a field dominated by homogeneous groups, mainly white males, in South Africa and globally.² This finding is likely multifactorial, involving both internal and external, real and perceived influences. In contrast, historically, although women were barred from practising surgery, they could fill roles as bonesetters.³ The number of female orthopaedic surgeons is increasing slowly, although data from the USA shows that female faculty growth is slower (7.3%) than in other specialities (14.7%) (p < 0.001).⁴ Meanwhile, in South Africa, we have seen a shift in gender with female orthopaedic surgeons over 55 years only at 2%, whereas those under 55 years showed a marginal increase to 3%. These margins are expected to increase as we qualify more female 'orthopods'.²

The lack of representation among various demographics comprising women, racial and ethnic minorities, and individuals from different socioeconomic backgrounds, has been seen among surgical disciplines.⁴ These disparities limit the perspectives brought into clinical practice and research, and affect the accessibility and cultural competence of care provided to the diverse patient population.^5-6 Studies have consistently shown that patients fare better when treated by clinicians who understand their cultural backgrounds and specific needs.^5-6 They are likelier to trust their healthcare providers, adhere to treatment plans, and feel satisfied with their care. Thus, fostering diversity within orthopaedics is not merely about equitable representation, it's about enhancing the effectiveness of our practice.^5-6

Dell et al. in 2018 reported 1.63 orthopaedic surgeons per 100 000 population in South Africa.² Most of the orthopaedic surgical workforce is concentrated in Gauteng, Western Cape, and KwaZulu-Natal, leaving rural provinces such as Eastern Cape, North West, Limpopo, Mpumalanga, and Northern Cape with fewer orthopaedic surgeons.² The reasons could also be multifactorial: a) specialists' socioeconomic-driven factors, b) specialist posts located in academic institutions, mainly in urban areas, and c) qualified orthopaedic surgeons choosing to pursue subspecialty training locally or abroad. On the other hand, the sectoral maldistribution of the orthopaedic surgical workforce sees most orthopaedic surgeons concentrated in the private sector in South Africa. This is far worse when compared to other high-income countries.²

 

Where do we need to go?

To address this issue, we must adopt proactive strategies to attract and retain underrepresented groups in our speciality.⁴ This includes establishing early awareness and exposure through workshops comprising plaster of Paris applications. Sawbones bioskills, volunteer board-certified orthopaedic symposiums for interns/ medical students, mentorship programmes creating inclusive academic environments, and promoting diverse leadership within our society through our medical schools.⁴ Efforts must also focus on redefining the narrative around orthopaedics to highlight those in the field's diverse experiences and contributions. SAOA diversity subdivision, the South African Female Orthopaedic Surgeons' Society (SAFOSS), and private sector partnerships have already commenced these initiatives. The short- and long-term effects of these programmes will be evaluated by examining the number of diverse applicants among orthopaedic residents, as a response to gender and ethnic equity injustices of the past. The Department of Health registrars' steering committees in South Africa are enforcing the Employment Equity Act and Promotion of Equality and Prevention of Unfair Discrimination Act. The Equity Act has made considerable strides, not only in public but also in the private sector. However, we need to be careful regarding implementation. The example of exemplary implementation is our Springbok rugby team, particularly with Rassie Erasmus picking a well-diversified but competent team. Orthopaedic leaders must balance diversifying their departments and recruiting talented candidates. Moreover, we must consider the importance of research that addresses health disparities in orthopaedic care. We can generate valuable insights that inform our practice and policy by focusing on issues such as access to care, outcomes among various demographic groups, and the unique presentations of musculoskeletal conditions in diverse populations.

 

How do we get there?

The fact is that we can't fix what we don't measure.⁷ It is important to establish measurable attributes of the ideal orthopaedic surgeon to identify the key factors necessary for attracting and supporting diverse orthopaedic registrar candidates. These ideal candidates should also be documented in a national database, such as the SAOA. According to Shah et al. in 2020, the American Academy of Orthopaedic Surgeons (AAOS) designated the fostering of diversity as a strategic objective. They actively promote initiatives like the 'Faces of Orthopaedics' campaign, which aims to publicly showcase diversity within the field. While achieving these goals remains challenging, particularly due to the historical underrepresentation of women and minorities in orthopaedics, progress is possible.⁴ Other surgical specialities facing similar gender and racial disparities, such as obstetrics, gynaecology, and general surgery, have made significant strides toward greater diversity, demonstrating that meaningful change is attainable.⁴ The mentorship and leadership initiatives by SAOA, through the SAFOSS, should be measurable, especially with orthopaedic residency applications.

In conclusion, embracing diversity in orthopaedics is essential to achieving better patient health outcomes. It requires commitment and continuous effort from all stakeholders, including medical educators, institutional leaders, and practising orthopaedic surgeons. Let us work together to create a more inclusive future in orthopaedics that values diverse perspectives and addresses the needs of every individual we serve. By prioritising diversity, we can transform our fleld, improve patient care, and build a richer, more equitable healthcare system for generations to come.

 

References

1. Kok A. The Promotion of Equality and Prevention of Unfair Discrimination Act 4 of 2000: Proposals for legislative reform. S Afr J Hum Rights. 2008;24(3):445-71.         [ Links ]

2. Dell A, Gray S, Fraser R, et al. Orthopaedic surgeon density in South Africa. World J Surg. 2018;42:3849-55.         [ Links ]

3. Rohde RS, Wolf JM, Adams JE. Where are the women in orthopaedic surgery? Clin Orthop Relat Res. 2016;474(9):1950-56.         [ Links ]

4. Shah KN, Ruddell JH, Scott B, et al. Orthopaedic Surgery Faculty: An evaluation of gender and racial diversity compared with other specialties. JBJS Open Access. 2020;5(3).         [ Links ]

5. Chen M, Strony JT, Kroneberger EA, et al. Patient preferences and perceptions of provider diversity in orthopaedic surgery. JBJS. 2023;105(21):1703-708.         [ Links ]

6. Wright MA, Murthi AM, Aleem A, Zmistowski B. Patient disparities and provider diversity in orthopaedic surgery: a complex relationship. J Am Acad Orthop Surg. 2023;31(3):132-39.         [ Links ]

7. Brooks JT, Dixon T, Simpson Mason B, Archdeacon M. An organizational approach to addressing racism in orthopaedic surgery: AOA Critical Issues Symposium. JBJS. 2022;104(20):e88.         [ Links ]

 

 

* Corresponding author: mthethwap@ukzn.ac.za