Does Medical Students’ Sense of Belonging Affect Their Interest in Orthopaedic Surgery Careers? A Qualitative Investigation

Abstract

Background The concept of social belonging has been shown to be important for retention and student success in collegiate environments and general surgery training. However, this concept has never been explored in relation to medical students’ impressions of orthopaedic surgery careers. Question/purpose To investigate medical students’ sense of belonging in orthopaedic surgery and how it affects their interest in pursuing orthopaedic surgery careers. Methods Medical students from four medical schools were invited to participate in telephone interviews aimed to investigate medical students’ reasons for considering (or not considering) orthopaedic surgery as a future career. Students were selected using random sampling and theoretical sampling methods (selecting participants based on specific characteristics) to obtain a diversity of student perspectives across medical school year, gender, race, age, and interest in orthopaedics. Semistructured interviews with open-ended questions and face validity were used to minimize bias in the interview process. Analysis was performed using grounded theory methodology, a rigorous and well-established method for creating conceptual models based on qualitative data. The result seeks to be a data-driven (as opposed to hypothesis-driven) theory that provides perspective on human behavior. Interviews were conducted until the point of thematic saturation, defined as the point when no new ideas occur in subsequent interviews; this was achieved at 23 students (16 self-identified as women, 12 self-identified as underrepresented minorities). Results Medical students articulated stereotypes about orthopaedic surgeons, in particular, that they were white, male, and athletic. Students derived their sense of belonging in orthopaedic surgery from how closely their identities aligned with these stereotypes about the field. Students who felt a sense of belonging described themselves as being part of a cultural “in-group,” and students who did not feel a sense of belonging felt that they were in a cultural “out-group.” Members of the in-group often reported that orthopaedic experiences further reinforced their positive identity alignment, which typically led to increased interest and continued engagement with the field. Conversely, students in the out-group reported that their exposures to orthopaedics further reinforced their lack of identity alignment, and this typically led to decreased interest and engagement. Many students in the out-group reported pursuing other specialties due to a lack of belonging within orthopaedics. Conclusion Students derive their sense of belonging in orthopaedics based on how closely their identity aligns with stereotypes about the field. Importantly, there were gender and racial factors associated with orthopaedic stereotypes, and thus with belonging (self-identifying as the in-group). Moreover, out-group students tended not to choose orthopaedic surgery careers because of a lack of belonging in the specialty. Clinical Relevance With knowledge of the factors that influence students’ sense of belonging, academic orthopaedic departments can focus on interventions that may lead to a more diverse pool of medical students interested in orthopaedic surgery. These might include explicitly addressing stereotypes about orthopaedics and cultivating positive identity alignment for students from diverse backgrounds through targeted mentorship fostering partnerships with affinity organizations, and creating space to talk about barriers. Targeted interventions such as these are needed to interrupt the cycle of in-group and out-group formation that, in this small multicenter study, appeared to deter students with underrepresented identities from pursuing orthopaedic surgery careers.

Getting the culture right

“…8 It has been shown that medical students are more likely to pursue orthopaedics if they see themselves as having the same traits as the traditional 'white, athletic, male' orthopaedic surgeon. 9 However, diversity has repeatedly been shown to improve innovation and patient outcomes, [10][11][12] so we need to work harder to make a career in orthopaedics accessible to all.…”

Interpersonal Interactions and Biases in Orthopaedic Surgery Residency: Do Experiences Differ Based on Gender?

“…Previous studies have evaluated the impact of experiences in youth through medical school that result in the decisions of women to pursue careers in orthopaedic surgery [3,11,22,25]. This decision is often informed by what they observe in the experiences of women in training as well as longstanding stereotypes that can affect feelings of belonging [8]. The environment faced by women while in medical and surgical training programs has been documented [18] and impacts not only the opinions of students regarding the field but also the wellbeing of women residents.…”

“…The perceived experiences of women residents in orthopaedic surgery and the stereotypes of the specialty and people in orthopaedic surgery can influence a medical student's belonging in and desire to pursue a career in orthopaedic surgery [8,11], and the slow growth in gender diversity in orthopaedic surgery has been attributed, in part, to these perceptions. One study surveyed medical students and found that perceptions of long hours, high physical demands, and the predominance of men in the field were deterrents to pursuing careers in orthopaedic surgery for women [2].…”

New Beginnings and Revealing Invisible Identities

“…A study by Gerull et al on medical students’ sense of belonging revealed that students held stereotypes about orthopaedic surgeons and derived a sense of belonging from how closely their identities aligned with these stereotypes. Students who experienced a lack of identity alignment felt like they were in a cultural “out-group.” 1 Additionally, the “out-group” students reported that their peer interactions with the “in-group” negatively affected their perception of orthopaedics because of their exclusionary attitude 1 . Fortunately, another study found that underrepresented minority (URM) students who perceived orthopaedics as less diverse and inclusive changed their mind after an orthopaedic rotation 2 .…”