DOI: 10.1002/jor.
24685
EDITORIAL
The importance of diversity, equity, and inclusion in
orthopedic research
Diverse workforces and inclusive workplaces improve productivity,
innovation, and overall quality‐of‐care for all patients,1,2 increase
public trust in medical research,3 and are generally good for
business.4 Unfortunately, orthopedics lags behind other biomedical
fields in the recruitment of women and underrepresented minorities
into training programs and faculty ranks5‐7 and focused recruitment
efforts have not reduced the gender, racial, or ethnic gaps in ortho-
pedic residency programs.7 These gaps exist among both clinical and
research faculty in academic orthopedic surgery departments,8 as
well as in other departments that house orthopedic researchers, such
as engineering. The Orthopaedic Research Society (ORS) is in a pri-
vileged and unique position to positively influence recruitment and
retention efforts because orthopedic research laboratories are often
entry points for students who aspire to be scientists, engineers,
physicians, and/or surgeons. As a premier orthopedic professional
society, ORS has the responsibility to set cultural standards for safe
and inclusive environments for all members and affiliates to imple-
ment and follow.
In 2019, the president of the ORS (co‐author JCI) formed a Task
Force to address diversity, equity, and inclusion (DE&I) within the
Society. Our charge was to recommend how the ORS can (a) increase
understanding of the importance of DE&I to the ORS mission, (b)
foster inclusion by promoting communication and building commu-
nities that engage underrepresented groups and the greater ORS
membership, and (c) develop resources to increase the cultural
competency of the global research community and ORS. For
6 months, we reviewed the current ORS diversity statement, avail-
able literature, and membership data, and discussed best practices
and goals for promotion of a diverse, equitable, and inclusive culture
in the ORS. In this editorial we summarize our findings and outline
next steps.
WH AT IS HU MAN D IV ER SI TY , H OW
D I V E R S E I S O R S , AN D W H Y IS IN C R E A S I N G
D I V E R S IT Y IM P O R T A N T ?
Human diversity is multidimensional and intersectional. Our diversity
results from inborn traits, learned characteristics, and individual ex-
periences. Inborn traits include gender identity, race, ethnicity, age,
and sexual orientation (Figure 1, white ring). The next dimensional
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© 2020 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
J Orthop Res. 2020;38:1661–1665.
category consists of characteristics we can learn, change, or control
such as language, religion, and marital/dependent status (Figure 1,
purple ring). Finally, professional diversity is represented by aca-
demic credentials and work experiences (Figure 1, blue ring). The
combination and intersectionality of traits and experiences make
individuals unique.
ORS collects information from its membership on many aspects
of professional identity (eg, degree obtained, current position). In
regards to other dimensions of human diversity, ORS only collects
information on two gender identities (female or male) from those
members who choose to disclose. Though the ORS strives to improve
the inclusion of all underrepresented groups, the lack of data on any
other aspect of member diversity limits our understanding of where
deficiencies exist and where efforts to address them are most
needed.
Available gender data show that in 2018 ORS ranked third
amongst 19 AAOS Board of Specialty Societies in female membership
at 24.7%, trailing only the Ruth Jackson Orthopaedic Society (95.9%),
which has a goal of advancing the science and practice of orthopedic
surgery among women, and the American Spinal Injury Society
(42.8%).5 Over a 5‐year period (2015‐2019), the number of ORS
members identifying as female grew from 595 to 994, but the percent
of female members rose just 1% during this time (from 23.5% to
24.5%). On the other hand, the number of individuals who did not
report a gender identity increased from 1.8% to 13.9% between 2015
and 2016, and was 13.5% in July 2019. To understand ORS gender
diversity in greater depth, the Task Force reviewed the most recent
dataset (2 July 2019) and considered three categories of members
(Active, Associate, and Affiliate). The Associate (mostly students/trai-
nees) and Affiliate (eg, vendors) members have a greater percentage of
women than the Active members (eg, faculty and principal
investigators; Figure 2). Associate and Affiliate members were less
likely to reveal a gender identity as male or female. This disparity may
reflect inadequate gender identity options in surveys or beliefs by
some individuals, especially younger people, that revealing a gender
identity is either harmful for professional advancement or irrelevant.
Membership diversity is important for the long‐term success of
ORS and the fields of orthopedics and musculoskeletal research.
Diverse research teams are more productive and innovative, have
more highly cited publications, are more equipped to solve complex
problems and adapt to change, and produce more impactful,
wileyonlinelibrary.com/journal/jor | 1661
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1662 | EDITORIAL

F I G U R E 1 Dimensions of human diversity. Adapted from Loden and Rosener.9 ORS, Orthopaedic Research Society; STEM, science,
technology, engineering, and mathematics [Color figure can be viewed at wileyonlinelibrary.com]

equitable, and comprehensive outcomes because their collective
experiences and perspectives allow for better decision making.1,10,11
Diverse teams not only garner more professional success, but are
also better prepared to close gaps in orthopedic healthcare outcomes
for women and minoritized individuals, such as the higher risk for
infections and other complications in racial and ethnic minorities
12,13
after a joint replacement. Recognition of disparities in muscu-
loskeletal treatment of racially or ethnically diverse individuals is
14
troublingly low among orthopedic surgeons. More awareness and
research in these areas are essential to address such disparities in
musculoskeletal and orthopedic healthcare treatments and out-
comes. A more diverse and inclusive ORS community can educate
and identify solutions for these problems.
Medical school classes and many graduate programs in the
United States are now gender‐balanced and have more racial and
ethnic diversity than ever. Unlike other research, medical and sur-
gical specialties, orthopedics does not yet reflect this balance.5‐7
Despite these challenges, success stories provide lessons to consider.
Orthopedic departments with more diversity in their faculty have
greater success in recruiting women and underrepresented mino-
rities into training and faculty positions.15,16 Structured programs,
such as the Perry Initiative and Nth Dimension, also appear to make a
difference in increasing the number of women and underrepresented
minorities in orthopedic surgery.17,18 This success indicates that
mentoring matters. However, maximum benefit from diversity in-
itiatives will not be achieved if these learners do not also see role

F I G U R E 2 Self disclosed gender identities

of ORS members in July 2019. ORS,
Orthopaedic Research Society [Color figure
can be viewed at wileyonlinelibrary.com]

EDITORIAL
models at orthopedic meetings, are not included in decision‐making
processes or leadership of professional societies, are not allowed to
express their perspectives and utilize their experiences to enhance
productivity, and/or feel physically or psychologically unsafe.
A commitment to DE&I at ORS meetings and sponsored events is
essential for providing all individuals with full access to professional
development and advancement. In a competitive research environ-
ment, success in securing research funding and academic promotions
requires evidence of research productivity, impact, and recognition
of investigator reputation at the national and international levels.
ORS meetings are a valuable platform for investigators to gain re-
cognition and visibility for their ideas, augmenting the chance of
success in future publications, grants, and promotions. Given that the
success of diverse investigators improves the recruitment of diverse
research and clinical trainees, as well as research and clinical out-
comes, the inclusion of diverse groups in membership, leadership, and
presentations at meetings of ORS is foundational to the success of
diversity efforts throughout orthopedics.
HOW C AN ORS PROMOTE AN IN CL USIVE
ENVIRONMENT ?
Inclusive environments are mosaics of individuals in which differ-
ences are celebrated and viewed as strengths, as opposed to melting
pots in which assimilation is favored and biases persist. Within the
ORS, the Women's Leadership Forum (WLF) has welcomed women to
the field, provided a network of mentors and peers, and nominated
and sponsored women for awards and podium positions as well as
board/committee membership since 2005. The WLF's success is re-
markable. In 2018, the ORS was one of nine orthopedic research
societies (out of 23) with a greater percentage of women on the
Board of Directors than in their membership (44% vs 25%).19 Over
the last 25 years, the field has also seen increases in the number of
women in leadership roles within the ORS, on the Editorial Board of
this journal, and in women cited as first and corresponding authors in
this journal.20,21
While the WLF has developed women leaders and fostered a
sense of belonging for women within the ORS, there is still much to
do to advance the inclusion for all minoritized individuals in the
Society. Symposia and panels composed only of men (“manels”) or
white individuals perpetuate the impression that women or people of
color are not experts and are not welcome in the field. When women
and minoritized groups are not represented on panels, other biases
often emerge. For example, women are less likely to be introduced
with a professional title (eg, Dr X) than male co‐panelists.22 The
subtle (and often unintentional) message to the woman and the au-
dience is that she is less qualified than other panelists. These and
other microaggressions, which could be intentional or unintentional,
can be prevented by populating program committees with diverse
members, by addressing each other with respect, and by seeking
broad input from a diverse membership. Each of us can take steps to
identify our own unconscious biases (as we all have them) that
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| 1663
inadvertently prevent us from being inclusive. These actions include
reviewing our contact lists, asking our colleagues for feedback, and
taking online Implicit Aptitude Tests (www.implicit.harvard.edu).
Awareness of personal unconscious biases is the first step to chan-
ging our behavior and becoming advocates for inclusion.
The “leaky pipeline” in science is well documented, as women and
underrepresented minorities are not well represented in the pro-
fessoriate, C‐suite, or other senior leadership positions, despite more
women receiving advanced degrees.23 For example, women have
comprised more than half of the class in doctoral programs in biology
or biomedical sciences for well over 20 years, but the percentage of
faculty positions held by women or federal research funding awarded
to women are far below 50%.24 Motherhood is one of several drivers
of gender imbalance at higher career levels (eg, faculty, department
chairs, deans) in STEM (science, technology, engineering, and
mathematics) fields. Indeed nearly twice as many new mothers as
new fathers leave full‐time employment after becoming parents.25
Male and female scientists share drive and capacity to excel in re-
search careers, but our systems do not equitably support women
during their transition to parenthood. Reasonable accommodations
for new parents, especially new mothers, at professional meetings
would address some of these concerns.25 Arrangements could in-
clude providing dependent‐care travel grants, on‐site lactation
rooms, help with freezing and shipping of milk home, and affordable,
high‐quality child care. The risk of not providing these services is
greater to the Society's future than potential liabilities, which can be
managed with careful planning.
In addition to the pressures of parenthood, unconscious bias and
harassment are major factors that drive women and minoritized in-
dividuals (especially sexual and gender minorities but also racial and
ethnic minorities) from STEM fields.26 Sexual harassment and coer-
cion occur at scientific meetings and significantly decrease feelings of
safety and inclusion. As many as 75% of physics undergraduates
reported some form of sexual harassment while attending a scientific
meeting.27 The ORS has a Code of Conduct that forbids sexual har-
assment at its events; however, it is likely that many instances are
not reported because victims fear retaliation or believe that nothing
will be done. Such demoralizing experiences may lead these in-
dividuals to leave the field, despite years of training and lifelong
interests. Other forms of harassment also contribute to individuals
not reaching their full potential. These include but are not limited to
persistent comments about appearance or parenthood, slurs, and
inappropriate touching or communications (eg, text messages). The
consequences can include a reduction in the victim's sense of be-
longing and/or exacerbation of imposter syndrome. A consensus
study of the National Academies of Science, Engineering, and Medi-
cine concluded that professional societies have a major role in up-
holding behavioral standards during meetings and collaborative
research events.26 Importantly, the report also concluded that pro-
fessional societies can be drivers of change in the community via
their capacity to educate, inform, train, codify, and reinforce cultural
expectations for their field. The Task Force strongly endorses these
conclusions and would like to see the ORS fulfill this responsibility.

1664 | EDITORIAL
NE XT STEP S
In October 2019, the ORS Board of Directors reviewed the findings
from the Task Force, approved a revised Diversity and Inclusion
Statement for the Society (Box 1), and formed a new DE&I committee
that will further the work of the Task Force. Under the new ORS
2025 strategic plan, the Board of Directors also identified DE&I as a
core value of the ORS and defined a community objective to cultivate
a diverse, inclusive, and engaged ORS by increasing access and op-
portunities. These first steps lay the foundation for more discussions
and programs to better connect ORS members to each other and to
those who benefit from our work, especially patients and learners.
The new DE&I Committee will monitor and prioritize issues in a
rapidly changing area. Immediate needs include expanding our under-
standing of diversity in the ORS and increasing the diversity profile of
our membership. The paucity of data on dimensions of human diversity
within the ORS membership concerned the Task Force because it
prevents the Society from tracking the success of new initiatives and
can promote an inaccurate perception that the ORS does not value
member diversity. Benefits of collecting more data include: better re-
cognition of human diversity in the ORS; improved definition of member
needs; informed ORS meeting programming; representative diversity in
conference speakers, moderators, and organizers; better capabilities to
evaluate how ORS demographics compare to other organizations and to
the communities suffering from musculoskeletal and orthopedic condi-
tions; and becoming a resource for members who are studying diversity
at their institutions and/or recruiting new scientists or engineers.
Security and privacy concerns with data collection are manageable risks
with proper investments in technology, deidentification of data, and
assurances that protections are in place regarding access to the data.
Overall, benefits of collecting more data on the diversity and inclusion
of the ORS outweigh the risks.
We envision that the new DE&I committee will build on the ideas
identified by the Task Force and address contemporary issues going
forward. We anticipate that this committee will drive data collection
efforts, monitor DE&I initiatives and progress, and organize training and
educational events that celebrate and increase awareness of its im-
portant role in the Society. The new committee will also advise the
presidential line, Board of Directors, programming committee and other
groups and committees in ORS, including staff, for years to come. In
sum, the DE&I Committee members will advocate for DE&I throughout
the Society and work to identify and remove barriers (known and yet
unknown) that prevent access and reduce interest in orthopedics.
The ORS is poised to lead the orthopedic research community in
implementing the best DE&I principles and to shape the future or-
thopedic workforce. Innovation, diligence and sustained commitment,
including financial investments from the Society, will be required to
achieve DE&I goals. ORS leaders should have competencies in these
areas and promote, through words and action, the conviction that
DE&I are important to the Society. Ultimately everyone is re-
sponsible for achieving DE&I in our field, not just those who are from
underrepresented groups or whom we wish to recruit, retain, and
assist. We encourage everyone to examine and understand how bias
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Box 1 ORS Diversity and Inclusion Statement
The ORS is a dynamic scientific community that advances
musculoskeletal discovery to improve health. Society ac-
tivities and governance aim to engage conscientious in-
dividuals from diverse social, scientific, and professional
backgrounds to achieve our goals and positively impact our
community. The ORS cultivates a diverse, inclusive, and
engaged community by promoting and increasing equitable
access and opportunities to individuals of all races, ages,
ethnicities, nationalities, gender identities, sexual orienta-
tions, abilities, incomes, religions, and all other forms of
human diversity.
affects their actions and to participate in DE&I efforts within the
Society.
In conclusion, as the premier orthopedic research community, ORS
has a responsibility to recruit, train, and retain a scientific and health-
care workforce that will discover and deliver treatments for millions of
people who suffer from musculoskeletal disability across the globe. To
achieve its new mission statement of accelerating musculoskeletal re-
search to improve health, ORS must foster the best research and in-
novation, be as diverse as the population being served, and engage the
entire workforce to deliver equitable solutions to patients.
AU TH OR CO NTRIB UTION S
Authors are listed in alphabetical order because contributions were
equal. The following authors were members of the ORS Task Force:
TA, KCF, BF, KMK, KJL, XSL, DMM, RO, RMQ, MvdM, and JJW.
These authors reviewed the report and provided crucial feedback:
CJH, JCI, and CMR. All authors approved the manuscript.
Tamara Alliston1
Kharma C. Foucher2
Brenda Frederick3
Christopher J. Hernandez4
James C. Iatridis5
Kenneth M. Kozloff6
Karl J. Lewis7
X. Sherry Liu8
Deana M. Mercer9
Ruth Ochia10
Robin M. Queen11
Clare M. Rimnac12
Marjolein C. H. van der Meulen4
Jennifer J. Westendorf13
1
Department of Orthopaedic Surgery, University of California
San Francisco, San Francisco, California
2
Department of Kinesiology and Nutrition, University of Illinois, Chicago,
Illinois
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EDITORIAL | 1665

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