Annual Meeting Recap Perceptions and Awareness of Gender Representation in Spine Surgery:

Insights and Lessons from the North American Spine Society (NASS) Women in Spine Symposium

Hania Shahzad, MD UC Davis Health Sacramento, CA

Lisa K. Cannada, MD Novant Health Orthopaedics Charlotte, NC

Elizabeth Yu, MD, PhD The Ohio State University Columbus, OH

Melissa Erickson, MD Duke University Durham, NC

Kathryn Jurenovich, DO SJWH Medical Education Department Warren, OH

There is a significant underrepresentation of women in spine surgery, as is the case in neurosurgery and orthopedic surgery, as well. Women are generally a minority in surgical fields, but the underrepresentation in spine surgery appears even more pronounced when compared to other surgical specialties.¹⁻⁴ This underrepresentation is evident not only in leadership positions, including department heads, professor level appointments, and chairpersons but also in the realm of research.⁵ The gender disparity observed in competitive subspecialties has multifaceted underlying reasons, which may encompass the unique characteristics of surgical fields, associated lifestyles, and gender discrimination issues. One contributing factor could be that these trends have only recently begun to shift, and many female spine surgeons are younger than their male counterparts.⁶⁻⁷ Orthopedic surgery has historically carried stereotypes of being physically demanding and a male-dominated field. In contrast, neurosurgery, while not characterized by the same stereotypes, is known for its long hours. Despite that, a survey of the membership of the Ruth Jackson Orthopedic Society (RJOS) in July 2019 suggested that factors such as female mentorship, family, pregnancy, significant others, and physical attributes did not influence women's choice of fellowship specialty.⁸ In contrast, women pursuing these predominantly male-dominated fields may experience negative pressures and be discouraged from pursuing these subspecialties. According to a survey conducted by the American Academy of Orthopedic Surgeons, 81% of women, as opposed to 35% of men, reported facing discrimination, bullying, sexual harassment, and nonsexual harassment in their orthopedic surgery practice.⁹ Approximately 81.5% of women, compared to 0.51% of men, reported being discouraged from pursuing careers as orthopedic surgeons, neurosurgeons, or spine surgeons due to their gender.¹⁰ These data may explain why orthopedic surgery fellowships had the lowest rate of female applicants between 2010 and 2014. Moreover, after completing neurosurgical residency training in the United States, only 13% of women chose to pursue spine surgery fellowships.³ Critical scrutiny of the perceptions of women in spine surgery, as well the associated stereotyping, is, thus, critical. This study investigates attendees' perceptions of gender representation in spine surgery, as observed at the Women in Spine Symposium during the 38th annual NASS meeting. At the 38th NASS Annual Meeting in Los Angeles in October 2023, a Women in Spine Symposium was convened. This event was sponsored by the Depuy Synthesis and was a collaborative effort of a team of female spine surgeons and researchers. Eighty people, representing various segments of the spine community, including neurosurgeons, orthopedic surgeons, industry representatives and advanced practice provers (APPs), participated.

The audience participated in a trivia game focused on the representation of women in spine surgery. Attendees joined the game anonymously by scanning a QR code. The trivia questions, outlined in Table 1, covered three distinct themes. Fact-based questions were designed to evaluate participants' statistical knowledge of the current representation of women in spine surgery, offering options with both correct and incorrect percentage values. Additionally, questions explored the perceptions of respondents concerning the factors contributing to low representation. Open-ended queries allowed participants to freely express their opinions and insights.

In conjunction with the trivia, an experience board was introduced, providing respondents with an opportunity to anonymously share both positive and negative experiences. This was facilitated by scanning a QR code and inputting their responses. Engagement across various questions differed. On average, 78% of the attendees responded to the survey, and a total of 44% of their responses were accurate. The statistical breakdown for each question is presented in Table 1.

Table 1. List of questions posed to respondents concerning the representation of women in spine surgery.

The analysis of the 7-question trivia suggested a significant lack of awareness regarding the current representation of women in spine surgery. Only five respondents (27.8%) correctly identified that women's representation was less than 10%. Astonishingly, merely a single participant (6.7%) believed that the representation was below 15%, while the majority of nine participants (60%) thought that women in spine surgery comprised less than 5%. In terms of perceived underrepresentation, 10 respondents (58.8%) identified spine surgery as having the lowest representation of women, whereas four (23.5%) thought this was the case for orthopedics, and three (17.7%) believed it was neurosurgery (Figure 1).

Figure 1. Section A Responses—Gender Representation Facts

Regarding fellowship applicants, seven (41.2%) expected women to account for 10%, with the second most popular choice being 5% (five, or 29.4%). Only four (23.5%) correctly identified it as 3%, while one (5.9%) overestimated it at 25% (Figure 2). When it came to the presence of women on editorial boards, ten respondents (62.5%) believed that only 1% of women were represented, while four (25%) correctly identified that 5.5% of women were on editorial boards. Two (12.5%) believed it was as high as 10%. While many respondents correctly identified the percentages of female versus male surgeons experiencing various forms of harassment, bullying, and discrimination, one respondent (6.3%) incorrectly reversed the percentages. Nearly all the respondents (15, 93.8%) incorrectly identified factors such as family, pregnancy, and significant others influencing the fellowship choice for women pursuing spine surgery. Only one (6.3%) correctly identified this as a false statement. Concerning men's awareness of these situations, the most popular choices were "no" or "maybe"; however, at least five (31.3%) believed they were aware (Figure 3).

Figure 2. Section B responses—Factors that influence women when pursuing spine fellowship.

Figure 3. Section B responses—Factors that influence women when pursuing spine fellowship.

Figure 4 displays the responses to the question of whether women are discouraged from pursuing spine surgery due to their gender, and Figure 5 presents the responses to the question regarding the reasons for the low representation of women in spine surgery.

Figure 4. Section C—Responses to open-ended question regarding gender based discouragement

Figure 5. Section C—Responses to open-ended question regarding reasons for low representation of women in spine surgery

The results of this study highlighted a knowledge gap of the symposium attendees. Attendees perceived the representation of women and spine surgery to be even lower than the current data suggests. This discrepancy may be attributed to a lack of visibility, potentially contributing to the overall perception of underrepresentation. Addressing this aspect is crucial when promoting a career in spine surgery to women, as evidence suggests that a predominantly male field can discourage women from pursuing careers in spine surgery.¹¹⁻¹² Dispelling this misconception, especially within the health care community, is crucial, starting at the earliest educational levels (eg, medical school). Exposing women to the contributions of female spine surgeons is essential to foster their interest and commitment to these specialized fields. NASS, as one of the largest spine societies, provides a unique platform for initiatives like focused symposiums highlighting the contributions of women in spine surgery, academic research studying gender disparities , and incentives for female medical students, researchers, and attendees. Such efforts can actively promote early exposure to spine surgery among women at the formative stages of their careers. Furthermore, this study affirmed that the majority of attendees held the belief that male colleagues lacked awareness of the challenges faced by women in the field of spine surgery. The literature also points to a higher percentage of women encountering these challenges compared to men⁹, even though men appear to be less cognizant of such situations.²,⁹,¹¹ Since medical students, when pursuing orthopedic surgery, do not exhibit a gender preference for their mentors.¹³ Given the predominance of men in spine surgery, it becomes imperative for male practitioners to acquire knowledge about these experiences in order to mentor equitably and instigate meaningful change. There is a need for targeted efforts aimed at gender-sensitive education, particularly for male orthopedic surgeons in both practice and training. The findings from the Women in Spine symposium shed light on critical aspects of gender representation and perception within the field of spine surgery. This underscores the clear need for education and awareness campaigns within the spine surgery community to rectify misconceptions and provide accurate information about gender representation in the field. A multifaceted approach is essential, encompassing the establishment of confidential reporting systems, mentorship programs, professionalism and conflict resolution education, diversity and inclusion training, support groups, and access to mental health services. Furthermore, ongoing policy review and enforcement, leadership support, ombudsman services, awareness campaigns, and anonymous surveys should be integral components of the strategy. The overarching objective is to foster a culture of respect, inclusivity, and support, ensuring the well-being and professional development of trainees while eradicating harmful practices in the field. It is also important to acknowledge that this study has limitations, including a small sample size, lack of demographic information about the respondents, and reliance on self-reported data. The focus on a specific event, the NASS’ Women in Spine Symposium, may not fully reflect year-round awareness or efforts to promote gender diversity in spine surgery. Future research could involve longitudinal studies and in-depth interviews. Women-centric symposia play a vital role in promoting women's interest in spine surgery by offering visibility, awareness, education, networking, community, and support while inspiring future generations and advocating for policy changes. In conclusion, this study highlights a knowledge gap among attendees and reveal the importance of dispelling misconceptions to foster gender diversity in the field.

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