It has been widely reported in recent years that orthopaedic surgery remains one of the least diverse specialties in medicine.
I have been encouraged by the attention and the increasing number of colleagues who have approached me asking, “What can I do? How can I help?” These questions reinforce optimism. After all, Martin Luther King, Jr. often said the “greatest tragedy of the [Civil Rights era] was not the strident clamor of the bad people, but the appalling silence of the good people.”
For those who are aware or becoming aware of racial disparities in the field and wish to help enact change, it is crucial to understand the root causes of the issue. This helps to build the skill set needed to effectively discuss and dismantle systemic challenges to parity for patients and medical practitioners.
Though Black people were free following the Civil War, Reconstruction did not immediately provide economic means for successful Black communities. Obviously segregation prevented Black Americans from holding many jobs and limited their earning potential. Black students could not attend better-funded, better-resourced white schools—including medical schools.
While the American Medical Association (AMA) technically allowed Black delegates, in practice substantial barriers to entry remained. For instance, a delegate had to belong to a local medical society which, particularly in the South, was difficult if not forbidden for Black doctors. Nevertheless, the Black community continued to educate Black doctors. Between 1868 and 1904, seven Black medical schools were founded in the United States.
Enter the Flexner Report. Abraham Flexner, an examiner with a reputation for the overhaul of medical education and a knack for philanthropy, was commissioned to undertake a review of all U.S. medical schools and recommend standards of operation for quality and safety. The report is now thought to be covertly funded by the AMA who both genuinely wanted to better the field of medical education and had a business interest in limiting access to their exclusive club.
The Flexner Report had what I like to refer to as, “The Good, The Bad, and the Ugly.” Under the “good” heading, at least the report acknowledged Black medical schools for the first time. It also called out the lack of funding and resources causing issues in further institutional advancement. However, the “bad” side was that he failed five of the seven black medical schools, implying Black students and practitioners did not receive adequate training, thereby forcing their closure.
Flexner’s ”ugly” support of segregation in medical care was likely a contributing factor. He favored Black medical education for the purpose of Blacks serving Blacks. He wrote, “Black students should be trained as ‘sanitarians’ rather than surgeons and their primary role should be to protect White people from disease. A well-taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an MD degree is dangerous.”
The impact of the closures was both immediate and lasting. Only Howard University (Washington, D.C.) and Meharry Medical College (Nashville) remained, further limiting the access for the few aspiring Black doctors with means to acquire a medical education. Segregation of other institutions lingered for decades. Up until 1964 when the Civil Rights Act was passed—in my lifetime—12 of 26 medical schools in the southern United States were still segregated. The three largest historically black colleges and universities (HBCUs) with medical schools (Howard, Meharry, and Moorhouse College in Atlanta) still graduate more than 70% of Black doctors.
Perhaps most troubling, the ratio of Black doctors to the Black population in our country completely stagnated. In 1910, the year the Flexner Report was published, the ratio of Black physicians to the Black population was 2.5%. In 2008, when the AMA finally officially denounced its own institutional racism, the ratio was still just 2.2%. It is estimated an additional 28-35,000 black doctors would have been educated between 1910 and 2019 had the other five schools remained open.
If we can all accept the root cause and direct outcomes of this history, we can come together to rectify the issue. To answer the questions posed in my opening paragraph, there are three key strategies that will help close racial and ethnic gaps in graduate medical education.
Recognize, Address, and Educate
We must recognize that U.S. medical history cannot be separated from slavery. Much as we would not perform an amputation on a diabetic without addressing their blood sugar, or a knee replacement on a 350 lb. patient without a discussion about obesity, we cannot have a conversation about how to diversify medical providers without the context I’ve provided above.
Once we recognize these facts, we can build the skill set to address the issue of underrepresentation of Black, Latino and Native American doctors. It’s important to actively seek out data and evidence-based practices to root out biases in ourselves and our institutions. This is not just an academic exercise; we know these disparities negatively impact patient outcomes for these underrepresented groups.
Therefore, we as physicians have an obligation to educate ourselves and others on the need for intervention. So many providers and patients are still unaware of the problems because they are not directly affected. We can encourage them to practice empathy to move past apathy to find collective solutions.
Invest in Black, Latino, and Native American Education
As a nation, we need to make greater strides in educating underrepresented populations to increase their likelihood of application and admission to college (and, subsequently, medical school). This will require significant investment in the education pipeline, as well as direct support given that many Black, Latino and Native American families still lack the resources to pay for higher education. There might be a few more billion-dollar donors out there to make medical school tuition free in perpetuity, but let’s not count on it!
With many state courts dismantling affirmative action programs, all eyes are on new initiatives like direct admission and Common App designed to create inclusivity and improve access to college.
Increase Diversity in Leadership Roles
Much like a diverse medical team, diverse and inclusive leadership improves patient care. Though slow, the country continues to make progress in diversifying hospital boards and C-Suites.
As we work toward balancing the scales, CEOs, deans and chairs can take a look at the makeup of their staff, fellows and residents and decide to actively recruit more Black, Latino and Native American candidates. A key part of my own success was the sponsorship of influential leaders; in medical school, John Lachman, MD, the storied chair of orthopaedics at Temple University, recommended me to another Temple alumnus, John Bergfeld, MD, who personally invited me to enter the residency program at Cleveland Clinic.
We need to replicate this intervention. We need to see more intentional action from decision-makers to turn the tide. It will require structured, systemic initiatives like the ones at NYU Langone and the Kaiser Permanente Bernard J. Tyson School of Medicine, which opened in 2020 with a model specifically dedicated to its namesake’s long tradition of forging new paths in equity, inclusion and diversity.
This may be particularly true in orthopaedic surgery and sports medicine, where the needle has been even slower to move. In my 30 years at the University of Minnesota, we have yet to educate a Black sports medicine fellow. There are promising signs on the horizon, like the NFL’s nascent partnership with HBCUs to improve the sports medicine pipeline, but we need more action to encourage Black, Latino and Native American medical students to enter orthopaedic residency and choose sports medicine, and more effort to create additional spots for diverse practitioners on our medical teams. Together, we can move from apathy to empathy to action, and improve patient care.
Joel Boyd, MD, is an Adjunct Assistant Professor in the Department of Orthopaedic Surgery at the University of Minnesota; Head Team Physician for the Minnesota Wild; and Co-Chair of the AOSSM Diversity, Equity and Inclusion Committee. He was the first African American orthopedic surgery resident at the Cleveland Clinic and the first NHL (National Hockey League) and second NFL (National Football League) team physician of color, and serves on the NHL’s DEI task force, Hockey is for Everyone.