October 2016

Women’s Work: Overcoming gender barriers in lower extremity specialties

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In lower extremity healthcare, as in politics, it hasn’t been easy for women to succeed in traditionally male-dominated roles. The gender demographics have shifted toward parity over time—in some specialties more than others—but challenges still remain.

By Emily Delzell

One need look no further than the current presidential election to know that, even though it’s 2016, being a woman in a traditionally male field still makes a difference. Yet, if the majority of current polls prove right on November 8, Hillary Clinton will shatter one of the last glass ceilings for women in the US, becoming this country’s first female chief executive.

In some lower extremity specialties those barriers began falling long ago, and the faces of leaders in O&P, podiatry, biomechanics, athletic training, and even orthopedic surgery (notorious, at least in the past, for its “jock and fraternity” culture1-3) are increasingly female. Some are even at or approaching parity, especially among students. But women are still in the minority in many of these fields.

According to the American Orthotic & Prosthetic Association (AOPA), in 2014 20% of practitioners who had registered with the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) were women, a 748% increase since 1994; ABC also estimates women and men now enter O&P in about a 1:1 ratio.4 Among professional members of the American Society for Biomechanics (ASB) who report their gender, 31% are women, as are 42% of student members (2016 data).5

American Podiatric Medical Association (APMA) data show that, in 2015, the profession was almost exactly 75% men and 25% women. The APMA has been tracking gender in the profession only since 2012, when it reported 22.79% of podiatrists were women.6 The American Association of Colleges of Podiatric Medicine has been following the gender balance among podiatry students for decades, however. In 2015, 39% of its student members were women, up from 23% in 1985.6

“I recall in the not so distant past looking around a conference room and picking out just a handful of women in row upon row of attending podiatrists, but now this is less visible with many, many young women filling up those seats,” said Georgeanne Botek, DPM, podiatry section head at the Cleveland Clinic in Ohio. “The dynamic for me as a female has been a positive one–most of the time.”

Fewer than 14% of orthopedic surgery residents in 2010 were women, the smallest percentage for any medical specialty except cardio­thoracic surgery1 and, in a 2015 American Academy of Orthopaedic Surgeons (AAOS) census, just 5% of respondents were women.7

Women make up more than 50% of the National Athletic Trainers’ Association (NATA) membership (and 60% of its student membership) but hold 32.4% of collegiate head athletic trainer positions and only 19.5% of Division I head athletic trainer positions, according to a 2014 survey.8

Botek and the other six women interviewed for this article, who are leading their lower extremity fields in clinical, research, and professional roles, agreed paths to education, advancement, and leadership are more open and welcoming to women than ever.

Donna Robertson, MS, ATC, LAT, CPed, (clockwise from left) with her plaque in 2000 as the first woman inducted into the Alabama Athletic Trainer's Associa- tion Hall of Hame; at the 2004 Athens Olympics with track and field silver medalist Coby Miller; and at Foot Solu- tions in The Villages, FL, with pro golfers Nancy Lopez and Helen Alfredsson.

Donna Robertson, MS, ATC, LAT, CPed, (clockwise from left) with her plaque in 2000 as the first woman inducted into the Alabama Athletic Trainers’ Association Hall of Hame; at the 2004 Athens Olympics with track and field silver medalist Coby Miller; and at Foot Solutions in The Villages, FL, with pro golfers Nancy Lopez and Helen Alfredsson.

There are still challenges. Solid gender-specific data in these fields are hard to come by, but many of these women think equal pay for equal work isn’t a given, that reasonable parental leave, for most, is rarer, and that work-life balance in a demanding career is always going to be challenging.

Their perspectives span the last 50-plus years, a period that saw the rise of what historians sometimes call “second-wave feminism,” a postsuffrage movement aimed at dismantling the societally entrenched idea that women’s biology made them fundamentally unsuited—emotionally and physically—for “male” professions, as well as the fight for equal pay and against workplace discrimination.9

Among the movement’s accomplishments was the successful enactment in 1972 of Title IX, legislation prohibiting sex discrimination in education programs, including athletics, that receive federal funds. Schools were given six years to implement the law in full.

It ultimately brought millions of girls into athletics. Before Title IX only 3.7% of high school girls played a sport, versus 50% of boys.10 Today about 40% of high school girls take part in athletic programs,9 and many who become lower extremity professionals come to their fields by that route.4

Old school

Athletic training and pedorthic pioneer Donna Robertson, MS, ATC, LAT, CPed, began her career in athletics before Title IX. It was sports, along with an athletic injury, that led her directly into her future professions. Her junior college record as a volleyball player earned her a scholarship in 1972 to the University of Northern Alabama (UNA) in Florence, the first year the university offered women sports scholarships.

A fall from a horse in the spring of her second year in junior college kept Robertson from using the award.

“I dislocated and had multiple fractures to my ankle, which ended my volleyball career,” she said. “The volleyball team had managers to carry water and towels and do first aid, and the coach asked if I’d consider that. I told her no, I was so disappointed in not being able to play. But after I thought about it for about a week, I decided I wanted to be involved. And I wanted to find a way to help my own ankle.”

Robertson learned to treat her injury and many others from a male athletic trainer at UNA; since women weren’t allowed in the training room, she’d knock on the door and wait for him to come out and answer questions. She gained knowledge and experience, focusing on foot and ankle injuries.

In her senior year, members of the 1968 Olympic women’s volleyball team and coaches Mary Jo Peppler and Marilynn McReavy Nolan were in the audience when Robertson delivered a presentation on injury prevention for female athletes. They invited her to work with players at the Olympic training facility in Pasadena, TX. She then earned another scholarship, this time for a graduate assistantship at Murray State University in Kentucky with athletic trainer Tom “Doc” Simmons, ATC, who was starting the first coed athletic training room in the southeast.

In 1975, legendary football coach Paul “Bear” Bryant personally hired Robertson as the first women’s athletic trainer at University of Alabama (UA) in Tuscaloosa. Her $650 budget was a fraction of the men’s and her training room tiny—a converted storage area carpeted with old turf from UA’s Bryant Denny Stadium.

“Coach promised me that if I would contend with that storage area and take care of women’s athletics, at that time two-hundred-plus athletes, I’d get a new training room within the year,” Robertson said. “And, of course, every day as a female athletic trainer you had to prove yourself because that was a man’s world.”

She eventually got her new space, and in 1977 she became the first female certified athletic trainer in the Southeastern Conference. In 1978, she earned a master’s degree in health, physical education, and recreation from UA. In 1987 she became a certified pedorthist, fitting athletic teams around the US. Along the way she opened University Orthopedic Clinic (the first sports medicine clinic in Alabama) and an athletic shoe store called The Total Approach, both in Tuscaloosa, and a clinical practice at the Pedorthic Care Center in Birmingham.

“As women in these roles we have to continually prove ourselves, and I feel education is our key,” she said. “Having my master’s degree and athletic training experience gave me more respect within the male community. Getting my athletic training certification carried me further, and starting the sports medicine clinic opened up a whole new level.”

Among patients, acceptance was easier.

“I saw each patient as a gift to extend my knowledge and professional career, and I feel like what boosted my career was the people I treated and their successful outcomes, which they told others about,” she said.

Like Robertson, Mary Lloyd Ireland, MD, associate professor of orthopedic surgery at the University of Kentucky in Lexington, was an elite pre-Title IX athlete, swimming competitively through medical school at University of Tennessee Center for Hip Sciences (UTCHS) in Memphis and trying out for the Olympics in 1972 and 1976.

She also had early athletic injuries to her shoulder and back. Her orthopedist didn’t encourage her to think about his field as a profession, but she already had the “competitive bug” and wanted a career in medicine.

“My adviser at UTCHS discouraged me from going into orthopedics. There was a sex bias then that women shouldn’t go into orthopedics,” said Ireland, who graduated from medical school in 1978. “So I started off doing pediatrics, and after a couple days I said, there’s no way I can do this. I’d thought I wanted to do orthopedics, but by then I knew I’d be miserable if I didn’t. I followed my passion.”

Mary Lloyd Ireland, MD, at the 1992 Olympics (top) and in 2007 (left) and 2014 (right).

Mary Lloyd Ireland, MD, at the 1992 Olympics and in 2007 (left) and 2014.

She did her residency at the University of California, Irvine, where she was the only woman among 16 orthopedic surgery trainees.

“Having been an athlete, I knew I had to compete and be a team player,” Ireland said. “In any specialty, women have to do a better job and stand out a bit more, because you will stand out positively. If you don’t do a good job, then they’ll sure remember that too.”

With patients, Ireland saw her status as a woman as far less important.

“I had the confidence to know I could take care of patients, and I listened to them. What athletes really care about is that you know what you’re doing,” said Ireland, who was the team physician for the University of Kentucky’s football and other athletic programs for 12 years starting in the mid-1980s, one of her many roles as a lead physician for college and Olympic athletes.

One of her early mentors was the late Jacqueline Perry, MD, a pioneer in gait and biomechanics, who is perhaps best known for her work with postpolio syndrome patients. Ireland worked with Perry while a resident at Rancho Los Amigos Medical Center in California.

In terms of equal pay and benefits, Ireland, who spent 22 years in private practice before joining the University of Kentucky faculty eight years ago, said it wasn’t much of an issue for her when she was one of three orthopedists in her own practice.

“Since I joined the university, I feel my voice may not be heard as well,” she said. “That was one of the reasons I went into private practice, because I could control my money, put it into research or however I wanted to direct it. It’s been good to be with a university at the end of my career, and I enjoy teaching, but you still have some questions about how much of a difference you can make within the university structure being female.”

Inroads

Orthopedic surgeon Jo A. Hannafin, MD, PhD, and biomechanist Irene Davis, PhD, PT, FACSM, FAPTA, FASB, went through their education and training a little later than Robertson and Ireland.

That small gap in years (Hannafin earned her MD and a PhD in physiology and biophysics in 1985, and Davis got her master’s and PhD in biomechanics in 1984 and 1990, respectively) meant at least a few more female peers and perhaps faster acceptance (or at least less surprise) from male peers and faculty.

Hannafin, for example, was encouraged by a male surgeon to go into orthopedics, and in a way that made her change her mind about the specialty, which she’d already ruled out during a rotation in medical school at the Albert Einstein College of Medicine in the Bronx, NY.

Irene Davis, PhD, PT, FACSM, FAPTA, FASB, above and in the gait lab.

Irene Davis, PhD, PT, FACSM, FAPTA, FASB, inset and in the gait lab.

“My stereotype was of a big ex-jock doing a lot physical stuff, with not a lot of devotion to the details of patient care, and that stereotype was wrong, but that’s what I thought then,” said Hannafin, a professor of orthopaedic surgery at Weill Cornell Medical College and attending surgeon and senior scientist at the Hospital for Special Surgery (HSS), both in New York, NY.

Then came the need for a one-month elective that would give Hannafin—another elite athlete—the flexibility to leave work for five days to race at the trials for the women’s rowing world championships.

“Martin Levy [an orthopedic surgeon at Albert Einstein, where he now directs its orthopedic surgery residency program] said we could work it out, and he was amazing—he taught me how to suture and how to assist in the operating room,” Hannafin said. “He just poured his energy into me, and at the end of the month said something very telling that I’ll never forget: ‘You could be good at this.’ After watching him in his practice I thought, he has so much fun doing what he does. He’s taking care of athletes all day, and he’s solving their problems.”

Hannafin made it onto the world championship team and, while at training camp, made what she calls “a visceral decision based on this one-month interaction with this remarkable guy” to apply for ortho­pedics instead of pediatrics.

Davis, in some ways, got into biomechanics because of a then-insurmountable no-women policy in another male-dominated field.

Jo A. Hannafin, MD, PhD, at the 2016 Rio Games with rowing silver medalist and future orthopedic surgeon Gevvie Stone, MD.

Jo A. Hannafin, MD, PhD, at the 2016 Rio Games with rowing silver medalist and future orthopedic surgeon Gevvie Stone, MD.

“I wanted to be an FBI agent. I love using information and seeing what I can sort out; research is kind of like that, so it still satisfies that part of me,” said Davis, professor of physical medicine and rehabilitation at Harvard Medical School and director of the Spaulding National Running Center in Boston.

She was 15 years old then, and wrote to the FBI to ask about opportunities. She still has the letter she received, signed by J. Edgar Hoover, saying the FBI didn’t allow female agents.

Davissaid she found biomechanics much more open to women.

“I went to my first biomechanics meeting in 1987 and there were only a handful of women, but other than that I honestly never thought about it. I feel like this profession has always been very welcoming to women,” she said.

Leadership, role models, and gender bias

During her training and early career, Davis was able to follow the example of a few pioneering women in biomechanics, including Doris Miller, PhD, who in 1999 became the first woman to serve as ASB president. While working on her PhD at Pennsylvania State University in State College, Davis, who in 2008 was the ASB’s fourth woman president, formed strong, lasting bonds with the two other women in the program.

O&P and athletic training also saw women taking the lead role in major professional organizations by the turn of the 21st century.

Michelle Hall, MS, CPO, FAAOP(D).

Michelle Hall, MS, CPO, FAAOP(D).

The AAOP had its first female president in 1999 (Stephanie D. Langdon-Bash, CPO, FAAOP) and the NATA (Julie Max, MEd, ATC) did so in 2000. It wasn’t until 2009 that a woman became president of the American College of Foot & Ankle Surgeons (Mary Crawford, DPM), while the American Podiatric Medical Association (APMA) marked the milestone in 2010 (Kathleen M. Stone, DPM). Jo Hannafin in 2013 was the first woman president of the American Ortho­paedic Society for Sports Medicine (AOSSM). The AAOS has yet to have a woman president.

Michelle Hall, MS, CPO, FAAOP(D), prosthetics residency director at Gillette Lifetime Specialty Healthcare in St. Paul, MN, said the career of Langdon-Bash, currently a practitioner for Hanger Clinic in Phoenix, AZ, and the West Coast lead for its residency programs, inspired women in her generation. Hall’s first AOPA meeting, in 2003, was “very male-dominated,” she said.

“It felt like a boys’ club initially,” said Hall, who was the AAOP’s third female president in 2013. “Granted, I was new to the profession and didn’t know many people. Thankfully I had a good mentor [Donald Shurr, CPO, PT] who started introducing me. I use the same approach with my protégés.”

Hall did say she encountered not-so subtle gender bias when interviewing for residencies.

“I will never forget one inter­viewer’s question; she asked, ‘This is a male-dominated profession; do you think you’ll be able to handle that?’ I said, ‘Well, I came from engineering.’ Enough said! I hadn’t really felt [gender] would be an issue. I was surprised, and I think in retrospect, a bit disappointed that sort of question was being asked.”

Georgeanne Botek experienced something similar when applying for postgraduate training in the 1990s.

Georgeanne Botek, DPM.

Georgeanne Botek, DPM.

“There were programs that had reputations for taking only men,” she said. “I remember interviewing for a particular residency and feeling I didn’t get the time of day, as my interviewers were watching and discussing football as my interview was going on. Now those same residencies previously known to take only men are accepting female residents.”

Today, Botek sees gender as much less of an issue.

“I’m happy that now, as a staff attending and holding a leadership role in my institution, I can help facilitate and impact the profession of younger women in podiatry,” she said. “At times, it can be difficult jumping into a conversation when surrounded by men, but feeling comfortable in one’s skin and having more life experiences enables me to do so.”

Hall said her experience is consistent with research suggesting that women generally benefit more than men from mentors, female or male.11,12 She recalls having had “fantastic” male mentors for her clinical and national leadership roles.

“I’m very thankful to those individuals,” she said. “It hasn’t really been until the last few years that I’ve had an informal female mentor [Alicia J. Davis, MPA, CPO, FAAOP]. She’s a longtime residency director, and it’s been really helpful to ask her questions and rely on her expertise.”

Women’s professional groups within lower extremity specialties match mentors with mentees, provide a structure for women to discuss female-centric issues, and promote professional development and leadership. These include the Ruth Jackson Orthopaedic Society (rjos.org), The Perry Initiative (perryinitiative.org), the American Association of Women Podiatrists (americanwomenpodiatrists.com), the Women in Orthotics and Prosthetics Committee (oandp.org/wop), and many others.

Female role models don’t just benefit women at the start of their professions. Rosemary Ragle, MS, ATC, recently left the University of Connecticut in Storrs after 16 years as head athletic trainer for women’s basketball, a span that saw the Huskies win nine Division I national championships. She’s now a clinical instructor at HSS and head athletic trainer for the New York Liberty of the Women’s National Basketball Association.

A major part of her decision to join HSS was the inspiring array of women she’d be working with, including Jo Hannafin.

“I was so impressed with the women of HSS, from the physical therapists to the athletic trainers to the orthopedic surgeons to the chief medical officer,” Ragle said. “College athletics still tends to be very male-dominated, and I was intrigued by and wanted to be part of what I saw as a female-dominated group. My hope is to learn from these impressive women and become a better, stronger female in my field.”

Balance

When asked if athletic training in general is male-dominated, Ragle initially demurred, saying that, even as an undergraduate at Troy State University in Alabama in the 1990s, there were more women in her program than men.

“But you know, when I think about it, I’m the last female in my graduating class still in the profession, and I’m also unmarried and have no children—think there’s a connection?” she said. “I think a lot of women are drawn to the field because they love athletics and, unfortunately or fortunately, I didn’t have that barrier where you had to make a decision.”

Irene Davis, who feels that, in biomechanics, her gender hasn’t mattered much, said one way women who are considering the field differ from men is in their concern with work-life balance.

“The questions of males and females are very similar; basically, how do I advance my career, but what females come to me differently about is to ask, ‘How do you balance it all?’” said Davis.

Hannafin’s group at HSS, which includes four female orthopedic surgeons who live very different lives, gives younger women who are interested in the profession a chance to see examples of women striking a good balance in diverse ways.

Rosemary Ragle, MS, ATC, in the UConn training room and at one of the Huskies' regular-season games.

Rosemary Ragle, MS, ATC, in the UConn training room and at one of the Huskies’ regular-season games.

Taking time off for childbirth, child care, and other family responsibilities is one reason Michelle Hall thinks there are still too few female O&P practitioners who are business owners and managers.

“I think a lot of people were choosing family and were less able to take on leadership roles. In the same respect, many didn’t have those extra hours to do the volunteering [that comes with achieving those roles], often done at home after work is done,” said Hall, who considered orthopedic surgery but ultimately decided on O&P, in part because of the better life-work balance she thought it offered.

With more and more women entering and rising in the profession, however, said Hall, “the pendulum is starting to swing toward employers allowing the flexibility to have that family and career balance.”

Mentoring should remain a high priority, she said.

“Even as the gender gap closes, there’s still a strong need for mentoring within our profession,” Hall said. “Mentors, regardless of gender, can really encourage us to push the envelope of what we can do and how we can participate within our profession.”

REFERENCES
  1. Lewis VO, Scherl SA, O’Connor MI. Women in orthopaedics—way behind the number curve. J Bone Joint Surg Am 2012;94(5):e30.
  2. Farooq S, Kang SN, Ramachandran M. Sex, power and orthopaedics. J R Soc Med 2009;102(4):124-125.
  3. Miller EK, LaPorte DM. Barriers to women entering the field of orthopedic surgery. Orthopedics 2015;38(9):530-533.
  4. Calabro A. Steady increase found in female demographics for the O&P field. Business News. Georgia Tech Colleges of Sciences website. http://www.ap.gatech.edu/mspo/March%202010%20OPBN%20Hovorka%20comments.pdf. Published March 2010. Accessed October 7, 2016.
  5. Stacie I. Ringleb, PhD, secretary and membership chair, American Society of Biomechanics, email communication, October 6, 2016.
  6. Beth Shaub, director of Membership Services, American Podiatric Medical Association, email communication, October 7, 2016.
  7. AAOS Orthopaedic Surgeon Census 2014. American Academy of Orthopaedic Surgeons website. http://www.aaos.org/2014OPUS/. Accessed October 9, 2016.
  8. Acosta VR, Carpenter LJ. Status of women in intercollegiate sport: a longitudinal, national study. 2014 update. Women in Intercollegiate Sport website. acostacarpenter.org. Accessed October 3, 2016.
  9. Maren Wood L. The women’s movement. Protest, change and backlash: The 1960s. In Walbert D, ed. Postwar North Carolina. Learn NC website. http://www.learnnc.org/lp/editions/nchist-postwar/6055. Accessed October 3.
  10. Stevenson B. Title IX and the evolution of high school sports. Wharton Sports Business Initiative website. http://whartonsportsbiz.org. Accessed October 4, 2016.
  11. Hill JF, Yule A, Zurakowski D, Day CS. Residents’ perceptions of sex diversity in orthopaedic surgery. J Bone Joint Surg Am2013;95(19):e1441-e1446.
  12. Srivastava SB. Network Intervention: Assessing the effects of formal mentoring on workplace networks. Social Forces2015;94(1):427-452.
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