Gender equity, waiting lists and the trauma and orthopaedic profession

By Meryam Benaichouche
5th year medical student at University College London

Given the UK’s ageing demographic, T&O doctors are forced to confront problems of chronic pain and non-urgent presentations leading to a rise in elective procedures, such as elective joint replacements (EJR), and outpatient referrals¹. However, the seismic disruption of COVID to ‘non-essential operations’² have led waiting times for non-urgent interventions and elective surgical procedures to rise exponentially. This is troubling given that significant delay of EJRs - including ‘the operation of the century’³, the total hip arthroplasty - can lead to deterioration of physical, mental and social wellbeing⁴. Sustaining and improving standards of orthopaedic care since COVID, and improving patient quality of life, now desperately rely on managing both the patients on the waiting lists, and actively managing the waiting list itself. All of which are impossible tasks without a sustainable workforce. This piece will focus on addressing waiting times as a key intervention for upholding standards of care, and efforts towards gender equity in T&O as a means of sustaining the workforce long-term.

Sustaining standards of care

Managing waiting patients requires T&O departments to work with primary care networks to create soft interventions; a supportive, scalable sequence of resources (Figure 1) that allows patients to self-manage during the waiting period to prevent physical and mental health deteriorations⁵. Managing the waiting list itself involves a review process that assesses present condition and reprioritises patients according to need. The benefits of this dual approach are two-fold. Firstly, preventing further health deterioration. Secondly, optimising patient engagement during normally silent waiting periods. Surveys⁵ point to a lack of clarity and anxiety, and not just ongoing pain, as reasons for poor patient feedback. Acting on these concerns, notwithstanding the larger, arduous task of cutting waiting times, can massively increase patient satisfaction rates.

A patient-supported blend of digitalisation in the form of video consultations and telephone follow-ups for those who do not need in-person assessment can also serve to cut waiting times. Patient initiated follow up (PIFU) systems, modelled and implemented effectively in a minority of trusts⁷, have been shown to reduce up to a third of outpatient appointments (Table 1) when patients' conditions are stable.

The suggestions above share an increased role of patients in managing their conditions. Such interventions are framed in the literature as 'patient-led' or as promoting patient 'ownership'. Whilst true from one viewpoint, it is important to acknowledge a shift in the duty of healthcare provision and recent trends in redistributing much of this labour to the patient. The ability of patients to take up this labour falls along existing structural, socio-economic and racial inequalities which risk deepening ‘health inequity’⁸.

Sustaining the workforce: Recruitment, retainment, retirement

A survey⁹ of the T&O workforce anticipates a capacity gap due to early retirement by senior clinicians, delays in qualification secondary to reduced training opportunities for current trainees and anticipated poor recruitment. Equally important are poor perceptions of the T&O specialty amongst students, particularly female medical students, and the inevitable effects of this on perpetuating future recruitment bottlenecks. Sustaining a workforce thus requires tapping into groups of doctors past, present and - the focus of this piece - future.

Recruitment: A 'feminist' take

The direct progression of doctors into specialty training after the foundation programme has fallen to almost 30%¹⁰ with ‘low morale, disconnect, unmanageable change and lack of personal and professional support’ being cited as leading causes¹¹. With over half of training doctors being women¹², T&O, a specialty where 92% of consultants are men, is placed in a uniquely precarious position. Gender equity in T&O hereby becomes an urgent matter of sustaining staff quality and quantity. Though legitimate efforts to increase the visibility of women in T&O exist, the reality is that 'women in surgery' events alone do not alter negative perceptions of discrimination and gender bias in orthopaedics¹³. T&O faculties with greater female faculty members expectedly recruit more female trainees but accepting that 'representation' may not be a reality for all T&O programs at this stage is the first step in sincerely tackling the gender divide in orthopaedics. Prioritising opportunities for female medical students to access T&O surgical mentorship and teaching is definitively more effective at creating and sustaining interest and should trump visibility-centred catchphrase sloganeering. Male mentorship, when positive and sincere, is equally effective¹⁴. Involving male members in the institutional effort through formal mentorship schemes not only increases job satisfaction amongst consultants but helps to create a co-led interest in gender equity. One whereby gender equity is a shared task and shared responsibility.

Conclusion

The influence of government imperatives on NHS services necessitates a state-driven model of healthcare delivery that increasingly crafts healthcare users as co-producers of and collaborators in healthcare delivery¹⁵. As individuals to be ‘cared for’¹⁶, sometimes before illness has even taken place, in the form of preventative strategies and community-based social care measures¹⁷. This evolution attempts to serve a complex ageing population with multiple morbidities and social care needs, but has, in the process, redirected limited financial resources away from acute or hospital-based services. The effect of this on the surgical workforce, particularly providers of elective surgeries such as T&O, is increased rates of burnout and low levels of self-esteem and motivation. The task of addressing waiting lists seems sisyphean and introducing clinician-led strategies to manage waiting lists is crucial in moving forward. Furthermore, anticipated bottlenecks in recruitment highlight why gender equity in T&O is everybody’s problem. Well-meaning strategies, which focus on female visibility, replicate labour inequalities by framing gender issues as exclusively ’women’s work’. In T&O, men must be encouraged into positions to positively and actively affect various scales of change, even if it is more appropriate for such efforts to be driven by female leadership. It is increasingly apparent that 92% of T&O leadership cannot simply ally itself but must help steer the ship.

References

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