The BOA announced their Inclusive Orthopaedics initiative in 2022 to stimulate cultural change and improve diversity and inclusion across T&O.

https://www.boa.ac.uk/about-us/diversity-and-inclusion/inclusive-orthopaedics-initiative.html

This article will cover:​

 

1. Basic Principles

2. Differential Attainment

3. Faith & Belief

4. Ethnicity & Race

5. LGBTQ+

6. Neurodiversity

7. Disability

8. Edits / updates / improvements?

Please see our separate articles including being a woman in Orthopaedics and sexual harassment.

1. Basic Principles
 
A more diverse orthopaedic community better serves our patients and best supports our colleagues. Trauma and Orthopaedics should be an inclusive surgical profession that inspires, attracts, and retains the best talent from a wide variety of backgrounds. The overriding principle is to listen to individuals lived experience and work hard to create an environment where all individuals are valued and not discriminated against.

Diversity is about who’s in the room – the degree of heterogeneity of characteristics in a trauma meeting for example. It is fact-based and can be measured. It needs to be improved within T&O.
 

Inclusion is about inviting contribution – it’s about seeking input and insight from a diverse group. It is behavioural and can be learnt.
 

Belonging is about creating for everybody a sense of welcome and being valued, not despite their diversity – and not solely because of it either. It’s about making space for everyone and valuing the richness that comes from different perspectives and experiences. It is values-based and comes from individual belief systems.

 

Racism is the process by which systems and policies, actions and attitudes, create inequitable opportunities and outcomes for people based on race.
 

Sexism refers to discrimination or prejudice based on gender or sex, typically against women. The term has origins in the feminist movement and refers to the incorrect belief that men are inherently more valuable than women or superior in some way.

Privilege is having greater access to power and resources than non-white/male people in the same situation do.

Microaggressions are commonplace daily verbal, behavioural or environmental slights, whether intentional or unintentional, that communicate hostile, derogatory, or negative attitudes toward stigmatised or culturally marginalised groups.
 

Examples:
Assuming the male surgeon in the room is the consultant.
Not pronouncing or spelling an individual’s name correctly.
Asking “where do you really come from?”.
A lack of awareness of personal space and personal boundaries.
Ignoring individuals and dissing an individual’s opinion or perspective.
 

Please be aware of how your actions influence and impact upon those around you at all levels.

Watch this TED talk: 3 ways to be more inclusive https://www.youtube.com/watch?v=jtJkIjUQHtE

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2. Differential Attainment
Differential attainment is the systematic difference in examination outcome between different groups of students depending on their protected characteristics and
socioeconomic background. 
The RCS has accepted that differential attainment exists in surgical examinations and it is widely believed that examination outcomes in surgery shine a light on inequalities that learners experience throughout the training environment.

Read their report in detail: 
https://diversity.rcseng.ac.uk/wp-content/uploads/2023/08/Differential-attainment-in-the-MRCS-pdf.pdf

In particular:

Men are significantly more likely to pass the MRCS Part A at the first attempt than women.

White candidates are more likely to pass the MRCS Part A and Part B at the first attempt than ethnic minority candidates.
Candidates under the age of 29 are more likely to pass the MRCS Part A and Part B at the first attempt than those aged over the age of 29.

Those from less privileged socioeconomic backgrounds perform less well in the MRCS than candidates from more privileged backgrounds.
 

The RCS research stresses the importance of understanding the true cause of this and hypothesises that this may be a result of an ‘accumulation of educational disadvantage over time.

The RCS is putting into place a number of steps to try to change the attainment gap:

https://diversity.rcseng.ac.uk/how-we-are-changing/differential-attainment/

 

3. Faith & Belief
Religious Wear
There are clear guidelines surrounding the wearing of religious garments in surgery. Most frequently this involves headscarves, turbans, kippots, veils, and covering the forearms. This is all covered in detail under NHS England, NHS Improvement. Uniforms and Workwear: Guidance for NHS Employers
https://www.england.nhs.uk/publication/uniforms-and-workwear-guidance-for-nhs-employers/#:~:text=Document-,Uniforms%20and%20workwear%3A%20guidance%20for%20NHS%20employers,-PDF226%20KB

Headwear
Headwear, for example, turbans and kippot, veils (Christian or niqab) and headscarves are permitted on religious grounds, provided that patient care, health and safety, infection control and security and safety of patients or staff is not compromised.
Normal cloth headscarves may be worn for each theatre attendance and washed at 60C with or without an additional theatre cap.
Alternatively, orthopaedic hoods or single use theatre disposable headscarves approved by infection control may be worn.
Orthopaedic hoods need to be opaque and cover the chest to fully meet faith requirements - as long as garments are secured neatly this is reasonable from infection control point of view.

See this excellent article about the wearing of hijabs in theatre:  https://hijabintheor.com/
 

The RCS have published an article on the experiences of hijabi women in theatre which is worth a read: 
https://publishing.rcseng.ac.uk/doi/full/10.1308/rcsbull.2022.118
 

Sleeves
In a few instances, staff have expressed a preference for disposable over-sleeves – elasticated at the wrist and elbow – to cover forearms during patient care activity.
Disposable over-sleeves can be worn where gloves are used, but strict adherence to washing hands and wrists must be observed before and after use. Oversleeves must be discarded in exactly the same way as disposable gloves.

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This is a brilliant podcast about experiences of Hijabi Muslim Women in surgery - well worth a listen: 
https://open.spotify.com/episode/4nQFCMnPIYy1IIi7fQhapS?si=EMA9VBCpRXG_oReExkiRMg
 

Ramadan and other Religious Fasts
During the month of Ramadan, many Muslims will fast each day between sunrise and sunset, and perform additional prayers and other religious duties. Staff should be aware of the potential effects on colleagues of not eating or drinking during the day, combined with a change to sleep patterns, and should consider taking steps to
support them. It should not be assumed that all Muslim colleagues will be observing Ramadan in the same way, or that those who are fasting will want the employer to make special arrangements for them. 

Employers should encourage all trainees to discuss with them any impact that they think fasting could have on their work, and any measures that could be helpful.
Steps that employers and colleagues could consider to support trainees who are observing Ramadan include:

• Actively acknowledge Ramadan in your department communications

• Making colleagues aware that it is Ramadan and encouraging them to be supportive of their fasting colleagues, in particular by not offering them food or drink

• Arranging shifts to accommodate employees' preferences where possible, for example:

o Swapping into night shifts rather than on-call days
o Allowing for lower energy and concentration levels in the afternoon, for example by scheduling theatre lists in the morning, and clinics/admin in the
afternoon
o Allowing flexible working, for example an earlier start time, a short lunch break or extra breaks for prayer.
o Accommodating requests for annual leave

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Other religious fasts include:

• Baha’i faith - 19-day period in March

• Christianity - some Christians fast during Lent, on Ash Wednesday, and Good Friday

• Hinduism - Some Hindus observe fasting during various religious festicals such as Navaratri (Autumn)

• Judaism - Some Jeish religious festivals involve fasting, best known is Yom Yippur

• Mormonism - church members are encouraged to fast on 1 Sunday each month

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Religious Celebrations

It is important to support our colleageus in place than for other celebrations. Be aware of these others and help your colleagues toIt is important to support colleagues in obtaining leave for important religious festivals where possible. This may be more simple for Christian celebrations where Bank holidays are celebrate them!

• Eid and Ramadan - two Eids, approximately 10 weeks apart, Ramadan is the period of fasting. Both Eids are equally important for Muslims and, where possible, it is vital for them to attend the Eid prayers in congregation, which usually take place in the morning. 

• Diwali - The Hindu religious holiday “Festival of Lights

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4. Ethnicity & Race

An unacceptable differential attainment still remains discriminating against those in ethnic minority groups. This is in regards to career progression and training opportunities, passing postgraduate exams, and also in obtaining consultant posts. 

 

Listen to this interview with orthopaedic consultant, Samantha Tross for a candid conversation about personal journeys, social responsibility, and Black History Month: 

https://open.spotify.com/episode/1BP6o2YJbAepaFnmJE1DB2?si=A6pRG-UfSE6Ytm4coPRIOA

Melanin Medics is a non-profit charitable organisation supporting present and future African and Caribbean doctors. Their focus is on supporting African and Caribbean aspiring medics, medical students and doctors in the UK who have been found to face a number of challenges on their career journeys.

https://www.melaninmedics.com/

The British Indian Orthopaedic Society (BIOS) aims to provide educational and research support to Orthopaedic Surgeons of Indian origin (UK or India born) currently in Training or Practicing in the UK, as well as those, who at any time have been trained in the UK over a substantial period but are now settled in India or other countries.

https://britishindianorthopaedicsociety.org.uk/

5. LGBTQ+

 

Listen to these great RCS(Eng) special edition “LGBTQ+ in Surgery” podcasts for a great insight into being an LGBTQ+ surgeon:

Approaches to LGBTQ+ visibility in surgery: 
https://open.spotify.com/episode/0Gg5OZmnE4EYmOyNS7kpcY?si=87nxh79HS2uaQXum0H4vzA

Life as an out LGBTQ+ Consultant: 
https://open.spotify.com/episode/18hZbl4tzpo31aWbDoV1u2?si=aHAE700VSj-t_MgLLExdFg

The trainee perspective: 

https://open.spotify.com/episode/0ZheZkNkJ1xnHSo0A4Ixij?si=E299YvUYREGwzFB4AwplPQ

Coming out as a transgender surgeon:
https://open.spotify.com/episode/0nduT2Up4ZqIinbcZbVtju?si=p6fL9YWoSLSRTYPcB5gjtw

Pride Ortho is a community of proactive lesbian, gay, bisexual, transgender, queer (LGBTQ+) individuals and their allies with a mission to provide mentorship, networking, and a sense of belonging for members of our orthopaedic community. Visit their website for loads of great information and advice:

https://prideortho.org/

Read these insightful interviews with various colleagues in our BOTA membership: 
https://www.boa.ac.uk/about-us/diversity-and-inclusion/pride-month.html

RCS England Pride in Surgery (PRISM)
A group of LGBTQ+ individuals and allies working towards cultural change in surgery.  Developing a network of LGBTQ+ individuals and allies; provide mentorship and pastoral support; produce inclusive policies and guidance; raise the visibility and profile of the surgical LGBTQ+ workforce; and perform outreach work with medical students and trainees to encourage them to pursue a surgical career. Working with RCSEng to ensure that its policies are inclusive, that any barriers to career advancement for LGBTQ+ surgeons and trainees are removed, and that RCSEng is an inclusive employer.

https://www.rcseng.ac.uk/careers-in-surgery/prism/

• 
  Pronouns

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  Gender pronouns are the terms people choose to refer to themselves that reflect their

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  gender identity. These might be he/him, she/her or gender-neutral pronouns such as

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  they/them.

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  Knowing and using a person’s correct pronouns fosters inclusion, makes people feel

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  respected and valued, and affirms their gender identity.

• 
  It’s important people, workplaces and organisations support people’s use of self-identified

• 
  first names and self-identified pronouns.

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  Being misgendered and/or misnamed can make the person feel disrespected, invalidated

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  and dismissed.

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  One way is to not assume a person’s pronouns, for example use the gender-neutral “they”

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  when one does not know a person’s gender, or respectfully ask what pronouns they use.

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  Use gender-inclusive terms when addressing a group e.g. everyone, colleagues, team,

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  attendees.

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  Apologize if you’ve misgendered someone - addressing someone they way they’ve asked to

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  be addressed demonstrates respect to the person.

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  By using gender-neutral pronouns, people are not making assumptions about another

• 
  person’s gender, nor are they making stereotypical assumptions about job roles — such as

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  using “he” pronouns for a doctor/surgeon or “she” pronouns for a nurse.

• 
  To show inclusivity, consider sharing your own pronouns - you can introduce your name and

• 
  pronouns in every setting, normalizing the practice of sharing pronouns and not making

• assumptions of people’s gender identity.

• 
  Adding pronouns to email signatures/Zoom + Teams name can also help normalise the

• 
  importance of using correct pronouns, avoid assumptions and fostering an inclusive

• 
  environment.

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  How to be inclusive of trans people in surgery

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  (many thanks to Alex Ashman, Pride in Surgery (PRISM) publicity lead for their content)

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   Transgender and gender-diverse people have always existed but, due to their

• 
  increased visibility, surgeons are increasingly likely to knowingly encounter

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  them in their day-to-day practice.

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   Transgender people are a diverse group, and need not have undergone

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  medical or legal processes to have statutory protection from discrimination.

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   Staff may be unaware that some colleagues and patients are LGBTQ+, and

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  should challenge discriminatory comments using an ‘active bystander’

• 
  approach.

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   Avoid assumptions about the gender of individuals and their partners. Refer

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  to individuals using the name, title and pronouns that they use.

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   Avoid disclosing a patient or colleague’s LGBTQ+ status without their

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  consent.

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   In clinical contexts where questions about an individual’s sexuality, gender,

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  anatomy, or previous procedures are genuinely appropriate, these should be

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  approached with sensitivity and in a confidential setting.

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   - LGBTQ+ people face barriers to healthcare, and so treatment with dignity

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  and respect is vital, particularly in the context of surgery.

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   - Avoid excessive fixation on the fact that an individual is transgender;

• instead focus on their individual care needs.

• 
  Watch this webinar summarising how we can support our LGBTQ+ staff: 

• 
  https://horizonsnhs.com/caring4nhspeople-webinar-24-june/

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  Read this RCS article: How can surgeons help transgender patients and colleagues feel

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  welcome?

• https://publishing.rcseng.ac.uk/doi/full/10.1308/rcsbull.2023.126

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  6. Neurodiversity

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  Dyslexia

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  One in  10 people are affected by dyslexia in the UK and 2% of doctors have the condition -

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  is an important topic for medical professionals.

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  Watch this webinar exploring dyslexia and how Mr David Holmes has learnt to cope with it.

• 
  https://app.medall.org/contents/v-boa-bota-culture-diversity-day-dyslexia-and-me-david-

• 
  holmes

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  Listen to this podcast: How to thrive in a high stress job when you are neurodivergent

• https://youarenotafrog.com/episodes/178/

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  7. Disability

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  Have a look at these useful resources:

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  The Association of Disabled Professionals:

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  Expertise of disabled professionals to improve the educational and employment

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  opportunities of disabled people.

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  https://adp.org.uk/

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  Association of Medical Professionals with Hearing Loss:

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  Provides information, promotes advocacy and mentorship, and creates a network for

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  individuals with hearing loss interested in health care fields.

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  https://www.amphl.org/

• 
  DIAL UK (Disability Information and Advice Line:

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  A national organisation for a network of approximately 130 local disability information and

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  advice services run by and for disabled people.

• https://www.dialuk.info/

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  8. Edits / updates / improvements?

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  These support / welfare articles require constant updating to reflect the changing world of

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  the modern Orthopaedic trainee.

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  If you have any edits / updates / improvements for this article please email them to:

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  wins@bota.org.uk

• Thank you for your support.

• ​

• Original article by Robyn Brown.Adapted for BOTA by Florence Shekleton.Many thanks to Nathanael Ahearn, Karen Chui, and Alex Ashman for their input on thisdocument.