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C OPYRIGHT Ó 2017 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

AOA Critical Issues

Leadership, Communication, and Negotiation Across

a Diverse Workforce*
An AOA Critical Issues Symposium
Denis R. Clohisy, MD, Michael J. Yaszemski, MD, PhD, and Joanne Lipman
Investigation performed at the University of Minnesota, Minneapolis, Minnesota

Abstract: The current workforce in the United States is rapidly changing and is increasingly inclusive of individuals from
a broad range of ages, ethnicities, and cultural backgrounds. Engaging and leading a diverse workforce creates great
opportunities for innovation and adaptation in our evolving medical economic and clinical care delivery environment. For
optimal engagement of employees and partners, orthopaedic surgeons must develop the necessary skills for executing
change inside complex organizations and across teams composed of a variety of providers and skilled workers. Im-
portant skills include leadership, effective communication, and negotiation within an ever-changing employee milieu.
Understanding generalizable differences between age-based generations can increase the effectiveness of one’s
strategies to execute change and increase organizational performance. One of the greatest impediments to effective
communication and negotiations that all leaders face is unconscious bias. For leaders, even the tiniest unconscious
biases have an outsized impact. Common domains that harbor unconscious bias include sex, race, and ethnicity. Ad-
dressing unconscious bias begins with developing awareness and then deploying various tactics that might include equity
in compensation, promotion, and “being heard.” Effective negotiation skills also are essential to lead a diverse workforce
and develop a successful organization. The most basic goal in any negotiation should be to establish a relationship (or
deepen an existing relationship) while seeking an agreement that provides win-win opportunities for all parties. To ef-
fectively achieve a win-win scenario, leaders must recognize and address their tendency to interpret others’ behaviors,
values, and beliefs through the lens of their own beliefs and experiences. Finally, and fortunately, there is a set of leader
attributes that transcends the generational differences and diversity that is encountered in the workplace. These attri-
butes include integrity, credibility, effective listening, having a vision of your destination, fairness, humility, and caring.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor
reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or
more exchanges between the author(s) and copyeditors.

*Presented as a symposium at the 128th Annual Meeting of the American Orthopaedic Association, June 25, 2015, in Providence, Rhode Island.

Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms
are provided with the online version of the article (http://links.lww.com/JBJS/C882).

J Bone Joint Surg Am. 2017;99:e60(1-5) d http://dx.doi.org/10.2106/JBJS.16.00792

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The current workforce in the United States is rapidly changing
and is increasingly inclusive of individuals from a broad range
of ages, ethnicities, and cultural backgrounds. Most medical
schools and orthopaedic surgery departments would report
that the majority of individuals working to achieve the day-
to-day operations of their organizations are women, younger
than the age of 30, older than the age of 60, or part of a mi-
nority. A recent publication from Forbes magazine summarized
findings from a survey of 321 chief executives1. Those polled
were running companies with an annual revenue of ‡$500
million, with 40% of the chief executives running organizations
with an annual revenue of >$5 billion. Participants were asked
to evaluate the extent to which they agreed or disagreed that a
diverse workforce was important for achieving future innova-
tions in companies; 48% strongly agreed and 85% somewhat
or strongly agreed that a diverse and inclusive workforce was
crucial to drive future innovation. In addition, it is interesting
to note that census data projections predict dramatic changes
within the workforce. Specifically, by 2050, there will be no
racial or ethnic majority in our country, and 83% of the growth
in the working-age population will originate from new immi-
grants and their children5.
Diversity among orthopaedic surgeons has increased
substantially over the past 40 years. Diversity among resident
trainees is the best measure of past and future workforce trends.
A recent report found that 20% of orthopaedic residents repre-
sent minorities, with the highest numbers being Asian (11.7%)
and African American (4%)2. Growth in the percentage of mi-
nority residents has increased for Asians (4.5% per decade) and,
more gradually, for Hispanics (1.4% per decade) and African
Americans (0.68% per decade)2. Between 1970 and 2016, the
percentage of female residents increased from 0.6% to 13%, and
recent data identified a higher rate of women (96%) matching
for orthopaedic fellowships than men (81%)3,4.
While engaging and leading a diverse workforce creates
great opportunity for innovation and adaptation in our rapidly
changing economic environment, it also highlights the need
for leaders to be effective communicators and negotiators in-
side a complex, ever-changing employee milieu. Fortunately,
there are several basic sets of principles and areas of knowledge
that can help to guide leaders and assist in the adaptation of
their styles and strategies to be more effective in the future.
Understanding the various age-based generational divisions
represented in the workforce can provide definition of and
clarity around the need to consider generational differences
when developing employee-targeted leadership strategies. In
addition, there is clear evidence that unconscious bias is present
in all of us, and understanding and adapting to these biases will
improve effectiveness as one leads a diverse workforce. Fortu-
nately, when we study leadership attributes that effectively mo-
tivate and inspire employees, there is a set of attributes that
transcends generational differences and diversity encountered
in the workplace. Finally, given the complex composition of
our workforce, it is helpful to apply basic tenets of negotiation
to advance the various strategies and missions that leaders pur-
sue either with large organizations or individual employees.
L E A D E R S H I P, C O M M U N I C AT I O N , AND N E G O T I AT I O N A C R O S S
A D I V E R S E WO R K F O R C E
Generational Differences
Understanding generalizable differences between age-based
generations can increase the effectiveness of strategies to execute
change and increase organizational performance. The majority
of our current workforce is composed of 3 generations5. These
include Baby Boomers (Boomers), Generation X (Gen Xers)
and Generation Y (Millennials). Generally speaking, Boomers
were born between 1943 and 1965, Gen Xers were born between
1965 and 1978, and Millennials were born between 1978 and
2002. In the domains of work ethic, views on authority, and
work-life balance, the Gen Xers and the Millennials are similar,
but distinctly different from the Boomers. Boomers are often
workaholics, are uncomfortable with authority, and are willing
to sacrifice work-life balance for professional advancement. In
contrast, Gen Xers and Millennials tend to work only as hard as
needed, are comfortable with authority, and place a high value
on work-life balance. Boomers, Gen Xers, and Millennials tend
to have different views on the need for supervision and to whom
they are loyal. In general, Boomers are insulted by supervision
and are loyal to the company, Gen Xers expect intermittent
supervision and are loyal to people, and Millennials expect con-
tinuous supervision and are loyal to ideas.
Unconscious Bias
One of the greatest challenges facing the orthopaedic community
is unconscious bias. Everyone (physicians as well as patients) has
biases that are buried so deep inside of us that we are unaware
that they exist. These biases may be against any “outsider” group,
including minorities, women, the disabled, the obese, and the
elderly. Understanding and adapting to our biases will improve
effectiveness as one leads across a diverse and inclusive workforce.
It is important to note that implicit bias is not inherently
bad; it is a survival mechanism. Scientists estimate that we are
bombarded with 11 million bits of information every second.
However, the human brain can process just 40 pieces of infor-
mation simultaneously6. Therefore, the subconscious takes
shortcuts. This can be extraordinarily useful. Our ancestors,
for example, had to react immediately if they were confronted
by a tiger or a hostile member of another tribe7.
But unconscious bias manifests itself whenever one sees
someone who is not in their “tribe” (e.g., if you’re a man, that
might be a woman; if you’re white, that might be someone who
is black). An implicit association test developed at Harvard
University has found that the vast majority of people have some
unconscious bias, in particular against women and blacks8,9.
For leaders, even the tiniest unconscious biases have an
outsized impact. A Rice University researcher created a com-
puter simulation of a company with an entry-level workforce
that was evenly divided between men and women. Each worker
was assigned a randomly generated performance score that was
programmed with a miniscule 1% bias against women. The
result? The top level of the organization was 65% male10.
In medicine, this kind of subtle bias helps to explain the lack
of women in the top ranks. A study published recently in the
Proceedings of the National Academy of Sciences found that elite male
faculty members in the biological sciences, including several dozen
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Nobel prizewinners, train up to 40% fewer women than either less-
distinguished or female faculty. It concluded that bias against
women was at the heart of the problem, and, as a result, women
“are vastly underrepresented at the faculty level in the life sciences.”11
In another study, led by Yale University researchers, sci-
entists were asked to evaluate resumes for a laboratory job. The
resumes were identical, except some applicants were named
“John,” and others were named “Jennifer.” The scientists believed
that they were making impartial, evidence-based assessments, but
the results showed otherwise. The scientists judged the male ap-
plicants to be more competent, and offered salaries that averaged
$4,000 more than those offered to the identical female applicants12.
If we consider race, the impact is even more pronounced.
The identical-resume experiment has been conducted using
black-sounding names (e.g., Jamal) and white-sounding names
(e.g., Greg), with the same result. In one study, resumes with
“white” names received 50% more callbacks than those with
“black” names13. This experiment pitted average resumes with
“white” names against highly skilled resumes with “black”
names. The white-sounding names received more callbacks13.
Furthermore, in an experiment pitting black male job applicants
with clean criminal records against white male applicants with
felony convictions, the whites got as many or more callbacks14.
We cannot eliminate our implicit biases, but we can take
steps to counteract them. Organizations are actively applying
methods to identify and neutralize unconscious biases. The
first step for leaders is awareness. Some companies have put
programs in place to remind leaders of their own biases. For
example, Google and the Royal Bank of Canada (RBC), both
very male-dominated industries, have introduced what they
call “bias cheat sheets” that leaders can refer to when hiring
or considering whom to promote. The cheat sheets ask various
questions: Do I typically hire the same type of person or per-
sonality type? When I say a candidate isn’t the right “fit,” what
do I mean? Whom do I encourage to speak out at meetings?
When it comes to recruiting at the entry level, the RBC
also designates 1 person on each college recruiting team to play
devil’s advocate to try to identify bias, such as whether a can-
didate is the best qualified or simply has something in common
with the interviewer (e.g., rowing crew or belonging to the
same fraternity). Google encourages its employees to call out
any examples of bias in other employees, even in a boss. Other
companies are trying more subtle approaches. Cardinal Health
has changed its approach to career fairs, staffing its booth with
female pharmacists rather than male, to send the message that
female applicants are welcome.
A second step that leaders can take is to even the playing
field when it comes to compensation. A Carnegie Mellon econo-
mist has found that men are 4 times more likely to ask for raises,
and that when women do ask, they ask for 30% less15. That is one
reason that there is still a substantial pay gap: according to the
2016 U.S. Census figures, women earn just 79 cents for every
dollar a man earns16. In the medical profession, a new study found
that even though nursing is overwhelmingly a female profession,
male nurses earn an average $5,100 more per year than female
colleagues in similar positions17.
L E A D E R S H I P, C O M M U N I C AT I O N , AND N E G O T I AT I O N A C R O S S
A D I V E R S E WO R K F O R C E
Awareness is the critical first step to effectively manage
biases. In the United Kingdom, new legislation will require
companies to publicly publish the wage gap between male and
female workers18; in the U.S., some companies have pledged
to do so voluntarily19. But even leaders who do not make those
figures public can perform an annual comparison of salaries to
make certain that compensation is balanced among different gen-
ders, races, and ethnicities.
A third step leaders can take is to reevaluate the promotion
process and whom they are choosing to promote. Medical schools
often lament about the lack of diversity in the top ranks. Leaders say
that they want more women in top jobs but there are not enough
qualified women. In reality, the problem is not at the top—it is at
the bottom, where there is a greater representation of women and
minorities. Why are white men more likely to be promoted up
through the ranks? Unconscious bias is one issue, as the Rice Uni-
versity computer model illustrates. But social scientists also have
identified another reason: women do not put their hands up for
promotion unless they feel they are 100% qualified for a position,
whereas men will raise their hands when they are 60% qualified20.
There are several interesting experiments for counteract-
ing this trend. At eBay, executive recruiters are required to
present diverse slates for every job opening. Google has begun
sending out what it calls “nudge notes” to remind women to
raise their hands for promotions. The tech giant has a system in
which engineers can nominate themselves for promotions, but
it noticed that men did so far more frequently than women. By
sending out simple nudge notes (basically saying, “we’ve no-
ticed that women aren’t nominating themselves, but hey, you
should”), they reversed the trend.
The fourth way in which some organizations are combat-
ing bias is by changing the way that meetings are run. Women
and minorities often find themselves overlooked or ignored in
meetings, or they make a suggestion that no one seems to hear
until a man repeats it and then gets the credit. Additionally,
women are frequently interrupted: one study found that male
technology executives interrupt women 3 times more frequently
than they interrupt other men21. The solution for this is simple:
everyone in a meeting, regardless of status, should be empow-
ered to call out those incidents (i.e., to recognize Susan, Shakoya,
or whomever it was that was interrupted or shut down, or whose
contribution was co-opted by someone else).
It is important for leaders to bake diversity into the incen-
tive system. At Kimberly-Clark, which makes Kleenex, Kotex,
and Huggies (among other products), most of the executives
have been white men, while the vast majority of customers are
women. So, the chief executive officer (CEO) made a concerted
effort to hire and promote more women. Many of the steps that
he took were geared toward making the company more family-
friendly (e.g., building lactation rooms for new mothers). But
perhaps the most crucial step that he took was changing the
incentive system for executive bonuses. Employees are judged
on 4 “buckets” regarding bonuses, and 1 of those buckets now
includes not just hiring, but retaining and promoting women.
Substantial effort has been applied to manage uncon-
scious bias in the field of medicine through education. These
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efforts include educational programs within medical schools,
universities, and health systems22. The Association of American
Medical Colleges (AAMC) has played a leading role in educating
about unconscious bias23 by providing single-day workshops and
4-day courses on the topic24. The AAMC also has provided sum-
mary suggestions from the literature, which can be applied dur-
ing the hiring process to mitigate some effects of unconscious
bias when evaluating applicants24. These include asking mem-
bers of selection committees to take an online “Implicit Associ-
ation Test” (http://implicit.harvard.edu/); provide an objective,
structured interview process; acknowledge that assessments of
candidates (including letters of recommendation) may present
skewed representations; recognize that cultural differences can
affect first impressions; and commit ample time for interviewing
and evaluating candidates because sex bias emerges more when
evaluations are performed under pressure.
Universal Leadership Qualities
In the rapidly changing culture of delivering musculoskeletal
care, all surgeons will be positioned to accept and excel in
leadership roles, ranging from leading a small team of care
providers to leading care delivery and/or academic activity in-
side large health systems and multispecialty groups.
Fortunately, there is a set of leader attributes that tran-
scends the generational differences and diversity that are encoun-
tered in the workplace. These attributes include integrity,
credibility, effective listening, having a vision of your desti-
nation, fairness, humility, and caring. Integrity is achieved
through actions that engender trust and competence. Cred-
ibility is gained through actions that lead to both success and
failure. Credibility demands honesty, humility, and compas-
sion during times of victory and defeat. Effective listening
requires hearing and learning through dialogue that is re-
spectful, challenges ideas, and assimilates the views of all
individuals at all levels of an organization. Leading requires
both a vision of where your organization is headed and the
ability to motivate others to execute the vision because they
are passionate about it. The softer attributes of fairness and
caring are essential for leaders. Leaders with high emotional
intelligence are self-aware, caring, and fair. They manage
relationships in a manner that is persuasive and not coercive.
They create agendas and visions that attract and do not ma-
nipulate others. Leaders who achieve or continuously pursue
these attributes will observe that a diverse and inclusive
workforce will follow them, execute a shared vision, and
enhance the likelihood of industry-leading innovation.
Successful Negotiations
Leaders in orthopaedics participate in negotiations at many
levels, ranging from high- stakes organizational negotiations
to negotiations with an individual employee. Organizational
negotiations can involve an academic department, a service
contract, a university, or a health system. Individual employee
negotiations can involve a high-impact, visible organizational
leader or an employee who provides a straightforward but
needed service. Fortunately, successful negotiations across di-
L E A D E R S H I P, C O M M U N I C AT I O N , AND N E G O T I AT I O N A C R O S S
A D I V E R S E WO R K F O R C E
verse and inclusive partnerships can be achieved through prin-
ciples that transcend a diverse and inclusive workforce.
A basic goal of any negotiation is to establish a relationship
or deepen an existing relationship, while seeking an agreement
that provides win-win opportunities for all parties. Different view-
points, conflicting goals, and high stakes can cause deterioration
of negotiations, from focusing on the relationship and a win-win
outcome to focusing only on the details of a contract. Dialogue
and actions that fail to develop or deepen the relationship between
the parties may create an “I win and you lose” end point. Estab-
lishing an “I win and you lose” negotiation atmosphere is not
recommended if the end product requires a durable partnership.
To effectively achieve a win-win scenario, leaders must
recognize and address their tendency to interpret others’ be-
haviors, values, and beliefs through their own lens of beliefs
and experiences. This type of bias (conscious or unconscious)
may serve as an obstacle to trusting your counterpart (and vice
versa), and may inhibit your ability to understand how you can
benefit by helping your counterpart to achieve his or her goals.
Another critically important potential pitfall in negotiations is
the presence of stereotypes (conscious or unconscious), which
limit, or in the worst cases, distort (or make inaccurate) one’s
ability to understand a counterpart’s expectations and inten-
tions. Without self-reflection and consultation to address the
inaccuracy of one’s own “lens” and preexisting stereotypes, the
outcomes of negotiations will not reach their full potential.
Conclusion
Leading across a diverse workforce provides unprecedented op-
portunities for success. Achieving success will require the devel-
opment of strategies and tactics that are based on understanding
generational differences and recognizing and managing biases.
Leadership attributes, including integrity, credibility, effective lis-
tening, having a vision of your destination, fairness, humility, and
caring, will resonate with and attract productive and innovative
employees. The growing diversity of our workforce and the inter-
national economy may initially add complexity to successful ne-
gotiations, but striving for a win-win outcome and understanding
behaviors, values, and beliefs through the lens of others will po-
sition leaders to be successful in challenging negotiations. n
Denis R. Clohisy, MD1
2
Michael J. Yaszemski, MD, PhD
Joanne Lipman
3
1
Department of Orthopaedic Surgery, University of Minnesota,
Minneapolis, Minnesota
2
Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
3
Gannett Co., Inc., McLean, Virginia
E-mail address for D.R. Clohisy: clohi001@umn.edu
E-mail address for M.J. Yaszemski: Yaszemski.Michael@mayo.edu
E-mail address for J. Lipman: joanneblipman@gmail.com
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