Predictors of the response of operating room personnel to surgeon behaviors

Microaggressions and Implicit Bias in Hand Surgery

Implicit bias and microaggressions are well-known phenomenon and have recently been acknowledged as contributing to health care disparities. Within Hand Surgery, implicit bias and microaggressions occur in patient-surgeon, surgeon-peer, surgeon-staff, and training environment interactions. Although racial and gender biases are well studied, biases can also be based on age, sexual orientation, socioeconomic background, and/or hierarchal rank. Academia has well-documented evidence of implicit bias and microaggressions, contributing to current disparate demographics of trainees, physicians, and leaders within Hand Surgery. Awareness is fundamental to combating bias and microaggressions; however, actions must be taken to minimize negative effects and change culture.

Gender Bias in the Evaluation of Surgical Performance: Results of a Prospective Randomized Trial

OBJECTIVE

The study aims to determine the influence of trainee gender on assessments of coronary anastomosis performance.

SUMMARY OF BACKGROUND DATA

Understanding the impact of gender bias on the evaluation of trainees may enable us to identify and utilize assessment tools that are less susceptible to potential bias.

METHODS

Cardiothoracic surgeons were randomized to review the video performance of trainees who were described by either male or female pronouns. All participants viewed the same video of a coronary anastomosis and were asked to grade technique using either a Checklist or Global Rating Scale (GRS). Effect of trainee gender on scores by respondent demographic was evaluated using regression analyses. Inter-rater reliability was assessed using the Cronbach's alpha.

RESULTS

103 cardiothoracic surgeons completed the Checklist (trainee gender: male n=50, female n=53) and 112 completed the GRS (trainee gender: male n=56, female n=56). For the Checklist, male cardiothoracic surgeons who were in practice <10 years ( P = 0.036) and involved in training residents ( P = 0.049) were more likely to score male trainees higher than female trainees. The GRS demonstrated high inter-rater reliability across male and female trainees by years and scope of practice for the respondent (alpha >0.900) when compared to the Checklist assessment tool.

CONCLUSIONS

Early career male surgeons may exhibit gender bias against women when evaluating trainee performance of coronary anastomoses. The GRS demonstrates higher interrater reliability and robustness against gender bias in the assessment of technical performance than the Checklist, and such scales should be emphasized in educational evaluations.

The other side of conflict: Examining the challenges of female orthopaedic surgeons in the workplace

BACKGROUND

As more women begin to enter the traditionally male-dominated field of orthopaedics, it is critical to examine their experiences in navigating gender-based conflicts in the workplace.

METHODS

An anonymous survey was distributed via a web link to approximately 1,100 members of Ruth Jackson Orthopaedic Society (RJOS) and 1,600 members of Women in Orthopaedics (WIO) Facebook group, with an estimated response rate of 50% and 50% respectively and protocols to mitigate duplicate response. Questions included demographics and presented several workplace scenarios.

RESULTS

Of the 373 respondents, 72% described experiencing some type of workplace conflict self-attributed to being female. Additionally, 8% reported either being forced out or leaving their previous job due to workplace conflict, leading to depression, anxiety, and burnout. 17% of respondents would not choose the same career again if given the opportunity.

CONCLUSIONS

Workplace conflict diminishes a surgeon's career satisfaction and may ultimately contribute to burnout. Understanding the relationship between gender bias and orthopaedic surgery is essential in moving towards change, and addressing these issues will create a more positive working environment for female surgeons.

Association Between Surgeon and Anesthesiologist Sex Discordance and Postoperative Outcomes: A Population-Based Cohort Study

OBJECTIVE

To examine the effect of surgeon-anesthesiologist sex discordance on postoperative outcomes.

SUMMARY BACKGROUND DATA

Optimal surgical outcomes depend on teamwork, with surgeons and anesthesiologists forming two key components. There are sex and gender-based differences in interpersonal communication and medical practice which may contribute to patients' perioperative outcomes.

METHODS

We performed a population-based, retrospective cohort study among adult patients undergoing one of 25 common elective or emergent surgical procedures from 2007-2019 in Ontario, Canada. We assessed the association between differences in sex between surgeon and anesthesiologists (sex discordance) on the primary endpoint of adverse postoperative outcome, defined as death, readmission, or complication within 30-days following surgery using generalized estimating equations.

RESULTS

Among 1,165,711 patients treated by 3,006 surgeons and 1,477 anesthesiologists, 791,819 patients were treated by sex concordant teams (male surgeon/male anesthesiologist: 747,327 and female surgeon/female anesthesiologist: 44,492) while 373,892 were sex discordant (male surgeon/female anesthesiologist: 267,330 and female surgeon/male anesthesiologist: 106,562). Overall, 12.3% of patients experienced one or more adverse postoperative outcomes of whom 1.3% died. Sex discordance between surgeon and anesthesiologist was not associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio [aOR] 1.00, 95% confidence interval [CI] 0.97-1.03).

CONCLUSIONS

We did not demonstrate an association between intraoperative surgeon and anesthesiologist sex discordance on adverse postoperative outcomes in a large patient cohort. Patients, clinicians, and administrators may be reassured that physician sex discordance in operating room teams is unlikely to clinically meaningfully affect patient outcomes after surgery.

Impact of surgeon and anaesthesiologist sex on patient outcomes after cardiac surgery: a population-based study

BACKGROUND

Effective teamwork between anaesthesiologists and surgeons is essential for optimising patient safety in the cardiac operating room. While many factors may influence the relationship between these two physicians, the role of sex and gender have yet to be investigated.

OBJECTIVES

We sought to determine the association between cardiac physician team sex discordance and patient outcomes.

DESIGN

We performed a population-based, retrospective cohort study.

PARTICIPANTS AND SETTING

Adult patients who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral or tricuspid valve surgery between 2008 and 2018 in Ontario, Canada.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause 30-day mortality. Secondary outcomes included major adverse cardiovascular events at 30 days and hospital and intensive care unit lengths of stay (LOS). Mixed effects logistic regression was used for categorical outcomes and Poisson regression for continuous outcomes.

RESULTS

79 862 patients underwent cardiac surgery by 98 surgeons (11.2% female) and 279 anaesthesiologists (23.3% female); 19 893 (24.9%) were treated by sex-discordant physician teams. Physician sex discordance was not associated with overall patient mortality or LOS; however, patients who underwent isolated CABG experienced longer hospital LOS when treated by an all-male physician team as compared with an all-female team (adjusted OR=1.07; p=0.049). When examining the impact of individual physician sex, the length of hospital stay was longer when isolated CABG procedures were attended by a male surgeon (OR=1.10; p=0.004) or anaesthesiologist (OR=1.02; p=0.01).

CONCLUSIONS

Patient mortality and length of stay after cardiac surgery may vary by sex concordance of the attending surgeon-anaesthesiologist team. Further research is needed to examine the underlying mechanisms of these observed relationships.

Gender differences in surgical case volume among ophthalmology trainees

BACKGROUND

The number of females in ophthalmology has steadily increased over recent decades. The aim of this study was to evaluate whether there is a difference in procedural volume and cataract surgery between male and female trainees in the Royal Australian and New Zealand College of Ophthalmologists (RANZCO).

METHODS

A longitudinal retrospective review of de-identified surgical RANZCO trainee logbook data from 2008 to 2020 was undertaken. Data from 241 trainee logbooks were analysed for: location of training, gender, date of commencement of training, maternity/paternity leave status, number of surgeries observed, assisted, supervised and unsupervised. Surgical cases were grouped as: (1) all surgical cases; (2) complete cataract cases and (3) partial cataract cases.

RESULTS

Among 241 trainees (40.7% females), 197 263 procedures were performed. Total surgical volume was 21.1% lower at 4 years for females (median 665.5 vs. 843.5; p = 0.036). Completed cataract surgery was 21.5% lower at 18 months (median 87.5 vs. 111.5; p = 0.022) and 41.7% lower at 4 years (median 216 vs. 369; p < 0.001). Interrupted training was significantly more common in females (30.6% vs. 0.7%; p < 0.001). However, linear regression analysis did not identify parental leave or duration as a significant predictor for number of completed cataracts (p = 0.206). Complication rate was not different between males and females (p = 0.35).

CONCLUSIONS

Female trainees completed 41.7% fewer cataract operations at the end of their training compared to male counterparts with the gap widening between years 1 and 4 of training. The current data demonstrates that female and male RANZCO trainees are not receiving equivalent operating experiences.

2020 Women in Thoracic Surgery update on the status of women in cardiothoracic surgery

BACKGROUND

Women in Thoracic Surgery (WTS) has previously reported on the status of women in cardiothoracic (CT) surgery. We sought to provide a 10-year update on women in CT.

METHODS

An anonymous REDCap survey link was emailed to female diplomats of the ABTS. Survey questions queried respondents regarding demographics, training, accolades, practice details, and career satisfaction. The survey link was open for 30 days. Results were compared to the 2019 Society of Thoracic Surgeons work force survey. Descriptive analyses were performed using frequency and proportions. Comparisons were performed using Student's t-tests, Fisher exact and chi-squared tests.

RESULTS

Of 354 female diplomats, 309 were contacted and 176 (57%) responded. The majority of respondents were age 36-50 (59%), Caucasian (67.4%), and graduated from traditional-track programs (91.4%). Most respondents reported practicing in an urban (64%) and academic setting (73.1%). 36.4% and 23.9% reported a general thoracic and adult cardiac practice (22.7% mixed practice, 9.6% congenital). Fifty percent of respondents reported salaries between $400,000-700,000 annually; 37.7% reported salaries <90% of their male colleagues. 21.6% of respondents in academia are full professor; 53.4% report having a leadership role. While 74.1% would pursue a career in CT again, only 27.3% agreed that CT surgery is a healthy and positive environment for women.

CONCLUSIONS

The number of women in CT surgery has steadily increased. While women are rising in academic rank and into leadership positions, salary disparities and the CT surgery work environment remain important issues in achieving a diverse work force.

Women Surgeons' Experiences of Interprofessional Workplace Conflict

IMPORTANCE

Gender differences in interprofessional conflict may exist and precipitate differential achievement, wellness, and attrition in medicine.

OBJECTIVE

Although substantial attention and research has been directed toward improving gender equity in surgery and addressing overall physician wellness, research on the role of interprofessional conflict has been limited. The objective of this study was to understand scenarios driving interprofessional conflict involving women surgeons, the implications of the conflict on personal, professional, and patient outcomes, and how women surgeons navigate conflict adjudication.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative approach was used to explore the nature, implications, and ways of navigating interprofessional workplace conflict experienced by women surgeons. The setting was a national sample of US women surgeons. Purposive and snowball sampling were used to recruit women surgeons in training or practice from annual surgical society meetings. Participants were eligible if they were currently in a surgical training program or surgical practice. Nearly all participants had experienced at least 1 workplace conflict with a nonphysician staff member resulting in a formal write-up.

EXPOSURES

A workplace conflict was defined as any conflict resulting in the nonphysician staff member taking action such as confronting the woman surgeon, reporting the event to supervisors, or filing a formal report.

MAIN OUTCOMES AND MEASURES

Interviews were conducted between February 19, 2019, and June 21, 2019. Recordings were transcribed and deidentified. Inductive thematic analysis was used to examine data in relation to the research questions.

RESULTS

Thirty US women surgeons (8 [27%] age 25-34 years, 16 [53%] age 35-44 years, 5 [17%] age 45-54 years, and 1 [3%] age 55-64 years) of varying surgical specialties were interviewed. Conflicts were often reported as due to a breakdown in communication or from performance-related disputes. Participants perceived personal and professional implications including self-doubt, depression, frustration, anxiety, loss of sleep, reputational harms, and delays to advancement. Participants also described potential patient safety implications primarily due to decreased communication resulting from some surgeons being hesitant to engage in subsequent interactions. Participants described a variety of navigation strategies including relationship management, rapport building, and social capital. The success of these processes tended to vary by individual circumstances, including the details of the conflict, practice setting, level of support of leadership, and individual personality of the surgeon.

CONCLUSIONS AND RELEVANCE

This qualitative study highlights women surgeons' experiences with interprofessional workplace conflict. Interprofessional culture building, broader dissemination of implicit bias training, and transparent and equitable adjudication systems are potential strategies for avoiding or mitigating the implications of these conflicts.