Association between patient-surgeon race and gender concordance and patient-reported outcomes following breast cancer surgery

Diversity, Equity, and Inclusion in US Anesthesiology Residency Matching

BACKGROUND

Patient outcomes are improved with physician-patient gender, racial, and ethnic concordance. However, female, Black, Hispanic or Latino, Native Hawaiian-Pacific Islander (NH-PI), and American Indian-Native Alaskan (AI-AN) physicians are underrepresented in anesthesiology. The American Association of Medical Colleges 2018 Diversity in Medicine Report revealed that women comprise only 35% of anesthesiologists yet nearly half of medical school graduates are women. More than 77% of anesthesiologists are White or Asian. Anesthesiology applicant and match trends may provide insights needed to address underrepresentation within anesthesiology. We hypothesized that proportionally fewer women and racially and ethnically minoritized applicants apply and match into anesthesiology.

METHODS

This retrospective observational study identified 47,117 anesthesiology applicants among the 546,298 residency applicants in the Electronic Residency Application Service (ERAS) system between 2011 and 2022 and stratified applicants by self-reported gender, race, and ethnicity. The demographics of anesthesiology trainees reported in the 2014 to 2015, 2018 to 2019, and 2022 to 2023 Accreditation Counsel of Graduate Medical Education (ACGME) Data Resource Books were used as surrogates for matched applicants as demographics are not reported by the National Residency Match Program. To facilitate comparisons, ERAS applicants were grouped into 4-year epochs to align with consolidated ACGME reports corresponding to the application years. Odds ratios (OR); 95% confidence interval of applying to and matching into anesthesiology were analyzed.

RESULTS

Women had lower odds of applying to anesthesiology compared to men overall (OR, 0.55; 95% CI, 0.54-0.56, P < .0001) and maintained significantly lowered odds of applying within each epoch. Women had similar odds of matching into anesthesiology residency compared to men (OR, 1.10; 95% CI, 1.06-1.14, P < .0001). Black, Hispanic or Latino, Asian and NH-PI, and AI-AN applicants had similar odds to White applicants of applying to anesthesiology but odds of matching were significantly lower overall ( P < .0001) for Asian and NH-PI (OR, 0.66; 95% CI, 0.63-0.70), Black (OR, 0.49; 95% CI, 0.45-0.53), Hispanic or Latino (OR, 0.50; 95% CI, 0.46-0.54), and AI-AN (OR, 0.20; 95% CI, 0.15-0.28) applicants. The odds of matching among some minoritized applicants increased in the ACGME 2022 to 2023 report year.

CONCLUSIONS

From 2011 to 2022, women had lower odds of applying to anesthesiology residency than men yet had similar odds of matching. Racial and ethnic minoritized groups had significantly lower odds of matching compared to White applicants despite similar odds of applying. These findings highlight disparities in the anesthesiology match and may help identify opportunities to promote workforce diversity within the field. More detailed reporting of gender, race, and ethnicity in annual match data may better define barriers to entry and identify opportunities for improvement.

Race and Ethnicity Impacts Patient-Reported Outcomes in Implant-Based Breast Reconstruction

BACKGROUND

Addressing social determinants of health is critical in achieving health equity, and of the many determinants, race and ethnicity are key contributors in postmastectomy breast reconstruction. The purpose of this study was to investigate the impact of race and ethnicity on patient-reported outcomes (PROs) after implant-based breast reconstruction (IBBR) and to provide reference values for each cohort.

METHODS

We identified all patients who underwent IBBR between January 2017 and August 2022 and completed the BREAST-Q longitudinally. Race and ethnicity were self-categorized as White, Asian, Black, or Hispanic. Reference values were established. Outcomes of interest were BREAST-Q scores preoperatively, and 6 months, 1 year, and 2 years postoperatively. Generalized estimating equation (GEE) modeling was performed to assess race and ethnicity as independent predictors of BREAST-Q scores.

RESULTS

Overall, 3281 patients were included, of whom 2479 (75.6%) were White, 296 (9.0%) were Asian, 239 (7.3%) were Black, and 267 (8.1%) were Hispanic. There were significant differences in Physical Well-being of the Chest at all timepoints; Satisfaction with Breasts and Psychosocial Well-being at preoperative, 6 months, and 1 year; and in Sexual Well-being at 1 year. GEE modeling showed that relative to White patients, Asian subjects scored significantly lower on all BREAST-Q domains, while Black and Hispanic patients scored significantly lower on the Physical Well-being of the Chest domain.

CONCLUSION

Racial and ethnic disparities persist within IBBR, with minority patients scoring lower on the BREAST-Q than White patients. This study suggests that more work is needed to understand and improve these PROs in minority patient populations. Individualized reference values may prove beneficial in assessing outcomes over time.

Exploring Racial Disparities in Awareness and Perceptions of Oncology Clinical Trials: Cross-Sectional Analysis of Baseline Data From the mychoice Study

BACKGROUND

Black/African American adults are underrepresented in oncology clinical trials in the United States, despite efforts at narrowing this disparity.

OBJECTIVE

This study aims to explore differences in how Black/African American oncology patients perceive clinical trials to improve support for the clinical trial participation decision-making process.

METHODS

As part of a larger randomized controlled trial, a total of 244 adult oncology patients receiving active treatment or follow-up care completed a cross-sectional baseline survey on sociodemographic characteristics, clinical trial knowledge, health literacy, perceptions of cancer clinical trials, patient activation, patient advocacy, health care self-efficacy, decisional conflict, and clinical trial intentions. Self-reported race was dichotomized into Black/African American and non-Black/African American. As appropriate, 2-tailed t tests and chi-square tests of independence were used to examine differences between groups.

RESULTS

Black/African American participants had lower clinical trial knowledge (P=.006), lower health literacy (P<.001), and more medical mistrust (all P values <.05) than non-Black/African American participants. While intentions to participate in a clinical trial, if offered, did not vary between Black/African American and non-Black/African American participants, Black/African American participants indicated lower awareness of clinical trials, fewer benefits of clinical trials, and more uncertainty around clinical trial decision-making (all P values <.05). There were no differences for other variables.

CONCLUSIONS

Despite no significant differences in intent to participate in a clinical trial if offered and high overall trust in individual health care providers among both groups, beliefs persist about barriers to and benefits of clinical trial participation among Black/African American patients. Findings highlight specific ways that education and resources about clinical trials could be tailored to better suit the informational and decision-making needs and preferences of Black/African American oncology patients.

Gender diversity in the National Joint Registry

Aims

Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons.

Methods

Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration.

Results

Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001).

Conclusion

Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons.

A Comparison of Demographic Diversity Between Orthopaedic Surgery Residents and ACGME Foot and Ankle Fellows From 2007 to 2022

Background

Academic medicine emphasizes the need to recruit a diverse workforce in graduate medical education. Orthopaedic surgery residency has demonstrated efforts to model program compositions with evolving US demographics. However, it remains unclear whether orthopaedic fellowships, particularly foot and ankle, also reflect these efforts.

Methods

Using the publicly available Accreditation Council for Graduate Medical Education (ACGME) Data Resource Book, a census of the gender and racial/ethnic identities of orthopaedic foot and ankle fellows, as well as active orthopaedic surgery residents, were compiled from 2007 to 2022. Linear trend analysis was conducted to evaluate the trends of orthopaedic residents and foot and ankle fellows, with a Pearson correlation for comparison.

Results

Prior analysis demonstrated no significant change in sex and ethnic diversity of fellows from 2006 to 2015. The majority of foot and ankle fellows were White (31%-69%) and male (63%-88%). Linear analysis demonstrated growing diversity in female and non-White active orthopaedic surgery residents. Similarly, there was an increasing number of female foot and ankle fellows (0%-38%) reflective of the trend in orthopaedic residency (12%-20%); however, there was no significant change among racial/ethnic identities. Pearson correlation analysis between the trend of orthopaedic residency residents and foot and ankle fellows suggests moderate correlation among female, Asian, and "Unknown" racial/ethnic categories.

Conclusion

The proportion of foot and ankle female fellows in ACGME-accredited fellowships has matched or exceeded the percentage of female orthopaedic residents. Despite increased diversity of orthopaedic surgery residents over the past 2 decades, ACGME-accredited foot and ankle fellowships do not yet reflect similar trends among racial/ethnic minorities.

Level of Evidence

Level III, retrospective cohort study.

Observations on the Representation of Asians in Surgical Training and Leadership

INTRODUCTION

Diversity in medicine has a positive effect on outcomes, especially for Asian patients. We sought to evaluate representation of Asians across entry and leadership levels in surgical training.

METHODS

Publicly accessible population data from 2018 to 2023 were collected from the US Census Bureau, the Association of American Medical Colleges, and the American Board of Surgery (ABS). Frequencies based on self-identified Asian status were identified, and proportions were calculated.

RESULTS

The US census showed Asians constituted 4.9% of the US population in 2018 versus 6% in 2023. The proportion of Asian medical students rose from 21.6% to 24.8%; however, Asian surgical residency applicants remained constant at 20%. ABS certifications of Asians have increased from 13.7% to 18.5%. ABS examiners increased from 15.7% to 17.1%.

CONCLUSIONS

In 5 years, Asians have made numeric gains in medical school and surgical training. However, Asian representation lags at Board examiner levels compared to the medical student population. The ABS has made recent efforts at transparency around examiner and examinee characteristics. A pillar of ensuring a well-trained surgical workforce to serve the public is to mandate that all surgical trainees and graduates undergo fair examinations, and are fairly assessed on their qualifications. Observed progress should further invigorate all surgical applicants, residents and leadership to take an even more active role in making surgery more diverse and welcoming to all, by including careful analyses of diversity at all levels.

Social concordance and patient reported experiences in countries with different gender equality: a multinational survey

BACKGROUND

Patient reported experiences (PREMs) are important indices of quality of care. Similarities in demography between patient and doctor, known as social concordance, can facilitate patient-doctor interaction and may be associated with more positive patient experiences. The aim of this research is to study associations between gender concordance, age concordance and PREMs (doctor-patient communication, involvement in decision making, comprehensiveness of care and satisfaction) and to investigate whether these associations are dependent on a countries' Gender Equality Index (GEI).

METHODS

Secondary analysis on a multinational survey (62.478 patients, 7.438 GPs from 34 mostly European countries) containing information on general practices and the patient experiences regarding their consultation. Multi-level analysis is used to calculate associations of both gender and age concordance with four PREMs.

RESULTS

The female/female dyad was associated with better experienced doctor-patient communication and patient involvement in decision making but not with patient satisfaction and experienced comprehensiveness of care. The male/male dyad was not associated with more positive patient experiences. Age concordance was associated with more involvement in decision making, more experienced comprehensiveness, less satisfaction but not with communication. No association was found between a country's level of GEI and the effect of gender concordance.

CONCLUSION

Consultations in which both patient and GP are female are associated with higher ratings of communication and involvement in decision making, irrespective of the GEI of the countries concerned. Age concordance was associated with all PREMs except communication. Although effect sizes are small, social concordance could create a suggestion of shared identity, diminish professional uncertainty and changes communication patterns, thereby enhancing health care outcomes.

Parental leave and family building experiences among head and neck surgeons in the United States: Career impact and opportunities for improvement

BACKGROUND

The availability of paid parental leave is an important factor for retention and wellness. The experiences of head and neck surgeons with parental leave have never been reported.

METHODS

A survey was electronically distributed to head and neck subspecialty surgeons in the United States. Responses were collected and analyzed.

RESULTS

Male surgeons had more children and took significantly less parental leave than women. Thirty percent of respondents reported that parental leave negatively impacted compensation, and 14% reported a delay in promotion due to leave, which impacted women more than men. The vast majority reported they are happy or neutral about covering those on leave. Most respondents utilized paid childcare, and approximately one quarter of respondents spending 11%-20% of their income on childcare.

CONCLUSIONS

This study illuminates the current disparities regarding parental leave-taking within the subspecialty of head and neck surgery in the United States. Women surgeons are more likely to be impacted professionally and financially.

The Influence of Patient and Surgeon Characteristics on Press Ganey Provider Ratings in Plastic Surgery

BACKGROUND

Although patient satisfaction ratings are increasingly used as hospital and provider performance metrics, these ratings may be affected by factors extraneous to surgeon performance.

OBJECTIVES

The aim of this study was to assess whether outpatient Press Ganey ratings for plastic surgery providers were tied more to provider or patient characteristics.

METHODS

All Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) responses for plastic surgery providers from 2017 to 2023 from a single institution were analyzed. Ordered logistic regression models were used to identify characteristics associated with provider ratings.

RESULTS

In total, 6442 surveys from 4594 patients representing 29 plastic surgery providers were analyzed. Across the patient cohort, 23.2% (N = 1492) rated plastic surgery providers lower than a 10/10. After adjustment, provider characteristics including provider gender, patient-provider gender concordance, and years in practice were not associated with overall provider ratings (all P > .05). In contrast, patient characteristics were associated with provider ratings. Older patient age (odds ratio [OR], 1.02; P < .001) was associated with higher ratings. Finally, self-reported overall health and mental health were associated with lower provider ratings (both P < .05); specifically, mental health categories lower than "Excellent" were associated with significantly lower provider ratings (overall mental health "Very Good': OR, 0.57; "Good": OR, 0.53; "Fair": OR, 0.59; "Poor": OR, 0.55; all P < .05).

CONCLUSIONS

Press Ganey ratings for plastic surgeons are influenced by patient characteristics, including age and mental health. Because satisfaction ratings are increasingly used as performance metrics in plastic surgery, adjusted rating models may be needed to more accurately reflect surgeon performance.

Examining Racial and Gender Diversity in the Plastic Surgery Pipeline: Where is the Leak?

Background

There is limited information about minority representation throughout the plastic and reconstructive surgery (PRS) pipeline. The aim of this study was to examine trends in representation among minorities at different stages of the PRS training pathway, starting with potential candidates in high school through practicing physicians.

Methods

The PRS pipeline was defined as high school; college; medical school applicants, matriculants, and graduates; PRS residency applicants, matriculants, and active residents; and PRS practicing physicians. Racial data for each stage were obtained from the US Census and Association of American Medical Colleges. The proportion of races at each stage were divided by their US population counterpart proportions to produce representation quotients (RQs). Medians and interquartile ranges (IQRs) are reported. Mann-Whitney U tests compared RQ values within identities between successive stages.

Results

Black students had high representation in high school (RQ = 1.26 [IQR: 1.21-1.29]) but had significant, stepwise decreases in representation in subsequent stages. A similar trend was observed for Hispanic individuals, who had their highest representation in high school (1.43 [1.37-1.50]), followed by significant decreases in RQ at nearly every subsequent stage up to and including practicing physicians (0.30 [0.28-0.31). Asian individuals were overrepresented at every stage (high school RQ: 1.01 [1.00-1.03]; practicing physician RQ: 2.30 [2.27-2.32]). White individuals were underrepresented before residency but had an RQ that approximated 1 in subsequent stages.

Conclusions

Racial minorities experienced decreases in representation at each successive stage in the PRS pipeline following high school. Ongoing diversity efforts should focus on premedical recruitment and professional support for minority students.