Culture of Safety and Gender Inclusion in Cardiothoracic Surgery

History and Current Status of Well-being Among Organizations (Impact of Wellness on a Section, Division, Institution and Profession, ACGME Requirements, Policies)

The authors provide an overview of cultural adjustments and policy changes to support wellness in medicine. Subsequently, the data around wellness in cardiothoracic surgery, as well as policies and interventions that have been put into place to address wellness concerns in cardiothoracic surgery is discussed. The authors focus on both trainees and attendings and provide both a list of actions to address deficits in wellness management in the field, as well as resources available to promote well-being among cardiothoracic surgeons.

Gender representation among speaking and leader roles at European cardio-thoracic surgical annual meetings

OBJECTIVES

Our goal was to evaluate gender representation among session leaders and abstract presenters at European cardio-thoracic surgical annual meetings.

METHODS

We did a descriptive study of the gender distribution among session leaders and abstract presenters at 2 European cardio-thoracic international meetings from 2017 to 2022. Data from publicly available programmes were used to generate a list of session leaders and abstract presenters. The primary outcome was to evaluate the proportion of female sessions leaders at the annual meetings. Descriptive analyses were performed including the Cochran-Armitage trend test for linear trend of proportions.

RESULTS

A total of 1025 sessions of 11 annual meetings of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Thoracic Surgeons were examined. A total of 397 (13.2%) out of 3007 total session leaders and 955 (15.2%) out of 6251 abstract presenters were female. From 2017 to 2022, the proportions of both female session leaders and abstract presenters trended significantly [10.4% to 21.9% (P < 0.001) and 13.7% to 18.3% (P < 0.001), respectively]. The EACTS female members and female meeting attendees significantly increased from 2017 to 2022 [11.1% to 15.9% (P < 0.001) and 23.7% to 26.9% (P < 0.001)], respectively. Most of the women attendees at the EACTS and the European Society of Thoracic Surgeons meetings who were session leaders and speakers came from Germany, Italy, the United Kingdom and the United States.

CONCLUSIONS

Women are under-represented compared to men in leadership and speaking roles at European cardio-thoracic surgical annual meetings. In the past few years, an encouraging positive trend over time for female leadership roles has been noted; as a result, the proportion of female society members is represented at the annual meetings. However, a substantial gender gap still exists in leading roles of meeting attendees.

Gender trends in cardiothoracic surgery authorship

OBJECTIVE

In recent years, the historically low proportion of women cardiothoracic surgeons and trainees has been a subject of intense focus. Publications remain a key metric of academic success and career advancement. We sought to identify trends in the gender of first and last author publications in cardiothoracic surgery.

METHODS

We searched for publications between 2011 and 2020 in 2 US cardiothoracic surgery journals, identifying those with Medical Subject Heading publication types of clinical trials, observational studies, meta-analyses, commentary, reviews, and case reports. A commercially available, validated software (Gender-API) was used to associate gender with author names. Association of American Medical Colleges Physician Specialty Data Reports were used to identify concurrent changes in the proportion of active women in cardiothoracic surgery.

RESULTS

We identified 6934 (57.1%) pieces of commentary; 3694 (30.4%) case reports; 1030 (8.5%) reviews, systematic analyses, meta-analyses, or observational studies; and 484 (4%) clinical trials. In total, 15,189 total names were included in analysis. Over the 10-year study period, first authorship by women rose from 8.5% to 16% (0.42% per year, on average), whereas the percentage of active US women cardiothoracic physicians rose from 4.6% to 8% (0.42% per year). Last authorship was generally flat over the decade, going from 8.9% in 2011% to 7.8% in 2020 and on average, increased at just 0.06% per year (P = .79).

CONCLUSIONS

Over the past decade, authorship by women has steadily increased, more so at the first author position. Author-volunteered gender identification at the time of manuscript acceptance may be useful to more accurately follow trends in publication.

Practice patterns of female cardiothoracic surgeons older than age 58 years: Are we making progress?

OBJECTIVE

Women remain a small minority of cardiothoracic surgeons, and within adult cardiac surgery, the gender gap widens. This study examines the career pathway and trajectory of female adult cardiac surgeons.

METHODS

Female cardiothoracic surgeons were identified from the American Board of Thoracic Surgery diplomates over 58 years. Publicly available information was obtained to determine years in practice, practice type, academic and leadership title(s), and location of practice.

RESULTS

The average number of years in practice for female adult cardiac surgeons was 13.1. Those categorized as adult cardiac surgeons composed 25.4% (n = 90) of all female cardiothoracic diplomates and 134 (37.9%) were categorized as other subspecialty practice. Of the adult cardiac surgeons, 33.3% (n = 30) practiced privately and the remainder in academic practice. Academic titles were held by 47.8% (43 out of 90) and 30% (27 out of 90) held a position of leadership. Of those in academic practice, 25% (11 out of 42) are titled professor, whereas 43% (18 out of 42) are assistant professors. Most commonly, those in positions of leadership held the title "director," which reflects 37% (10 out of 27) of individuals. Practice locations were distributed throughout the United States, with the highest number in the northeast (26.7%).

CONCLUSIONS

Only a small portion of female cardiothoracic surgeons pursue a career in adult cardiac surgery compared to their male counterparts. From 1999 to 2009, 1300 individuals were board certified cardiothoracic surgeons, of whom only 103 (7.9%) were female. Of these, the majority of female cardiothoracic surgeons entered academic practice. Although the overall number of practicing female adult cardiac surgeons has increased with a growth rate of 10.7%, this number remains extremely low. A discrepancy remains between gender representation of academic titles and leadership positions. Although the field has increased female representation over the past few decades, work remains to ensure all potential talent is encouraged and supported.

Career Progression and Research Productivity of Women in Academic Cardiothoracic Surgery

BACKGROUND

The objective of this work was to delineate career progression and research productivity of women practicing cardiothoracic surgery in the academic setting.

METHODS

Cardiothoracic surgeons at the 79 accredited US cardiothoracic surgery training programs in 2020 were included in this cross-sectional analysis. Data regarding subspecialization, training, practice history, and publications were gathered from public sources including department websites, CTSNet, and Scopus.

RESULTS

A total of 1065 surgeons (51.3% cardiac, 32.1% thoracic, 16.6% congenital) were identified. Women accounted for 10.6% (113) of the population (7.9% of cardiac, 15.5% of thoracic, 9.6% of congenital surgeons). The median number of cardiothoracic surgeons per institution was 12 (interquartile range [IQR], 10-17), with a median of 1 woman (IQR, 0-2). Fifteen of 79 programs (19%) had no women. Among women faculty 5.3% were clinical instructors, 51.3% were assistant professors, 23.0% were associate professors, 16.8% were full professors, and 3.5% had unspecified titles (vs 2.0%, 32.9%, 23.0%, 37.5%, and 4.6% among men, respectively; P < .001). Women and men authored a comparable number of first-author (0.4 [IQR, 0.0-1.3] vs 0.5 [IQR, 0.0-1.1], P = .56) publications per year but fewer last-author (0.1 [IQR, 0.0-0.7] vs 0.4 [IQR, 0.0-1.3], P < .0001) and total publications per year (2.7 [IQR, 1.0-6.2] vs 3.7 [IQR, 1.3-7.8], P = .05) than men. The H-index was lower for women than for men overall (8.0 [IQR, 3.0-15.0] vs 15.0 [IQR, 7.0-28.0], P < .001) but was similar between men and women who had been practicing for 10 to 20 years.

CONCLUSIONS

Gender disparities persist in academic cardiothoracic surgery. Efforts should be made to support women in achieving senior roles and academic productivity.

Demographics of Current and Aspiring Integrated Six-year Cardiothoracic Surgery Trainees

BACKGROUND

The integrated 6-year thoracic surgery (I-6) residency model was developed in part to promote early interest in cardiothoracic surgery in diverse trainees. To determine gaps in and opportunities for recruitment of women and minority groups in the pipeline for I-6 residency, we quantified rates of progression at each training level and trends over time.

METHODS

We obtained 2015 to 2019 medical student, I-6 applicant, and I-6 resident gender and race/ethnicity demographic data from the American Association of Medical Colleges and Electronic Residency Application Service public databases and Accreditation Council for Graduate Medical Education Data Resource Books. We performed χ², Fisher exact, and Cochran-Armitage tests for trend to compare 2015 and 2019.

RESULTS

Our cross-sectional analysis found increased representation of women and all non-White races/ethnicities, except Native American, at each training level from 2015 to 2019 (P < .001 for all). The greatest trends in increases were seen in the proportions of women (28% vs 22%, P = .46) and Asian/Pacific Islander (25% vs 15%, P = .08) applicants. There was also an increase in the proportions of women (28% vs 24%, P = .024) and White (61% vs 58%, P = .007) I-6 residents, with a trend for Asian/Pacific Islanders (20% vs 17%, P = .08). The proportions of Hispanic (5%) and Black/African American (2%) I-6 residents in 2019 remained low.

CONCLUSIONS

I-6 residency matriculation is not representative of medical student demographics and spotlights a need to foster early interest in cardiothoracic surgery among all groups underrepresented in medicine while ensuring that we mitigate bias in residency recruitment.

Medical Students' Attitudes Towards Cardiothoracic Surgery in the United Kingdom: A Cross-Sectional Survey of 1675 Students

OBJECTIVES

The objectives of this study were the following: (i) assess interest levels in cardiothoracic surgery (CTS) among UK-based medical students, (ii) identify potential motivators and barriers to pursuing CTS training, (iii) explore the influence of gender on interest in CTS in greater depth.

METHODS

Medical students from all year groups across UK medical schools were invited to participate in a cross-sectional, national online survey. Responses were collected from 02/12/2019 to 08/12/2019.

RESULTS

1675 medical students from 31 UK medical schools responded, with an estimated 5.3% response rate. Of the respondents, 33.7% respondents reported having exposure to CTS, primarily through their medical school or through extracurricular activities (48.4% and 38.8%, respectively). When assessing interest in CTS, 31.4% were interested in undertaking a career in CTS, with a larger proportion of students expressing interest with no exposure to CTS than those with exposure. However, interest in pursuing CTS decreased with exposure as medical students transitioned from pre-clinical to clinical stages. Additionally, male participants were more interested in seeking a CTS post than their female counterparts (38% vs. 27.6%). The length of training (p = 0.0009) and competitive nature (p < 0.0001) of gaining a CTS post were the primary deterring factor for female participants, compared to their male counterparts.

CONCLUSIONS

This study shows the importance of quality of exposure and its impact on students' interests in pursuing a career in CTS. The negative relationship between exposure and interest in CTS can be associated with the realisation of the challenges that come with pursuing CTS.

Social Disparities in the Thoracic Surgery Workforce

Diversity fosters innovation, advances the work environment, and enriches patient care. Despite that, only 17%, 5%, and 3% of cardiothoracic (CT) surgeons in academia were women, Hispanic, and Black, respectively. Diversity, equity, and inclusion goals and deliberate initiatives are necessary to eradicate disparities in the CT workforce. Leading organizational changes from the top down is paramount and above all else, changes and improvements should be based on a meritocracy.

Demographic Landscape of Cardiothoracic Surgeons and Residents at United States Training Programs

BACKGROUND

Recruiting and promoting women and racial/ethnic minorities could help enhance diversity and inclusion in the academic cardiothoracic (CT) surgery workforce. However, the demographics of trainees and faculty at US training programs have not yet been studied.

METHODS

Traditional, integrated (I-6), and fast-track (4+3) programs listed in the Accreditation Council for Graduate Medical Education (ACGME) public database were analyzed. Demographics of trainees and surgeons, including gender, race/ethnicity, subspecialty, and academic appointment (if applicable), were obtained from ACGME Data Resource Books, institutional websites, and public profiles. Chi-square and Cochran-Armitage trend tests were performed.

RESULTS

In July 2020, 78 institutions had at least one CT surgery training program; 40 (51%) had only a traditional program, 20 (26%) traditional and I-6, 6 (8%) all three types of program, and 4 (5%) only I-6. The proportion of female trainees increased significantly from 2011 to 2019 (19% vs 24%, p<0.001), with female I-6 trainees outnumbering female traditional trainees since 2018. Significant increases by race/ethnicity were observed overall and by program type, notably for Asians and Hispanics in I-6 programs and Blacks in traditional programs. Finally, of the 1,175 CT surgeons identified, 633 (54%) were adult cardiac surgeons, 360 (37%) assistant professors, 116 (10%) women, and 33 (3%) Black.

CONCLUSIONS

The demographic landscape of CT surgery trainees and faculty across multiple training pathways reflects increasing representation by gender and race/ethnicity. However, we must continue to work toward equitable representation in the workforce to benefit the diverse patients we treat.

Female and Country Representation on Editorial Boards of Cardiothoracic Surgery Journals

Editorial board positions are prestigious and have important implications as gatekeepers for the advancement of academic surgeons. We assessed the composition of editorial boards of cardiothoracic surgery journals to identify female and low- and middle-income country (LMIC) representation. Journals listed as "Cardiac and Cardiovascular Systems" in the 2019 InCites Journal Citation Reports (JCR) directory by Clarivate Analytics were manually searched to identify journals pertaining to cardiothoracic surgery. Editorial boards for each journal were reviewed as available on journal websites, assessing for sex and country income group (high-income country vs. LMIC) of editorial board members. Descriptive statistics were performed, and differences were assessed through t tests and correlations using STATA version 14. Twenty-two cardiothoracic journals were identified, of which 16 were listed on JCR and 6 were sister journals. A total of 1,970 editorial board members were identified, of whom 206 (10.5%) were female and 103 (5.2%) from LMICs (each, p < 0.001). Female representation varied between 0% and 29.7% across journals. There were 391 associate and deputy editors, 62 (15.9%) were female and 15 (3.8%) from LMICs (each, p < 0.001). Only 1 (4.5%) of the 22 journals had a female Editor-in-Chief. A total of 15 LMICs were represented: Brazil (56 members), China (11 members), and India (11 members). LMIC representation varied between 0% and 76.6% (Brazilian Journal of Cardiovascular Surgery), with the second highest representation being only 16.33%. After excluding the Brazilian Journal of Cardiovascular Surgery (the only country-specific journal), LMIC representation was only 3.7% on editorial boards. The intersection between female sex and LMIC origin was found in only three editorial board members. A statistically significant positive correlation was seen between percentage of females in editorial boards and journal impact factor (r= 0.769, p < 0.001). No correlation was seen between percentage of LMIC in boards and impact factor (r = -0.306, p = 0.250). Our findings suggest editorial boards of cardiothoracic surgery journals remain highly imbalanced in terms of sex and country income group. Disparities in editorial boards may further result in less inclusive review processes, which may lead to fewer publications and slower academic advancement by underrepresented groups. Societies should partake in active assessment and reporting of disparities across their editorial boards as well as assessment of implicit biases and barriers impeding female and LMIC researchers from joining their boards.

Characterization of Cardiothoracic Surgeons Actively Leading Basic Science Research

BACKGROUND

There is increasing concern regarding the attrition of surgeon-scientists in cardiothoracic (CT) surgery. However, the characteristics of CT surgeons who are actively leading basic science research (BSR) have not been examined. We hypothesized that early exposure to BSR during training and active grant funding are important factors that facilitate the pursuit of BSR among practicing CT surgeons.

MATERIALS AND METHODS

We created a database of 992 CT surgeons listed as faculty at accredited United States CT surgery teaching hospitals in 2018. Data regarding each surgeon's training/professional history, publication record, and National Institutes of Health funding were acquired from publicly available online sources. Surgeons who published at least one first- or last-author paper in 2017-2018 were considered to be active, lead researchers.

RESULTS

Of the 992 CT surgeons, 73 (7.4%) were actively leading BSR, and 599 (60.4%) were actively leading only non-BSR. Only 2 women were actively leading BSR. Surgeons actively leading BSR were more likely to have earned a PhD degree (20.5% versus 9.7%, P = 0.0049), and more likely to have published a first-author BSR paper during training (76.7% versus 40.9%, P< 0.0001). Surgeons actively leading BSR were also more likely to have an active National Institutes of Health grant (34.2% versus 5.8%, P< 0.0001), especially an R01 grant (21.9% versus 2.5%, P< 0.0001).

CONCLUSIONS

A small minority of CT surgeons at academic training hospitals are actively leading BSR. In order to facilitate the development of surgeon-scientists, additional support must be given to trainees and junior faculty, especially women, to enable early engagement in BSR.

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.

US women in thoracic surgery: reflections on the past and opportunities for the future

Herein, we examine the state of women in thoracic surgery from the United States (US) perspective in terms of our past, present, and opportunities for the future. We explore the achievements of the first three women certified in thoracic surgery in 1961 and describe the progress made resulting in the current state. Women constitute slightly more than 50% of all medical students in the US, yet women remain underrepresented in thoracic surgery. The disparity is most notable for female representation in senior academic leadership positions, reflecting stagnation in progress. The lack of gender equity has important implications for projected workforce shortages and patient safety in cardiothoracic surgery. Recent organized efforts in scholarships and leadership training, as well as increasing awareness and mentorship, may herald progress on the horizon. Ultimately, however, engagement of leadership and top-down change are needed to achieve equity and, thereby, to improve patient health and satisfaction.

Equal means equal: Cardiothoracic surgery in its second century

OBJECTIVE

As the specialty of cardiothoracic surgery turns the corner into its second century of existence, there has been an uptick in the number of women and underrepresented minorities entering the field, but we have a long way to go before race and gender equity prevails.

METHODS

In this report, specific barriers to diversity without exclusion and mechanisms to breakdown these barriers will be explored.

RESULTS

Barriers to inclusion include a long-standing deficiency in exposure, encouragement, mentorship, and sponsorship to actively attract underrepresented groups to the specialty. Diversity will not occur passively. It will take a concerted effort best employed through a top-down approach at the local and national level, and it has to seem normal.

CONCLUSIONS

Cardiothoracic surgery is an outstanding field for anyone and everyone who seeks a challenging, rewarding career, regardless of their gender, race, or ethnic background. It is the responsibility of leadership to dispel the tradition that certain individuals are not welcome.

Is the perceived impact of disciplinary procedures on medical doctors' professional practice associated with working in an open culture and feeling supported? A questionnaire among medical doctors in the Netherlands who have been disciplined

INTRODUCTION

Disciplinary procedures can have a negative impact on the professional functioning of medical doctors. In this questionnaire study, doctors' experience with open culture and support during a disciplinary procedure is studied to determine whether open culture and support are associated with perceived changes in the professional practice of doctors.

METHODS

All doctors who received a warning or a reprimand from the Dutch Medical Disciplinary Board between July 2012 and August 2016 were invited to fill in a 60-item questionnaire concerning open culture, perceived support during the disciplinary procedure and the impact of the procedure on professional functioning as reported by doctors themselves. The response rate was 43% (n=294).

RESULTS

A majority of doctors perceive their work environment as a safe environment in which to talk about and report incidents (71.2% agreed). Respondents felt supported by a lawyer or legal representative and colleagues (92.8% and 89.2%, respectively). The disciplinary procedure had effects on professional practice. Legal support and support from a professional confidant and a professional association were associated with fewer perceived changes to professional practice.

CONCLUSION

Our study shows that doctors who had been disciplined perceive their working environment as open. Doctors felt supported by lawyers and/or legal representatives and colleagues. Legal support was associated with less of a perceived impact on doctors' professional practice.

Gender imbalance in executive management positions at the Mexican National Institutes of Health

BACKGROUND

Around the world, there is a significant difference in the proportion of women with access to leadership in healthcare with respect to men. This article studies gender imbalance and wage gap in managerial, executive, and directive job positions at the Mexican National Institutes of Health.

METHODS

Cohort data were described using a visual circular representation and modeled using a generalized linear model. Analysis of variance was used to assess model significance, and posterior Fisher's least significant differences were analyzed when appropriate.

RESULTS

This study demonstrated that there is a gender imbalance distribution among the hierarchical position at the Mexican National Health Institutes and also exposed that the wage gap exists mainly in the (highest or lowest) ranks in hierarchical order.

CONCLUSIONS

Since the majority of the healthcare workforce is female, Mexican women are still underrepresented in executive and directive management positions at national healthcare organizations.

The Society of Thoracic Surgeons National Database 2019 Annual Report

The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety for cardiothoracic surgery. The STS National Database has 4 components, each focusing on a distinct discipline-Adult Cardiac Surgery, General Thoracic Surgery, Congenital Heart Surgery, and mechanical circulatory support with the STS Interagency Registry for Mechanical Circulatory Support (Intermacs)/Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides the fourth annual summary of the status of the STS National Database.