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

Gender disparities in cardiothoracic surgery: a comparative study in India

Background

This study aimed to examine the prevalence of gender bias in the field of cardiothoracic vascular surgery in India and compared women surgeons and trainees in India and abroad.

Methods

This was a comparative, cross-sectional analytical study using an online questionnaire. The survey included questions about demographics, career choice, training, academic and leadership opportunities, and the impact of choosing cardiothoracic-vascular surgery as a career on personal life.

Results

A total of 203 practicing surgeons and trainees participated in the study and included 121 (59.6%) men and 82 (40.3%) women. Out of the 82 women, 48 (58.5%) were from India, and 34 (41.5%) were from other countries. Satisfaction with the specialty was similar among men and women (105 (86.7%) vs. 68 (82.9%), p = 0.44 respectively). Majority (n = 30, 62.5%) of the female surgeons in India reported being discriminated against, as well as receiving favored treatment 11 (22.9%). Compared to men, women surgeons in India were more frequently advised against pursuing a career in cardiothoracic and vascular surgery (p < 0.001) and were more frequently subjected to gender-related references (p < 0.001). In addition, they had fewer presentation opportunities (p = 0.016) at national or regional meetings during their training compared to men. Additionally, 50% (24) of the women in India reported being single, in contrast to 7% (6) of men, and only 15 (31.3%) women reported having a child, compared to 57 (66.3%) of the men.

Conclusion

The study revealed significant gender disparities within the field of cardiothoracic vascular surgery in India and highlights the urgent need to address gender disparities and bias in cardiothoracic vascular surgery.

Diversity presentations at cardiothoracic surgery meetings: Opportunity to align our actions with our values

OBJECTIVE

Substantial efforts have been directed toward identifying and addressing cardiothoracic surgical disparities in both patient care and our workforce. We aimed to characterize the presence over time of diversity and disparities-related content at cardiothoracic surgical society meetings.

METHODS

Annual meeting program books from the American Association for Thoracic Surgery and the Society of Thoracic Surgeons from 2013 to 2023 were manually reviewed to identify abstract presentations, invited talks, and dedicated sessions related to diversity, equity, or social determinants of health. Relevant presentations were further categorized as issues in the surgical workforce versus patient care. Applicable presentations and sessions were quantified in each domain and proportions compared with the χ2 test.

RESULTS

Of 7812 presentations over 11 years, 167 (2.1%) were related to issues of diversity. These included 118 abstracts, among which 19 (16.1%) covered workforce diversity issues whereas 99 (83.9%) addressed patient care inequities. Among 48 invited disparities talks, 28 (58.3%) related to workforce challenges and 20 (41.7%) explored variabilities in patient care. Seventeen complete sessions were dedicated to diversity and disparities, with 9 (52.9%) addressing those in the workforce and 8 (47.1%) related to patient care. Comparing the first 5 years with the final 5 years of study, the proportion of talks (abstracts and invited) related to diversity and inclusion increased 3-fold.

CONCLUSIONS

Recent years have shown an explosion in cardiothoracic surgery meeting content focused on diversity but still account for a diminutive proportion of overall content. These data highlight an opportunity to further align scholarly activity with our values.

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.

Abuse, Bullying, Harassment, Discrimination, and Allyship in Cardiothoracic Surgery

Abuse, bullying, harassment, and discrimination are prominent workplace occurrences within cardiothoracic (CT) surgery that cause burnout and threaten the well-being of surgeons. Under-represented and marginalized groups experience higher incidences of these negative events, and CT surgery is one of the least diverse specialties. The CT surgery workforce and institutional leadership must prioritize mentorship, sponsorship, and allyship to promote a diverse and healthy specialty for surgeon recruitment, growth, and job satisfaction.

Industry payments and implicit bias in cardiothoracic surgery: Difference in industry payments to cardiothoracic surgeons by gender

OBJECTIVE

Industry payments, as sources of revenue and prestige, may contribute to gender implicit bias. We examined industry payments to cardiothoracic surgeons to determine differences with respect to gender while accounting for practice focus and experience.

METHODS

Payments to cardiothoracic surgeons from 2014, 2016, 2018, 2020, and 2022 were abstracted from the Centers for Medicare and Medicaid Services Open Payment database. Data were restricted to individual payments >$1000 and the following payment criteria: consulting fees, compensation for services other than consulting, honoraria, education, compensation for serving as faculty or as a speaker for a nonaccredited and noncertified continuing education program, and grant. Physician profiles were queried for gender, practice type, and year of last fellowship completion. Descriptive statistics were reported based on these factors.

RESULTS

In 2014, 509 cardiothoracic surgeons (497 men and 12 women) received meaningful industry payments. Male surgeons received $10,471,192 (99.3%) with median payment of $6500 and mean of $21,069, whereas women received $70,310 (0.7%) with median of $3500 and mean of $5859. In 2022, 674 cardiothoracic surgeons (613 men and 61 women) received industry payments, with men receiving $10,967,855 (92.4%) with a median payment of $6611 and mean of $17,892 and women receiving $905,431 (7.6%) with a median payment of $6000 and mean of $14,843.

CONCLUSIONS

Industry payments to women increased from 2014 to 2022 as the proportion of women in practice rose. Industry support of women, with increases in compensation and roles as speakers, consultants, and educators, offers a potential strategy to combat implicit bias within cardiothoracic surgery.

Female Surgeons in Cardiac Surgery: Does the Surgeon's Gender Affect the Outcome of Routine Coronary Artery Bypass Graft and Isolated Aortic Valve Surgery?

BACKGROUND

 The increasing presence of female doctors in the field of cardiac surgery has raised questions about their surgical quality compared to their male colleagues. Despite their success, female surgeons are still underrepresented in leadership positions, and biases and concerns regarding their performance persist. This study aims to examine whether female surgeons perform worse, equally well, or better than their male counterparts in commonly performed procedures that have a significant number of female patients.

METHOD

 A retrospective cohort of patients from 2011 to 2020 who underwent isolated coronary artery bypass graft (CABG) and aortic valve surgery was studied. To compare the surgical quality of men and women, a 1:1 propensity score matching (two groups of 680 patients operated by men and women, respectively, factors: age, logarithm of EuroSCORE (ES), elective, urgent or emergent surgery, isolated aortic valve, or isolated CABG) was performed. Procedure time, bypass time, x-clamp time, hospital stay, and early mortality were compared.

RESULTS

 After propensity score matching between surgeons of both sexes, patients operated by males (PoM) did not differ from patients operated by females (PoF) in mean age (PoM: 66.72 ± 9.33, PoF: 67.24 ± 9.19 years, p = 0.346), log. ES (PoM: 5.58 ± 7.35, PoF: 5.53 ± 7.26, p = 0.507), or urgency of operation (PoM: 43.09% elective, 48.97% urgent, 7.94% emergency, PoF: 40.88% elective, 55.29% urgent, 3.83% emergency, p = 0.556). This was also the case for male and female patients separately. Female surgeons had higher procedure time (PoM: 224.35 ± 110.54 min; PoF: 265.41 ± 53.60 min), bypass time (PoM: 107.46 ± 45.09 min, PoF: 122.42 ± 36.18 min), and x-clamp time (PoM: 61.45 ± 24.77 min; PoF: 72.76 ± 24.43 min). Hospitalization time (PoM: 15.96 ± 8.12, PoF: 15.98 ± 6.91 days, p = 0,172) as well as early mortality (PoM: 2.21%, PoF: 3.09%, p = 0.328) did not differ significantly. This was also the case for male and female patients separately.

CONCLUSION

 Our study reveals that in routine heart surgery, the gender of the surgeon does not impact the success of the operation or the early outcome of patients. Despite taking more time to perform procedures, female surgeons demonstrated comparable surgical outcomes to their male counterparts. It is possible that women's inclination for thoroughness contributes to the longer duration of procedures, while male surgeons may prioritize efficiency. Nevertheless, this difference in duration did not translate into significant differences in primary outcomes following routine cardiac surgery. These findings highlight the importance of recognizing the equal competence of female surgeons and dispelling biases regarding their surgical performance.

Mind the Gap! Working Toward Gender Equity in Pediatric and Congenital Heart Disease: Present and Future

Evidence from medicine and other fields has shown that gender diversity results in better decision making and outcomes. The incoming workforce of congenital heart specialists (especially in pediatric cardiology) appears to be more gender balanced, but past studies have shown many inequities. Gender-associated differences in leadership positions, opportunities presented for academic advancement, and recognition for academic contributions to the field persist. In addition, compensation packages remain disparate if evaluated based on gender with equivalent experience and expertise. This review explores these inequities and has suggested individual and institutional changes that could be made to recruit and retain women, monitor the climate of the institution, and identify and eliminate bias in areas like salary and promotions.

Diversity in the Cardiothoracic Surgery Workforce: What I Can Do

Within the cardiothoracic surgery workforce, there are significant gaps in the numbers of women and underrepresented in medicine minorities, but some progress has been made in gender diversity at the resident level. Individual surgeons play an important role in combatting discrimination and harassment, while also promoting women and minorities through mentorship and sponsorship. More importantly, a multifaceted and structured approach is needed to increase diversity at the institutional level with strategies to create a culture of inclusion, working to retain underrepresented minority and female surgeons, and eliminating bias in the recruitment process.

Workforce diversity in cardiothoracic surgery: An examination of recent demographic changes and the training pathway

INTRODUCTION

The purpose of our study was to examine changes in the demographic makeup of resident physicians in integrated 6-year cardiothoracic surgery and traditional thoracic surgery residency programs from 2013 to 2022 compared with other surgical subspecialties and determine potential leaks in the training pathway.

METHODS

Data from US Graduate Medical Education reports from 2013 to 2022 and medical student enrollment data from the Association of American Medical Colleges were obtained. Average percentages of women and underrepresented minorities were calculated in 2 5-year intervals: 2013 to 2017 and 2018 to 2022. Average percentages of women, Black, and Hispanic medical students and residents were calculated for the 2019 to 2022 period. Pearson χ2 tests were conducted to determine significant differences in proportions of women, Black/African American, and Hispanic trainees across time (α = 0.05).

RESULTS

Thoracic surgery and I6 residents saw a significant increase in the proportion of women trainees across the 2 time periods (19.9% (210 out of 1055) to 24.6% (287 out of 1169) (P < .01) and 24.1% (143 out of 592) to 28.9% (330 out of 1142) (P < .05)), respectively. There was no significant change in the proportion of Black and Hispanic trainees in thoracic surgery fellowship or integrated 6-year cardiothoracic residency programs. Hispanic trainees were the only group whose proportion of cardiothoracic surgery trainees was not significantly lower than their medical school proportion. Women and Black trainees had significantly lower proportions of thoracic surgery residents and integrated 6-year cardiothoracic residency program residents than their proportions in medical school (P < .01).

CONCLUSIONS

Cardiothoracic surgery has not significantly increased the number of Black and Hispanic trainees during the past decade. The lower proportion of Blacks and women in thoracic surgery residency and fellowship programs compared with their proportion in medical schools is concerning and is an opportunity for intervention.

The Cost of Being a Woman in Academic Cardiothoracic Surgery: Joint Collaboration of The Society of Thoracic Surgeons Workforces on Diversity, Equity, and Inclusion and Cardiothoracic Surgery Practice Models

BACKGROUND

Gender disparity in the cardiothoracic surgery workforce is challenging to enumerate and quantify. The purpose of our work is to use the most current data to quantify the percentage of women in academic cardiothoracic surgery and salary disparity between women and men.

METHODS

We performed a cross-sectional analysis of data collected by the Accreditation Council for Graduate Medical Education Data Resource Book 2021 and Association of American Medical Colleges Faculty Data for U.S. Medical School Faculty 2019, 2020, and 2021. We used descriptive analysis of the number of faculty and mean salaries of academic cardiothoracic surgeons according to academic rank and gender. Salary disparity in cardiothoracic surgery was compared with salary disparities seen among surgical specialties and academic clinicians.

RESULTS

Over the past 3 years, women comprised 11.5% of the cardiothoracic workforce. In 2021, cardiothoracic surgeons who were women earned $0.71 to $0.86 for every $1.00 earned by cardiothoracic surgeons who were men. Ascending academic rank correlated with greater gender salary disparity; women professors earned less than men of equal and lower academic rank. From 2019 to 2021, women of the academic ranks of associate professor, professor, and chief of cardiothoracic surgery experienced a decrease in mean salaries, whereas men of equivalent academic ranks experienced an increase in mean salaries.

CONCLUSIONS

Gender disparity in cardiothoracic surgery persists, with low representation of women and salary disparity at every academic rank.

Academic Rank and Productivity Among United States Cardiothoracic Surgeons

BACKGROUND

Despite a significant growth of women trainees in cardiothoracic surgery recently, women remain a minority of cardiothoracic surgeons and hold a minority of leadership positions. This study evaluates differences in cardiothoracic surgeon subspecialty choices, academic rank, and academic productivity between men and women.

METHODS

The Accreditation Council for Graduate Medical Education database was used to identify 78 cardiothoracic surgery academic programs in the United States, including integrated, 4+3, and traditional fellowships, as of June 2020. A total of 1179 faculty members were identified within these programs, 585 adult cardiac surgeons (50%), 386 thoracic surgeons (33%), and 168 congenital surgeons (14%), and other, 40 (3%). Data were collected using institutional websites, ctsnet.org, doximity.com, linkedin.com, and Scopus.

RESULTS

Of the 1179 surgeons, only 9.6% were women. Overall, women composed 6.7% of adult cardiac, 15% of thoracic, and 7.7% of congenital surgeons. Among subspecialties, women represent 4.5% (17 of 376) of full professors and 5% (11 of 195) of division chiefs in cardiothoracic surgery in the United States, have shorter career durations, and lower h-indices compared with men. However, women had similar m-indices, which factors in career length, compared with men in adult cardiac (0.63 vs 0.73), thoracic (0.77 vs 0.90), and congenital (0.67 vs 0.78) surgeons.

CONCLUSIONS

Career duration, including cumulative research productivity, appears to be the most important factors predicting full professor rank, potentially contributing to persistent sex-based disparities in academic cardiothoracic surgery.

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.

Another Day, Another 82 Cents: A National Survey Assessing Gender-based Wage Differences in Board-certified Plastic Surgeons

Background

Of 7461 actively practicing United States American Board of Plastic Surgery certified plastic surgeons, only 17% are women. In relation to this small number, gender inequities within the field have been the source of national discussions. Our study assessed the status of the gender-based wage-gap in plastic surgery and sought to identify possible causes.

Methods

An anonymous 43-question survey was distributed to 2981 members of the American Society of Plastic Surgeons in 2021. Male and female responses were compared; an analysis also considering board-certification year was performed. Chi-square and Fisher exact tests were used for bivariate analysis. Continuous variables were compared with two-sample t tests and Wilcoxon rank sum tests.

Results

Ten percent of contacted American Society of Plastic Surgeons members responded to our survey. Of the 288 respondents, 111 (38.5%) were women, and 177 (61.5%) were men. Men were more likely to have salaries over $400K USD per year (P < 0.0001). Earlier certification year was associated with pay greater than $400K per year (P = 0.0235) but was insignificant once stratified by gender (women: P = 0.2392, men: P = 0.7268). Earlier certification year was associated with production-based and self-determined wages (P = 0.0097), whereas later board-certification year was associated with nonnegotiable salaries (P < 0.0001).

Conclusions

Women are significantly less likely to make salaries comparable to those of male plastic surgeons, related to shorter careers on average. An increase in female representation and career duration within the field is needed to improve the current wage-gap.

Women in Thoracic Surgery 2020 Update-Subspecialty and Work-Life Balance Analysis

BACKGROUND

While women comprise nearly half of medical school graduates, they remain underrepresented in cardiothoracic (CT) surgery. To better understand ongoing barriers, we aimed to delineate issues relevant to the CT subspecialities, emphasizing personal life.

METHODS

An anonymous Research Electronic Data Capture (REDCap; hosted at Indiana University School of Medicine) survey link was emailed to female diplomats of the American Board of Thoracic Surgeons (ABTS). The survey included questions on demographics, professional accolades, practice details, and personal life. Survey responses were compared across subspecialities using χ² testing.

RESULTS

Of 354 female ABTS diplomats, we contacted 309, and 176 (57%) completed the survey. By subspecialty, 42% practice thoracic, 26% adult cardiac, and 10% congenital cardiac; 19% report a mixed practice. The subspecialties differed in length of training (congenital-the longest), practice location (mixed practice-less urban), and academic rank (thoracic-most full professors at 17%), but were largely similar in their personal lives. Among all respondents, 65% are in a committed relationship, but 40% felt that being a CT surgeon negatively impacted their ability to find a partner. Sixty percent have children, but 31% of those with children reported using assisted reproductive technology, surrogacy, or adoption. The number with leadership roles (eg, division chief, committee chair of national organization) did not differ among subspecialities, but was low, ranging from 0 to <30%.

CONCLUSIONS

Women remain underrepresented in CT surgery, particularly in the academic rank of full professor and in leadership positions. We advocate for scholarship and mentorship opportunities to encourage women to enter the field, increased female leadership, and policies to enable families.

Women in mechanical circulatory support: She persisted!

Many women physicians have blazed trails and played instrumental roles in advancing the field of Advanced Heart Failure (AHF), Mechanical Circulatory Support (MCS), and cardiac transplantation to its current recognition and glory. In contrast to other areas of cardiology, women have played an integral role in the evolution and emergence of this sub-specialty. Although the ceiling had been broken much later for women cardiothoracic (CT) surgeons in the field of AHF, the ingress of women into surgical fields particularly CT surgery was stonewalled due to pervasive stereotyping. The constancy, commitment, and contributions of women to the field of AHF and MCS cannot be minimized in bringing this field to the forefront of innovation both from technological aspect as well as in redesigning of healthcare delivery models. Integrated team-based approach is a necessity for the optimal care of MCS patients and forced institutions to develop this approach when patients with durable left ventricular assist devices (LVAD) began discharging from the hospitals to local communities. Women in various roles in this field played a pivotal role in developing and designing patient centered care and coordination of care in a multidisciplinary manner. While embracing the challenges and turning them to opportunities, establishing partnerships and finding solutions with expectations to egalitarianism, women in this field continue to push boundaries and subscribe to the continued evolution of the field of AHF and advanced cardiac therapies.

Impact of Gender in Congenital Heart Surgery – Results from a National Survey

OBJECTIVE

There are limited data regarding the impact of gender within congenital heart surgery. Our aim was to assess gender-related experiences by surgeons in this field.

METHODS

A cross-sectional survey was emailed to practicing congenital heart surgeons to ascertain the perception of gender in 5 domains: training, professional career, clinical practice, personal life, and career outlook.

RESULTS

The survey response rate was 94% (17/18) for women and 44% (112/257) for men. More than half of women (53%) were discouraged from pursuing congenital heart surgery (P < .001) and reported a negative impact of gender in attaining their first congenital heart surgery job (P < .001) compared with men. Despite similar demographics, women reported lower starting annual salaries ($150K-$250K vs $250K-$400K), lower current annual salaries ($500K-$750K vs $750K-$1M), lower academic ranks (clinical instructor 6% vs 4% [P = .045], assistant professor 35% vs 19% [P = .19], associate professor 41% vs 25% [P = .24], and professor 6% vs 41% [P = .005]) along with lower annual salaries at the associate professor ($500K-$750K vs $1M-$1.25M) and professor levels ($1M-$1.25M vs >$1.5M) compared with men. Sexual harassment was experienced more frequently by women both in training (65% vs 6%, P < .001) and in practice (65% and 4%, P < .001).

CONCLUSIONS

This survey highlights many areas of gender-related differences: discouragement due to gender to pursue congenital heart surgery, sexual harassment in training and practice, salary and academic rank differentials, negative gender perception at work, and lower career satisfaction for women. Despite various differences between both genders, the majority in each group would choose to enter this profession again as well as encourage others to do so.

The State of Racial and Gender Diversity In Cardiothoracic Surgery Training

BACKGROUND

The field of cardiothoracic surgery has been striving to increase its gender and racial diversity. We sought to examine changes in gender and racial diversity in cardiothoracic fellowships and integrated residencies in the past decade.

METHODS

Accreditation Council for Graduate Medical Education data was obtained from 2011 to 2019. Presence of linear trends was assessed for year-by-year data. Average percentages of women and under-represented minorities were then calculated in three-year intervals. Intervals were compared with t-test and chi-square tests.

RESULTS

There was no statistically significant increase in percent female trainees in cardiothoracic fellowships (18.5% to 22.1% [p=0.10]) or integrated residencies (22.8% to 27.8% [p=0.17]), despite a significant increase in percent female applicants to fellowship (18.2% to 35.3% [p<0.01]) and integrated residency (8.9% to 33.0% [p<0.01]). Cardiothoracic fellowships had no increase in under-represented minority trainees (8.3% to 9.4% [p=0.48]). Under-represented minority trainees in integrated residencies increased from 2.7% to 6.9% [p=0.03]. Although there was no significant increase in under-represented minority applicants to fellowships (10.2% to 11.3% [p=0.66]), the percent of under-represented minority applicants to integrated residencies increased from 13.1% to 19.3% [p<0.01].

CONCLUSION

Cardiothoracic surgery training programs are attracting more female applicants, but this has not resulted in more female trainees. While percentages of under-represented minorities increased among integrated residency applicants and trainees, they remain low compared to other specialties. This data reflects positive changes but highlights that much remains to be done to increase diversity in cardiothoracic surgery training.

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.