Underrepresented in Surgery: (Lack of) Diversity in Academic Surgery Faculty

Sex, Race, and Ethnicity of Faculty and Department Chairs in Orthopaedic Surgery and Comparable Fields: 2015 to 2022

INTRODUCTION

The field of orthopaedic surgery has disproportionately low numbers of women and underrepresented in medicine (URM) groups. Although the representation of women and URM in orthopaedics has increased over the past several years, the growth has not kept up with other surgical specialties.

METHODS

This is a retrospective review of data presented by the Association of American Medical Colleges (AAMC) regarding US medical school faculty and department chair makeup in 2018 to 2022 and 2015 data from the AAMC Group on Women in Medicine and Sciences reports. Data regarding the sex and race/ethnicity of faculty and department chairs in orthopaedic surgery, a comparable surgical specialty (otolaryngology), surgery, and all medical fields were assessed. Otolaryngology was chosen as a comparable specialty because orthopaedic surgery and otolaryngology are the only two surgical specialties classified within the AAMC faculty report, separate from any medical counterpart.

RESULTS

Among orthopaedic surgery, otolaryngology, surgery, and all clinical sciences, the representation of women and individuals from URM groups increased between 2015 and 2022. During this time, orthopaedic surgery had the lowest growth rate of the four groups in female faculty (+0.63%/year), URM faculty (+0.32%/year), and URM department chairs (+0.11%/year). However, orthopaedic surgery did have an increase in female department chairs (0.96%/year to 7% in 2022), similar to increases seen in surgery and all clinical sciences.

DISCUSSION

The increase in representation in female and URM faculty and department chairs in orthopaedic surgery lags behind comparable fields and medicine as a whole. In addition, orthopaedic surgery had the lowest representation of female and URM faculty in 2015 and 2022. Improving the representation of female and URM orthopaedic faculty and department chairs is critical because this may encourage more diverse medical students to consider pursuing a career in the field.

Dissecting Diversity: A Comprehensive Look at the Present Landscape and Future Challenges in Surgical Specialties

BACKGROUND

As the US demographic evolves, surgical fields must adapt to ensure equitable healthcare. Healthcare disparities notably affect minority populations, with communities of color often facing physician shortages and higher rates of diseases such as coronary disease, stroke, and cancer. Research shows that minority physicians significantly improve patient satisfaction and outcomes in underserved communities, highlighting the need for increased physician diversity to enhance cultural competency and patient centered care. Data from the Association of American Medical Colleges (AAMC) reveals minimal increases in underrepresented minorities (URM) in surgical residency and academic careers over the past thirty-six years, with little change URM applicants and matriculants in the nine surgical specialties recognized by the American College of Surgeons from 2010 to 2018.

OBJECTIVE

This review aims to critically evaluate the current landscape of racial and gender diversity in six out of the nine defined surgical specialties (general surgery, plastic surgery, neurosurgery, orthopedic surgery, cardiothoracic surgery, and vascular surgery) in the US.

DESIGN

We conducted a comprehensive literature review to assess of the state of diversity within surgical specialties in the United States. By analyzing the benefits of diversity in surgical fields, evaluating the effectiveness of various diversity programs and initiatives, examining the comparative diversity between surgical subspecialties, and assessing the impact of diversity on patient outcomes, our aim is to highlight the critical importance of enhancing diversity in surgical fields.

RESULTS

While nuances in representation and diversity vary across surgical specialties, all fields persistently exhibit underrepresentation of certain racial/ethnic groups and persistent gender disparities. These disparities manifest throughout various phases, including in residency, and in the recruitment and retention of URM individuals in surgery and surgical subspecialties. While interventions over the past decade have contributed to improving diversity in surgical fields, significant disparities persist. Limitations include the time required for recent interventions to show significant impacts and the inability of established interventions to eliminate disparities.

CONCLUSIONS

Despite the clear benefits, diversity within surgical specialties remains an uphill battle. Addressing the diversity gap in surgical fields is crucial for improving patient outcomes, healthcare access, and workplace environments, requiring strategies such as targeted recruitment, mentorship programs, and addressing systemic biases. This review highlights the undeniable imperative for change and serve a call to action.

Surgeon Intersectionality and Academic Promotion and Retention in the US

Introduction

Efforts have been made to increase the number of women and physicians who are underrepresented in medicine (UIM). However, surgery has been slow to diversify, and there are limited data surrounding the impact of intersectionality.

Objective

To assess the combined association of race and ethnicity and sex with rates of promotion and attrition among US academic medical department of surgery faculty.

Design, Setting, and Participants

This was a retrospective cohort study using faculty roster data from the Association of American Medical Colleges. All full-time academic department of surgery faculty with an appointment any time from January 1, 2005, to December 31, 2020, were included. Study data were analyzed from September 2022 to February 2023.

Exposures

Full-time academic faculty in a department of surgery with a documented self-reported race, ethnicity, and sex within the designated categories of the faculty roster of Association of American Medical Colleges.

Main Outcomes and Measures

Trends in race and ethnicity and sex, rates of promotion, and rates attrition from 2010 to 2020 were assessed with Kaplan-Meier and Cox time-to-event analyses.

Results

A total of 31 045 faculty members (23 092 male [74%]; 7953 female [26%]) from 138 institutions were included. The mean (SD) program percentage of UIM male faculty increased from 8.4% (5.5%) in 2010 to 8.5% (6.2%) in 2020 (P < .001), whereas UIM female faculty members increased from 2.3% (2.6%) to 3.3% (2.5%) over the 10-year period (P < .001). The mean program percentage of non-UIM females increased at every rank (percentage point increase per year from 2010 to 2020 in instructor: 1.1; 95% CI, 0.73-1.5; assistant professor: 1.1; 95% CI, 0.93-1.3; associate professor: 0.55; 95% CI, 0.49-0.61; professor: 0.50; 95% CI, 0.41-0.60; all P < .001). There was no change in the mean program percentage of UIM female instructors or full professors. The mean (SD) percentage of UIM female assistant and associate professors increased from 3.0% (4.1%) to 5.0% (4.0%) and 1.6% (3.2%) to 2.2% (3.4%), respectively (P =.002). There was no change in the mean program percentage of UIM male instructors, associate, or full professors. Compared with non-Hispanic White males, Hispanic females were 32% less likely to be promoted within 10 years (hazard ratio [HR], 0.68; 95% CI, 0.54-0.86; P <.001), non-Hispanic White females were 25% less likely (HR, 0.75; 95% CI, 0.71-0.78; P <.001), Hispanic males were 15% less likely (HR, 0.85; 95% CI, 0.76-0.96; P =.007), and Asian females were 12% less likely (HR, 0.88; 95% CI, 0.80-0.96; P =.03). Non-UIM males had the shortest median (IQR) time to promotion, whereas non-UIM females had the longest (6.9 [6.8-7.0] years vs 7.2 [7.0-7.6] years, respectively; P < .001). After 10 years, 79% of non-UIM males (13 202 of 16 299), 71% of non-UIM females (3784 of 5330), 68% of UIM males (1738 of 2538), and 63% of UIM females (625 of 999) remained on the faculty. UIM females had a higher risk of attrition compared with non-UIM females (HR, 1.3; 95% CI, 1.1-1.5; P = .001) and UIM males (HR, 1.2; 95% CI, 1.0-1.4; P = .05). The mean (SE) time to attrition was shortest for UIM females and longest for non-UIM males (8.2 [0.14] years vs 9.0 [0.02] years, respectively; P < .001).

Conclusion and Relevance

Results of this cohort study suggest that intersectionality was associated with promotion and attrition, with UIM females least likely to be promoted and at highest risk for attrition. Further efforts to understand these vulnerabilities are essential.

When I Don't see me, Am I seen? Race and student perception of the surgery clerkship

INTRODUCTION

Increasing interest in general surgery from students who are Under-Represented in Medicine (URiM) is imperative to advancing diversity, equity, and inclusion efforts. We examined medical student third year surgery clerkship evaluations quantitatively and qualitatively to understand the experiences of URiM and non-URiM learners at our institution.

METHODS

Evaluations from 235 graduated medical students between the years of 2019 and 2021 were analyzed. T-tests were used to compare numerical data. Free-text comments were qualitatively analyzed using inductive thematic analysis by two independent reviewers with conflicts resolved by a third.

RESULTS

Evaluations were completed by 214 non-URiM students (91.1 ​%) and 21 (8.9 ​%) URiM students. There were no significant differences between URiM and non-URiM students in ratings of faculty and resident teaching. When asked whether residents were positive role models for patient care, non-URiM students were more likely than URiM students to agree (3.284 vs. 2.864, p ​= ​0.040). When asked whether they considered faculty to be positive role models, non- URM students were also more likely to answer affirmatively than URiM students (3.394 vs. 2.909 p ​= ​0.013). Qualitative comments were similar between the two groups. When asked what the strengths of the clerkship were, the most commonly evoked theme was "interactions with team" with subthemes of "team integration" "feeling valued" and positive "faculty" or "resident" interactions. "Operative experience" was the second most commonly evoked strength of the clerkship. The most common criticisms of the clerkship involved "negative interactions with team" with subthemes of "not prioritized above other learners" and "ignored." Negative "academic experience" was the next most commonly evoked weakness, with an affiliated theme of "lack of teaching."

CONCLUSIONS

URiM students are less likely than non-URiM students to see surgical residents and faculty as positive role models. Integrating medical students into the team, taking time to teach, and allowing students to feel valued in their roles improves the clerkship experience for trainees and can contribute to recruitment efforts.

The Elephant in the Room: Racial Microaggressions and Implicit Bias in Surgical Training

OBJECTIVE

The aim of this study was to examine the association between race, experience of microaggressions, and implicit bias in surgical training.

BACKGROUND

There is persistent underrepresentation of specific racial and ethnic groups in the field of surgery. Prior research has demonstrated significant sex differences among those who experience microaggressions during training. However, little research has been conducted on the association between race and experiences of microaggressions and implicit bias among surgical trainees.

METHODS

A 46-item survey was distributed to general surgery residents and residents of surgical subspecialties through the Association of Program Directors in Surgery listserv and social media platforms. The questions included general information/demographic data and information about experiencing, witnessing, and responding to microaggressions during surgical training. The primary outcome was the prevalence of microaggressions during surgical training by self-disclosed race. Secondary outcomes were predictors of and adverse effects of microaggressions.

RESULTS

A total of 1624 resident responses were obtained. General surgery residents comprised 825 (50.8%) responses. The female-to-male ratio was nearly equal (815:809). The majority of respondents identified as non-Hispanic White (63.4%), of which 5.3% of residents identified as non-Hispanic Black, and 9.5% identified as Hispanic. Notably, 91.9% of non-Hispanic Black residents (n=79) experienced microaggressions. After adjustment for other demographics, non-Hispanic Black residents were more likely than non-Hispanic White residents to experience microaggressions [odds ratio (OR): 8.81, P <0.001]. Similar findings were observed among Asian/Pacific Islanders (OR: 5.77, P <0.001) and Hispanic residents (OR: 3.35, P <0.001).

CONCLUSIONS

Race plays an important role in experiencing microaggressions and implicit bias. As the future of our specialty relies on the well-being of the pipeline, it is crucial that training programs and institutions are proactive in developing formal methods to address the bias experienced by residents.

Rapidly Increasing Number and Cost of Residency Applications in Surgery

BACKGROUND

Surgical specialties represent the most competitive residency positions to obtain, and applicants for these spots may apply to increasingly more programs in an attempt to match. We describe trends in residency applications across all surgical specialties from 2017 to 2021 application cycles.

MATERIALS AND METHODS

This review of the 2017, 2018, 2019, 2020, and 2021 surgical residency application cycles used the American Association of Medical Colleges' Electronic Residency Application Service (ERAS) databases. Data from a total of 72,171 applicants to United States surgical residencies during the study's time period were included. The 2021 ERAS fee schedule was used to calculate the cost of applications.

RESULTS

The number of applicants across the study interval remains unchanged. Trends suggest more women and underrepresented minorities in medicine are applying to surgical residencies today compared to 5 years ago. The mean number of applications per applicant increased 32.0% from 39.3 in 2017 to 51.8 in 2021, resulting in an increased application fee cost of $329 per applicant. Mean total cost for application fees alone in 2021 were $1211 per applicant. In 2021, the cost of applying to surgical residency for all applicants was over $26 million, a nearly $8 million increase from 2017.

CONCLUSIONS

There has been an increase in the number of applications per applicant in the past 5 residency application cycles. Increased applications create barriers and burdens for applicants, and residency program personnel. These rapid increases are unsustainable and require intervention, although a viable solution has yet to be elucidated.

Gender and Racial Diversity Among Colon and Rectal Surgery Trainees and Leaders

BACKGROUND

Despite recent changes in women and underrepresented minorities in medicine, there still exists large gender and racial gaps in surgical training and leadership.

OBJECTIVE

We hypothesize that gender and racial representation have improved among general and colorectal surgical trainees and leadership over the past 20 years.

DESIGN

This cross-sectional study examines gender and racial representation of general and colorectal surgery residents, colorectal faculty members, and the American Society of Colon and Rectal Surgeons Executive Council.

SETTINGS

We extracted data from the Journal of the American Medical Association Graduate Medical Education yearly reports for information on surgical residents. We used the American Society of Colon and Rectal Surgeons website and publicly available practice websites to obtain information regarding colon and rectal surgery residents, faculty members, and the American Society of Colon and Rectal Surgeons Executive Council.

MAIN OUTCOME MEASURES

We primarily focused on the gender and underrepresented minority breakdowns of general surgery residents, colorectal surgery residents, and the American Society of Colon and Rectal Surgeons Executive Council.

RESULTS

We found that between 2001 and 2021, the number of women and people identifying as underrepresented minorities increased within general surgery programs. In addition, there has been a similar increase in underrepresented minorities and women entering colorectal surgery residency programs. Finally, there has been a steady, significant increase in women representation in the American Society of Colon and Rectal Surgeons Executive Council, with a slower increase in underrepresented minorities on the council.

LIMITATIONS

The study is limited by using previously collected data and relying on publicly available profiles for gender and race information.

CONCLUSIONS

General and colon and rectal surgery have significantly increased gender and racial diversity at the training and leadership levels.

DIVERSIDAD RACIAL Y DE GNERO ENTRE LOS APRENDICES Y LDERES DE CIRUGA DE COLON Y RECTO

ANTECEDENTES: A pesar de los cambios recientes en las mujeres y las minorías subrepresentadas en la medicina, todavía existen grandes brechas de género y raza en la capacitación y el liderazgo quirúrgico.OBJETIVO: Presumimos que la representación racial y de género ha mejorado entre los pasantes y el liderazgo en cirugía general y colorrectal en los últimos 20 años.DISEÑO: Este es un estudio transversal que examina la representación racial y de género de los residentes de cirugía general y colorrectal, miembros de la facultad colorrectal y el Consejo Ejecutivo de la Sociedad Estadounidense de Cirujanos de Colon y Recto.CONFIGURACIÓN: Extrajimos datos de los informes anuales de Educación Médica para Graduados del Journal of the American Medical Association para obtener información sobre los residentes quirúrgicos. Utilizamos el sitio web de la Sociedad Estadounidense de Cirujanos de Colon y Recto, así como los sitios web de práctica disponibles públicamente para obtener información sobre los residentes de cirugía de colon y recto, miembros de la facultad y el Consejo Ejecutivo de la Sociedad Estadounidense de Cirujanos de Colon y Recto.MEDIDAS PRINCIPALES DE RESULTADO: Nos enfocamos principalmente en los desgloses de género y minorías subrepresentadas de residentes de cirugía general, residentes de cirugía colorrectal y el Consejo Ejecutivo de la Sociedad Estadounidense de Cirujanos de Colon y Recto.RESULTADOS: Encontramos que entre 2001 y 2021, la cantidad de mujeres y personas que se identificaron como minorías subrepresentadas aumentó dentro de los programas de cirugía general. Además, ha habido un aumento similar en minorías subrepresentadas y mujeres que ingresan a programas de residencia en cirugía colorrectal. Finalmente, ha habido un aumento constante y significativo en la representación de mujeres en el Consejo Ejecutivo de la Sociedad Estadounidense de Cirujanos de Colon y Recto con un aumento más lento en las minorías subrepresentadas en el consejo.LIMITACIONES: El estudio está limitado por el uso de datos recopilados previamente y por confiar en perfiles disponibles públicamente para la información de género y raza.CONCLUSIONES: La cirugía general y de colon y recto han hecho algunos avances significativos en el aumento de la diversidad racial y de género en los niveles de formación y liderazgo. (Traducción-Yesenia.Rojas-Khalil ).

Effective Mentoring Across Differences-Best Practices and Effective Models to Address the Needs of Underrepresented Trainees in Surgical Residency Programs

BACKGROUND

Mentorship plays a critical role in the career development of surgical trainees and faculty. As the surgical workforce continues to diversify, mentoring trainees who differ) race, ethnicity, country of origin, socioeconomic status, educational background, religion, gender, sexual orientation or ability) can pose challenges to the experience for both mentor and mentee.

OBJECTIVE

The aim of this manuscript is to introduce surgical educators to the systemic barriers faced by trainees and to models of effective mentorship.

METHODS

At the 2022 APDS Meeting, a panel convened to highlight the current challenges of mentoring across differences and effective models for surgical educators. This paper highlights and expands the summary of this panel.

RESULTS

Examples of novel mentoring models are described.

CONCLUSIONS

Acknowledgment of barriers, Implementation of deliberate mentoring strategies, and collaboration with national surgical organizations and surgery departments and faculty may help to reduce physician attrition.

Health Inequities in Orthopaedic Trauma Surgery in the United States: A Scoping Review

BACKGROUND

Health inequities have been shown to have negative effects on patient care and the healthcare system. It is important for orthopaedic trauma surgeons and researchers to understand the extent to which patients are affected by these inequities.

METHODS

We conducted a scoping review as outlined by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. We searched PubMed and Ovid Embase for articles relating to orthopaedic trauma surgery and health inequities.

RESULTS

After exclusion criteria were applied, our final sample consisted of 52 studies. The most frequently evaluated inequities were sex (43 of 52 [82.7]), race/ethnicity (23 of 52 [44.2]), and income status (17 of 52 [32.7]). The least frequently evaluated inequities were lesbian, gay, bisexual, transgender, and queer identity (0 of 52 [0.0]) and occupational status (8 of 52 [15.4]). Other inequities evaluated included rural/underresourced (11 of 52 [21.1]) and educational level (10 of 52 [19.2]). No trend was observed when examining inequities reported by year.

CONCLUSION

Health inequities exist in orthopaedic trauma literature. Our study highlights multiple inequities in the field that need further investigation. Understanding current inequities and how to best mitigate them could improve patient care and outcomes in orthopaedic trauma surgery.

Effects of race and test preparation resources on standardized test scores, a pilot study

BACKGROUND

Little research exists on the relationship between pre-examination resources, race, and standardized test outcomes. This study aimed to determine the effect of test preparation resources and race on test scores.

METHODS

We surveyed medical students at an allopathic institution on the use of test preparation materials and their test scores. Students were grouped by self-identified race. Underrepresented in Medicine (URiM) students were defined as Black/African American (AA), Hispanic/Latino (HL), Native American (NA) and multiple races. Univariate analysis and linear regression were used for statistical analysis.

RESULTS

192 students completed the survey (response rate = 33%). URiM students reported more MCAT attempts than other students. No differences between scores existed between races. There was no association between scores and the use of test preparation resources.

CONCLUSIONS

We found that URiM students took the MCAT more times than their peers; however, we found no racial/ethnic differences in examination preparation resources or scores.

Outcomes of a pilot virtual mentorship program for medical students interested in surgery

BACKGROUND

Lack of mentorship may deter medical students who identify as underrepresented minorities (URM) from entering academic surgery.

METHODS

30 mentor-medical student pairs from the AWS 2020 virtual mentorship pilot-program were surveyed pre-and post-program to explore 1) feasibility of meetings, and, 2) program's perceived efficacy in fostering professional development skills. Participants responded using a 5-point Likert scale (1 = not at all; 5 = completely). Proportions of participants in each category were compared.

RESULTS

Proportion of participants perceiving monthly meetings to be completely feasible did not differ from pre-to post-program surveys for mentees (75%(21/28) vs. 71%(12/17); p = 0.743) or mentors (71%(17/24) vs 71%(13/18); p = 1.00). Compared to pre-program responses, mentees endorsed "completely" (Likert scale 5) improving with regard to their elevator speech (p = 0.001), developing their curriculum vitae (p = 0.003), ability to network (p = 0.021), and acquiring skills for career advancement (p = 0.003).

CONCLUSION

Virtual mentorship may be a feasible and effective means of increasing access to mentors for URM medical students.

Analysis of Diversity, Equity, and Inclusion Initiatives Presented Across US Academic Department of Surgery Websites in 2021

Despite increased attention devoted to diversity, equity, and inclusion (DEI) within academic medicine, representation, lack of workforce and leadership diversity, and bias within medicine remain persistent problems. The purpose of the current study was to understand the current efforts and attention to DEI within academic departments of surgery in the United States. 251 department of surgery websites were reviewed, using a standardized data collection form and scoring procedure, accompanied by a 10 percent fidelity check by an independent reviewer. Only 16% of departments of surgery included DEI-specific information, such as a DEI mission statement or initiatives on their departmental sites, with less than seven percent of departments reporting a DEI committee. Such public information may have implications for recruitment and retention of diverse faculty and trainees, downstream effects for patient care, and could be critical to public accountability to improve diversity and create a culture of equity and inclusion.

Institutional Variability in Representation of Women and Racial and Ethnic Minority Groups Among Medical School Faculty

IMPORTANCE

Bolstering the ranks of women and underrepresented groups in medicine (URM) among medical faculty can help address ongoing health care disparities and therefore constitutes a critical public health need. There are increasing proportions of URM faculty, but comparisons of these changes with shifts in regional populations are lacking.

OBJECTIVE

To quantify the representation of women and URM and assess changes and variability in representation by individual US medical schools.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study assessed US medical school faculty rosters for women and URM, including American Indian and Alaska Native, Black, Hispanic, and Native Hawaiian or other Pacific Islander faculty. US allopathic medical schools participating in the Association of American Medical Colleges (AAMC) Faculty Administrative Management Online User System from 1990 to 2019 (updated December 31 for each year), were included. Faculty data were analyzed from yearly cross-sections updated as of December 31 for each year from 1990 to 2019. For census data, decennial census data were used for years 1990, 2000, and 2010. Intercensal estimates were used for all other years from 1990 to 2019.

MAIN OUTCOMES AND MEASURES

Trends and variability in representation quotient (RQ), defined as representation of a group within an institution's faculty compared to its respective US county.

RESULTS

There were 121 AAMC member institutions (72 076 faculty) in 1990, which increased to 144 institutions (184 577 faculty) in 2019. The median RQ of women faculty increased from 0.42 (IQR, 0.37-0.46) to 0.80 (IQR, 0.74-0.89) (slope, +1.4% per year; P < .001). The median RQ of Black faculty increased from 0.10 (IQR, 0.06-0.22) to 0.22 (IQR, 0.14-0.41) (slope, +0.5% per year; P < .001), but remained low. In contrast, the median RQ of Hispanic faculty decreased from 0.44 (IQR, 0.19-1.22) to 0.34 (IQR, 0.23-0.62) (slope, -1.7% per year; P < .001) between 1990 and 2019. Absolute total change in RQ of URM showed an increase; however, the 30-year slope did not differ from zero (+0.1% per year; P = .052). Although RQ of women faculty increased for most institutions (127 [88.2%]), large variability in URM faculty trends were observed (57 institutions [39.6%] with increased RQ and 10 institutions [6.9%] with decreased RQ). Nearly one-quarter of institutions shifted from the top to bottom 50th percentile institutional ranking by URM RQ with county vs national comparisons.

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that representation of women in academic medicine improved with time, while URM overall experienced only modest increases with wide variability across institutions. Among URM, the Hispanic population has lost representational ground. County-based population comparisons provide new insights into institutional variation in representation among medical school faculty.

Demographic Factors Associated With Research and Career Interests in Aspiring Academic Surgeons: What are the Implications for Tomorrow's Workforce?

OBJECTIVE

To evaluate the research and career interests of aspiring academic surgeons and determine the influence of demographic factors.

DESIGN

Cross-sectional survey SETTING: Single institution, academic general surgery residency program PARTICIPANTS: Medical students invited to interview during 2019-2020 and 2020-2021 residency cycle RESULTS: One hundred fifty-four of 160 (96%) potential respondents representing 63 medical schools completed the survey, American Association for Public Opinion Research Response Rate 6. Fifty-three percent of the study population was female. Seventeen percent identified as Black, 14% Asian, 13% Latinx, 50% white, and 6% other. Respondents were most interested in education, professional development, and surgical culture (32%) followed by basic and translational science (23%), global and community health (20%), and health services (18%). On multiple logistic regression, interest in global/community health was associated with identifying as Black (OR 5.9 [2.0, 17.8] p = 0.001) and female (OR 2.7 [1.0, 7.0] p = 0.044). A plurality of participants were undecided on future specialty (n = 63, 41%). The most common specialty interests were surgical oncology (n = 28, 18%); trauma, acute care, or surgical critical care (n = 21, 14%); pediatric and cardiothoracic surgery (n = 20 for each, 13%); and abdominal transplant (n = 15, 10%).

CONCLUSIONS

In this cross-sectional survey of highly competitive academic general surgery applicants, respondents who were underrepresented in medicine (URiM) and women were more interested in research fields with a history of lower relative NIH funding. In light of these findings, academic programs seeking a more diverse residency workforce should consider strategies beyond recruitment to promote the scholarly achievement of women and URiM residents.

Exploring Characteristics of Academic General Surgery Residency Applicants: A Group Concept-Mapping Approach

OBJECTIVE

Holistic review, which emphasizes qualitative attributes over objective measures, has been proposed as a method for selecting candidates for surgical residency in order to improve diversity in graduate medical education, and, ultimately, the field of surgery. This study seeks to articulate desirable traits of applicants as a first-step in standardizing the holistic review process.

DESIGN

Using Group Concept Mapping, a web-based mixed-methods participatory research methodology, residency selection committee members were asked to 1) list desirable characteristics of applicants, 2) group these into categories, 3) rate their importance to academic/clinical success on a 5-point Likert scale (1 = not at all important, 5 = extremely important), and 4) rate the degree to which each characteristic is feasible to assess on a 3-point Likert scale (1 = not at all feasible, 3 = very feasible). Grouped characteristics submitted to hierarchical cluster analysis depicted committee's consensus about desirable qualities/criteria for applicants. Bivariate scatter-plots and pattern-matching graphics demonstrated which of these criteria were most important and reliably assessed.

SETTING

A single academic general surgery residency training program in Western Pennsylvania.

PARTICIPANTS

Members of the selection committee for the UPMC General Surgery Residency program who had participated in at least 1 prior cycle of applicant selection.

RESULTS

Desirable characteristics of highly qualified applicants into an academic general surgery residency were clustered into domains of 1) scholarly work and research, 2) grades/formal assessments, 3) program fit, 4) behavioral assets, and 5) aspiration. Behavioral assets, which was felt to be the most important to clinical and academic success were considered to be the least feasible to reliably assess. Within this domain, initiative, being self-motivated, intellectual curiosity, work ethic, communication skills, maturity and self-awareness, and thoughtfulness were viewed as most frequently reliably assessed from the application and interview process.

CONCLUSIONS

High quality applicants possess several behavioral assets that faculty deem are important to academic and clinical success. Adapting validated metrics for assessing these assets, may provide a solution for addressing subjectivity and other challenges scrutinized by critics of holistic review.

Practical Approaches to Foster Diversity in Surgical Faculty Recruitment

This Viewpoint discusses a targeted and purposeful approach to help standardize the process to identify, recruit, and hire diverse talent.

An Analysis of Underrepresented in Medicine Away Rotation Scholarships in Surgical Specialties

BACKGROUND

Underrepresented in medicine (UIM) visiting student clerkship scholarships provide an opportunity for supporting diversity. Although these scholarships have become a popular initiative to recruit diverse surgical applicants, they have not been thoroughly analyzed regarding which programs offer scholarships and the characteristics of the scholarships. UIM scholarship opportunity disparities may exist depending on location, funding, reputation, and program size among different specialties.

OBJECTIVE

To describe the characteristics and prevalence of UIM visiting student scholarships by examining institutional and program websites for the surgical specialties.

METHODS

Using the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System for 2021, residency training and diversity websites were identified and evaluated for the availability of UIM visiting student scholarships in July 2021. Eight surgical specialties were examined. Scholarships were categorized by how UIM was defined, the funding amount provided, and scholarship application requirements. We analyzed the association of the program's National Institutes of Health funding, size, type, region, reputation, and population density of the program's area via Doximity on scholarship availability using chi-square and multivariate analysis.

RESULTS

Of the 1058 analyzed programs, 314 (29.7%) had a UIM visiting student scholarship. There were 4 different definitions of UIM used among the analyzed programs. The average scholarship amount offered was $1,852.25 ($500-$4,000). Depending on the specialty, different variables were associated with whether a program had a UIM scholarship.

CONCLUSIONS

Currently, UIM scholarship offerings were variable between programs and surgical specialties.

Evaluating the Thematic Nature of Microaggression among Racial and Ethnic Minority Surgeons

BACKGROUND

It is well documented that surgeons who identify as racial and ethnic minorities experience discrimination while navigating the surgical environment. There is evidence to suggest that the most prevalent form of discrimination experienced is microaggressions. This study sought to identify common microaggressions experienced in the surgical workplace by racial and ethnic minority surgeons with the use of a validated scale.

METHODS

A one-time, deidentified survey was administered to surgeons who identified as a racial and ethnic minority via email. The survey included demographic questions and a shortened version of the Racial Microaggressions Scale, a validated 32-item scale developed to measure microaggressions in everyday life. Subscale means were calculated and compared using sample t-tests along with an analysis of variance.

RESULTS

A total of 185 surgeons completed the survey with 166 included in the final analysis (97 male-identifying, 67 female-identifying). Significantly different microaggression experiences between race and ethnicity were found on the environmental (p < 0.001), foreigner/not belonging (p ≤ 0.001), low achieving/undesirable (p < 0.001), criminality (p < 0.001), and invisibility (p < 0.001) subscales with higher scores denoting more frequent experiences. Black and African American surgeons scored higher than Asian and Asian American and Hispanic and Latino surgeons on the low achieving/undesirable subscale (1.7 vs 0.9 and 1.2, respectively) and the invisibility subscale (1.5 vs 0.8 and 0.8, respectively). In addition, Asian and Asian American and Hispanic and Latino surgeons scored significantly higher on the foreigner/not belonging subscale compared with Black and African American surgeons (1.6 and 1.6 vs 0.9, respectively).

CONCLUSIONS

The current study suggests that surgeons who identified as a racial and ethnic minority experience microaggressions in various ways. Understanding the specific experience of racial and ethnic minority surgeons is important as the surgical workplace strives to create more inclusive environments by acknowledging the lived experience of its diverse workforce.

Bias and discrimination in surgery: Where are we and what can we do about it?

Bias is an inclination or preconceived outlook that favors toward or against an idea, person, or group. It manifests in implicit and explicit ways throughout all aspects and institutions of society. These cognitive shortcuts are often based on stereotypes and can lead to prejudice and discrimination in medicine as they mediate interactions with patients, between providers, and at the institutional level. It is important to understand the drivers and consequences of bias in order to overcome barriers to representation, equity, and inclusion. This paper provides definitions of bias; discusses its manifestations across academic medicine at the institutional and individual levels; and concludes by examining techniques to reduce bias and measure progress. Equity for patients, families, and members of the broader surgical community cannot be achieved without reducing bias and discrimination. We call for action to increase intentional efforts that reduce the influences of bias in healthcare, research, and education, particularly in the field of pediatric surgery.

Racial, ethnic, and gender diversity of applicants and matriculants to neurological surgery residency programs

OBJECTIVE

The aim of this study was to identify trends in the demographic constitution of applicants and matriculants to neurological surgery based on race, ethnicity, and gender.

METHODS

The authors conducted a cross-sectional study using compiled demographic data obtained from the Association of American Medical Colleges. Trends analyzed included proportional changes in race, ethnicity, and gender of applicants and matriculants to neurosurgical residency programs from academic years 2010-2011 to 2018-2019.

RESULTS

A total of 5100 applicants and 2104 matriculants to neurosurgical residency programs were analyzed. No significant change in the percentage of overall women applicants (+0.3%, 95% CI -0.7% to 1.3%; p = 0.77) or in the percentage of women matriculants (+0.3%, 95% CI -2.2% to 2.9%; p = 0.71) was observed. For applicants, no change over time was observed in the percentages of American Indian or Alaska Native (AI/AN) men (0.0%, 95% CI -0.3% to 0.3%; p = 0.65); Asian men (-0.1%, 95% CI -1.2% to 1.1%; p = 0.97); Black or African American men (-0.2%, 95% CI -0.7% to 0.4%; p = 0.91); Hispanic, Latino, or of Spanish Origin men (+0.4%, 95% CI -0.8% to 1.7%; p = 0.26); White men (+0.5%, 95% CI -2.1% to 3.0%; p = 0.27); Asian women (+0.1,% 95% CI -0.9% to 1.1%; p = 0.73); Black or African American women (0.0%, 95% CI -0.6% to 0.5%; p = 0.30); Hispanic, Latino, or of Spanish Origin women (0.0%, 95% CI -0.4% to 0.4%; p = 0.71); and White women (+0.3%, 95% CI -1.1% to 1.7%; p = 0.34). For matriculants, no change over time was observed in the percentages of AI/AN men (0.0%, 95% CI -0.6% to 0.6%; p = 0.56); Asian men (0.0%, 95% CI -2.7% to 2.7%; p = 0.45); Black or African American men (-0.3%, 95% CI -1.4% to 0.8%; p = 0.52); Hispanic, Latino, or of Spanish Origin men (+0.6%, 95% CI -0.8 to 2.0%; p = 0.12); White men (-1.0%, 95% CI -5.3% to 3.3%; p = 0.92); Asian women (+0.1%, 95% CI -1.3% to 1.5%; p = 0.85); Black or African American women (0.0%, 95% CI -0.6% to 0.7%; p = 0.38); Hispanic, Latino, or of Spanish Origin women (-0.1%, 95% CI -0.7% to 0.5%; p = 0.46); and White women (+0.3%, 95% CI -2.4% to 3.0%; p = 0.70).

CONCLUSIONS

Despite efforts to diversify the demographic constitution of incoming neurosurgical trainees, few significant advances have been made in recent years. This study suggests that improved strategies for recruitment and cultivating early interest in neurological surgery are required to further increase the diversification of future cohorts of neurosurgical trainees.

Racial and Ethnical Diversity Within the Neurosurgery Resident and Faculty Workforce in the United States

BACKGROUND

Promoting workplace diversity leads to a variety of benefits related to a broader range of perspectives and insights. Underrepresented in medicine (URiM), including African Americans, Latinx, and Natives (Americans/Alaskan/Hawaiians/Pacific Islanders), are currently accounting for approximately 40% of the US population.

OBJECTIVE

To establish a snapshot of current URiM representation within academic neurosurgery (NS) programs and trends within NS residency.

METHODS

All 115 NS residencies and academic programs accredited by the Accreditation Council for Graduate Medical Education in 2020 were included in this study. The National Residency Matching Program database was reviewed from 2011 to 2020 to analyze URiM representation trends over time within the NS resident workforce. The academic rank, academic and clinical title(s), subspecialty, sex, and race of URiM NS faculty (NSF) were obtained from publicly available data.

RESULTS

The Black and Latinx NS resident workforce currently accounts for 4.8% and 5.8% of the total workforce, respectively. URiM NSF are present in 71% of the Accreditation Council for Graduate Medical Education-accredited NS programs and account for 8% (148 of 1776) of the workforce. Black and Latinx women comprise 10% of URiM NSF. Latinx NSFs are the majority within the URiM cohort for both men and women. URiM comprise 5% of all department chairs. All are men. Spine (26%), tumor (26%), and trauma (17%) were the top 3 subspecialties among URiM NSF.

CONCLUSION

NS has evolved, expanded, and diversified in numerous directions, including race and gender representation. Our data show that ample opportunities remain to improve URiM representation within NS.

Closing the Gap: Training Experiences and Career Outcomes for Underrepresented Minorities in Plastic Surgery

Background:

The present study assesses training characteristics, scholastic achievements, and traditional career accomplishments of ethnically underrepresented in medicine (UIM) plastic and reconstructive surgery (PRS) faculty relative to non-UIM PRS faculty.

Method:

A cross-sectional analysis of core PRS faculty appointed to accredited United States residency training programs (n = 99) was performed.

Results:

Of the 949 US PRS faculty, a total of 51 (5.4%) were identified as UIM. Compared with non-UIM faculty, there were few differences when evaluating medical education, residency training, pursuit of advanced degrees, and attainment of subspecialty fellowship training. UIM faculty were more likely than non-UIM faculty to have graduated from a medical school outside the United States (25% versus 13%, P = 0.014). In addition, UIM faculty did not differ from non-UIM counterparts in traditional career accomplishments, including promotion to full professor, obtaining NIH funding, serving as program director, receiving an endowed professorship, appointment to a peer-reviewed editorial board, scholarly contributions (H-index and number of publications), and appointment to chief/chair of their division/department.

Conclusions:

The historical lack of ethnic diversity that comprise US academic PRS faculty persists. This study reveals that those UIM faculty who are able to obtain faculty appointments are equally successful in achieving scholastic success and traditional career accomplishments as their non-UIM counterparts. As we strive toward increasing representation of UIM physicians in academic plastic surgery, the field will benefit from efforts that promote a pipeline for underrepresented groups who traditionally face barriers to entry.

Improving Equity, Diversity, and Inclusion in Plastic, Reconstructive, and Aesthetic Surgery in Canada: A Call to Action

The global COVID-19 pandemic has brought to light the significant inequities in the delivery of healthcare, vaccine inequity, and differential access to life-saving treatments, which have disproportionately impacted marginalized and racialized populations. In this article, we acknowledge and recognize the centuries-old legacies perpetuating inequity, injustice, and oppression, we discuss the principles of Equity, Diversity, and Inclusion (EDI) and we call our Canadian plastic surgery colleagues and trainees to action. We propose a plan for (1) Education, (2) Mitigating Disparities in the Clinical Setting, and (3) Policy, Societies, and Leadership Education.

Diversity in the Adult and Pediatric Heart Transplant Surgeon Workforce between 2000 and 2020

There is a paucity of literature evaluating trends in the demographic composition of the cardiothoracic surgery workforce. Using the United Network for Organ Sharing database, we retrospectively analyzed the changes in sex, race, and ethnicity of surgeons performing heart transplantations between 2000−2020. Surgeons performing heart transplantations for adult (≥18 years) and pediatric (<18 years) patients between 2000−2020 were identified and stratified by sex (male, female) and by race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic of any race). Between 2000−2020, the proportion of non-White and female cardiothoracic surgeons performing adult and pediatric heart transplantations increased. Nevertheless, there remains a lack of diversity in the workforce, particularly when compared to the general United States population.

Bursting the Hidden Curriculum Bubble: A Surgical Near-Peer Mentorship Pilot Program for URM Medical Students

The hidden curriculum of unspoken professional expectations negatively impacts medical student interest in surgery. Medical student mentorship and early surgical exposure have been shown to demystify the hidden curriculum. Although residents and faculty play a vital role, near-peer mentorship may aid in uncovering the hidden curriculum and promoting medical student interest in surgery, especially for those learners who are underrepresented in medicine. We developed and implemented a formalized near-peer mentorship program composed of quarterly small group Surgical Peer Teacher led lessons and one-on-one Surgical Support Team mentorship meetings covering surgical curriculum topics for medical students at an academic medical school. This structured near-peer mentorship model provides a mechanism to demystify surgical culture, increase early access to surgical mentorship, and develop mentorship skills amongst students. This program aims to uncover the surgical hidden curriculum to improve surgical career support and interest among medical students with less exposure and access to physician role models. This longitudinal mentorship model is student-run and can be easily adapted to enhance existing support models at medical schools. Future studies will evaluate utilization, impact on surgical specialty interest, and efficacy in demystifying the surgical hidden curriculum.

Lofty goals and strategic plans are not enough to achieve and maintain a diverse workforce: an American Association for the Surgery of Trauma Diversity, Equity, and Inclusion Committee conversation

The American Association for the Surgery of Trauma Diversity, Equity, and Inclusion (DEI) Ad Hoc Committee organized a luncheon symposium with a distinguished panel of experts to discuss how to ensure a diverse surgical workforce. The panelists discussed the current state of DEI efforts within surgical departments and societal demographic changes that inform and necessitate surgical workforce adaptations. Concrete recommendations included the following: obtain internal data, establish DEI committee, include bias training, review hiring and compensation practices, support the department members doing the DEI work, commit adequate funding, be intentional with DEI efforts, and develop and support alternate pathways for promotion and tenure.

The current status of the diversity pipeline in surgical training

OBJECTIVE

Recent initiatives have emphasized the importance of diversity, equity, and inclusion in academic surgery. Racial/ethnic disparities remain prevalent throughout surgical training, and the "diversity pipeline" in resident recruitment and retention remains poorly defined.

METHODS

Data was retrospectively collected using two separate datasets. The Association of American Medical Colleges database was used to obtain demographic data on US medical school graduates. The US Graduate Medical Education annual report was used to obtain demographic data on surgical residents. Wilcoxon signed-rank test was used to compare racial/ethnic distribution within surgical residency programs with graduating medical students. Linear regression analysis was performed to analyze population trends over time.

RESULTS

The study population included 184,690 surgical residents from 2011 to 2020. Nine resident cohorts were created according to surgical specialty - general surgery, neurosurgery, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, cardiothoracic surgery, urology, and vascular surgery. Among surgical programs, White residents were overrepresented in 8 of 9 specialties compared to the concurrent graduating medical student class for all years (p < 0.01 each, no difference in ophthalmology). Black residents were underrepresented in 8 of 9 specialties (p < 0.01 each, no difference in general surgery). Asian representation was mixed among specialties (4 overrepresented, 1 equal, 4 underrepresented), as was Hispanic representation (5 overrepresented, 4 equal) (p < 0.01 each).

CONCLUSIONS

These data suggest that racial/ethnic disparities are inherent to the process of recruitment and retention of surgical residents. Efforts to improve the "diversity pipeline" should focus on mentorship and development of minority medical students and creating an equitable learning environment.

Examination of Elective Bariatric Surgery Rates Before and After US Affordable Care Act Medicaid Expansion

Importance

There is limited evidence on whether the Affordable Care Act Medicaid expansion beginning in 2014 improved access to elective procedures. Uninsured individuals are at higher risk of obesity and may have experienced improved uptake of bariatric surgery following Medicaid expansion.

Objective

To examine the association between Medicaid expansion and the receipt of inpatient elective bariatric surgery among Medicaid-covered and uninsured individuals aged 26 to 64 years.

Design Setting and Participants

This cohort study used difference-in-differences analysis of all-payer data (2010-2017) of 637 557 elective bariatric surgeries for patients aged 26 to 74 years from 11 Medicaid expansion states and 6 nonexpansion states. Nonexpansion states and individuals aged 65 to 74 years were control cohorts. Data analysis was performed from July 6, 2020, to July 23, 2021.

Exposure

Living in a Medicaid expansion state.

Main Outcomes and Measures

The main outcomes were the (1) number of elective bariatric surgeries, (2) population count, and (3) rate of bariatric surgery (number of surgeries per 10 000 population) among Medicaid-covered and uninsured individuals.

Results

Of the 600 798 elective bariatric surgeries in adults aged 26 to 64 years between 2010 and 2017 from the 17 study states, Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in nonexpansion states. A total of 296 798 patients (78.9%) in expansion states were women vs 177 386 (78.9%) in nonexpansion states. Among individuals aged 26 to 64 years, the median age was 44 (IQR, 37-52) years. Racial and ethnic distribution was non-Hispanic White, 60.2%; non-Hispanic Black, 17.7%; Hispanic, 16.6%; and other, 5.5%. Between 2013 and 2017, the volume of bariatric surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states and 16.5% in nonexpansion states. Medicaid expansion was associated with a 36.6% annual increase (95% CI, 8.2% to 72.5%) in surgery volume, a 9.0% annual increase (95% CI, 3.8% to 14.5%) in the population, and a 25.5% change (95% CI, -1.3% to 59.4%) in the rate of bariatric surgery. By race and ethnicity, Medicaid expansion was associated with an increase in the rate of bariatric surgery among non-Hispanic White individuals (31.6%; 95% CI, 6.1% to 63.0%) but no significant change among non-Hispanic Black (5.9%; 95% CI, -19.8% to 39.9%) and Hispanic (28.9%; 95% CI, -24.4% to 119.8%) individuals.

Conclusions and Relevance

This cohort study found that Medicaid expansion was associated with increased rates of bariatric surgery among lower-income non-Hispanic White individuals, but not among Hispanic and non-Hispanic Black individuals.

Trends in Diversity Related to Gender and Race in the Surgical Specialties and Subspecialties Inclusive of Oral and Maxillofacial Surgery

Medical training in the United States has undergone multiple evolutions and maturations. The Flexner Report and its effects, written in 1910, still has significant impact on modern professional education in the medical and dental arenas. The National Academy of Medicine (Institute of Medicine) in 2003 documented the need for diversity in the health care workforce, and the Association of American Medical Colleges additionally looked at Medical Education and health care through the lens of Academic Medicine. Both these reports reflected that health care institutions, providers, educators, students, and surgical residents are mandated to improve the health of the nation.

The imperative for scientific societies to change the face of academia: Recommendations for immediate action

As organizations that facilitate collaboration and communication, scientific societies have an opportunity, and a responsibility, to drive inclusion, diversity, equity, and accessibility in science in academia. The American Association for Anatomy (AAA), with its expressed and practiced culture of engagement, can serve as a model of best practice for other professional associations working to become more inclusive of individuals from historically underrepresented groups. In this publication, we acknowledge anatomy's exclusionary past, describe the present face of science in academia, and provide recommendations for societies, including the AAA, to accelerate change in academia. We are advocating for scientific societies to investigate inequities and revise practices for inclusivity; develop and empower underrepresented minority leadership; and commit resources in a sustained manner as an investment in underrepresented scientists who bring diverse perspectives and lived experiences to science in academia.

Diversification of Academic Surgery, Its Leadership, and the Importance of Intersectionality

Importance

Diversity in academic surgery is lacking, particularly among positions of leadership.

Objective

To evaluate trends among racial/ethnical minority groups stratified by gender along the surgical pipeline, as well as in surgical leadership.

Design, Setting, and Participants

This cross-sectional and longitudinal analysis assessed US surgical faculty census data obtained from the Association of American Medical Colleges faculty roster in the Faculty Administrative Management Online User System database. Surgical faculty members captured in census data from December 31, 2013, to December 31, 2019, were included in the analysis. Faculty were identified from the surgery category of the faculty roster, which includes general surgeons and subspecialists, neurosurgeons, and urologists.

Main Outcomes and Measures

Gender and race/ethnicity were obtained for surgical faculty stratified by rank. Descriptive statistics with annual percentage of change in representation are reported based on faculty rank.

Results

A total of 15 653 US surgical faculty, including 3876 women (24.8%), were included in the data set for 2019. Female faculty from racial/ethnic minority groups experienced an increase in representation at instructor and assistant and associate professorship appointments, with a more favorable trajectory than male faculty from racial/ethnic minority groups across nearly all ranks. White faculty maintain most leadership positions as full professors (3105 of 3997 [77.7%]) and chairs (294 of 380 [77.4%]). The greatest magnitude of underrepresentation along the surgical pipeline has been among Black (106 of 3997 [2.7%]) and Hispanic/Latinx (176 of 3997 [4.4%]) full professors. Among full professors, although Black and Hispanic/Latinx male representation increased modestly (annual change, 0.07% and 0.10%, respectively), Black female representation remained constant (annual change, 0.00004%) and Hispanic/Latinx female representation decreased (annual change, -0.16%). Overall Hispanic/Latinx (20 of 380 [5.3%]) and Black (13 of 380 [3.4%]) representation as chairs has not changed, with only 1 Black and 1 Hispanic/Latinx woman ascending to chair from 2013 to 2019.

Conclusions and Relevance

A disproportionately small number of faculty from minority groups obtain leadership positions in academic surgery. Intersectionality may leave female members of racial/ethnic minority groups more disadvantaged than their male colleagues in achieving leadership positions. These findings highlight the urgency to diversify surgical leadership.

Looking Beyond the Numbers: Increasing Diversity and Inclusion Through Holistic Review in General Surgery Recruitment

OBJECTIVE

The purpose of this study is the examine the effect of a holistic review process on the recruitment of women and students underrepresented in medicine (UIM) in a general surgery residency program.

DESIGN

A retrospective study comparing the proportion of women and UIM students ranked and matched into categorical positions from 2013 to 2020 before and after the implementation of the holistic application review process. United States Medical Licensing Exam (USMLE) scores and American Board of Surgery In-training Exam (ABSITE) scores were also compared between groups.

SETTING

General Surgery residency program at a tertiary, academic center.

PARTICIPANTS

Medical students applying for and matriculated to categorical positions.

RESULTS

After the implementation of holistic review in 2017, there was a statistically significant increase in the proportion of women (42% vs. 61%, p < 0.01) and UIM students (14% vs. 20%, p = 0.046) ranked in our program compared with the prior "traditional" approach. The proportion of matched female (33% vs. 54%, p = 0.11) and UIM applicants (14% vs. 21%, p = 0.48) also increased after holistic review, although the changes were not statistically significant. The median USMLE Step 1 scores were equivalent for both ranked (250 vs. 250, p = 0.81) and matched (250 vs. 249, p = 0.32) applicants before and after the intervention. The median ABSITE scores for the matched intern classes was lower after initiation of holistic review (519 vs. 483, p = 0.01). However, these scores were consistently above the national medians and subgroup analysis showed no difference between the median aggregate ABSITE scores for UIM and female categorical interns and non-UIM males (475 vs. 520, p = 0.09).

CONCLUSIONS

Increasing emphasis is being placed on the diversification of residency training to reflect an expanding, diverse patient population. The incorporation of a holistic review process, providing broader assessment of applicants, can play a pivotal role in increasing the proportion of women and UIM students represented in the general surgery recruitment process.