Addressing Gender-Related Implicit Bias in Surgical Resident Physician Education: A Set of Guidelines

The shifting trends in the epidemiology and risk factors of non-accidental fractures in children

BACKGROUND

Fractures are a common presentation of non-accidental trauma (NAT) in the pediatric population. However, the presentation could be subtle, and a high degree of suspicion is needed not to miss NAT.

OBJECTIVE

To analyze a comprehensive database, providing insights into the epidemiology of fractures associated with NAT.

PARTICIPANTS AND SETTING

The TriNetX Research Network was utilized for this study, containing medical records from 55 healthcare organizations. TriNetX was queried for all visits in children under the age of 6 years from 2015 to 2022, resulting in a cohort of over 32 million.

METHODS

All accidental and non-accidental fractures were extracted and analyzed to determine the incidence, fracture location, and demographics of NAT. Statistical analysis was done on a combination of Python and Epipy.

RESULTS

Overall, 0.36 % of all pediatric patients had a diagnosis of NAT, and 4.93 % of fractures (34,038 out of 689,740 total fractures) were determined to be non-accidental. Skull and face fractures constituted 17.9 % of all NAT fractures, but rib/sternum fractures had an RR = 6.7 for NAT. Children with intellectual and developmental disability (IDD) or autism spectrum disorder (ASD) had a 9 times higher risk for non-accidental fractures. The number of non-accidental fractures significantly increased after 2019.

CONCLUSIONS

The study findings suggest that nearly 1 out of all 20 fractures in children under age 6 are caused by NAT, and that rib/sternum fractures are most predictive of an inflicted nature. The study also showed a significant increase in the incidence of NAT, during and after the pandemic.

Gender diversity at spine surgery academic conferences: a 15-year investigation

BACKGROUND CONTEXT

Enhancing gender diversity at academic conferences is critical for advancing women's representation and career trajectories in spine surgery.

PURPOSE

To discover trends in women's representation at major spine conferences over a 15-year period.

STUDY DESIGN/SETTING

Conference records from the 2007-2021 annual meetings of the Congress of Neurological Surgeons, North American Spine Society, and Scoliosis Research Society (SRS).

PATIENT SAMPLE

Authors of spine-related presentations.

OUTCOME MEASURES

Authorship by gender.

METHODS

Retrospective bibliometric analysis with univariate and multivariate modeling to identify trends and predictors of gender diversity.

RESULTS

Among 8,948 presentations, 750 (8.4%) had female first authors and 618 (6.9%) had female senior authors. There was no change in rates of female first authorship (p=.41) or senior authorship (p=.88) over time. The strongest predictors of female first authorship were having a female senior author (OR 7.32, p<.001), and delivering presentations at SRS (OR 1.95, p=.001). Factors negatively associated with female first authorship included poster format (OR 0.82, p=.039) and conference location in the United States/Canada (OR 0.76, p=.045). Similar trends were encountered for senior authorship. Productivity per senior author was similar between genders (p=.160); whereas a gender gap in productivity per first author during 2007 to 2011 (p=.020) equalized by 2017 to 2021 (p=.300). Among the 10 most productive authors of each gender, male authors delivered more presentations, but all authors shared similar format, content, and location.

CONCLUSIONS

Women's representation in spine-related presentations did not increase at three major conferences over a 15-year period. Our findings regarding the positive effects of female mentorship, and international or virtual venues merit further investigation to address the gender gap. The upstream pipeline of recruiting women into academic spine surgery also needs to be addressed.

LEVEL OF EVIDENCE: 3

Extent and types of gender-based discrimination against female medical students and physicians at five university hospitals in Germany - results of an online survey

Objective

There is a gap in research on gender-based discrimination (GBD) in medical education and practice in Germany. This study therefore examines the extent and forms of GBD among female medical students and physicians in Germany. Causes, consequences and possible interventions of GBD are discussed.

Methods

Female medical students (n=235) and female physicians (n=157) from five university hospitals in northern Germany were asked about their personal experiences with GBD in an online survey on self-efficacy expectations and individual perceptions of the "glass ceiling effect" using an open-ended question regarding their own experiences with GBD. The answers were analyzed by content analysis using inductive category formation and relative category frequencies.

Results

From both interviewed groups, approximately 75% each reported having experienced GBD. Their experiences fell into five main categories: sexual harassment with subcategories of verbal and physical, discrimination based on existing/possible motherhood with subcategories of structural and verbal, direct preference for men, direct neglect of women, and derogatory treatment based on gender.

Conclusion

The study contributes to filling the aforementioned research gap. At the hospitals studied, GBD is a common phenomenon among both female medical students and physicians, manifesting itself in multiple forms. Transferability of the results beyond the hospitals studied to all of Germany seems plausible. Much is known about the causes, consequences and effective countermeasures against GBD. Those responsible for training and employers in hospitals should fulfill their responsibility by implementing measures from the set of empirically evaluated interventions.

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium

OBJECTIVE

To examine differences in resident operative experience between male and female general surgery residents.

BACKGROUND

Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level.

METHODS

Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents.

RESULTS

There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02).

CONCLUSIONS

Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

Gender Disparities in Critical Care Procedure Training of Internal Medicine Residents

Background

Procedural training is a required competency in internal medicine (IM) residency, yet limited data exist on residents' experience of procedural training.

Objectives

We sought to understand how gender impacts access to procedural training among IM residents.

Methods

A mixed-methods, explanatory sequential study was performed. Procedure volume for IM residents between 2016 and 2020 was assessed at two large academic residencies (Program A and Program B: 399 residents and 4,020 procedures). Procedural rates and actual versus expected procedure volume by gender were compared, with separate analyses by clinical environment (intensive care unit [ICU] or structured procedural service). Semistructured gender-congruent focus groups were conducted. Topics included identity formation as a proceduralist and the resident procedural learning experience, including perceived gender bias in procedure allocation.

Results

Compared with men, women residents performed disproportionately fewer ICU procedures per month at Program A (1.4 vs. 2.7; P < 0.05) but not at Program B (0.36 vs. 0.54; P = 0.23). At Program A, women performed only 47% of ICU procedures, significantly fewer than the 54% they were expected to perform on the basis of their time on ICU rotations (P < 0.001). For equal gender distribution of procedural volume at Program A, 11% of the procedures performed by men would have needed to have been performed by women instead. Gender was not associated with differences in the Program A structured procedural service (53% observed vs. 52% expected; P = 0.935), Program B structured procedural service (40% observed vs. 43% expected; P = 0.174), or in Program B ICUs (33% observed vs. 34% expected; P = 0.656). Focus group analysis identified that women from both residencies perceived that assertiveness was required for procedural training in unstructured learning environments. Residents felt that gender influenced access to procedural opportunities, ability to self-advocate for procedural experience, identity formation as a proceduralist, and confidence in acquiring procedural skills.

Conclusion

Gender disparities in access to procedural training during ICU rotations were seen at one institution but not another. There were ubiquitous perceptions that assertiveness was important to access procedural opportunities. We hypothesize that structured allocation of procedures would mitigate disparities by allowing all residents to access procedural training regardless of self-advocacy. Residency programs should adopt structured procedural training programs to counteract inequities.

Human visual explanations mitigate bias in AI-based assessment of surgeon skills

Artificial intelligence (AI) systems can now reliably assess surgeon skills through videos of intraoperative surgical activity. With such systems informing future high-stakes decisions such as whether to credential surgeons and grant them the privilege to operate on patients, it is critical that they treat all surgeons fairly. However, it remains an open question whether surgical AI systems exhibit bias against surgeon sub-cohorts, and, if so, whether such bias can be mitigated. Here, we examine and mitigate the bias exhibited by a family of surgical AI systems-SAIS-deployed on videos of robotic surgeries from three geographically-diverse hospitals (USA and EU). We show that SAIS exhibits an underskilling bias, erroneously downgrading surgical performance, and an overskilling bias, erroneously upgrading surgical performance, at different rates across surgeon sub-cohorts. To mitigate such bias, we leverage a strategy -TWIX-which teaches an AI system to provide a visual explanation for its skill assessment that otherwise would have been provided by human experts. We show that whereas baseline strategies inconsistently mitigate algorithmic bias, TWIX can effectively mitigate the underskilling and overskilling bias while simultaneously improving the performance of these AI systems across hospitals. We discovered that these findings carry over to the training environment where we assess medical students' skills today. Our study is a critical prerequisite to the eventual implementation of AI-augmented global surgeon credentialing programs, ensuring that all surgeons are treated fairly.

Resident Operative Autonomy and Attending Verbal Feedback Differ by Resident and Attending Gender

Objectives

This study tests the null hypotheses that overall sentiment and gendered words in verbal feedback and resident operative autonomy relative to performance are similar for female and male residents.

Background

Female and male surgical residents may experience training differently, affecting the quality of learning and graduated autonomy.

Methods

A longitudinal, observational study using a Society for Improving Medical Professional Learning collaborative dataset describing resident and attending evaluations of resident operative performance and autonomy and recordings of verbal feedback from attendings from surgical procedures performed at 54 US general surgery residency training programs from 2016 to 2021. Overall sentiment, adjectives, and gendered words in verbal feedback were quantified by natural language processing. Resident operative autonomy and performance, as evaluated by attendings, were reported on 5-point ordinal scales. Performance-adjusted autonomy was calculated as autonomy minus performance.

Results

The final dataset included objective assessments and dictated feedback for 2683 surgical procedures. Sentiment scores were higher for female residents (95 [interquartile range (IQR), 4-100] vs 86 [IQR 2-100]; P < 0.001). Gendered words were present in a greater proportion of dictations for female residents (29% vs 25%; P = 0.04) due to male attendings disproportionately using male-associated words in feedback for female residents (28% vs 23%; P = 0.01). Overall, attendings reported that male residents received greater performance-adjusted autonomy compared with female residents (P < 0.001).

Conclusions

Sentiment and gendered words in verbal feedback and performance-adjusted operative autonomy differed for female and male general surgery residents. These findings suggest a need to ensure that trainees are given appropriate and equitable operative autonomy and feedback.

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Discrimination and insomnia: Examining depressive symptoms and nicotine withdrawal through a serial mediation model in a sample of smokers

Insomnia is a common sleep disorder associated with poor health outcomes. Individuals from racially underrepresented groups as well as women tend to report more severe insomnia symptoms, and frequent experiences of discrimination have been found to drive such disparities. Smokers commonly experience sleep problems since nicotine can alter the sleep-wake cycle. Discrimination is associated with increased nicotine dependence, and such discrimination may also intensify tobacco withdrawal, specifically mood and cognitive-related aspects of withdrawal. The potential impact of discrimination on withdrawal symptoms and related mood symptoms like depression may lead to increases in insomnia symptoms. However, no studies to date have evaluated the indirect association of discrimination with insomnia severity through nicotine withdrawal and depressive symptoms. Therefore, this cross-sectional survey of n = 110 non-Hispanic Black and White current smokers (48.2 % Black, 69.1 % women) investigated these associations through a serial mediation model. Controlling for race, gender, nicotine dependence levels, and income, multivariate analyses supported a significant indirect effect of discrimination on insomnia severity through depressive symptoms. Analyses supported the hypothesized serial mediation model whereby discrimination is positively associated with depressive symptoms, which in turn are linked to more severe nicotine withdrawal, leading to greater insomnia severity. Smokers encountering frequent experiences of discrimination might be at increased risk of suffering insomnia as a result of their increased depressive and withdrawal symptoms. Future work is necessary to understand the role of depressive symptoms in these associations as well as possible implications for smoking relapse and success of smoking cessation programs.

A survey of implicit bias training in physician assistant and nurse practitioner postgraduate fellowship/residency programs

BACKGROUND

There has been renewed focus on advancing inclusivity within organized medicine to reduce health disparities and achieve health equity by addressing the deleterious effects of implicit bias in healthcare and clinical outcomes. It is well documented that negative implicit attitudes and stereotypes perpetuate inequity in healthcare. The aim of this study is to investigate implicit bias training in postgraduate physician assistant (PA) and nurse practitioner (NP) education; describe delivery of content to trainees; and detail program directors' attitudes toward this type of training. Although there is research examining implicit bias training in physician residency education, there are no published studies on implicit bias training in postgraduate PA and NP postgraduate residency/fellowship programs.

METHOD

A non-experimental, descriptive study was designed to obtain information via survey from members of the Association of Postgraduate Physician Assistant Programs (APPAP).

RESULTS

The response rate was 41%. The majority of respondents (76%) felt that PA and NP postgraduate programs should include implicit bias instruction. Educational strategies used by PA and joint PA/NP postgraduate programs or their sponsoring institution to deliver implicit bias content to trainees include: implicit bias training modules (50%), facilitated group discussions (36%), invited speaker on implicit bias (33%), case studies on implicit bias (16%), and implicit association test (10%); however, 30% of postgraduate programs do not provide implicit bias training to PA and/or NP trainees. Barriers to implementing implicit bias training expressed by some postgraduate programs include: uncertainty in how to incorporate implicit bias training (16%); lack of strategic alignment with training program or sponsoring institution (13%); time constraints (10%); financial constraints (6%); lack of access to content experts (6%); and unfamiliarity with evidence supporting implicit bias training (6%).

CONCLUSION

The present study sheds some light on the current state of implicit bias training in PA and joint PA/NP postgraduate residency/fellowship programs. While the majority of programs offer some sort of implicit bias training, there is a need to standardize this training in PA and joint PA/NP postgraduate education curricula using an actionable framework.

Is Urology a gender-biased career choice? A survey-based study of the Italian medical students' perception of specialties

Background

Despite the well-established worldwide phenomenon of “the feminisation of medicine,” in Italy, Urology remains a male-dominated field.

Objective

The aims of our work are to assess data on medical students' choice of surgical specialty in Italy to investigate if a gender-biased trend exists and to find the key points that influence the decision-making process when choosing a specialty, with a focus on Urology.

Design

Data about access to residency programs in 2017–2020 were analysed through descriptive statistics. Investigations concerning the decision-making process were carried through distribution of an online anonymous survey to Italian medical students.

Results

Urology was among the specialties with the lowest proportion of female residents in Italy in the last 4 years: 37 (29.4%) in 2017, 27 (21.4%) in 2018, 40 (26.7%) in 2019, and 57 (25.2%) in 2020. The total number of participants of the survey was 1409, of which only 341 declared being keen to pursue a career path in surgery. Out of the 942 students not interested in surgery, 46.2% females and 22.5% males indicated a “sexist environment” as one of the reasons. Overall, the main reason for medical students not choosing Urology is the lack of interest in the specialty. Furthermore, there is a different perception of Urology as a sexist environment between female (23.4%) and male (3.2%, p < 0.001) medical students, which may influence their decision-making process.

Conclusions

In Italy, the prevalence of female medical graduates does not mirror the proportion of female doctors choosing a career in some surgical specialties, including Urology. Our survey results clearly identified that a large proportion of medical graduates are not choosing urology because of the perception of a sexist environment. While the reasons for this phenomenon remain unclear, the presence of a gender-biased perception of a sexist environment represents a possible explanation.

Early Barriers to Career Progression of Women in Surgery and Solutions to Improve Them: A Systematic Scoping Review

OBJECTIVE

This study aims to summarize the evidence concerning the barriers that exist to the career progression of women in surgery and to provide potential solutions to overcome these obstacles.

BACKGROUND

Visible and invisible impediments can hinder female doctors' pursuit of a surgical career, from choosing a surgical specialty to training opportunities and all the way through career progression.

METHODS

Database search of original studies about barriers for female surgeons during choice of surgical career, residency, and career progression. A query including possible solutions such as mentorship and network was included.

RESULTS

Of 4618 total articles; 4497 were excluded as duplicates, having incorrect study focus, or not being original studies; leaving 120 studies meeting the inclusion criteria. Of the articles included, 22 (18%) focused on factors affecting the pursuit of a surgical career, such as surgical work hours and limited time for outside interests, 55 (46%) analyzed the main barriers that exist during surgical residency and fellowship training, such as discrimination and sexual harassment, 27 (23%) focused on barriers to career advancement, heavy workloads, ineffective mentorship, unclear expectations for advancement, inequality in pay or work-home conflicts. Among studies reporting on possible solutions, 8 (6.5%) articles reported on the role of effective mentorship to support career advancement and to provide moral support and 8 (6.5%) on the emerging role of social media for networking. Our analysis showed how different impediments hinder surgical career progression for women, with notable consequences on burnout and attrition.

CONCLUSIONS

Identification and recognition of obstacles to career progression is the first step to addressing the gender gap in surgery. Active strategies should be improved to promote a culture of diversity and to create equal opportunity for women in surgery, while implementing structured mentoring programs and investing on an adequate communication on social media to engage the future generations.

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.

The Role of Implicit Bias in Surgical Resident Evaluations

BACKGROUND

Implicit bias is a key factor preventing the advancement and retention of women and underrepresented minorities in academic surgery.

PURPOSE

We examined the role of implicit bias in the technical component of the residency performance evaluation. The Fundamentals of Laparoscopic Surgery (FLS) score, an objective measure of technical performance, was compared to the subjective technical skills (TS) score given by attending surgeons.

PROCEDURES

FLS scores and the average TS scores from chief resident evaluations at a university program were analyzed from 2015 to 2019 (n = 29 residents; female 22%, underrepresented minorities 27%).  The average TS score for each resident was calculated, scores dichotomized above and below the mean for the program and analyzed across gender and racial identity.

MAIN FINDINGS

There were no significant differences in FLS or TS scores between male and female trainees or racial identity. The Kappa correlation coefficient between the 2 dichotomized scores was significantly lower for female (-0.50) versus male (0.23) trainees (p < 0.01); it was not significantly different between racial groups (p = 0.34).

PRINCIPAL CONCLUSIONS

There was statistically significant difference in agreement between the FLS and TS scores of individual female and male trainees, suggesting the presence of implicit bias in our pilot study. Further research with a larger sample size is warranted.

OBJECTIVE

To investigate the presence of implicit bias against women and underrepresented minorities in the technical component of the residency performance evaluation. We hypothesized that women and underrepresented racial minorities would have lower subjective technical skills (TS) scores as compared to their objective FLS scores, relative to the mean for the training program.

DESIGN

FLS scores and the average TS scores from chief resident performance evaluations were analyzed from 2015-2019. Both FLS and the average TS scores were dichotomized above and below the mean for the program and analyzed across gender and racial identity.  Research was approved by institutional IRB.

SETTING

This study was conducted at the University of Arizona General Surgery Residency Program at Banner University Medical Center in Tucson, Arizona. This is a tertiary care university training program.

PARTICIPANTS

Educational records of graduated general surgery chief residents from 2015 to 2019 were accessed for the study. We analyzed 37 TS scores from attending performance evaluations and 29 FLS scores reported to the program during the study period (22% female, 27% underrepresented racial minorities).

RESULTS

There were no significant differences in FLS or TS scores between male and female trainees or racial identity. The Kappa correlation coefficient between the 2 dichotomized scores was significantly lower for female (-0.50) versus male (0.23) trainees (p < 0.01); it was not significantly different between racial groups (p = 0.34).

CONCLUSIONS

There was a statistically significant difference in agreement between the FLS and TS score of individual female and male trainees, suggesting the presence of implicit bias in this pilot study. Further research with a larger sample size is warranted.

Physician Identification Badges: A Multispecialty Quality Improvement Study to Address Professional Misidentification and Bias

OBJECTIVE

To evaluate whether providing resident physicians with "DOCTOR" role identification badges would impact perceptions of bias in the workforce and alter misidentification rates.

PARTICIPANTS AND METHODS

Between October 2019 and December 2019, we surveyed 341 resident physicians in the anesthesiology, dermatology, internal medicine, neurologic surgery, otorhinolaryngology, and urology departments at Mayo Clinic in Rochester, Minnesota, before and after an 8-week intervention of providing "DOCTOR" role identification badges. Differences between paired preintervention and postintervention survey answers were measured, with a focus on the frequency of experiencing perceived bias and role misidentification (significance level, α=.01). Free-text comments were also compared.

RESULTS

Of the 159 residents who returned both the before and after surveys (survey response rate, 46.6% [159 of 341]), 128 (80.5%) wore the "DOCTOR" badge. After the intervention, residents who wore the badges were statistically significantly less likely to report role misidentification at least once a week from patients, nonphysician team members, and other physicians (50.8% [65] preintervention vs 10.2% [13] postintervention; 35.9% [46] vs 8.6% [11]; 18.0% [23] vs 3.9% [5], respectively; all P<.001). The 66 female residents reported statistically significantly fewer episodes of gender bias (65.2% [43] vs 31.8% [21]; P<.001). The 13 residents who identified as underrepresented in medicine reported statistically significantly less misidentification from patients (84.6% [11] vs 23.1% [3]; P=.008); although not a statistically significant difference, the 13 residents identifying as underrepresented in medicine also reported less misidentification with nonphysician team members (46.2% [6] vs 15.4% [2]; P=.13).

CONCLUSION

Residents reported decreased role misidentification after use of a role identification badge, most prominently improved among women. Decreasing workplace bias is essential in efforts to improve both diversity and inclusion efforts in training programs.

Prevalence and risk factors for burnout in U.S. vascular surgery trainees

OBJECTIVE

Burnout and suicidality are known risks for vascular surgeons above other surgical subspecialties, with surgical trainees at risk for exposure to factors that increase burnout. This study aimed to inform initiatives to improve wellness by assessing the prevalence of hazards in vascular training (mistreatment, duty-hour violations) and the rates of wellness outcomes (burnout, thoughts of attrition/specialty change/suicide). We hypothesized that mistreatment and duty-hour violations would predispose trainees to increased burnout.

METHODS

We performed a cross-sectional study of residents and fellows enrolled in accredited United States vascular surgery training programs using a voluntary, confidential survey administered during the 2020 Vascular Surgery In-Training Examination. The primary outcome assessed was burnout symptoms reported on a weekly basis or more frequently. The rates of wellness outcomes were measured. The association of mistreatment and duty hours with the primary outcome was modeled with multivariable logistic regression.

RESULTS

A total of 475 residents and fellows who were enrolled in one of 120 vascular surgery training programs completed the survey (84.2% response rate). Of 408 trainees completing burnout survey items, 182 (44.6%) reported symptoms of burnout. Fewer trainees reported thoughts of attrition (n = 42 [10.0%], specialty change (n = 35 [8.4%]), or suicide (n = 22 [4.9%]). Mistreatment was reported by 191 vascular trainees (47.3%) and was more common in female trainees (n = 63 [48.5%] reporting monthly or more frequently) compared with male trainees (n = 51 [18.6%]; P < .001). Duty-hour violations were also more commonly reported by female trainees (n = 31 [21.4%] reporting 3+ months in violation) compared with male trainees (n = 50 [16.2%]; P = .002). After controlling for race/ethnicity, postgraduate year, program type, and geography, female trainees were less likely to report burnout (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28-0.86). Trainees experiencing mistreatment monthly or more were three times more likely to report burnout (OR, 3.09; 95% CI, 1.78-5.39). Frequency of duty-hour violations also increased the odds of reporting burnout (1-2 months in violation: OR, 2.09; 95% CI, 1.17-3.73; 3+ months in violation: OR, 3.95; 95% CI, 2.24-6.97).

CONCLUSIONS

Nearly one-half of vascular surgery trainees reported symptoms of burnout, which was associated with frequency of mistreatment and duty-hour violations. Interventions to improve well-being in vascular surgery must be tailored to the local training environment to address trainee experiences that contribute to burnout.

Persistence of Gender Bias Over Four Decades of Surgical Training

OBJECTIVE

Female surgeons face gender-specific obstacles during residency training, yet longitudinal data on gender bias experienced by female surgery residents are lacking. We aimed to investigate the evolution of gender bias, identify obstacles experienced by female general surgery residents, and discuss approaches to supporting female surgeons during residency training.

METHODS

Between August 2019 and January 2021, we conducted a retrospective cohort study using structured telephone interviews of female graduates of the UCLA General Surgery Residency training program. Responses of early graduates (1981-2009) were compared with those of recent graduates (2010-2020). Quantitative data were compared with Fisher's exact tests and Chi-squared tests. Interview responses were reviewed to catalog gender bias, obstacles experienced by female surgeons, and advice offered to training programs to address women's concerns.

RESULTS

Of 61 female surgery residency graduates, 37 (61%) participated. Compared to early graduates (N = 20), recent graduates (N = 17) were significantly more likely to pursue fellowship training (100% vs. 65%, p < 0.01) and have children before or during residency (65% vs. 25%, p = 0.02). A substantial proportion in each cohort experienced some form of gender bias (71% vs. 85%, p = 0.43). Compared to early graduates, recent graduates were significantly less likely to report experiencing explicit gender bias (12% vs. 50%, p = 0.02) but equally likely to report implicit gender bias (71% vs. 55%, p = 0.50). Female graduates across the decades advocated for specific measures to champion work-life balance in residency (51%), strengthen female mentorship (49%), increase childcare support (41%), and promote women into leadership positions (32%).

CONCLUSIONS

While having children during residency has become more common and accepted over the decades, female surgery residents continue to experience implicit gender bias in the workplace. Female surgeons advocate for targeted interventions to establish systems for parental leave, address gender bias, and strengthen female mentorship.

Gendered Differences in Teaching Performance Evaluations of Obstetrics and Gynecology Residents

OBJECTIVE

Teaching performance evaluations are commonly used for career development and advancement. Due to possible gendered expectations, implicit or explicit bias may emerge in evaluations completed by learners. This study investigated how third-year medical students evaluated teaching performance of obstetrics and gynecology resident physicians based on resident gender.

SETTING

This study was conducted at the Medical College of Wisconsin in Milwaukee, Wisconsin.

DESIGN

This retrospective mixed methods study examined teaching performance evaluations of obstetrics and gynecology resident physicians from 2010 to 2018, completed by third-year medical students. A two-sample, two-sided t-test was used to compare numerical scores. Deductive content analysis of written comments focused on specific categories: positive or negative agentic or communal demeanors and characteristics, teaching skills, character and professionalism, leadership abilities, clinical skills and knowledge, and frequency of words and phrases used to describe residents.

SETTING

This study was conducted at the Medical College of Wisconsin in Milwaukee, Wisconsin.

RESULTS

Of 83 residents (71 females, 12 males), there was no statistical significance in the teaching performance evaluation scores between male and female residents (n = 10,753 total completed evaluations). Female residents had lower scores than male residents; males tended not to score below 4 (5-point response scale; 5 = outstanding). Of 3,813 written comments, male residents had more positive comments, with statistical significance in communal characteristics (71.4% male, 53.9% female, p = 0.01). Female residents received more negative comments, with statistical significance in communal characteristics (7.5% female, 2.8% male, p = 0.01). Frequency of words presented that male residents had more "standout" traits ("outstanding," "excellent," "exemplary"), "ability" terms ("intelligent," "bright," "talented," "smart"), and were often considered "fun," "funny," and "humorous." Female residents were described by "compassion" terms ("kind," "compassionate").

CONCLUSION

Student-completed teaching performance evaluations are a valuable assessment of teaching skills and influence department recognition, award distribution, fellowship and employment opportunities. This study found that medical students did evaluate female residents differently than male residents. Understanding gendered expectations may assist in findings ways to address discrepancies between male and female physician evaluations.

Gender differences in surgical case volume among ophthalmology trainees

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Implicit gender-career bias in postgraduate medical training still exists, mainly in residents and in females

BACKGROUND

More and more female residents enter postgraduate medical training (PGMT). Meanwhile, women are still underrepresented in academic medicine, in leadership positions and in most surgical specialties. This suggests that female residents' career development may still be negatively impacted by subtle, often unconscious stereotype associations regarding gender and career-ambition, called implicit gender-career bias. This study explored the existence and strength of implicit gender-career bias in doctors who currently work in PGMT, i.e. in attending physicians who act as clinical trainers and in their residents.

METHODS

We tested implicit gender-career bias in doctors working in PGMT by means of an online questionnaire and an online Implicit Association Test (IAT). We used standard IAT analysis to calculate participants' IAT D scores, which indicate the direction and strength of bias. Linear regression analyses were used to test whether the strength of bias was related to gender, position (resident or clinical trainer) or specialty (non-surgical or surgical specialty).

RESULTS

The mean IAT D score among 403 participants significantly differed from zero (D-score = 0.36 (SD = 0.39), indicating bias associating male with career and female with family. Stronger gender-career bias was found in women (β_female =0 .11; CI 0.02; 0.19; p = 0.01) and in residents (β_resident 0.12; CI 0.01; 0.23; p = 0.03).

CONCLUSIONS

This study may provide a solid basis for explicitly addressing implicit gender-career bias in PGMT. The general understanding in the medical field is that gender bias is strongest among male doctors' in male-dominated surgical specialties. Contrary to this view, this study demonstrated that the strongest bias is held by females themselves and by residents, independently of their specialty. Apparently, the influx of female doctors in the medical field has not yet reduced implicit gender-career bias in the next generation of doctors, i.e. in today's residents, and in females.

Physician gender as a source of implicit bias affecting clinical decision-making processes: a scoping review

BACKGROUND

The demographic profile of practicing physicians is changing as more female medical students are graduating and practicing in the field. While the education received may not differ by gender, studies have shown that physician practice outcomes vary by provider gender. Various factors could contribute to these differences, including culture and explicit biases which may lead to implicit bias. This study aims to identify the available evidence of gender-based implicit bias throughout the delivery process of medicine.

METHODS

This scoping review evaluated published literature within the PubMed, Ovid MEDLINE, PsychINFO, Web of Science, and BioMed Central databases pertaining to physician's gender as a factor in the delivery of medicine. Arksey and O'Malley's six-stage methodology was used as a framework and reported using the updated Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Searches occurred between May 2020 and June 2020, and the timeframe was not limited. Included articles had gender as a factor in the delivery of medicine and implicit bias. Articles were excluded if they did not include the gender of the physician. After screening by reviewers and a medical librarian, study characteristics were charted and analyzed.

RESULTS

The initial search resulted in 2420 records. After screening, 162 of the records were selected based on title and keyword relevance. After additional screening, 15 records were ultimately included in the review based on full-text evaluation. Records were organized into sub-topics post hoc focused on clinical qualities, diagnostics, treatment, and outcomes.

CONCLUSION

This scoping review found that gender-based implicit bias may be inadvertently acquired from culture and education. Although implicit bias is highly researched, much of the current literature focuses on the gender of the patient. This study found important gaps in the available literature regarding race and gender of the physician. Further studies could explore outcome differences between recent graduates and career physicians, for both female and male physicians.

The female medical workforce

In the UK, the proportion of female medical students has remained static over the last decade, at around 55%; however, at consultant level, only 36.6% of doctors are women. The reasons for this drop in numbers are not clear. Given the increase in number of female doctors in training, the proportion of female doctors at consultant level is lower than might be expected. This article discusses issues affecting the female medical workforce in anaesthesia, intensive care and pain medicine. It explores how gender stereotypes and implicit gender bias can affect the way women are perceived in the workplace, especially in leadership positions, and discusses health issues particular to the female medical workforce. While the issues in this article may not affect all women, the cumulative effect of being subject to gender stereotypes within a workplace not designed to accommodate the health needs of women may contribute to a work environment that may promote the attrition of women from our specialties.

Women in thoracic surgery: perspectives from South America

The thoracic surgery specialty is dominated by male surgeons worldwide, and South America is no exception. The training period to become a thoracic surgeon is long and requires a maximal commitment. Finding a balance between personal life and work is a challenge, especially for female surgeons. Consequently, the scarcity of female surgeons comes as no surprise. However, despite the low number of female thoracic surgeons who can serve as role models, the number of women participating in thoracic surgery residency programs in South America is growing.

Operating Room Educational Environment in Canada: Perceptions of Surgical Residents

OBJECTIVE

The educational experience in operating rooms (OR) plays a central role in the transformation of a trainee into a surgeon. As Canadian residency programs transition to competency-based medical education, and since most surgical competencies are attained in the OR, we investigated the perceptions of Canadian surgical residents about their OR learning environment.

DESIGN

Cross-sectional, national survey.

SETTING

An online questionnaire, including the validated 40-item operating room educational environment measure (OREEM) inventory, was sent to residency programs of all surgical specialties in Canada. The OREEM assesses the trainees' perceptions of the "trainer and training," "learning opportunities," "atmosphere in the operating room," "supervision, workload, and support," Each individual item was rated using a 5-point Likert scale ranging from "strongly disagree" (scores 1) to "strongly agree" (scores 5). The mean score of each individual item was measured, and the mean scores of each subscale and an overall score of the questions were also measured.

PARTICIPANTS

Surgical residents in Canada.

RESULTS

Four hundred thirty residents were included for final analysis. The overall mean OREEM score was 3.72 ± 0.4. "Atmosphere in the OR" was the subscale with the highest mean score (3.87 ± 0.5), while "supervision, workload, and support" had the lowest subscale mean score (3.49 ± 0.5). The overall OREEM mean score for junior and senior residents was 3.67 ± 0.4 and 3.80 ± 0.4, respectively (p = 0.001). No significant differences were seen in the mean OREEM score between males and females or different surgical programs. Nevertheless, general surgery had the lowest "supervision, workload, and support" subscale score (3.27 ± 0.5; p < 0.001).

CONCLUSIONS

The overall educational environment in OR may be considered satisfactory as perceived by Canadian surgical residents; however, several areas for potential improvement are identified and suggestions for optimizing the learning environment are described.

The Surgical Knowledge "Growth Curve": Predicting ABSITE Scores and Identifying "At-Risk" Residents

OBJECTIVE

Resident performance on the American Board of Surgery In-Training Examination (ABSITE) is used for evaluation of surgical knowledge and guides resident selection for institutional remediation programs. Remediation thresholds have historically been based on ABSITE percentile scores; however, this does not account for predictors that can impact a resident's exam performance. We sought to identify predictors of yearly ABSITE performance to help identify residents "at-risk" for performing below their expected growth trajectory.

DESIGN

The knowledge of the residents, as measured by standardized ABSITE scores, was modeled as a function of the corresponding postgraduate year via a linear mixed effects regression model. Additional model covariates included written USMLE-1-3 examination scores, gender, number of practice questions completed, and percentage correct of practice questions. For each resident, the predicted ABSITE standard score along with a 95% bootstrap prediction interval was obtained. Both resident-specific and population-level predictions for ABSITE standard scores were also estimated.

SETTING

The study was conducted at a single, large academic medical center (Massachusetts General Hospital, Boston, MA).

PARTICIPANTS

Six years of general surgery resident score reports at a single institution between 2014 and 2019 were deidentified and analyzed.

RESULTS

A total of 376 score reports from 130 residents were analyzed. Covariates that had a significant effect on the model included USMLE-1 score (PGY1: p = 0.013; PGY2: p = 0.007; PGY3: p = 0.011), USMLE-2 score (PGY1: p < 0.001; PGY2: p < 0.001; PGY3: p < 0.001; PGY4: p < 0.001; PGY5: p = 0.032), male gender (PGY1: p = 0.003; PGY2: p < 0.001; PGY3: p < 0.001; PGY4: p = 0.008), and number of practice questions completed (p=0.003). Five residents were identified as having "fallen off" their predicted knowledge curve, including a single resident on 2 occasions. Population prediction curves were obtained at 7 different covariate percentile levels (5%, 10%, 25%, 50%, 75%, 90%, and 95%) that could be used to plot predicted resident knowledge progress.

CONCLUSION

Performance on USMLE-1 and -2 examinations, male gender, and number of practice questions completed were positive predictors of ABSITE performance. Creating residency-wide knowledge growth curves as well as individualized predictive ABSITE performance models allows for more efficient identification of residents potentially at risk for poor ABSITE performance and structured monitoring of surgical knowledge progression.

Do male chairs of surgery have implicit gender bias in the residency application process?

INTRODUCTION

Medical students applying for general surgery residencies often require a letter of recommendation (LOR) from the Surgical Chair. However, LORs may reveal gender and ethnic bias. This study examines the presence of implicit bias in general surgery resident selection by evaluating chair LORs.

METHODS

A retrospective study of 149 LORs for categorical general surgery residents, at an academic institution, written by surgery chairs from 1980 to 2013 was performed. Two independent reviewers scored each letter for overall quality, mention of personality, academic deficiencies, technical skills, and standout adjectives. Scores were compared across gender and race and statistical analysis performed using SPSS.

RESULTS

Males comprised 85% of the applicants; racial makeup was Caucasian (90%), black (4%), Asian (4%), and Hispanic (2%). Male chairs wrote all letters. Letters for female students received higher overall scores than males (4.13 ± 0.16, 3.59 ± 0.08, p = 0.005). Discussion of personality was significantly less for Asian students (1.28 ± 0.08, 1.83 ± 0.48, 0.5 ± 0.224, 1.67 ± 0.67, p 0.050). No difference was present in mention of academic deficiencies, technical skills, or standout adjectives.

DISCUSSION

Female medical students invited to interview at a top academic general surgery residency had higher quality LORs than their male counterparts. Asian applicants had statistically significant less discussion of personality. Further examination of residency selection processes is necessary to implement changes that mitigate implicit bias in trainee selection.

'Too male, too pale, too stale': a qualitative exploration of student experiences of gender bias within medical education

OBJECTIVE

To explore medical student perceptions and experiences of gender bias within medical education.

SETTING

Gender bias-'prejudiced actions or thoughts based on the perception that women are not equal to men'-is a widespread issue. Within medicine, the pay gap, under-representation of women in senior roles and sexual harassment are among the most concerning issues demonstrating its presence and impact. While research investigating experiences of clinicians is gaining traction, investigation of medical students' experiences is lacking. This qualitative study analyses medical students' experiences of gender bias within their education to discern any patterns to this bias. Illuminating the current state of medical education gender bias will hopefully highlight areas in which student experience could be improved. Constructivist thematic analysis was used to analyse data, informed by William's patterns of gender bias, intersectional feminism and communities of practice theory.

PARTICIPANTS

Thirty-two medical students from multiple UK medical schools participated in individual interviews. Nine faculty members were also interviewed to triangulate data.

RESULTS

Gender bias has an overt presence during medical student education, manifesting in line with William's patterns of bias, impacting career aspirations. Physical environments serve to manifest organisational values, sending implicit messages regarding who is most welcome-currently, this imagery remains 'too male, too pale…too stale'. Existing gender initiatives require careful scrutiny, as this work identifies the superficial application of positive action, and a failure to affect meaningful change.

CONCLUSIONS

Despite progress having been made regarding overt gender discrimination, implicit bias persists, with existing positive action inadequate in promoting the advancement of women. Institutions should mandate participation in implicit bias education programmes for all staff and must strive to revise the imagery within physical environments to better represent society. Gender initiatives, like Athena Scientific Women's Academic Network, also require large-scale evaluation regarding their impact, which this work found to be lacking.