Bias in Surgical Residency Evaluations: A Scoping Review

Advancing Equity in Assessment in the Surgical Learning Environment

IMPORTANCE

Assessment is a fundamental part of teaching and learning that provides the basis for making inferences about the development of learners. Inequity in assessment disproportionately impacts underrepresented in medicine learners and can limit their opportunities for achievement.

OBSERVATIONS

Unfortunately, inequity in assessment is prevalent in the surgical learning environment due to systemic and individual factors. The Antideficit Achievement framework can be effectively applied to address sources of inequity.

CONCLUSIONS AND RELEVANCE

This paper explores sources of inequity in assessment in the surgical learning environment and illuminates them with a descriptive case study. Recommendations created using the Antideficit Achievement framework provide effective, practical ways to begin to advance equity in assessment in the surgical learning environment.

Is it gossip or feedback? Surgical attendings' perceptions of gossip within residency

OBJECTIVE

Gossip-evaluative talk about an absent third party-exists in surgical residency programs. Attending surgeons may engage in gossip to provide residents with feedback on performance, which may contribute to bias. Nevertheless, the perspectives of attending surgeons on gossip has not been studied.

DESIGN

In this qualitative study, semi-structured interviews about gossip in surgical training were conducted with attending surgeons. We performed a reflexive thematic analysis of transcripts with a grounded theory approach to describe attendings' perceptions of their role in gossip within surgical residency.

SETTING

Interviews were conducted from September 23, 2023, to November 27, 2023 via Zoom™.

PARTICIPANTS

Eighteen surgery attendings associated with 7 surgical training programs were interviewed.

RESULTS

Six themes were developed: 1) Attendings typically view gossip with a negative lens; thus, well-intended conversations about resident performance that meet the academic definition of gossip are not perceived as gossip; 2) Gossip can damage attendings' reputations as surgeons and educators; 3) Mitigating the negative impacts of gossip by maintaining accurate and objective standards of honest communication is hard; 4) Attendings express concerns about hearing other attendings' impressions of residents prior to formulating their own opinion; 5) The surgical hierarchy restricts the volume and content of gossip that reaches attendings, which may limit their knowledge of program culture; and 6) It is very difficult to mitigate gossip at the program level. Ultimately, attendings utilize gossip (e.g. triangulating their experience) with the goal of providing residents feedback.

CONCLUSIONS

Defining important conversations about resident performance as gossip should not discourage these critically important conversations but rather underscore the importance of combating harmful gossip through 3 behaviors: 1) committing to objective communication; 2) limiting or reframing information about resident performance that is shared with attendings who have yet to formulate their own opinions; and 3) regulating gossip in particular high-stakes microenvironments (e.g. the operating room).

Well-being Through the Synergy of Community Engagement, Health Equity, and Advocacy

Facets of well-being for cardiothoracic surgeons include interconnectivity, or a sense of belonging within a community, and social relatedness. Striving for health equity achieves a sense of belonging and meaning to one's work. In "Elevating Health Equity: The Synergy of Community Engagement and Advocacy," the imperative for mentorship and diversification within health care is expounded, establishing a multitiered blueprint for equity. Integral to this framework is the nurturing of a heterogeneous health care workforce, ameliorating racial and gender disparities in patient care. This article puts forth an intricate, empirically substantiated roadmap toward a more empathic and efficacious health care system.

Do certain phrases in letters of recommendation predict success in fellowship performance?

BACKGROUND

Letters of recommendation (LORs) are a valued, yet imperfect tool. Program directors (PDs) score phrases such as give my highest recommendation and top 5 to 10% of students as positive. Although positive phrases are valued by PDs, there is no evidence that these phrases predict performance. We attempt to identify whether 12 specific phrases found in letters of recommendation predict future performance of fellows.

METHODS

LORs were evaluated for 12 select phrases and statements. Alpha Omega Alpha (AOA) status, Step 2 Clinical Knowledge (CK) score, and whether the letter writer was personally known to our admission's committee were also categorized. Logistic regressions were performed to evaluate the relationship of the independent variables with fellow performance.

RESULTS

Using multivariate logistic regression, one of the best residents (OR = 4.02, 95% CI (1.0, 15.9), p < 0.05), exceeds expectations (OR = 4.74, 95% CI (1.4, 16.3), p = 0.01), and give my highest recommendation (OR = 3.87, 95% CI (1.3, 11.7), p = 0.02) predicted positive performance. Highly recommend (OR = 0.31, 95% CI (0.1, 1.0), p < 0.05) and top 5 to 10% (OR = 0.05, 95% CI (0.0, 0.6), p = 0.02) predicted negative performance. The remaining phrases did not correlate to fellowship performance.

CONCLUSION

The current LOR evaluation process may place undo importance on phrases that have limited bearing on a candidate's success in training. Training both letter readers and writers to avoid using coded language or avoid assigning improper importance to select phrases may help improve the candidate selection process.

Experiences With Unionization Among General Surgery Resident Physicians, Faculty, and Staff

Importance

Labor unions are a mechanism for employee advocacy, but their role in surgery resident wellness is poorly characterized.

Objective

To understand experiences with unionization among general surgery residents and residency program faculty and staff.

Design, Setting, and Participants

This exploratory qualitative study included data from the Surgical Education Culture Optimization Through Targeted Interventions Based on National Comparative Data (SECOND) trial. In the exploratory phase of the SECOND trial (from March 6, 2019, to March 12, 2020), semistructured interviews about wellness were conducted with residents, faculty (attending physicians), and staff (program administrators) at 15 general surgery residency programs. Unionization was identified as an emergent theme in the interviews. Data analysis was performed from March 2019 to May 2023.

Main Outcomes and Measures

The main outcome was resident and faculty experience with resident labor unions. In the qualitative analysis, lexical searches of interview transcripts identified content regarding resident labor unions. A codebook was developed inductively. Transcripts were coded by dyads, using a constant comparative approach, with differences reconciled by consensus.

Results

A total of 22 interview transcripts were identified with relevant content. Of these, 19 were individual interviews conducted with residents (n = 10), faculty (n = 4), administrative staff (n = 1), a program director (n = 1), a department chair (n = 1), and designated institutional officials (n = 2), and 3 were from resident focus groups. Residents from all postgraduate year levels, including professional development (ie, research) years, were represented. Interviewees discussed resident unions at 2 programs (1 recently unionized and 1 with a decades-long history). Interviewees described the lack of voice and the lack of agency as drivers of unionization ("Residents…are trying to take control of their well-being"). Increased salary stipends and/or housing stipends were the most concretely identified union benefits. Unanticipated consequences of unionization were described by both residents and faculty, including (1) irrelevance of union-negotiated benefits to surgical residents, (2) paradoxical losses of surgery department-provided benefits, and (3) framing of resident-faculty relationships as adversarial. Union executives were noted to be nonphysician administrators whose participation in discussions about clinical education progression may increase the time and effort to remediate a resident and/or reduce educators' will to meaningfully intervene. Active surgical resident participation within the union allows for an understanding of surgical trainees' unique needs and reduced conflict.

Conclusions and Relevance

In this qualitative study, unionization was a mechanism for resident voice and agency; the desire to unionize likely highlighted the lack of other such mechanisms in the training environment. However, these findings suggest that unionization may have had unintended consequences on benefits, flexibility, and teaching. Effective advocacy, whether within or outside the context of a union, was facilitated by participation from surgical residents. Future research should expand on this exploratory study by including a greater number of institutions and investigating the evolution of themes over time.

Exploring a Masters of Business Administration's Impact on Surgical Subspecialists

Objectives and Study Design

As healthcare evolves, more physicians are taking on administrative roles and pursuing additional graduate education, particularly obtaining a Master's in Business Administration (MBA.) To facilitate a better understanding of these practitioners, we conducted a comparative study of MD/MBA clinicians in multiple surgical fields.

Methods

This study aims to compare clinicians with MD/MBAs across multiple surgical subspecialties. Reported metrics include demographics, MBA program structure, salary changes, and professional pursuits. Nine studies were obtained from the PubMed, Cochrane, and Embase databases. Four studies met the inclusion criteria and were analyzed.

Results

The majority of MD/MBA degree holders in plastic surgery (95%), orthopedic surgery (89-96%), and ophthalmology (80%) are male. Ophthalmology (37%) demonstrates the highest number of subjects obtaining an MBA via a synchronous MD/MBA. Most clinicians return to clinical practice after degree completion and show high levels of non-clinical pursuits after receiving their MBAs.

Conclusions

Though there appear to be differences across surgical subspecialties regarding how an MBA is applied, most maintain clinical duties. Of those that do not, the largest portion transition to administrative duties, consulting, entrepreneurial endeavors, or other professional opportunities. Despite the financial ambiguity of an MBA, physicians value the transformative experience it offers.

Women in Plastic Surgery Innovation: A 10-Year Review of Gender Representation in Mammary Device Patents

BACKGROUND

This study aims to pioneer in evaluating women's representation in plastic surgery innovations, focusing on mammary prosthesis devices' inventorship. Despite growing gender parity in the field, women's involvement in innovation remains underexplored. This is especially crucial, as the predominant recipients of these innovative technologies are women, urging a necessity for broader female engagement in pioneering surgical advancements.

METHOD

Patents under the "A61F2/12: Mammary prostheses and implants" classification between the dates January 1, 2011, to December 31, 2020, were identified using Google Patents Advanced. Inclusion criteria included patents (not designs) in English and applications (not grants), with no litigation limitations. Data collected included ID, title, assignee (categorized as industry, academic, private, individual), inventors, and dates (priority, filing, and publication). Sex of inventors was identified with the literature validated gender API, with manual resolution of unresolved genders or with ga_accuracy scores of less than 75%. Data were analyzed using 2-tailed Student t tests, χ2 analysis, and Pearson correlation coefficient (significance set at P ≤ 0.05).

RESULTS

Of the more than 130,000 plastic surgery patents in English identified between the 10-year period, 1355 were classified as A61F2/12. A total of 374 unique patents were included for analysis (841 duplicates were removed, and 140 patents were excluded because of non-English character author names). There was a significant increase in patents over the decade (from 15 in 2011 to 88 in 2020, R2 = 0.74, P < 0.05), with a decrease in number of inventors per patent (R2 = 0.12, P < 0.05). Of the 1102 total inventors, 138 were female (11.2%), with a 4-fold increase in representation over the decade (R2 = 0.58, P < 0.05), including increase in patents filed with a woman first inventor (0%-14.8%). Women were equally likely to be first 3 inventors versus middle to last inventors (12.8% vs 11.1%, respectively).

CONCLUSIONS

Over a decade, mammary device innovations rose significantly. Although women inventors' representation improved, it remains disproportionate compared with women in residency/practice. Hence, interventions should aim to align inventor representation with training ratios, through institutional optimization, reducing gender segmentation, and enhancing funding opportunities.