Gender and diversity considerations in surgical training

Gender Distribution of Current Surgical Critical Care Fellows, Faculty, and Program Directors

As women surgeons continue to represent a minority within the surgical field while also holding lower ranked positions, gaining a sub-specialized set of clinical skills through surgical fellowships, like surgical critical care (SCC), is one approach to advance within the surgical field. A cross-sectional analysis was performed investigating the websites of all 106 US-based SCC fellowships. A total of 116 SCC fellows were included in this analysis, comprising 67 (59.3%) men and 46 (40.7%) women. There were 977 SCC fellowship faculty were evaluated, comprising 619 (67.9%) men and 292 (32.1%) women. Additionally, 103 SCC fellowship program directors were analyzed, consisting of 77 (74.8%) men and 26 (25.2%) women. There is a significantly lower proportion of women fellows and faculty members (P < .001) compared to men. SCC programs with female program directors on average have higher proportions of female fellows and faculty compared to programs with male program directors (52% and 36% vs 31% and 29%, respectively). There is a stable yet unbalanced gender distribution throughout all positions in SCC fellowship programs. Actively supporting women surgeons pursuing SCC fellowship and removing barriers to their advancement through effective interventions can disrupt the persistently low prevalence of women SCC fellows, faculty, and program directors.

The Medical Community's Evolving Focus on Physician and Surgeon Pregnancy: Thematic Trends From a Scoping Review

PURPOSE

The authors aimed to chronicle the evolution of the medical community's study of physician and surgeon pregnancy by investigating thematic trends in the literature in the context of pertinent sociopolitical events.

METHOD

A scoping review was conducted in Cochrane Library, Google Scholar, Ovid MEDLINE, Ovid Embase, Scopus, and Web of Science Core Collection from inception through August 11, 2020, using vocabulary and terms for physicians (including surgeons), pregnancy, and family leave. Study populations were categorized by all physician specialties or exclusively surgical specialties as well as by all career levels or exclusively trainees. Subthemes and themes were based on a priori assumptions of physician pregnancy and extrapolated from previously published reviews, respectively. Thematic trends were analyzed by plotting the total number of publications and the frequency of themes and subthemes by publication year.

RESULTS

After title and abstract and full-text reviews, 407 manuscripts met inclusion criteria. Publications on physician pregnancy first emerged in the 1960s and surged from 1988 to 1996 and again from 2010 to 2019. The first known manuscript exclusively on surgeon pregnancy was published in 1991; subsequent publication frequency trends for surgeon pregnancy generally paralleled those for all physician pregnancy publications albeit in reduced quantities. Four major themes were found: impact of pregnancy on the physician and her colleagues, pregnant physician work productivity, physician maternity leave policies, and physician maternal-fetal health outcomes.

CONCLUSIONS

As the number of women physicians increased and the sociopolitical environment progressed, the thematic focus of the literature on physician pregnancy evolved. Multi-institutional prospective observational studies are needed to develop definitive evidence-based recommendations that will positively impact physician pregnancy.

How Does Representation of Women on Editorial Boards Compare Among Orthopaedic, General Surgery, and Internal Medicine Journals?

BACKGROUND

Women have historically been underrepresented as editors of peer-reviewed medical journals. Studies have demonstrated that there are differences in editorial board reviewer behavior based on gender, suggesting that greater representation by women on editorial boards may improve the quality and diversity of the review process. Therefore, the current representation of women on the editorial boards of orthopaedic journals, particularly compared with peer-reviewed surgical and medical journals, is of interest.

QUESTIONS/PURPOSES

(1) What is the representation of women as members of editorial boards of prominent orthopaedic surgery journals? (2) How does it compare with representation on the editorial boards of journals in general surgery and internal medicine?

METHODS

The top 15 journals with a strong clinical emphasis based on Impact Factor (Clarivate Analytics) calculated by the 2018 Journal Citation Reports were identified for orthopaedic surgery, general surgery (and all general surgical subspecialties), and internal medicine (with representative internal medicine subspecialties). Clinical publications with their primary editorial office located in the United States led predominantly by physicians or basic scientists were eligible for inclusion. The members of an editorial board were identified from the journals' websites. The gender of editors with gender-neutral names (and editors whose gender we considered uncertain) was identified by an internet search for gender-specific pronouns and/or pictures from an institutional profile. Fisher exact tests and t-tests were used to analyze categorical and continuous variables, respectively. Significance was set at p < 0.05.

RESULTS

Of the editors analyzed, women made up 9% (121 of 1383) of editorial boards in the orthopaedic journals with the highest Impact Factors, compared with 21% (342 of 1665) of general surgery journals (p < 0.001) and 35% (204 of 587) of internal medicine journals (p < 0.001). The overall mean composition of editorial boards of orthopaedic journals was 10% ± 8% women, compared with that of general surgery, which was 19% ± 6% women (p < 0.001), and that of internal medicine, which was 40% ± 19% women (p < 0.001).

CONCLUSION

Women make up a smaller proportion of editorial boards at orthopaedic surgery journals than they do at general surgery and internal medicine journals. However, their representation appears to be comparable to the proportion of women in orthopaedics overall (approximately 6%) and the proportion of women in academic orthopaedics (approximately 19%). Ways to improve the proportion of women on editorial boards might include structured mentorship programs at institutions and personal responsibility for championing mentorship and diversity on an individual level.

CLINICAL RELEVANCE

Increasing representation of women on editorial boards may improve the diversity of perspectives and quality of future published research, generate visible role models for young women considering orthopaedics as a career, and improve patient care through enriching the diversity of our specialty.

Public Perceptions of General Surgery Residency Training

OBJECTIVE

Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety.

DESIGN

This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training.

CONCLUSIONS

Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.

Gender and ethnic diversity in academic general surgery department leadership

BACKGROUND

Diversity in surgery has been shown to improve mentorship and patient care. Diversity has improved among general surgery (GS) trainees but is not the case for departmental leadership. We analyzed the race and gender distributions across leadership positions at academic GS programs.

METHODS

Academic GS programs (n = 118) listed by the Fellowship and Residency Electronic Interactive Database Access system were included. Leadership positions were ascertained from department websites. Gender and race were determined through publicly provided data.

RESULTS

Ninety-two (79.3%) department chairs were white and 99 (85.3%) were men. Additionally, 88 (74.6%) program directors and 34 (77.3%) vice-chairs of education were men. A higher proportion of associate program directors were women (38.5%). Of 787 division-chiefs, 73.4% were white. Only trauma had >10% representation from minority surgeons. Women represented >10% of division chiefs in colorectal, thoracic, pediatric, and plastic/burn surgery.

CONCLUSION

Diversity among GS trainees is not yet reflected in departmental leadership. Effort is needed to improve disparities in representation across leadership roles.

Perceptions of support and policies regarding pregnancy, parenting, and family planning during veterinary training at United States veterinary medical training institutions

OBJECTIVE To gather information about issues associated with pregnancy, lactation, and parenting for US veterinary students and house officers (trainees) and their perception of pregnancy and parenting support services available at US veterinary training institutions. DESIGN Cross-sectional mixed-method survey. SAMPLE 2,088 veterinary students and 312 house officers from 27 US veterinary training institutions. PROCEDURES An email with a link to an online survey was sent to the associate dean for academic affairs at each of the 30 AVMA-accredited US veterinary training institutions with a request that it be forwarded to all veterinary students and house officers (interns and residents). RESULTS Among the 2,400 respondents, 185 (7.7%) reported that they were a parent, were pregnant, or had a significant other who was pregnant. Several significant differences in attitudes and perceptions of pregnancy and parenting support services provided by veterinary training institutions were identified between males and females, veterinary students and house officers, and respondents who were and were not parents. CONCLUSIONS AND CLINICAL RELEVANCE Results provided crucial information about an important facet of well-being for veterinary trainees and suggested that veterinary students and house officers face substantial challenges in becoming parents during their training programs and that perceptions of those challenges differ between males and females.

Current Policies and Support Services for Pregnant and Parenting Veterinary Medical Students and House Officers at United States Veterinary Medical Training Institutions

Wellness and work-life balance are prominent concerns in the veterinary profession and data suggest that personal relationship-building with peers and family assist veterinary trainees and veterinarians with wellness. The demographics of veterinary medical trainees (students, interns, and residents) have shifted to a female-dominated cohort and veterinary training overlaps with peak reproductive age for the majority of trainees. Despite a robust body of literature in the human medical profession surrounding pregnancy, parenting, and family planning (PPFP) among human medical students, interns, and residents, no comparable data exist within the United States veterinary medical community. This study reviewed policies and support services in place to support PPFP at accredited United States veterinary medical training institutions through the use of an online administrator survey and the review of handbooks and relevant written material. Results from this study highlight a lack of consistency across veterinary medical training institutions for policy and support services for PPFP for trainees, especially related to lactation support and parental leave. Our data can help facilitate the development of standards or best practices for policies and support services that support PPFP among veterinary medical trainees, and opens the dialogue to consider the unique needs of our shifted trainee demographics.

Personal and practice profile of male and female ophthalmologists in India

Background:

The aim of this study was to study the practice pattern, personal profile, and work-family balance of male and female ophthalmologists in India.

Materials and Methods:

This study was conducted through 41 point questionnaire sent to the members of All India Ophthalmological Society dealing with practice profile and personal circumstances of ophthalmologists.

Results:

Six hundred and twenty-two (8%) responses were obtained out of 7723 invitations sent. A total of 452 were male and 170 were female ophthalmologists. Age group of 30–39 years was most common age of respondents (male 155; 35.3%; female 81; 47.6%). Larger number of male ophthalmologists (157; 34.7%) worked for more than 9 h a day than female ophthalmologists (41; 24.1%) (P = 0.01). Larger number of male ophthalmologists (229; 50.7%) earned more than Rs. 1 lakh/month than female ophthalmologists (55; 32.4%) (P = 0.00001) More female ophthalmologists (21; 12.4%) than males (26; 5.8%) said that they faced cultural, ethnic or gender bias at work place (P = 0.002). Forty-four (25.9%) female and 54 (12%) male ophthalmologists said that they often curtailed their work for family needs (P = 0.0001). Two hundred and fifty-two (55.8%) male ophthalmologists and 78 (45.9%) female ophthalmologists considered their profession rewarding (P = 0.02).

Conclusion:

Ophthalmology as a profession was considered rewarding by both male and female ophthalmologists. However, female ophthalmologists were curtailing their work for family needs and earning less than male ophthalmologists. Female ophthalmologists were also subject to gender bias at workplace. These issues need to be tackled to improve the work satisfaction of ophthalmology workforce.

The Nonwhite Woman Surgeon: A Rare Species

BACKGROUND

As of 2012, 39% of medical student graduates were nonwhite, yet very few nonwhite women graduates chose to become surgeons.

METHODS

To better understand issues regarding nonwhite women in surgery, an online survey was sent to surgeons across the United States. Results are based on self-reported data. Mean data are reported.

RESULTS

A total of 194 surgeons (42% women) completed the survey; only 12% of responders were nonwhite. Overall, 56% of nonwhite women felt they earned less than what men surgeons earn for equal work. Nonwhite women surgeons earned less than what men surgeons ($224,000 vs. 351,000, p < 0.00002) and white women surgeons ($285,000, p = 0.02) earned. Overall, 96% of nonwhite surgeons believed that racial discrimination currently exists among surgeons.

CONCLUSIONS

The few nonwhite women surgeons in the United States recognize that they are paid significantly less than what other surgeons are paid. Inequitable remuneration and a discriminatory work environment encountered by nonwhite women surgeons must be addressed.

Residents' perceptions of sex diversity in orthopaedic surgery

BACKGROUND

Sex diversity in orthopaedic surgery lags behind other surgical specialties. Women comprise 13.2% of orthopaedic residents and 15% of full-time faculty, despite 47.8% of graduating medical students being women. The purposes of this study were to demonstrate how orthopaedic surgery has been less successful in recruiting women compared with general surgery and to identify the sex-specific factors that influenced orthopaedic surgery residents to choose their specialty.

METHODS

A search of graduate medical data was performed to compare the recruitment of women into orthopaedic and general surgery. Next, a seven-question survey was e-mailed to 2629 orthopaedic residents by the American Academy of Orthopaedic Surgeons. Questions were formulated to detect why orthopaedic surgery residents chose their specialty. Data were collected over six weeks and responses were analyzed with use of one-tailed t tests to make comparisons of responses on the basis of sex.

RESULTS

The historical data search showed that the percentage of female representation in both orthopaedic and general surgery has increased since 1968, but it has increased significantly faster in general surgery than in orthopaedic surgery (p &lt; 0.0001). Five hundred and twenty-nine (20%) of the 2629 orthopaedic surgery residents who were contacted responded to the survey. Of the respondents, 114 (22%) were female and 415 (78%) were male. Several significant differences were found in the responses between the sexes. These include the timing of the decision to enter orthopaedic surgery and positive influences in choosing orthopaedic surgery as a specialty. Additionally, women, significantly more than men, believed that more of their peers entered general surgery because of greater acceptance by senior faculty in that field (p &lt; 0.0001).

CONCLUSIONS

To our knowledge, this study is the first to survey residents on their perceptions of orthopaedic surgery and to identify factors that may hinder the recruitment of women into orthopaedic surgery. Our data show that increased exposure to orthopaedic content during medical school and increased female mentorship may help recruit more women into the orthopaedic surgery workforce.

Attrition in surgical residency programmes: Causes and effects

OBJECTIVE

To determine the rate and trend of attrition from a surgical residency programme and to identify the reasons for attrition.

METHODS

A questionnaire-based survey was conducted at a university hospital. Separate questionnaires were designed for residents and programme directors (PDs). The residents who left the training voluntarily from one of the five surgical residency programmes (i.e., general surgery, orthopaedics, neurosurgery, otorhinolaryngology and urology) during the academic years 2005-2011 were identified from a departmental database. The residents who did not respond after three attempts at contact, or those who refused to participate, were excluded.

RESULTS

During the last 6 years, 106 residents were recruited; 84 (78%) were men, of whom 34.5% left the programme voluntarily. Of 22 women, half (54%) left the programme voluntarily (P = 0.07). The overall 6-year attrition rate was 39%. The reasons identified for attrition, in descending order, were personal reasons, attitude of senior residents or faculty, and change of specialty. None of the residents cited an excess workload as a reason for their leaving the programme. About 40% rejoined the same specialty after leaving, while 35% chose a different specialty (80% chose a different surgical subspecialty and 20% chose medicine). There was a significant discrepancy in the perspective of residents and PDs about the reasons for attrition.

CONCLUSION

Attrition among surgical residents, in particular woman residents, is high. Personal reasons and interpersonal relations were the most commonly cited reasons. Programme managers and residents have significantly different perspectives, again an indication of a communication gap.

Do men outperform women during orthopaedic residency training?

BACKGROUND

Orthopaedic surgery residency has one of the lowest percentages of women (13.1%) of all primary surgical specialties. There are many possible reasons for this, including bias during the selection process.

QUESTIONS/PURPOSES

We therefore asked whether performance during residency might adversely bias the selection of future female orthopaedic residents by researching whether males and females perform equally in orthopaedic surgery residency.

METHODS

Ninety-seven residents enrolled in our residency between 1999 and 2009; six males and one female left the program, leaving 90 residents (73 males, 17 females) as the study cohort. Resident performance was compared for OITE scores, ABOS results, faculty evaluations, and in a resident graduate survey.

RESULTS

Males and females had similar faculty evaluations in all ACGME competency areas. Males and females had similar mean OITE scores for Years 2-5 of residency, although males had higher mean scores at Years 3 through 5. Males and females had similar mean ABOS Part 1 scores and ABOS Part 1 pass rates; however, fewer males than females took more than one attempt to pass. Males and females had similar Part 2 pass rates or attempts. For the 45 resident graduates surveyed, females pursued fellowships equally to males, worked slightly less hours in practice, and reported higher satisfaction with their career choice.

CONCLUSIONS

For the 90 residents at one residency program, we observed no differences between males' and females' performance. Although females pursue orthopaedic residency less frequently than males, performance during residency should not bias their future selection.

Enlightenment via simulation: "crone-ology's" first woman

A little known 18th century midwife, Angélique Marguerite Le Boursier (1715-1794) may well be the true founder of modern surgical simulation. This fiercely independent medical practitioner stood equally amongst the many enlightened minds of this period and fought with every modern method to reduce infant/maternal mortality during childbirth. Her original textbook Abrégé utilized some of the first color anatomical illustrations, her method of teaching complex birthing techniques to peasant woman throughout France, and most notably her birthing simulator complete with fluids (wet ware) were all available for close scrutiny. The color illustrations in Abrégé remain profoundly effective but the only existent models of her simulator are even more remarkable. Le Boursier du Coudray sought to bring education to the woman and physicians in villages and towns throughout France in response to the population crisis and the high birth morbidity and mortality. Her teaching methods affected untold thousands of medical practitioners, from midwives to surgeons. Voltaire wrote about her and she became an icon of progressive France, but remained ostracized by much of the conventional medical practitioners. She continued to train midwives for 23 years before retiring at the age of nearly 70. Madame du Coudray began to write, illustrate and simulate in the mid 18th century and obtained unprecedented success in bringing to the public the humane practices of modern childbirth with relevant understanding of anatomy and physiology. She is the matron not only of modern simulation methods in healthcare but was the epitome of professional healthcare commitment, educating approximately 10,000 students regardless of social status for free.