The effect of gender on operative autonomy in general surgery residents

Gender Differences in Autonomy Granted to Residents and Fellows During Procedural Training: A Systematic Review and Meta-Analysis

PURPOSE

Supervisors may be prone to implicit (unintentional) bias when granting procedural autonomy to trainees due to the subjectivity of autonomy decisions. The authors aimed to conduct a systematic review and meta-analysis to assess the differences in perceptions of procedural autonomy granted to physician trainees based on gender and/or race.

METHOD

MEDLINE, Embase, CENTRAL, Scopus, and Web of Science were searched (search date: January 5, 2022) for studies reporting quantitative gender- or race-based differences in perceptions of procedural autonomy of physician trainees. Reviewers worked in duplicate for article selection and data abstraction. Primary measures of interest were self-reported and observer-rated procedural autonomy. Meta-analysis pooled differences in perceptions of procedural autonomy based on trainee gender.

RESULTS

The search returned 2,714 articles, of which 16 were eligible for inclusion. These reported data for 6,109 trainees (median, 90 per study) and 2,763 supervisors (median, 54 per study). No studies investigated differences in perceptions of autonomy based on race. In meta-analysis of disparities between genders in autonomy ratings (positive number favoring female trainees), pooled standardized mean differences were -0.12 (95% confidence interval [CI], -0.19 to -0.04; P = .003; n = 10 studies) for trainee self-rated autonomy and -0.05 (95% CI, -0.11 to 0.01; P = .07; n = 9 studies) for supervisor ratings of autonomy.

CONCLUSIONS

Limited evidence suggests that female trainees perceived that they received less procedural autonomy than did males. Further research exploring the degree of gender- and race-based differences in procedural autonomy, and factors that influence these differences is warranted.

Co-Existing Vascular Surgery Integrated Residencies are Associated with Increased General Surgery Resident Proficiency and Autonomy in Vascular Cases

BACKGROUND

Integrated vascular surgery residency positions have doubled more than the last decade. Studies have investigated the impact of co-existing subspecialty surgical training programs on case volume of general surgery residents (GSRs). However, no studies have explored the impact of subspecialty training on GSR operative competency. The aim of this study is to understand the impact of integrated residencies on operative performance and autonomy of GSR performing vascular procedures.

METHODS

Autonomy and performance ratings of GSR participating in vascular surgery cases were collected from all institutions participating in the Society for Improving Medical Professional Learning application database from 2015 to 2023. Faculty and self-assessments of autonomy and performance on vascular cases performed by GSRs at programs with co-existing vascular integrated residency (VIR), vascular surgery fellowship (VSF), or no subspecialty vascular training (VX) were compared using Fisher's exact tests with Bonferroni corrections across training levels and case complexity.

RESULTS

Eleven thousand one hundred seventy five assessments (26% at institutions with VIR, 46% VSF, and 28% VX) were submitted by 920 GSRs and 343 faculty. Senior GSRs at programs with VSF achieved lower autonomy than those with VIR (P = 0.049) or VX (P = 0.042) based on faculty assessment. GSRs achieved a level of "practice ready" at significantly higher rates when training at programs with VIR, and at the lowest rates with VSF (P < 0.001). However, self-perception of autonomy and performance was highest among GSRs at programs with VX compared with VIR and VSF (P < 0.001).

CONCLUSIONS

The presence of VIR was associated with higher achievement of "practice ready" competency and higher levels of operative autonomy among senior GSRs performing vascular procedures. Shared-learning among peers and faculty expertise in teaching resident-level trainees may contribute to this finding.

Gender Disparity in Full Professor Rank Among Academic Physicians: A Systematic Review and Meta-Analysis

PURPOSE

The gender gap in promotion in academic medicine is well established. However, few studies have reported gender differences in promotion adjusted for scholarly production and national or international reputation, namely, career duration, publications, grant funding, and leadership positions. The authors performed a systematic review and meta-analysis of the differences between men and women in achieving benchmarks for promotion and analyze where such differences lie geographically and within specialties.

METHOD

A systematic search of Academic Search Premier, Business Source Complete, Cochrane Library, ERIC, GenderWatch, Google Scholar, Embase, MEDLINE, PubMed, Scopus, and Web of Science was conducted from inception to August 17, 2022. All studies that reported the number of male and female full professors on medical school faculty were included. The primary outcome was the adjusted odds ratio (AOR) for promotion to full professor for women compared with men.

RESULTS

Two hundred forty-four studies met the inclusion criteria. The unadjusted OR for promotion to full professor for women was 0.38 (95% confidence interval [CI], 0.36-0.41). Sixteen studies reported an AOR. The pooled AOR of promotion for women to full professor was 0.60 (95% CI, 0.46-0.77). The AOR for promotion to full professor was 0.55 (95% CI, 0.34-0.88) in surgery and 0.80 (95% CI, 0.57-1.11) in internal medicine. Statistical heterogeneity was high ( Q = 66.6, I2 = 79.4%, P < .001). On meta-regression, 77% of the heterogeneity was from studies outside the United States, where more disparity was reported (AOR, 0.29; 95% CI, 0.22-0.38).

CONCLUSIONS

Most studies continued to find decreased promotion of women. Gender disparity was particularly notable in surgery and in studies from outside the United States. The results suggest that differences in promotion were due to differences in productivity and leadership and to gender bias.

Gender differences in autonomy and performance assessments in a national cohort of vascular surgery trainees

OBJECTIVE

Gender disparities in surgical training and assessment are described in the general surgery literature. Assessment disparities have not been explored in vascular surgery. We sought to investigate gender disparities in operative assessment in a national cohort of vascular surgery integrated residents (VIRs) and fellows (VSFs).

METHODS

Operative performance and autonomy ratings from the Society for Improving Medical Professional Learning (SIMPL) application database were collected for all vascular surgery participating institutions from 2018 to 2023. Logistic generalized linear mixed models were conducted to examine the association of faculty and trainee gender on faculty and self-assessment of autonomy and performance. Data were adjusted for post-graduate year and case complexity. Random effects were included to account for clustering effects due to participant, program, and procedure.

RESULTS

One hundred three trainees (n = 63 VIRs; n = 40 VSFs; 63.1% men) and 99 faculty (73.7% men) from 17 institutions (n = 12 VIR and n = 13 VSF programs) contributed 4951 total assessments (44.4% by faculty, 55.6% by trainees) across 235 unique procedures. Faculty and trainee gender were not associated with faculty ratings of performance (faculty gender: odds ratio [OR], 0.78; 95% confidence interval [CI], 0.27-2.29; trainee gender: OR, 1.80; 95% CI, 0.76-0.43) or autonomy (faculty gender: OR, 0.99; 95% CI, 0.41-2.39; trainee gender: OR, 1.23; 95% CI, 0.62-2.45) of trainees. All trainees self-assessed at lower performance and autonomy ratings as compared with faculty assessments. However, women trainees rated themselves significantly lower than men for both autonomy (OR, 0.57; 95% CI, 0.43-0.74) and performance (OR, 0.40; 95% CI, 0.30-0.54).

CONCLUSIONS

Although gender was not associated with differences in faculty assessment of performance or autonomy among vascular surgery trainees, women trainees perceive themselves as performing with lower competency and less autonomy than their male colleagues. These findings suggest utility for exploring gender differences in real-time feedback delivered to and received by trainees and targeted interventions to align trainee self-perception with actual operative performance and autonomy to optimize surgical skill acquisition.

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.

Video-Based Assessment of Microsurgical Trainees: An Evaluation of Gender Bias

BACKGROUND

 Gender bias in graduate medical evaluations remains a challenging issue. This study evaluates implicit gender bias in video-based evaluations of microsurgical technique, which has not previously been described in the literature.

METHODS

 Two videos were recorded of microsurgical anastomosis; the first was performed by a hand/microsurgery fellow and the second by an expert microsurgeon. A total of 150 surgeons with microsurgical experience were recruited to evaluate the videos; they were told these videos depicted a surgical trainee 1 month into fellowship followed by the same trainee 10 months later. The only variable was the name ("Rachel" or "David") that each participant was randomly assigned to evaluate. Participants were asked to score each video for quality, technique, efficiency, as well as overall progression and development after the second video compared with the initial video. To focus on bias, these outcome measures were selected to be purposefully subjective and all ratings were based on a subjective 1to 10 scale (10 = excellent).

RESULTS

 The analysis included 150 participants (75% male). There were no statistically significant differences in scores between the "female" and "male" trainee. The trainees received the same median initial (1-month video) and final (11th-month video) scores for all criteria except initial technique, in which the female trainee received a 7 and the male trainee received an 8. Notably, 11-month scores were consistently the same or lower than 1-month scores for both study groups (p < 0.001). There were also no differences within either study group based on participant sex. Microsurgery practitioners overall rated both groups lower than those who do not currently practice microsurgery.

CONCLUSION

 Our study did not identify a gender bias in this evaluation method. Further investigation into how we assess and grade trainees as well as the presence and impact of implicit biases on varying surgical assessment methods is warranted.

A prospective study of surgeons' workloads and associated factors in real-world practice

New technologies such as laparoscopic and robotic surgery are spreading, and there is a demand for physicians to keep up with novel methods. In contrast to the recent focus on healthcare professional burnout, the mental and physical costs during surgery are not well-understood. We aimed to quantify surgeons' workloads in daily urological surgical practice and clarify potential background factors associated with such workloads. Urologists in Hokkaido, Japan, were invited to this study. Between December 2020 and December 2021, participants repeatedly reported workloads, which were assessed using the National Aeronautics and Space Administration-Task Load Index (NASA-TLX), after each surgery in conjunction with participants' names, patients' backgrounds, their roles (independent operator, operator under supervision, instructor, and 1st or 2nd assistant), and surgical outcomes, via SurveyMonkey®. Because of the heterogeneity among individuals, a linear mixed-effects model was utilized to analyze factors associated with NASA-TLX, calculating the parameter estimates (PE) of regression coefficients for each factor and their 95% confidence interval (CI). Sixty-five urologists (5 women) joined the study, and 2169 data were collected within 7 days after surgeries. A linear mixed-effects model revealed that female surgeons (PE + 15.56, 95% CI 2.36-28.77), urgent/emergency surgery (PE + 6.65, 95% CI 4.59-8.70), intraoperative complications (PE + 9.26, 95% CI 6.76-11.76), and near-miss incidents (PE + 3.81, 95% CI 2.27-5.36) were associated with higher workloads. Regarding the surgeons' role, operator under supervision (PE + 12.46, 95% CI 9.86-15.06) showed the highest workloads. Surgeons' workloads decreased as the number of previous cases of the same procedure increased. Surgeons' workloads were associated with various factors. Given that the highest workloads were for operators under supervision, instructors should be aware of trainees' high workloads and devise appropriate instructional interventions.

Junior doctors' workplace well-being and the determinants based on ability-motivation-opportunity (AMO) theory: Educational and managerial implications from a three-year longitudinal observation after graduation

PURPOSE

Junior doctors function as trainees from an educational perspective and as employees from a human resource management perspective. Employing the ability-motivation-opportunity (AMO) theory as a conceptual framework, this study longitudinally investigated the factors affecting the workplace well-being and career progression of junior doctors over a 3-year period following their graduation from medical schools.

MATERIALS AND METHODS

This 3-year prospective cohort study enrolled junior doctors who graduated from 2 medical schools in June 2019 in Taiwan. This study collected data by implementing web-based, self-administered structured questionnaires at 3-month intervals between September 2019 and July 2022. The collected data encompassed ability indicators (i.e. academic performance and perceived preparedness for clinical practice), motivation indicators (i.e. educational and clinical supervision), opportunity indicators (i.e. clinical unit cultures), and workplace well-being indicators (i.e. burnout, compassion satisfaction, and job performance). A total of 107 junior doctors participated, providing 926 total responses. The data were analysed using univariate analyses and structural equation modelling with path analysis.

RESULTS

Over the 3-year period following graduation, the junior doctors' confidence in their preparedness for clinical practice and the educational and clinical supervision had varying degrees of influence on the junior doctors' workplace well-being. The influence of clinical unit cultures, which can provide opportunities for junior doctors, became evident starting from the second year postgraduation; notably, unit cultures that emphasised flexibility and discretion played positive and critical roles in enhancing the junior doctors' workplace well-being lasted to the third year.

CONCLUSIONS

Our findings provide insights into the distinct critical factors that affect the socialisation of junior doctors within workplace environments over 3 consecutive years. These findings can provide guidance for medical educators and healthcare managers, helping them understand and support the progressive integration of junior doctors into their work environments.

Educational challenges and opportunities for the future generation of surgeons: a scoping review

PURPOSE

Surgery offers exciting opportunities but comes with demanding challenges that require attention from both surgical program administrators and aspiring surgeons. The hashtag #NoTrainingTodayNoSurgeonsTomorrow on 𝕏 (previously Twitter) underscores the importance of ongoing training. Our scoping review identifies educational challenges and opportunities for the next generation of surgeons, analyzing existing studies and filling gaps in the literature.

METHODS

Following the PRISMA guidelines, MEDLINE/PubMed was searched in February 2022, using the MeSH terms "surgeons/education," for articles in English or German on general, abdominal, thoracic, vascular, and hand surgery and traumatology targeting medical students, surgical residents, future surgeons, and fellows.

RESULTS

The initial search yielded 1448 results. After a step-by-step evaluation process, 32 publications remained for complete review. Three main topics emerged: surgical innovations and training (n = 7), surgical culture and environment (n = 19), and mentoring (n = 6). The articles focusing on surgical innovations and training mainly described the incorporation of structured surgical training methods and program initiatives. Articles on surgical culture examined residents' burnout, well-being, and gender issues. Challenges faced by women, including implicit bias and sexual harassment, were highlighted. Regarding mentoring, mentees' needs, training challenges, and the qualities expected of both mentors and mentees were addressed.

CONCLUSION

At a time of COVID-19-driven surgical innovations, the educational and working environment of the new generation of surgeons is changing. Robotic technology and other innovations require future surgeons to acquire additional technological and digital expertise. With regard to the cultural aspects of training, surgery needs to adapt curricula to meet the demands of the new generation of surgeons, but even more it has to transform its culture.

Understanding and addressing varying perceptions of autonomy

Recently, there has been a major shift in the concept of resident autonomy in the operating room. As a result, surgical residents' independence has decreased during their training years. This change has been secondary to multiple factors, including fragmented attending resident interactions, hospital demands for productivity, operating room efficiency, and the public's perception of resident participation in surgery. Multiple gender, personality, and racial biases have also influenced the autonomy of surgical residents. In this paper, we have analyzed the impact of all these factors on the current state of resident autonomy after reviewing relevant literature. We have proposed a strategy to increase resident autonomy via increased resident and faculty interactions, case planning, and encouraged recruitment of diverse vascular surgery trainees and faculty.

Evaluation Tools for Assessing Autonomy of Surgical Residents in the Operating Room and Factors Influencing Access to Autonomy: A Systematic Literature Review

BACKGROUND

Surgical residents in France lack a clear pedagogical framework for achieving autonomy in the operating room. The progressive acquisition of surgical autonomy is a determining factor in the confidence of operators for their future independent practice. Currently, there is no autonomy scale commonly used in Europe. The objective of this study is to identify existing tools for quantifying the autonomy of residents and the factors that influence it.

MATERIALS AND METHODS

We conducted a qualitative systematic review following the recommendations of the Systematic Review Without Meta-Analysis (SWiM) guidelines. Publications were extracted from the MEDLINE (PubMed), EMBASE, and PSYCINFO databases. All publications without date restrictions up to July 2022 were identified.

RESULTS

Among the 231 identified publications, 21 met the inclusion criteria. Seventeen publications used a graded autonomy assessment tool by the student and/or the teacher, while 4 used evaluations by an observing third party. We found 8 different autonomy scales, with the Zwisch Scale representing 57.1% of the cases. Factors influencing autonomy were diverse, including the work context, experience, and gender of the resident and their teacher.

DISCUSSION

We found heterogeneity in the tools used to "measure" the autonomy of a resident in the operating room. The SIMPL tool or the Zwisch Scale appear to be the most frequently used tools. The relationship between autonomy, performance, confidence, and knowledge may require multidimensional tools that encompass various areas of competence, but this could make their daily application more challenging. The factors influencing autonomy are numerous; and understanding them would improve teaching in the operating room. There is a significant lack of data on surgical autonomy in France, as well as a lack of evaluation in the field of gynecology-obstetrics worldwide.

Defining the Disparity: A Multi-Institutional Analysis of Factors Associated With Decreased Resident Operative Experience

INTRODUCTION

Technical learning in surgical training is multifaceted and existing literature suggests a positive relationship between case volume and proficiency. Little is known about factors associated with a decreased volume of operative experience. This study aimed to identify resident and program factors associated with general surgery residents (GSR) in the bottom quartile of logged case volume upon program completion.

METHODS

A post hoc analysis of a multicenter study was used to examine case logs for categorical GSR. Participants included graduates between 2010 and 2020 from 20 programs. Residents below and above the 25th percentile for total operative volume were compared.

RESULTS

The present study includes 1343 GSR who graduated over the 11-y period. In total, 336 residents were below the 25th percentile and 1007 residents were above the 25th percentile. Those below the 25th percentile were more likely to be female (41% versus 34%, P = 0.02), identify as underrepresented in medicine (22% versus 14%, P < 0.01), and pursue fellowship (86% versus 80%, P = 0.01) compared to those above the 25th percentile. Residents below the 25th percentile were more likely to have graduated from a low volume program (55% versus 25%, P < 0.01) and from top National Institutes of Health funded institutions (57% versus 52%, P = 0.01).

CONCLUSIONS

This study identified individual and program characteristics associated with lower operative volume of GSR. Understanding such characteristics will aid surgical educators to achieve better equity in training.

Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium

OBJECTIVE

To determine the relationship between race/ethnicity and case volume among graduating surgical residents.

BACKGROUND

Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed.

METHODS

A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups.

RESULTS

The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period.

CONCLUSIONS

In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

Preserving and Enhancing Resident Autonomy-Strategies for Surgical Educators

This Viewpoint suggests measures to improve surgical resident autonomy and thereby produce capable and resilient surgeons.

See One, Do One, Improve One's Wellness: Resident Autonomy in US General Surgery Programs, A Mixed-methods Study

OBJECTIVE

We sought to examine the factors associated with resident perceptions of autonomy and to characterize the relationship between resident autonomy and wellness.

BACKGROUND

Concerns exist that resident autonomy is decreasing, impacting competence.

METHODS

Quantitative data were collected through a cross-sectional survey administered after the 2020 ABSITE. Qualitative data were collected through interviews and focus groups with residents and faculty at 15 programs.

RESULTS

Seven thousand two hundred thirty-three residents (85.5% response rate) from 324 programs completed the survey. Of 5139 residents with complete data, 4424 (82.2%) reported appropriate autonomy, and these residents were less likely to experience burnout [odds ratio (OR) 0.69; 95% CI 0.58-0.83], suicidality (OR 0.69; 95% CI 0.54-0.89), and thoughts of leaving their programs (OR 0.45; 95% CI 0.37-0.54). Women were less likely to report appropriate autonomy (OR 0.81; 95% CI 0.68-0.97). Residents were more likely to report appropriate autonomy if they also reported satisfaction with their workload (OR 1.65; 95% CI 1.28-2.11), work-life balance (OR 2.01; 95% CI 1.57-2.58), faculty engagement (OR 3.55; 95% CI 2.86-4.35), resident camaraderie (OR 2.23; 95% CI, 1.78-2.79), and efficiency and resources (OR 2.37; 95% CI 1.95-2.88). Qualitative data revealed that (1) autonomy gives meaning to the clinical experience of residency, (2) multiple factors create barriers to autonomy, and (3) autonomy is not inherent to the training paradigm, requiring residents to learn behaviors to "earn" it.

CONCLUSION

Autonomy is not considered an inherent part of the training paradigm such that residents can assume that they will achieve it. Resources to function autonomously should be allocated equitably to support all residents' educational growth and wellness.

The domino effect: the impact of gender on operative self-efficacy

BACKGROUND

Studies suggest that there are key differences in operative experience based on a trainee's gender. A large-scale self-efficacy (SE) survey, distributed to general surgery residents after the American Board of Surgery In-Training Examination in 2020, found that female gender was associated with decreased SE in graduating PGY5 residents for all 4 laparoscopic procedures included on the survey (cholecystectomy, appendectomy, right hemicolectomy, and diagnostic laparoscopy). We sought to determine whether these differences were reflected at the case level when considering operative performance and supervision using an operative assessment tool (SIMPL OR).

METHODS

Supervision and performance data reported through the SIMPL OR platform for the same 4 laparoscopic procedures included in the SE survey were aggregated for residents who were PGY5s in 2020. Independent t-tests and multiple linear regression were used to determine the relationship between trainee gender and supervision/performance ratings.

RESULTS

For laparoscopic cases in aggregate (n = 2708), male residents rated their performance higher than females (3.57 vs. 3.26, p < 0.001, 1 = critical deficiency, 5 = exceptional performance) and reported less supervision (3.15 vs. 2.85, p < 0.001, 1 = show and tell, 4 = supervision only); similar findings were seen when looking at attending reports of resident supervision and performance. A multiple linear regression model showed that attending gender did not significantly predict resident-reported supervision or performance levels, while case complexity and trainee gender significantly affected both supervision and performance (p < 0.001).

DISCUSSION

Female residents perceive themselves to be less self-efficacious at core laparoscopic procedures compared to their male colleagues. Comparison to more case-specific data confirm that female residents receive more supervision and lower performance ratings. This may create a domino effect in which female residents receive less operative independence, preventing the opportunity to establish SE. Further research should identify opportunities to break this cycle and consider gender identity beyond the male/female construct.

Evaluation of Gender Bias Through Autonomy During Laparoscopic Cholecystectomy at a Rural Community General Surgery Residency Program

OBJECTIVE

Gender bias not only continues to exist in surgical specialties, but in the medical field overall. Despite females graduating from medical schools at the same rate as men, a discrepancy still exists in the number of females pursuing surgical specialties compared to their male counterparts. We hypothesized that surgical training occurring in smaller institutions with close-knit relationships between faculty and residents should decrease the likelihood of gender bias towards females, as measured by perceived autonomy during laparoscopic cholecystectomy.

DESIGN

All 17 surgery residents at a community surgery residency program were asked to voluntarily and anonymously complete an investigator-created questionnaire after every laparoscopic cholecystectomy from October 2020 to May 2022. The questionnaire included details regarding overall resident operative experience, case complexity, patient diagnosis, resident autonomy throughout the case, and perceived autonomy compared to their peers. Each respondent estimated their percent autonomy from 0% to 100% during 5 distinct portions of the case, from which, a mean overall percent autonomy was calculated.

RESULTS

A total of 233 questionnaires (98 female, 135 male) were completed during the study period, with 8 females and 9 males in the first study year and 7 females and 10 males in the second. Mean overall autonomy was statistically similar between males and females, 71% and 72% respectively (p = 0.967). Case difficulty was not statistically different between males and females (p = 0.445). There was a significant difference in autonomy of all residents with male and female attendings, 67.5% and 80.3%, respectively (p = 0.001), however this did not differ between male and female residents. Eighty-three percent of respondents felt that their level of autonomy was acceptable for their postgraduate year (PGY) level. Over 90 percent of respondents felt their autonomy was not affected by their gender.

CONCLUSIONS

There was no significant difference in perceived autonomy between male and female residents during laparoscopic cholecystectomy at our small general surgery residency program. Gender bias did not appear to be a prohibiting factor in the amount of autonomy given to male and female residents.

Association of Gender and Operative Feedback Quality in Surgical Residents

OBJECTIVE

Feedback is critical for learning, however, gender differences exist in the quality of feedback that trainees receive. For example, narrative feedback on surgical trainees' end-of-block rotations differs based on trainee-faculty gender dyads, with female faculty giving higher quality feedback and male trainees receiving higher quality feedback. Though this represents evidence of gender bias in global evaluations, there is limited understanding of how much bias might be present in operative workplace-based assessments (WBAs). In this study, we explore the quality of narrative feedback among trainee-faculty gender dyads in an operative WBA.

DESIGN

A previously validated natural language processing model was used to examine instances of narrative feedback and assign a probability of being characterized as high quality feedback (defined as feedback which was relevant as well as corrective and/or specific). A linear mixed model was performed, with probability of high quality feedback as the outcome, and resident gender, faculty gender, PGY, case complexity, autonomy rating, and operative performance rating as explanatory variables.

PARTICIPANTS

Analyses included 67,434 SIMPL operative performance evaluations (2,319 general surgery residents, 70 institutions) collected from September 2015 through September 2021.

RESULTS

Of 36.3% evaluations included narrative feedback. Male faculty were more likely to provide narrative feedback compared to female faculty. Mean probabilities of receiving high quality feedback ranged from 81.6 (female faculty-male resident) to 84.7 (male faculty-female resident). Model-based results demonstrated that female residents were more likely to receive high quality feedback (p < 0.01), however, there was no significant difference in probability of high quality narrative feedback based on faculty-resident gender dyad (p = 0.77).

CONCLUSIONS

Our study revealed resident gender differences in the probability of receiving high-quality narrative feedback following a general surgery operation. However, we found no significant differences based on faculty-resident gender dyad. Male faculty were more likely to provide narrative feedback compared to their female colleagues. Further research using general surgery resident-specific feedback quality models may be warranted.

Gender Differences Among Head and Neck Microvascular Reconstructive Surgeons

OBJECTIVE

To determine whether gender differences exist in the training history, practice patterns, and home lives of surgeons who perform microvascular reconstruction of the head and neck.

STUDY DESIGN

Cross-sectional survey.

SETTING

Medical facilities that employ surgeons who practice head and neck microvascular reconstruction in the United States.

METHODS

A survey was created using the Research Electronic Data Capture Framework and was distributed via email to microvascular reconstructive surgeons. Descriptive statistics were performed using Stata software.

RESULTS

No significant differences were found in training or current practice patterns between microvascular surgeons who identify as men versus those who identify as women. Women had fewer children (p = .020) and were more likely to be childless (p = .002). Whereas men were more likely to report a spouse/partner as primary caretaker, women were more likely to hire a professional caretaker or cite themselves as a primary caretaker (p < .001). Women were more likely to have finished residency (p = .015) and fellowship (p = .014) more recently and to practice in the Southeast (p = .006). Of the microvascular surgeons who reported practice setting switches, men more commonly changed positions for career advancement, whereas women were more likely to switch due to burnout (p = .002).

CONCLUSION

This study found no gender-based differences in training or practice patterns. However, significant differences were identified in childbearing, family structure, geographic practice location, and motives for switching practice.

The state of female hepato-pancreato-biliary (HPB) surgeons in China: see us in operation theater with great prospects

OBJECTIVE

This study aims to investigate the proportion and distribution of female HPB surgeons in China, describe their current status, and analyze the possible barriers and challenges in their careers.

METHOD

Tertiary hospitals with the division of HPB in mainland China in 2021 were enrolled and surgeon demographic information was collected through the review of official websites and/or telephone interviews.

RESULTS

The majority of female HPB surgeons (72.92%) were located in the first or second-tier cities in mainland China, with an increasing number of new female HPB surgeons entering the field annually, particularly after 2005 (from 27 to 52 per 5 years). Despite no significant difference in academic backgrounds, female HPB surgeons initiated their careers at an earlier age and took a longer time to obtain chief titles (P < 0.05). Interestingly, female HPB surgeons performed laparoscopic complex HPB cases at a similar rate (95.42%) to their male counterparts and were more likely to specialize in endoscopic surgery (P = 0.021), with a similar ratio of obtaining administrative positions.

CONCLUSION

Minimally invasive surgery may provide females with unprecedented opportunities in the HPB surgery field. However, despite the increasing numbers of female HPB surgeons, the proportion remains low in China.

Differences in Resident Self-Evaluation and Clinical Competency Committee Evaluation Using ACGME Milestone Versions 1.0 and 2.0

OBJECTIVE

Intentionally self-driven professional development of surgical resident physicians is a hallmark of surgical training and is expected to gain further traction as Entrustable Professional Activities (EPAs) become the new paradigm for surgical education. We aimed to analyze how surgical residents rate themselves as compared to the evaluation of the Clinical Competency Committee using ACGME Milestones Version 1 (M1.0) and Version 2 (M2.0).

DESIGN

We asked 22 general surgical trainees for self-evaluation of Milestones (both M1.0 and M2.0) from 2017 semiannually to 2022. ACGME-required Milestone evaluations by the Clinical Competency Committee (CCC) were independently performed after the time window for resident self-evaluation. Neither trainees nor CCC were aware of the other party's evaluations. There were 1552 paired data available for evaluating individual competencies by both trainees and CCC. Paired Wilcoxon signed-rank tests were then performed among the corresponding pairs.

SETTING

MercyOne Des Moines Medical Center, Des Moines, IA; Teaching tertiary referral center.

PARTICIPANTS

Twenty-two general surgical trainees at this hospital and 28 faculty surgeons participated in this study.

RESULTS

The average self-evaluation of surgical residents was lower in the M1.0 cohort compared to the corresponding CCC evaluation (1.96 ± 0.72 vs. 2.11 ± 0.67; p < 0.001). M1.0 self-assessments and CCC-assessments were statistically similar for ICS (p = 0.548) and PROF (p = 0.554) competencies and differed for MK (p < 0.001), PBLI (p < 0.001), PC (p < 0.001), SBP (p = 0.008). On the contrary, the M2.0 cohort demonstrated higher average self-evaluation of surgical residents compared to the corresponding CCC evaluation (2.75 ± 0.87 vs. 2.12 ± 0.97; p < 0.001). Significant differences were observed for all 6 ACGME competencies using M2.0 self-assessments and CCC-assessments (all p < 0.001). Multivariate regression modeling (p < 0.001, R2 = 0.255) predicted the degree of discordance between self-assessment and CCC-assessed achievement of competencies with a significant effect of gender (baseline male: coef = -0.232, p < 0.001), PGY level (-0.083 per year, p < 0.001) and Milestone version (0.831, p < 0.001). A significant interaction exists for all gender/Milestone combinations except for the female trainees with M1.0.

CONCLUSIONS

The difference between self-evaluated Milestone achievement and faculty-driven CCC evaluation of surgical resident physician performance is more evident in Milestones 2.0 than in Milestones 1.0. Residents self-evaluate higher compared to faculty using Milestones 2.0. This discrepancy is seen among both genders and is more pronounced among male residents overestimating core competencies with M2.0 self-evaluation than formal CCC assessment.

Surgical Education: Disparities in Education May Impact the Quality and Likelihood of Completion of Training

Female surgical trainees experience bias that begins at the preclinical stages of medical school, extending into their surgery clerkships, and then into their residency training. There are important implications in terms of training opportunities and career advancement, mentorship, sponsorship, and ultimately burnout. Childbearing and lactation also impact the experiences and perceptions of female trainees who have children. There are limited interventions that have improved the experience of women in surgical training. Mentorship appears to play an important role in ameliorating some of the negative consequences of the training environment and improving outcomes for women surgeons.

Bias in Surgical Residency Evaluations: A Scoping Review

OBJECTIVE

Given widespread disparities in the surgical workforce and the advent of competency-based training models that rely on objective evaluations of resident performance, this review aims to describe the landscape of bias in the evaluation methods of residents in surgical training programs in the United States.

DESIGN

A scoping review was conducted within PubMed, Embase, Web of Science, and ERIC in May 2022, without a date restriction. Studies were screened and reviewed in duplicate by 3 reviewers. Data were described descriptively.

SETTING/PARTICIPANTS

English-language studies conducted in the United States that assessed bias in the evaluation of surgical residents were included.

RESULTS

The search yielded 1641 studies, of which 53 met inclusion criteria. Of the included studies, 26 (49.1%) were retrospective cohort studies, 25 (47.2%) were cross-sectional studies, and 2 (3.8%) were prospective cohort studies. The majority included general surgery residents (n = 30, 56.6%) and nonstandardized examination modalities (n = 38, 71.7%), such as video-based skills evaluations (n = 5, 13.2%). The most common performance metric evaluated was operative skill (n = 22, 41.5%). Overall, the majority of studies demonstrated bias (n = 38, 73.6%) and most investigated gender bias (n = 46, 86.8%). Most studies reported disadvantages for female trainees regarding standardized examinations (80.0%), self-evaluations (73.7%), and program-level evaluations (71.4%). Four studies (7.6%) assessed racial bias, of which all reported disadvantages for trainees underrepresented in surgery.

CONCLUSIONS

Evaluation methods for surgery residents may be prone to bias, particularly with regard to female trainees. Research is warranted regarding other implicit and explicit biases, such as racial bias, as well as for nongeneral surgery subspecialties.

The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (GOAST)

Aims

Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme.

Methods

This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender.

Results

All participants gave permission for their data to be used. In total, 274 UK orthopaedic trainees submitted data (65% men (n = 177) and 33% women (n = 91)), with a total of 285,915 surgical procedures logged over 1,364 trainee-years. Males were lead surgeon (under supervision) on 3% more cases than females (61% (115,948/189,378) to 58% (50,285/86,375), respectively; p < 0.001), and independent operator (unsupervised) on 1% more cases. A similar trend of higher operative numbers in male trainees was seen for senior (ST6 to 8) trainees (+5% and +1%; p < 0.001), those with no time OOP (+6% and +8%; p < 0.001), and those with orthopaedic experience prior to orthopaedic specialty training (+7% and +3% for lead surgeon and independent operator, respectively; p < 0.001). The gender difference was less marked for those on LTFT training, those who took time OOP, and those with no prior orthopaedic experience.

Conclusion

This study showed that males perform 3% more cases as the lead surgeon than females during UK orthopaedic training (p < 0.001). This may be due to differences in how cases are recorded, but must engender further research to ensure that all surgeons are treated equitably during their training.

Discrepancies in Gender Representation Between Integrated and Independent Plastic Surgery Programs

PURPOSE

Despite increasing female representation in integrated plastic surgery training programs, independent programs have lower representation and slow improvement in female enrollment. Self-reported resident data were used to investigate trends of female representation in integrated and independent programs.

METHODS

Data were collected from Accreditation Council of Graduate Medical Education resources of active residents' characteristics. Self-reported gender data were collected for integrated, independent, and general surgery programs from annual reports since 2009. χ2 analysis was conducted to compare female enrollment of integrated programs, independent programs, general surgery programs, and general surgery programs with matriculation-year adjustment.

RESULTS

In 2008, 89 independent programs had nearly identical percentage of female enrollment with 30 integrated programs at 23.8% and 23.1%, respectively. Differences in representation between independent and integrated programs became significant in 2012, with independent programs demonstrating 25.1% female enrollment compared with 30.5% in integrated programs. This trend of higher female representation in integrated programs has persisted since 2012. To correct for preexisting disparity in general surgery programs, we compared female enrollment of independent programs with female enrollment of that class' general surgery matriculation-year 5 years earlier. In all examined years, general surgery still had proportionally higher female enrollment compared with independent programs, even with conservative 5-year matriculation adjustment.

CONCLUSIONS

Dramatic differences in female enrollment were found between integrated and independent programs, with representation in integrated programs rising more quickly. Adjustments for previous rates of female enrollment in general surgery did not yield explanation for low independent program enrollment. Increasing female representation in independent training models will continue to create a more diverse workforce.

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.

Volume, Distribution, and Inequities by Race and Gender of Clinical Experiences Reported by Medical Students Entering Obstetrics and Gynecology Residencies

OBJECTIVE

To assess for inequities by race and gender of fourth year medical students' (MS4s) self-reported clinical experience in obstetrics and gynecology (Ob/Gyn).

DESIGN

This was a voluntary, cross-sectional survey. Participants provided demographic data, information regarding their preparation for residency, and self-reported numbers of hands-on clinical experiences. Responses were compared across demographic categories to assess for disparity in pre-residency experiences.

SETTING

The survey was open to all MS4s matched to Ob/Gyn internships in the United States in 2021.

PARTICIPANTS

The survey was distributed primarily via social media. Eligibility was verified by participants supplying the names of their medical school of origin and their matched residency program prior to completing the survey. 1057/1469 (71.9%) MS4s entering Ob/Gyn residencies participated. Respondent characteristics were not different from nationally available data.

RESULTS

Median clinical experience numbers were calculated for hysterectomies (10; IQR 5-20), suturing opportunities (15; IQR 8-30), and vaginal deliveries (5.5; IQR 2-12). Non-White students had fewer hands-on experiences with hysterectomy, suturing, and cumulative clinical experiences when compared to White MS4s (p values <0.001). Female students had fewer hands-on experiences with hysterectomies (p < 0.04), vaginal delivery (p < 0.03), and cumulative experiences (p < 0.002) than male students. When assessed by quartiles, non-White students and female students were less likely to be in the top quartile for experience and more likely to be in the bottom quartile for experience than their White and male counterparts, respectively.

CONCLUSIONS

A significant number of medical students entering Ob/Gyn residency have minimal hands-on clinical experience with foundational procedures. Additionally, there are racial and gender disparities in clinical experiences of MS4s matching to Ob/Gyn internships. Future work should identify how biases in medical education may affect the access to clinical experience in medical school, and potential interventions to mitigate inequities in procedures and confidence prior to residency.

Model-Based Operative Performance Expectations for Quantifying Competency in General Surgery

Importance

Understanding how to translate workplace-based assessment (WBA) ratings into metrics that communicate the ability of a surgeon to perform a procedure would represent a critical advancement in graduate medical education.

Objective

To evaluate the association between past and future performance in a comprehensive assessment system for the purpose of assessing point-in-time competence among general surgery trainees.

Design, Setting, and Participants

This case series included WBA ratings from September 2015 to September 2021 from the WBA system of the Society for Improving Medical Professional Learning (SIMPL) for all general surgery residents who were provided a rating following an operative performance across 70 programs in the US. The study included ratings for 2605 trainees from 1884 attending surgeon raters. Analyses were conducted between September 2021 and December 2021 using bayesian generalized linear mixed-effects models and marginal predicted probabilities.

Exposures

Longitudinal SIMPL ratings.

Main Outcomes and Measures

Performance expectations for 193 unique general surgery procedures based on an individual trainee's prior successful ratings for a procedure, clinical year of training, and month of the academic year.

Results

Using 63 248 SIMPL ratings, the association between prior and future performance was positive (β, 0.13; 95% credible interval [CrI], 0.12-0.15). The largest source of variation was postgraduate year (α, 3.15; 95% CrI, 1.66-6.03), with rater (α, 1.69; 95% CrI, 1.60-1.78), procedure (α, 1.35; 95% CrI, 1.22-1.51), case complexity (α, 1.30; 95% CrI, 0.42-3.66), and trainee (α, 0.99; 95% CrI, 0.94-1.04) accounting for significant variation in practice ready ratings. After marginalizing overcomplexity and trainee and holding rater constant, mean predicted probabilities had strong overall discrimination (area under the receiver operating characteristic curve, 0.81) and were well calibrated.

Conclusions and Relevance

In this study, prior performance was associated with future performance. This association, combined with an overall modeling strategy that accounted for various facets of an assessment task, may offer a strategy for quantifying competence as performance expectations.

Advancing Urology Resident Surgical Autonomy

PURPOSE OF REVIEW

This paper aims to survey current literature on urologic graduate medical education focusing on surgical autonomy.

RECENT FINDINGS

Affording appropriate levels of surgical autonomy has a key role in the education of urologic trainees and perceived preparedness for independent practice. Recent studies in surgical resident autonomy have demonstrated a reduction in autonomy for trainees in recent years. Efforts to advance the state of modern surgical training include creation of targeted curricula, enhanced with use of surgical simulation, and structured feedback. Decline in surgical autonomy for urology residents may influence confidence after completion of their residency. Further study is needed into the declining levels of urology resident autonomy, how it affects urologists entering independent practice, and what interventions can advance autonomy in modern urologic training.

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.

Patient inequities in affording surgical resident operative autonomy at Veterans Affairs teaching hospitals, does it extend to female patients?

BACKGROUND

Examining surgical resident operative autonomy within the Veterans Affairs (VA) System, we previously showed residents were afforded autonomy more frequently on Black patients. We hypothesized that, compared to males, female surgical patients receive less attending involvement and more resident autonomy during surgery.

METHODS

Retrospective review of all general/vascular surgeries performed at teaching VA hospitals from 2004 to 2019. Operative procedures are coded at the time of surgery as attending primary surgeon (AP), attending with resident (AR), or resident primary surgeon--attending not scrubbed (RP). The primary outcome was the difference in supervision rates between patient sexes.

RESULTS

618,578 operations were examined-24.9% AP, 68.9% AR, and 6.2% RP. Overall, 5.9% of cases were performed on women. The rate of RP cases was higher in males compared to females (6.3% vs 5.3%, p < 0.001).

CONCLUSION

Female veterans are less likely to have residents operate on them autonomously. Reasons for this require further characterization.

Assessment of Potential Gender Bias in General Surgery Resident Milestone Evaluations

This quality improvement study uses Accreditation Council for Graduate Medical Education Milestone evaluation scores to compare the scores of men and women surgical residents.

Blinded intraoperative skill evaluations avoid gender-based bias

INTRODUCTION

Gender bias has been identified consistently in written performance evaluations. Qualitative tools may provide a standardized way to evaluate surgical skill and minimize gender bias. We hypothesized that there is no difference in operative time or GEARS scores in robotic hysterectomy for men vs women surgeons.

METHODS

Patients undergoing robotic hysterectomies performed between June 2019 and March 2020 at 8 hospitals within the same hospital system were captured into a prospective database. GEARS scores were assigned by crowd-sourced evaluators by a third party blinded to any surgeon- or patient-identifying information. One-way ANOVA was used to compare the mean operative time and GEARS scores for each group, and significant variables were included in a one-way ANCOVA to control for confounders. Two-tailed p-value < 0.05 was considered significant.

RESULTS

Seventeen women and 13 men performed a total of 188 hysterectomies; women performed 34 (18%) and men performed 153 (81%). Women surgeons had a higher mean operative time (133 ± 58 vs 86.3 ± 46 min, p = 0.024); after adjustment, there were no significant differences in operative time (p = 0.607). There was no significant difference between the genders in total GEARS score (20.0 ± 0.77 vs 20.2 ± 0.70, p = 0.415) or GEARS subcomponent scores: bimanual dexterity (3.98 ± 0.03 vs 4.00 ± 0.03, p = 0.705); depth perception (4.04 ± 0.04 vs 4.05 ± 0.02, p = 0.799); efficiency (3.79 ± 0.02 vs 3.82 ± 0.02, p = 0.437); force sensitivity (4.01 ± 0.04 vs 4.05 ± 0.05, p = 0.533); or robotic control (4.16 ± 0.03 vs 4.26 ± 0.01, p = 0.079).

CONCLUSION

There was no difference in GEARS score between men vs women surgeons performing robotic hysterectomies. Video-based blinded assessment of skills may minimize gender biases when evaluating surgical skill for competency evaluation and credentialing.

The American Board of Surgery flexible endoscopy curriculum prepares individuals to pass the fundamentals of endoscopic surgery manual skills test

BACKGROUND

The American Board of Surgery (ABS) has required Fundamentals of Endoscopic Surgery (FES) certification for general surgery applicants since 2018. Flexible Endoscopy Curriculum (FEC) completion is recommended prior to taking the FES exam. The objective of the study was to determine if FEC completion prepares individuals to pass the FES manual skills test.

METHODS

Participants included first-attempt FES examinees from June 2014 to February 2019. De-identified data were reviewed, Self-reported data included gender, PGY, glove size, upper (UE) and lower (LE) endoscopy experience, simulation training time, and participation in an endoscopy rotation (ER). FES skills exam performance was reported by FES staff. Those completing all vs. none of the FEC were compared.

RESULTS

Of 2023 participants identified, 809 (40.0%) reported completion of all FEC components, 1053 (52.1%) completed of some, and 161 (8.0%) completed none. Men and candidates taking FES later in residency were more likely to complete all FEC requirements (p = 0.002, p < 0.001). FES pass rates were higher for those who completed all FEC components compared to those who completed none (88.4% vs 72.7%, p < 0.001). On logistic regression analysis, completion of all components (OR 2.3, 95% CI 1.5-3.7, p < 0.001) and male gender (OR 3.1, 95% CI 1.7-5.7, p < 0.001) were predictors of passing, while glove size (OR 1.5, 95% CI 1.0-2.5, p = 0.08), simulator time (OR 1.1, 95% CI 0.9-1.4, p = 0.37) and PGY were not (OR 1.1, 95% CI 0.9-1.4, p = 0.38). On multivariate analysis controlling for glove size and gender, completion of all FEC components was still associated with a higher likelihood of passing the FES skills exam (OR 1.6, 95% CI 1.2-2.1, p < 0.001).

CONCLUSIONS

Completion of FEC is strongly associated with passing the FES skills test. This study supports the ABS recommendation for completion of FEC prior to taking the FES skills test.

Surgical Experience Disparity Between Male and Female Surgeons in Japan

Question

Does gender disparity exist in the number of surgical experiences among male and female surgeons in Japan?

Findings

In this cross-sectional study covering 1 147 068 total operations in 6 surgical fields performed between 2013 and 2017, surgical experience was classified by surgeons’ gender and years of experience. The number of operations per surgeon was lower for female compared with male surgeons, except in the first 2 years after medical registration; this gender gap widened as the difficulty level of surgery increased.

Meaning

The findings indicate a marked disparity in the surgical experience of female and male surgeons in Japan.

Importance

Women are vastly underrepresented in surgical leadership and management in Japan. The lack of equal opportunities for surgical training is speculated to be the main reason for this disparity; however, this hypothesis has not been investigated thus far.

Objective

To examine gender disparity in the number of surgical experiences among Japanese surgeons.

Design, Setting, and Participants

This retrospective, multicenter cross-sectional study used data from the National Clinical Database, which contains more than 95% of all surgical procedures in Japan. Participants included male and female gastroenterological surgeons who performed appendectomy, cholecystectomy, right hemicolectomy, distal gastrectomy, low anterior resection, and pancreaticoduodenectomy between January 1, 2013, and December 31, 2017.

Exposures

Differences in the number of surgical experiences between male and female surgeons.

Main Outcomes and Measures

The primary outcomes were the total number of operations and number of operations per surgeon by gender and years of experience. Data were analyzed from March 18 to August 31, 2021.

Results

Of 1 147 068 total operations, 83 354 (7.27%) were performed by female surgeons and 1 063 714 (92.73%) by male surgeons. Among the 6 operative procedures, the percentage of operations performed by female surgeons were the highest for appendectomy (n = 20 648 [9.83%]) and cholecystectomy (n = 41 271 [7.89%]) and lowest for low anterior resection (n = 4507 [4.57%]) and pancreaticoduodenectomy (n = 1329 [2.64%]). Regarding the number of operations per surgeon, female surgeons had fewer surgical experiences for all 6 types of operations in all years after registration, except for appendectomy and cholecystectomy in the first 2 years after medical registration. The largest gender disparity for each surgical procedure was 3.17 times more procedures for male vs female surgeons for appendectomy (at 15 years after medical registration), 4.93 times for cholecystectomy (at 30-39 years), 3.65 times for right hemicolectomy (at 30-39 years), 3.02 times for distal gastrectomy (at 27-29 years), 6.75 times for low anterior resection (at 27-29 years), and 22.2 times for pancreaticoduodenectomy (at 30-39 years).

Conclusions and Relevance

This cross-sectional study found that female surgeons had less surgical experience than male surgeons in Japan, and this gap tended to widen with an increase in years of experience, especially for medium- and high-difficulty operations. Gender disparity in surgical experience needs to be eliminated, so that female surgeons can advance to leadership positions.

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.

Gender and Racial/Ethnic Disparities in Operative Volumes of Graduating General Surgery Residents

INTRODUCTION

Gender disparities in resident operative experience have been described; however, their etiology is poorly understood, and racial/ethnic disparities have not been explored. This study investigated the relationship between gender, race/ethnicity, and surgery resident case volumes.

MATERIALS AND METHODS

A retrospective analysis of graduating general surgery resident case logs (2010-2020) at an academic medical center was performed. Self-reported gender and race/ethnicity data were collected from program records. Residents were categorized as underrepresented in medicine (URM) (Black, Hispanic, Native American) or non-URM (White, Asian). Associations between gender and URM status and major, chief, and teaching assistant (TA) mean case volumes were analyzed using t-tests.

RESULTS

The cohort included 80 residents: 39 female (48.8%) and 17 URM (21.3%). Compared to male residents, female residents performed fewer TA cases (33 versus 47, P < 0.001). Compared to non-URM residents, URM residents graduated with fewer major (948 versus 1043, P = 0.008) and TA cases (32 versus 42, P = 0.038). Male URM residents performed fewer TA cases than male non-URM residents (32 versus 50, P = 0.031). Subanalysis stratified by graduation year demonstrated that from 2010 to 2015, female residents performed fewer chief (218 versus 248, P = 0.039) and TA cases (29 versus 50, P = 0.001) than male residents. However, from 2016 to 2020, when gender parity was achieved, no significant associations were observed between gender and case volumes.

CONCLUSIONS

Female and URM residents perform fewer TA and major cases than male non-URM residents, which may contribute to reduced operative autonomy, confidence, and entrustment. Prioritizing gender and URM parity may help decrease case volume gaps among underrepresented residents.

Examining the barriers faced by female surgical trainees: a qualitative study

INTRODUCTION

Today, women make up 56% of medical students, yet just 13% of surgical consultants - a number that has remained static since 2013. This qualitative study explored some of the barriers to female success in modern surgery.

METHODS

Semistructured qualitative interviews were undertaken primarily with female surgical trainees to determine the barriers they face. Male trainees and training programme directors (TPDs) were also interviewed for triangulation.

RESULTS

20 interviews were performed (16 female trainees, 3 male trainees, and 1 TPD) between October 2019 and March 2020. Family pressures and becoming a mother were significant barriers for women training in surgery - a barrier that did not apply to male trainees who were fathers, often resulting in women choosing to train less than full time (LTFT). Unfortunately LTFT training presents further obstacles for female trainees. The set-up of the national training programme in surgery provides many non-gender-specific barriers, chiefly moving hospital every 6 months causing disrupted training and long commutes, disproportionately affecting females with child care responsibilities. Sexism and discrimination are still common, both from colleagues and patients. Many participants perceived inherent differences between genders in communication and methods for coping with stress.

CONCLUSION

Greater gender equality in surgery may be achieved by changes in the structure and organisation of training to reduce the tension between the professional role and the predominantly female-led role of raising children. Better equality and diversity training and awareness at all levels in surgery may help to mitigate some of the conscious and unconscious bias that still exists.

Gender Representation Among Presenters in Ophthalmology Subspecialties in 2019: A Retrospective Review

PURPOSE

To describe gender representation at eight national ophthalmology conferences, stratified by role, session category, and sub-specialty.

DESIGN

Retrospective cross-sectional study.

STUDY POPULATION

3,817 presenters at the 2019 American Academy of Ophthalmology subspecialty days, American Society of Cataract and Refractive Surgery, American Glaucoma Society, American Society of Retina Specialists, American Society of Ophthalmic Plastic and Reconstructive Surgery, American Association for Pediatric Ophthalmology and Strabismus, North American Neuro-Ophthalmology Society, and American Uveitis Society meetings.

MAIN OUTCOME MEASURES

Gender of presenters in seven sub-specialties stratified by category and role.

RESULTS

The proportion of female presenters was less than the ABO-estimated proportion of women in their respective fields in glaucoma (28.0% vs. 39.8%), neuro-ophthalmology (35.3% vs. 45.3%), and pediatrics (42.1% vs. 53.3%) and greater than expected in retina (24.6% vs. 19.8%). Overall, the proportion of female presenters exceeded the ABO-estimated proportion of females in ophthalmology (24.5%) for clinical (mean: 38.5%, 95% CI: [35.8%, 41.4%]) and scientific (39.4% [30.3%, 49.2%]) sessions. For clinical sub-specialty sessions, the proportion of female leaders exceeded the overall proportion of female leaders in the respective sub-specialty in cornea (35.1%, [30.4%, 40.1%] vs. 24.6% all sessions). Females represented fewer than the expected number of surgical session leaders in cornea (22.0% [19.9%, 24.3%]), glaucoma (18.0% [13.2%, 24.1%]), pediatrics (22.0% [14.4%, 32.1%]), and retina (18.6% [14.2%, 24.1%]).

CONCLUSIONS

Gender representation varied, with fewer than expected female presenters in glaucoma, neuro-ophthalmology, and pediatrics. Females led relatively more clinical sessions, but were underrepresented in surgical sessions, in most sub-specialties.

Investigation of the Association Between Surgeon Sex and Laparoscopic Device Ergonomic Strain in Gynecologic Surgery

STUDY OBJECTIVE

To assess if female compared to male sex is associated with greater ergonomic strain with use of 4 advanced energy laparoscopic devices (LigaSure, HALO PKS, ENSEAL, and Harmonic scalpel).

DESIGN

Online survey distributed by e-mail using the REDCap platform. All responses were anonymous.

SETTING

Nationwide survey in the United States.

PARTICIPANTS

Gynecologic surgeons were surveyed through the Society of Gynecologic Surgeons listserv and 4 Obstetrics and Gynecology departmental listservs.

INTERVENTIONS

The survey was distributed between 5/01/2020-11/01/2020. The primary outcome was the presence of physical complaints due to laparoscopic devices. Descriptive statistics compared surgeon characteristics and ergonomic symptoms. Logistic regression was performed, adjusted for surgeon characteristics.

MEASUREMENTS AND MAIN RESULTS

The response rate was 39%, comprising 149 women (78%) and 41 men (22%). Women compared to men had a significantly younger age (mean 34 vs 44 years old, p<.01), smaller glove size (mean 6.5 vs 7.5, p<.01), shorter height (median 66 vs 71 in, p<.01), and were less frequently in practice for >10 years (19% vs 49%, p<.01). Women significantly more often reported physical complaints related to use of laparoscopic devices (79% vs 41%, p<.01). Women reported all devices had too large a fit for appropriate use (p<.01). Women were found to have 5.37 times the odds of physical complaints attributed to the use of laparoscopic instruments (cOR 5.37, 95% CI 2.56-11.25); with adjustment for glove size, age, and laparoscopic case volume and duration, this was no longer significant (aOR 2.02, 95% 0.59-6.93).

CONCLUSION

Women significantly more often report physical complaints and inappropriate fit of the LigaSure, HALO PKS, ENSEAL, and Harmonic scalpel. Female sex is associated with fivefold greater odds of physical complaints with laparoscopic device use. Further investigation of the surgeon factors underlying device-related strain is a critical next step to understanding and reducing surgeon ergonomic injury.

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.

Concurrent Validity Evidence for Entrustable Professional Activities in General Surgery Residents

BACKGROUND

A subset of Entrustable Professional Activities (EPAs) has been developed for general surgery. We aim to contribute validity evidence for EPAs as an assessment framework for general surgery residents, including concurrent validity compared to ACGME milestones, the current gold standard for evaluating competency.

STUDY DESIGN

This is a cross-sectional study in a general surgery training program within a tertiary academic medical center. EPA assessments were submitted using a mobile app and scored on a numerical scale, mirroring milestones. EPA score distribution was analyzed with respect to post-graduate year (PGY) level and phase of care. Proportional odds logistic regression identified significant predictors. Spearman rank and Wilcoxon rank tests were used for comparisons with milestone ratings.

RESULTS

From August 2018 to December 2019, 320 assessments were collected. EPA scores increased by PGY level. Operative phase EPA scores were significantly lower than nonoperative phase scores. PGY level, operative phase, and case difficulty significantly influenced entrustment scoring. EPA scores demonstrated strong correlation with nonoperative milestones patient care-1, medical knowledge-1, interpersonal and communication skills-2, interpersonal and communication skills-3, professionalism-1, professionalism-3, and practice-based learning and improvement-2 (ρ > 0.5, p < 0.05) and a weaker correlation with operative milestones patient care-3 and medical knowledge-2 (ρ < 0.5, p < 0.05).

CONCLUSIONS

The influence of PGY level and operative phase on entrustment scoring supports the validity of EPAs as a formative evaluation framework for general surgery resident performance. In addition, evident correlations between EPA scores and respective milestone ratings provide concurrent validity evidence.