The unspoken reality of gender bias in surgery: A qualitative systematic review

Short-time mentoring - enhancing female medical students' intentions toward surgical careers

BACKGROUND

Women pursuing a career in surgery or related disciplines are still in the minority, despite the fact that women compose at least half of the medical student population in most Western countries. Thus, recruiting and retaining female surgeons remains an important challenge to meet the need for surgeons and increase the quality of care. The participations were female medical students between their third and fifth academic year. In this study, we applied the well-established psychological theory of planned behavior (TPB) which suggests that the intention to perform a behavior (e.g. pursuing a career in surgery) is the most critical and immediate predictor of performing the behavior. We investigated whether a two-part short-mentoring seminar significantly increases students' intention to pursue a career in a surgical or related specialty after graduation.

METHOD

The mentoring and role-model seminar was conducted at 2 days for 90 minutes by six inspiring female role models with a remarkable career in surgical or related disciplines. Participants (N = 57) filled in an online survey before (T0) and after the seminar (T1). A pre-post comparison of central TPB concept attitude towards the behavior, 2) occupational self-efficacy and 3) social norm) was conducted using a paired sampled t-test. A follow-up survey was administered 12 months later (T2).

RESULTS

The mentoring seminar positively impacted female students' attitude towards a career in a surgical specialty. Female students reported a significantly increased positive attitude (p < .001) and significantly higher self-efficacy expectations (p < .001) towards a surgical career after participating in the mentoring seminar. Regarding their career intention after the seminar, female students declared a significantly higher intention to pursue a career in a surgical specialty after graduating (p < .001) and this effect seems to be sustainable after 1 year.

CONCLUSION

For the first time we could show that short-mentoring and demonstrating role models in a seminar surrounding has a significant impact on female medical student decision´s to pursue a career in a surgery speciality. This concept may be a practical and efficient concept to refine the gender disparity in surgery and related disciplines.

Barriers for pregnancy and perceptions of gender discrimination of urologists in training in France: Results of a national survey

INTRODUCTION

Gender discrimination seems more prevalent in surgery than other medical specialties. In addition, female urologists are more likely to have obstetric complications and to be discouraged from starting a family during training. The objective of this study was to determine the prevalence of perceived gender discrimination and barriers for pregnancy during fellowship, among French urology residents and fellows.

MATERIAL AND METHODS

The French Association of Urologists in Training performed a national online survey between August and September 2022. Participants were assured that their participation was anonymous. Respondents were questioned on demographics, gender discrimination and on pregnancy barriers during fellowship.

RESULTS

In total, 153 members answered the questionnaire out of the 427 members of the association (36%), among which 75 women (49%). Thirty nine percent of the female respondents found that their gender was a barrier in their career advancement, versus 1% of the male (P<0.0001). Forty female respondents (53%) perceived that female urologists earned less respect than their male counterparts versus 22% of the male (P<0.0001). Among the female respondents, 19 (25%) have felt that it would not be possible to become pregnant at the time they would have wanted it and 7 (9%) reported having already been threatened to lose a fellowship position in case of a pregnancy.

CONCLUSION

This survey found a high prevalence of gender discrimination among French urologists in training, perceived in majority by women. Female urologists perceived obstacles and received threats when wanting to become pregnant during their training.

Identifying and addressing mentorship gaps in European trauma and emergency surgical training. Results from the Young European Society of Trauma and Emergency Surgery (yESTES) mentorship survey

PURPOSE

European training pathways for surgeons dedicated to treating severely injured and critically ill surgical patients lack a standardized approach and are significantly influenced by diverse organizational and cultural backgrounds. This variation extends into the realm of mentorship, a vital component for the holistic development of surgeons beyond mere technical proficiency. Currently, a comprehensive understanding of the mentorship landscape within the European trauma care (visceral or skeletal) and emergency general surgery (EGS) communities is lacking. This study aims to identify within the current mentorship environment prevalent practices, discern existing gaps, and propose structured interventions to enhance mentorship quality and accessibility led by the European Society for Trauma and Emergency Surgery (ESTES).

METHODS

Utilizing a structured survey conceived and promoted by the Young section of the European Society of Trauma and Emergency Surgery (yESTES), we collected and analyzed responses from 123 ESTES members (both surgeons in practice and in training) across 20 European countries. The survey focused on mentorship experiences, challenges faced by early-career and female surgeons, the integration of non-technical skills (NTS) in mentorship, and the perceived role of surgical societies in facilitating mentorship.

RESULTS

Findings highlighted a substantial mentorship experience gap, with 74% of respondents engaging in mostly informal mentorship, predominantly centered on surgical training. Notably, mentorship among early-career surgeons and trainees was less reported, uncovering a significant early-career gap. Female surgeons, representing a minority within respondents, reported a disproportionately poorer access to mentorship. Moreover, while respondents recognized the importance of NTS, these were inadequately addressed in current mentorship practices. The current mentorship input of surgical societies, like ESTES, is viewed as insufficient, with a call for structured programs and initiatives such as traveling fellowships and remote mentoring.

CONCLUSIONS

Our survey underscores critical gaps in the current mentorship landscape for trauma and EGS in Europe, particularly for early-career and female surgeons. A clear need exists for more formalized, inclusive mentorship programs that adequately cover both technical and non-technical skills. ESTES could play a pivotal role in addressing these gaps through structured interventions, fostering a more supportive, inclusive, and well-rounded surgical community.

Gender Differences in the Pediatric Neurosurgical Workforce: Professional Practice, Work-Life Balance, and Beyond

BACKGROUND AND OBJECTIVES

Evidence suggests that female neurosurgeons experience unique challenges in the workplace including lack of academic advancement, challenges with work-life balance, harassment, and discrimination. How these factors influence the gender gap in neurosurgery remains unclear. This analysis investigated gender differences in pediatric neurosurgeons in professional and nonprofessional activities and responsibilities.

METHODS

A survey examining professional activities, work-life balance, family dynamics, career satisfaction, and workplace discrimination and harassment was administered to 495 pediatric neurosurgeons. Response rate was 49% (n = 241).

RESULTS

One-third of the pediatric neurosurgical workforce is female. There were no gender differences in race/ethnicity, American Board of Neurological Surgery/American Board of Pediatric Neurological Surgery certification rates, or pediatric neurosurgery fellowship completion. No gender differences were found in operative caseload, weekly hours worked, or working after 8 pm or weekends. Women took call more frequently than men ( P = .044). Men were more likely to work in academia ( P = .004) and have salary subsidization from external sources ( P = .026). Women were more likely to anticipate retirement by age 65 years ( P = .044), were less happy with call commitments ( P = .012), and worked more hours at home while off ( P = .050). Women more frequently reported witnessing and experiencing racial discrimination ( P = .008; P < .001), sexual harassment ( P = .002, P < .001), and feeling less safe at work ( P < .001). Men were more likely married ( P = .042) with 1 ( P = .004) or more children ( P = .034). Women reported significantly greater responsibility for child and domestic care ( P < .001). There were no gender differences in work-life balance, feeling supported at work, or having enough time to do things outside of work.

CONCLUSION

Despite little difference in workload and professional responsibilities, women held more domestic responsibilities and experienced and witnessed more racial and sexual discrimination in the workplace. Surprisingly, there were no reported differences in work-life balance or feeling supported at work between genders. These findings suggest that factors unique to female neurosurgeons may contribute to continued gender disparity in the field.

Gender diversity in pediatric surgery: academic ranks and scholarly productivity amongst pediatric surgeons

Purpose

Despite a growing number of women entering medical school, a small proportion of women pursue surgical specialties, including pediatric surgery. This multi-center study assesses gender-based differences in measures of scholarly productivity and distribution of faculty positions.

Methods

This is a retrospective web-based study of all pediatric surgeons at twelve large institutions across the United States. Data published by the American Association of Medical Colleges was compiled and analyzed to understand the gender distributions of medical students, general surgery residents, and pediatric surgery fellows. P-values were calculated using two-sided Student's independent t-tests and chi-squared tests.

Results

There have been a growing number of women applying into pediatric surgery, but the proportion of women matriculating into these fellowships is not concordant. Women are still underrepresented (28%) amongst the pediatric surgeon workforce. A total of 111 pediatric surgeons were identified for this study, which included 31 women (28%) and 80 males (72%). There was a significant difference in the distribution across academic ranks between genders (p < 0.001). Women had significantly fewer publications per year after residency, fewer total publications, and a lower h-index in comparison to men (p < .001, p = .005, p = .002, respectively).

Conclusions

Women are not only underrepresented in pediatric surgery, but there are also significant differences in the distribution of faculty positions and scholarly productivity when comparing men and women. There is a pressing need to improve gender diversity and identify barriers that may prevent women from advancing to leadership positions and achieving professional success.

The joy of surgery: how gender influences surgeons' experiences

INTRODUCTION

Burnout in medicine is an epidemic, and surgeons are not immune. Studies often focus on negative factors leading to burnout, with less emphasis on optimizing joy. The purpose of this study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, was to explore how gender may influence surgeon well-being to better inform organizational change.

METHODS

The study team developed a survey with the domains: facilitators of joy, support for best work, time for work tasks, barriers to joy, and what they would do with more time. The survey was emailed to 5777 addresses on the SAGES distribution list. Results were analyzed by calculating summary statistics.

RESULTS

223 surgeons completed the survey; 62.3% identified as men, 32.3% as women, and 5.4% did not indicate gender. Female compared to male respondents were younger (41.6 vs 52.5 years) and had practiced for fewer years (8.4 vs 19.4 years). The three greatest differences in facilitators of joy were being a leader in the field, leading clinical teams, and teaching, with a > 10 percentage point difference between men/women rating these highly (score of ≥ 8). Women generally perceived less support from their institutions than men. The greatest gender difference was in support for teaching, with 52.8% of men rating this highly compared to 30.2% of women. Only 52% of women felt respected by coworkers most of the time compared to 68.3% of men. Most (96.0%) respondents (men 95.7% and women 98.6%) reported wanting more time with family and friends.

CONCLUSION

This study demonstrates the complexity of the personal and professional factors that influence joy in surgery, highlight gender differences that impact joy and suggests opportunities for improved gender-based support. These results can inform potential organization-level changes and further research to better understand emerging differences in joy across gender identities.

Gender inequities in ENT: Insights from women speakers at American Head and Neck Society meetings

BACKGROUND

Gender inequity exists across national speakers at American Head and Neck Society (AHNS) conferences. This qualitative study explores potential causes of this disparity by surveying women invited to speak at AHNS between 2007 and 2019 and examining advice, resources, and meaningful actions from "those who made it."

METHODS

An internet search for contact information for the 131 female AHNS was performed. An electronic survey was distributed via email. Deidentified qualitative responses were coded by two independent researchers into themes. Themes characterize barriers that female head and neck (HN) surgeons face and describe ways to mitigate the impact of these for the next generation.

RESULTS

Contact information for 73/131 female AHNS speakers was obtained via internet search. Email responses were received from 22/73 (30%). Of those, respondents specialized in otolaryngology (n = 17), medical oncology (n = 2), palliative care (n = 1), vascular surgery (n = 1), and thoracic surgical oncology (n = 1). All speakers worked in academic settings at varying stages of their career with 81.8% (18/22) of respondents fellowship-trained (primarily HN surgery). Concerns about gender disparity in ENT were grouped into the following themes: (1) recruiting women to ENT, (2) removing barriers to career advancement, (3) diversifying ENT's national presence, and (4) improving the broader culture of HN surgery. Respondents emphasized a need for diversifying leadership, early exposure to otolaryngology in medical school, and connecting students with female role models. Outstanding research, involvement at annual meetings, and committee membership were consistently deemed important for establishing a national presence in the field. Implicit bias, "boys clubs" culture, and burdensome childcare responsibilities were described as barriers to career advancement.

CONCLUSIONS

While encouraging more women to enter otolaryngology residencies, increasing the number female role models and establishing strong mentoring networks may help to mitigate challenges. Meaningful progress requires the efforts of both male and female allies within the specialty. Simple solutions, such as educating on implicit bias, removing demographics from applications, and eliminating hidden penalties for maternity leave, may help improve diversity and mitigate barriers to career progression for underrepresented groups within ENT.

"I don't know if I can keep doing this": a qualitative investigation of surgeon burnout and opportunities for organization-level improvement

Introduction

Burnout is a pressing issue within surgical environments, bearing considerable consequences for both patients and surgeons alike. Given its prevalence and the unique contextual factors within academic surgical departments, it is critical that efforts are dedicated to understanding this issue. Moreover, active involvement of surgeons in these investigations is critical to ensure viability and uptake of potential strategies in their local setting. Thus, the purpose of this study was to explore surgeons' experiences with burnout and identify strategies to mitigate its drivers at the level of the organization.

Methods

A qualitative case study was conducted by recruiting surgeons for participation in a cross-sectional survey and semi-structured interviews. Data collected were analyzed using reflexive thematic analysis, which was informed by the Areas of Worklife Model.

Results

Overall, 28 unique surgeons participated in this study; 11 surgeons participated in interviews and 22 provided responses through the survey. Significant contributors to burnout identified included difficulties providing adequate care to patients due to limited resources and time available in academic medical centers and the moral injury associated with these challenges. The inequitable remuneration associated with education, administration, and leadership roles as a result of the Fee-For-Service model, as well as issues of gender inequity and the individualistic culture prevalent in surgical specialties were also described as contributing factors. Participants suggested increasing engagement between hospital leadership and staff to ensure surgeons are able to access resources to care for their patients, reforming payment plans and workplace polities to address issues of inequity, and improving workplace social dynamics as strategies for addressing burnout.

Discussion

The high prevalence and negative sequalae of burnout in surgery necessitates the formation of targeted interventions to address this issue. A collaborative approach to developing interventions to improve burnout among surgeons may lead to feasible and sustainable solutions.

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.

Female Surgical Ergonomics in Otolaryngology: A National Survey Study

OBJECTIVE

To assess the nature and impact surgical ergonomic challenges experienced by female otolaryngologists.

STUDY DESIGN

National survey study.

SETTING

Female otolaryngology residents, fellows and attendings recruited via social media posting and email distribution.

METHODS

We distributed a survey study to female otolaryngologists throughout the United States. The height and glove size of participants reporting difficulties with equipment and instruments were compared to those not reporting difficulties.

RESULTS

Ninety-six female otolaryngologists participated in our study, comprised of 43% residents, 10% fellows, and 47% attendings. Ninety percent of participants reported difficulties using equipment and 77% of participants reported difficulty with instruments, the most common being nasal endoscopic instruments (28%). The vast majority of participants reported pain during and (or) after the operation (92%). Head and neck (53%) and rhinology (44%) were identified as particularly challenging specialities, but only 25% of participants reported that ergonomics affected their career plans. Participants felt that adjustable equipment (60%), a variety of sizes of instruments (43%), and more discussion around ergonomics (47%) would help. Respondents reported adjusting the operating room to accommodate their size took extra time (44%) and was a mental burden (39%). Participants reporting difficulties with operating room equipment were significantly shorter than those without difficulties (64 inches vs 67 inches, P = .037), and those reporting difficulties with instruments had a smaller median glove size (6 vs 6.5, P = .018).

CONCLUSION

Surgical ergonomics represent a challenge for female otolaryngologists, particularly those with smaller hands and shorter height. Partnering with industry, we must address the needs of an increasingly diverse workforce to ensure that all surgeons can operate effectively and comfortably.

Gender Bias in Leadership Roles in General Surgery: A South Asian Perspective

This article addresses the significant issue of gender bias in leadership roles within the realm of general surgery, with a particular focus on the South Asian context. The persistence of cultural norms, entrenched gender stereotypes, and discriminatory practices in this region significantly limits the opportunities available to female surgeons. It calls on all stakeholders, including medical institutions, governing bodies, and surgeons, to take an active role in eliminating gender bias and fervently supporting diversity and inclusivity in leadership positions. By doing so, it argues, we can create a more equitable and promising future for the field of general surgery in South Asia.

Sex Disparities in Ophthalmology From Training Through Practice: A Systematic Review

Importance

Sex-based research in medicine has revealed inequities against females on almost every metric at almost every career stage; ophthalmology is no exception.

Objective

To systematically review the experiences of females in ophthalmology (FiO) from training through practice in high-income countries (HICs).

Evidence Review

A systematic review of English-language studies, published between January 1990 and May 2022, relating to FiO in HICs was performed. PubMed, MEDLINE, and Embase electronic databases were searched, as well as the Journal of Academic Ophthalmology as it was not indexed in the searched databases. Studies were organized by theme at each career stage, starting in medical school when an interest in ophthalmology is expressed, and extending up to retirement.

Findings

A total of 91 studies, 87 cross-sectional and 4 cohort, were included. In medical school, mentorship and recruitment of female students into ophthalmology was influenced by sex bias, with fewer females identifying with ophthalmologist mentors and gender stereotypes perpetuated in reference letters written by both male and female referees. In residency, females had unequal learning opportunities, with lower surgical case volumes than male trainees and fewer females pursued fellowships in lucrative subspecialties. In practice, female ophthalmologists had lower incomes, less academic success, and poorer representation in leadership roles. Female ophthalmologists had a greater scholarly impact factor than their male counterparts, but this was only after approximately 30 years of publication experience. Pervasive throughout all stages of training and practice was the experience of greater sexual harassment among females from both patients and colleagues. Despite these disparities, some studies found that females reported equal overall career satisfaction rating with males in ophthalmology, whereas others suggested higher burnout rates.

Conclusions and Relevance

Ophthalmology is approaching sex parity, however, the increase in the proportion of females in ophthalmology had not translated to an increase in female representation in leadership positions. Sex disparities persisted across many domains including recruitment, training, practice patterns, academic productivity, and income. Interventions may improve sex equity in the field.

Does gender affect experiences in the operating room for surgeons and anesthesiologists at a large academic center?

BACKGROUND

Although the number of women medical trainees has increased in recent years, they remain a minority of the academic workforce. Gender-based implicit biases may lead to deleterious effects on surgical workforce retention and productivity.

METHODS

All 440 attending surgeons and anesthesiologists employed at our institution were invited to complete a survey regarding perceptions of the perioperative work environment and resources. Odds ratios for dichotomous variables were calculated using logistic regressions, and for trichotomous variables, polytomous regressions.

RESULTS

243 participants (55.2%) provided complete survey responses. Relative to men, women faculty reported a greater need to prove themselves to staff; less respect and fewer resources and opportunities; more frequent assumptions about their capabilities; and a greater need to adjust their demeanor to connect with their team (p ​< ​0.05).

CONCLUSION

Perceived gender bias remains present in the perioperative environment. We need greater efforts to address barriers and create an equitable work environment.

UK pregnancy in orthopaedics (UK-POP): a cross-sectional study of UK female trauma and orthopaedic surgeons and their experiences of pregnancy

Aims

The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

Methods

This is a cross-sectional study using an anonymous 13-section web-based survey distributed to female-identifying T&O trainees, speciality and associate specialist surgeons (SASs) and locally employed doctors (LEDs), fellows, and consultants in the UK. Demographic data was collected as well as closed and open questions with adaptive answering relating to attitudes towards childbearing and experiences of fertility and complications associated with pregnancy. A descriptive data analysis was carried out.

Results

A total of 226 UK female T&O surgeons completed the survey. All regions of the UK were represented. Overall, 99/226 (44%) of respondents had at least one child, while 21/226 (9.3%) did not want children. Median age at first child was 33 years (interquartile range 32 to 36). Two-thirds (149/226; 66%) of respondents delayed childbearing due to a career in T&O and 140/226 (69%) of respondents had experienced bias from colleagues directed at female T&O surgeons having children during training. Nearly 24/121 (20%) of respondents required fertility assistance, 35/121 (28.9%) had experienced a miscarriage, and 53/121 (43.8%) had experienced obstetric complications.

Conclusion

A large proportion of female T&O surgeons have and want children. T&O surgeons in the UK delay childbearing, have experienced bias and have high rates of infertility and obstetric complications. The information from this study will support female T&O surgeons with decision making and assist employers with workforce planning. Further steps are necessary in order to support female T&O surgeons having families.

Gender Differences in North American and International Otolaryngology Clinical Practice Guideline Authorship: A 17-Year Analysis

OBJECTIVE

To analyze gender differences in authorship of North American (Canadian and American) and international published otolaryngology-head and neck surgery (OHNS) clinical practice guidelines (CPG) over a 17-year period.

METHODS

Clinical practice guidelines published between 2005 and 2022 were identified through the Canadian Agency for Drugs and Technology in Health (CADTH) search strategy in MEDLINE and EMBASE. Studies were included if they were original studies, published in the English language, and encompassed Canadian, American, or international OHNS clinical practice guidelines.

RESULTS

A total of 145 guidelines were identified, encompassing 661 female authors (27.4%) and 1756 male authors (72.7%). Among OHNS authors, women and men accounted for 21.2% and 78.8% of authors, respectively. Women who were involved in guideline authorship were 31.0% less likely to be an otolaryngologist compared to men. There were no gender differences across first or senior author and by subspeciality. Female otolaryngologist representation was the greatest in rhinology (28.3%) and pediatrics (26.7%). American guidelines had the greatest proportion of female authors per guideline (34.1%) and the greatest number of unique female authors (33.2%).

CONCLUSION

Despite the increasing representation of women in OHNS, gender gaps exist with regards to authorship within clinical practice guidelines. Greater gender diversity and transparency is required within guideline authorship to help achieve equitable gender representation and the development of balanced guidelines with a variety of viewpoints.

What is the educational value and clinical utility of artificial intelligence for intraoperative and postoperative video analysis? A survey of surgeons and trainees

INTRODUCTION

Surgical complications often occur due to lapses in judgment and decision-making. Advances in artificial intelligence (AI) have made it possible to train algorithms that identify anatomy and interpret the surgical field. These algorithms can potentially be used for intraoperative decision-support and postoperative video analysis and feedback. Despite the very early success of proof-of-concept algorithms, it remains unknown whether this innovation meets the needs of end-users or how best to deploy it. This study explores users' opinion on the value, usability and design for adapting AI in operating rooms.

METHODS

A device-agnostic web-accessible software was developed to provide AI inference either (1) intraoperatively on a live video stream (synchronous mode), or (2) on an uploaded video or image file (asynchronous mode) postoperatively for feedback. A validated AI model (GoNoGoNet), which identifies safe and dangerous zones of dissection during laparoscopic cholecystectomy, was used as the use case. Surgeons and trainees performing laparoscopic cholecystectomy interacted with the AI platform and completed a 5-point Likert scale survey to evaluate the educational value, usability and design of the platform.

RESULTS

Twenty participants (11 surgeons and 9 trainees) evaluated the platform intraoperatively (n = 10) and postoperatively (n = 11). The majority agreed or strongly agreed that AI is an effective adjunct to surgical training (81%; neutral = 10%), effective for providing real-time feedback (70%; neutral = 20%), postoperative feedback (73%; neutral = 27%), and capable of improving surgeon confidence (67%; neutral = 29%). Only 40% (neutral = 50%) and 57% (neutral = 43%) believe that the tool is effective in improving intraoperative decisions and performance, or beneficial for patient care, respectively. Overall, 38% (neutral = 43%) reported they would use this platform consistently if available. The majority agreed or strongly agreed that the platform was easy to use (81%; neutral = 14%) and has acceptable resolution (62%; neutral = 24%), while 30% (neutral = 20%) reported that it disrupted the OR workflow, and 20% (neutral = 0%) reported significant time lag. All respondents reported that such a system should be available "on-demand" to turn on/off at their discretion.

CONCLUSIONS

Most found AI to be a useful tool for providing support and feedback to surgeons, despite several implementation obstacles. The study findings will inform the future design and usability of this technology in order to optimize its clinical impact and adoption by end-users.

Checking Our Blind Spots: Examining Characteristics of Interviewees Versus Matriculants to a Hepatopancreatobiliary Surgical Fellowship Program

OBJECTIVE

Racial and gender biases exist within academic surgery; bias negatively impacts patient care, reimbursement, student training, and staff retention. Few studies have investigated the potential for bias in surgical fellowship recruitment. We aimed to compare the racial and gender diversity at our hepatopancreatobiliary (HPB) surgery fellowship program to nationwide standards. We further aimed to investigate differences in the demographics of resident interviewees versus matriculants to our HPB fellowship.

DESIGN

Retrospective review.

SETTING

North American HPB fellowship training programs.

PARTICIPANTS

Mayo Clinic's HPB surgery fellowship interviewees and North American HPB surgery fellowship graduates from 2013 to 2020.

RESULTS

When compared to general surgery residency graduates during the study period (in 2019), a lower proportion of North American HPB surgery fellowship graduates were female (26% HPB fellowship graduates vs. 43.1% residents, p = 0.005), with no difference in proportion of racially under-represented in medicine (rURM) HPB fellowship graduates (10.7%) compared to rURM proportion of general surgery residents nationally (14.5%). There was an upward trend in female representation among North American HPB fellowship graduates from 11% in 2013 to 32% in 2020, but proportions of rURM HPB fellows remained steadily low. When comparing HPB interviewees at our institution to national general surgery residents, no differences were observed in proportions of female (34.4% interviewees vs. 43.1% residents, p = 0.17) or rURM (interviewees = 6.8%, residents = 14.5%, p = 0.09) applicants. Additionally, there was no significant difference between the proportion of female or rURM interviewees and matriculants to our HPB program.

CONCLUSIONS

While fewer female graduating surgeons are pursuing HPB fellowship training than male graduates, this gender gap has narrowed over time. In contrast, the national percentage of rURM HPB fellowship graduates has remained low, mirroring stagnant proportions of rURM surgical residency graduates. When comparing HPB fellowship interviewees at our own institution to North American fellowship graduates, we observed similar proportions of female interviewees but lower proportions of rURM interviewees. Locally, these data will drive process change toward more intentional examination of our interview selection process. Nationally, more work is needed to increase the racial diversity of surgical residency and fellowship trainees to best reflect and serve our diverse patient populations.

Differences in Cholecystectomy Outcomes and Operating Time Between Male and Female Surgeons in Sweden

Importance

Female surgeons are still in the minority worldwide, and highlighting gender differences in surgery is important in understanding and reducing inequities within the surgical specialty. Studies on different surgical procedures indicate equal results, or safer outcomes, for female surgeons, but it is still unclear whether surgical outcomes of gallstone surgery differ between female and male surgeons.

Objective

To examine the association of the surgeon's gender with surgical outcomes and operating time in elective and acute care cholecystectomies.

Design, Setting, and Participants

A population-based cohort study based on data from the Swedish Registry of Gallstone Surgery was performed from January 1, 2006, to December 31, 2019. The sample included all registered patients undergoing cholecystectomy in Sweden during the study period. The follow-up time was 30 days. Data analysis was performed from September 1 to September 7, 2022, and updated March 24, 2023.

Exposure

The surgeon's gender.

Main Outcome(s) and Measure(s)

The association between the surgeon's gender and surgical outcomes for elective and acute care cholecystectomies was calculated with generalized estimating equations. Differences in operating time were calculated with mixed linear model analysis.

Results

A total of 150 509 patients, with 97 755 (64.9%) undergoing elective cholecystectomies and 52 754 (35.1%) undergoing acute care cholecystectomies, were operated on by 2553 surgeons, including 849 (33.3%) female surgeons and 1704 (67.7%) male surgeons. Female surgeons performed fewer cholecystectomies per year and were somewhat better represented at universities and private clinics. Patients operated on by male surgeons had more surgical complications (odds ratio [OR], 1.29; 95% CI, 1.19-1.40) and total complications (OR, 1.12; 95% CI, 1.06-1.19). Male surgeons had more bile duct injuries in elective surgery (OR, 1.69; 95% CI, 1.22-2.34), but no significant difference was apparent in acute care operations. Female surgeons had significantly longer operation times. Male surgeons converted to open surgery more often than female surgeons in acute care surgery (OR, 1.22; 95% CI, 1.04-1.43), and their patients had longer hospital stays (OR, 1.21; 95% CI, 1.11-1.31). No significant difference in 30-day mortality could be demonstrated.

Conclusions and Relevance

The results of this cohort study indicate that female surgeons have more favorable outcomes and operate more slowly than male surgeons in elective and acute care cholecystectomies. These findings may contribute to an increased understanding of gender differences within this surgical specialty.

Attitudes of Canadian medical students towards surgical training and perceived barriers to surgical careers: a multicentre survey

Background

Medical student interest in surgical specialties continues to decline. This study aims to characterize attitudes of Canadian medical students towards surgical training and perceived barriers to surgical careers.

Methods

An anonymous survey was custom designed and distributed to medical students at the University of Alberta and University of Calgary. Survey questions characterized student interest in surgical specialties, barriers to pursuing surgery, and influence of surgical education opportunities on career interest.

Results

Survey engagement was 26.7% in 2015 and 24.2% in 2021. General surgery had the highest rate of interest in both survey years (2015: 38.3%, 2021: 39.2%). The most frequently reported barrier was worry about the stress that surgical careers can put on personal relationships (2015: 70.9%, 2021: 73.8%, p= 0.50). Female respondents were significantly more likely to cite gender discrimination as a deterrent to surgical careers (F: 52.0%, M: 5.8%, p < 0.001).

Conclusions

Despite substantial interest, perception of work-life imbalance was the primary reported barrier to surgical careers. Further, female medical students' awareness of gender discrimination in surgery highlights the need for continued efforts to promote gender inclusivity within surgical disciplines to support early career women interested in surgery.

Gender Equality in Facial Plastic Surgery-A Female President's Perspective

This Viewpoint reviews the history, obstacles, and progress in equity for women in facial plastic surgery with the goal of promoting continued progress.

Gender Authorship Trends Among Craniofacial Publications: A 20-Year Analysis

This study aims to identify gender disparities within the subspecialty of craniofacial surgery as women surgeons remain underrepresented in academia and leadership, arenas heavily dictated by research productivity.

All craniofacial articles published in 3 major research journals from 2000 to 2020 were reviewed and evaluated in 5-year increments.

Information regarding author gender, authorship distribution, geographic origin, and publication type was collected. ANOVA, χ2, and logistic regression modeling were used for analysis.

In total, there were 3684 articles with 15 206 total authors-3128 (20.6%) were women, including 665 (21.3%) first authors, 1980 (63.2%) middle authors, and 487 (15.7%) senior authors. Mean women authorship increased significantly from 2000 to 2020 (0.33 vs 1.22 P < .001) with corresponding significant increases in first and senior authorship (8.63% vs 27.02; 5.65% vs 16.13%; P < .001). Statistically significant trends across time were observed for first and senior authorships (P < .001). Women were more likely to publish original publications as first and senior authors (OR: 1.83, P < .001; OR: 1.37, P = .0012). Women were less likely to publish editorial articles (OR 0.6, P < .001). The United States ranked third in publication output by female first authors but was behind all regions except Africa for output by female senior authors.

Although female authorship has increased significantly over the last 2 decades, women remain a minority within the craniofacial literature. Further research is needed to elicit the root of these disparities.

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.

Defining sources and ramifications of mistreatment among female vascular surgery trainees

OBJECTIVE

Mistreatment among vascular surgery trainees is a known risk factor for physician burnout. This study aims to characterize forms of and identify sources of mistreatment.

METHODS

This is a cross-sectional study of United States vascular surgery trainees who voluntarily participated in an anonymous survey administered after the 2021 Vascular Surgery In-Training Examination. The primary outcome measures were self-reported mistreatment and sources of mistreatment between genders. Logistic regression was used for multivariable analysis.

RESULTS

Representing all 125 vascular surgery training programs, 510 trainees (66.9% male) participated in the survey (83.6% response rate). Mistreatment was reported by 54.8% of trainees, with twice as many women reporting as men (82.3% vs 41.0%; P < .001). Women reported higher rates of being shouted at (44.1% vs 21.1%; P < .001); repeatedly reminded of errors (24.3% vs 16.1%; P = .04); ignored/treated hostilely (28.9% vs 10.5%; P < .001); subjected to crude/sexually demeaning remarks, stories, jokes (19.2% vs 2.1%; P < .001); evaluated by different standards (29.3% vs 2.1%; P < .001); and mistaken for a non-physician (75.2% vs 3.5%; P < .001). Among trainees reporting bullying, attendings were the most common source (68.5%). Patients and their families were the most common source of sexual harassment (66.7%), gender discrimination (90.4%), and racial discrimination (74.4%). Compared with men, women identified more patients and families as the source of bullying (50.0% vs 29.7%; P = .005), gender discrimination (97.2% vs 50.0%; P < .001), and sexual harassment (78.4% vs 27.3%; P = .003). Compared with men, women more frequently felt unprepared to respond to the behavior in the moment (10.4% vs 4.6%; P = .002), did not know how to report mistreatment at their institution (7.6% vs 3.2%; P = .04), and did not believe that their institution would take their mistreatment report seriously (9.0% vs 3.9%; P = .002). On multivariable analysis, female gender was an independent risk factor for both gender discrimination (odds ratio, 56.62; 95% confidence interval, 27.89-115) and sexual harassment (odds ratio, 26.2; 95% confidence interval, 3.34-14.8) when adjusting for children, training year, relationship status, and training program location.

CONCLUSIONS

A majority of vascular surgery trainees experience mistreatment during training. Sources and forms of abuse are varied. Understanding the sources of mistreatment is critical to guide intervention strategies such as faculty remediation and/or sanctions; allyship training for staff, residents, and faculty; and institutional procedures for patient-initiated abuse.

Obstacles Deterring Medical Students From Pursuing a Career in the Field of Surgery in Jazan University, Saudi Arabia

BACKGROUND

Particularly in Saudi Arabia, there is a dearth of trained specialists in the field of surgery. Understanding the obstacles that discourage medical students and residents from pursuing a surgical career is essential for resolving this shortage. This study intended to investigate the characteristics that influence medical students and trainees at Jazan University, Saudi Arabia, to pursue a career in surgery.

METHODOLOGY

This observational study employed a descriptive, cross-sectional approach. The intended audience consisted of fourth- to sixth-year medical students and medical residents. The questionnaire gathered information on demographics, academic year, previous surgical experience, perceptions of surgery as a specialty, and variables influencing career selections.

RESULTS

Out of 413 participants, 74.3% were considering a surgical career, with 24.4% interested in general surgery, followed by cardiac surgery (14.3%) and pediatric surgery (12.4%). Factors influencing career decisions included potential income (82%), the possibility of part-time work (82%), and partial leave (74%). A significant proportion of participants agreed or strongly agreed that the incidence of suicide (62%) and the risk of depression (72%) are higher in surgical specialties. Female participants were more likely to agree that their chance of becoming a spouse could be affected by a surgical career (p=0.002) and that meeting role models could influence their choice of surgical specialty (p=0.015).

CONCLUSION

Work-life balance, long working hours, and mental health concerns are identified as variables that discourage medical students and residents from pursuing a surgical career in the study. Efforts to encourage work-life balance, minimize workload, and provide support and resources for mental health issues should help surgeons suffer less stress and burnout. Moreover, encouraging an open-minded attitude and de-stigmatizing mental health concerns in the medical field should encourage individuals to seek assistance when necessary and lower the incidence of suicide and depression. Finally, tackling gender discrimination and encouraging diversity and inclusion in surgical specialties could attract more skilled surgeons.

Factors influencing gender preference towards surgeons among Jordanian adults: an investigation of healthcare bias

Studies investigating gender bias against female surgeons yielded conflicting results ranging from neutrality to a clear preference towards male surgeons. Yet, such bias remains understudied within Middle Eastern nations. We aimed to assess preferences of surgeons' gender among Jordanians and explore reasons for possible gender bias across different surgical specialties. A total of 1708 respondents were examined using a cross-sectional, self-administered questionnaire to evaluate the gender preferences of surgeons, characteristics associated with preferred surgeon's gender, and surgeon's preference in certain specialties. Nearly 52.0% of participants had no gender preference for surgeons. Among those with a preference, 75.7% preferred male surgeons while 24.3% preferred female surgeons. Reputation, knowledge, and experience were the most important factors when choosing a surgeon. Male surgeons were viewed as more trustworthy, knowledgeable, experienced, and communicative. Female surgeons were dominantly perceived as more compassionate, cooperative, and prone to listen. Male respondents were 5 times more likely to choose a surgeon of similar gender (OR 5.687; CI 3.791-8.531). Male surgeons were favored for cardiovascular and orthopedic surgeries. Similarly, female surgeons were favored in gynecological and obstetric surgeries, plastic surgeries, and breast surgeries. Female gender (OR 6.193; CI 4.077-9.408), living outside Amman (OR 1.517; CI 1.066-2.160), and being married (OR 2.504; CI 1.601-3.917) were all significant positive predictors of preferring female surgeons. Our findings highlight differences in gender preference and perception of surgeons among Jordanian adults.

Primum Non Discernere: Glass Ceilings and Female Representation at the European Association of Urology and European Society for Paediatric Urology Annual Meetings, 2012-2022

Background

The term glass ceiling coined by Loden in 1978 is commonly used to describe difficulties faced by minorities and women when trying to move into senior roles.

Objective

To analyse trends and patterns for female representation at the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) annual general meetings over the past decade.

Design setting and participants

We used objective data on female representation in the roles of chairs, moderators, and lecture speakers at the EAU and ESPU meetings from 2012 to 2022.

Outcome measurements and statistical analysis

We evaluated gender based representation in paediatric urology sessions at the EAU and ESPU meetings, collecting data on the overall number of sessions, lectures, symposiums, abstract/poster sessions, and courses, and analysed the male/female ratio. Data were derived from printed and digital programmes for the relevant meetings.

Results and limitations

During the period from 2012 to 2022, the percentage female representation varied from 0% (2012) to a maximum of 35% (2022) at EUA paediatric urology sessions, and from 13.5% (2014) to a maximum of 32% (2022) at ESPU meetings. Both associations show clear progression towards equality.

Conclusions

Female representation at EAU and ESPU meetings has risen over the years, reaching 35% and 32%, respectively, in 2022, which is in line with the number of female members. We hope that this motivates a move towards the equality objectives for 2030. A clear and fundamental societal change is needed, with fair and more consistent institutional policies and framework commitments in the areas of science, medicine, and global health. Gender equality and diversity taskforces are essential to achieve these goals.

Patient summary

We analysed the male/female ratio for participants in annual meetings held by the European Association of Urology and the European Society for Paediatric Urology. From a low level in 2012, the ratio increased to over 30% in 2022, in line with the female membership of the societies. Focus on fair and consistent policies is needed to ensure that women are well represented in medicine.

Rates of Burnout in Female Orthopaedic Surgeons Correlate with Barriers to Gender Equity

BACKGROUND

The primary purpose of this study was to investigate the relationships between career burnout and the barriers to gender equity identified by Canadian female orthopaedic surgeons. A secondary purpose was to assess relationships between the demographic characteristics of the female surgeons and career burnout and job satisfaction.

METHODS

An electronic survey was distributed to 330 Canadian female orthopaedic surgeons. Demographic variables including age, stage and years in practice, practice setting, and marital status were collated. The survey included the Gender Bias Scale (GBS) questionnaire and 2 questions each about career burnout and job satisfaction. The Pearson r correlation coefficient evaluated the relationships among the higher- and lower-order factors of the GBS, burnout, and job satisfaction. Spearman rank correlation coefficient assessed relationships among burnout, job satisfaction, and demographic variables.

RESULTS

Survey responses were received from 218 (66.1%) of the 330 surgeons. A total of 110 surgeons (50.5%) agreed or strongly agreed that they felt career burnout (median score = 4). Burnout was positively correlated with the GBS higher-order factors of Male Privilege (r = 0.215, p < 0.01), Devaluation (r = 0.166, p < 0.05), and Disproportionate Constraints (r = 0.152, p < 0.05). Job satisfaction (median = 4) was reported by 168 surgeons (77.1%), and 66.1% were also satisfied or very satisfied with their role in the workplace (median = 4). Burnout was significantly negatively correlated with surgeon age and job satisfaction.

CONCLUSIONS

Half of the female orthopaedic surgeons reported symptoms of career burnout. Significant relationships were evident between burnout and barriers to gender equity. Identification of the relationships between gender-equity barriers and burnout presents an opportunity to modify organizational systems to dismantle barriers and reduce this occupational syndrome.

CLINICAL RELEVANCE

Given the relationships between gender inequity and career burnout in this study of female orthopaedic surgeons, actions to dismantle gender barriers and address systemic biases are necessary at all career stages to reduce burnout.

Relationship Between Psychological Contract Violation and Physicians’ Destructive and Constructive Behaviors in Tertiary Public Hospitals: An Empirical Evidence in Beijing

Background

In China, physicians have long faced long working hours, high stress levels, and tensions between physicians and patients, which can lead to negative behaviors. Understanding physicians' expectations and requirements of the hospital and increasing satisfaction with their psychological contract can help improve physician motivation and stabilize the hospital team.

Aim

The study aims to analyze the relationship between physicians' psychological contract violations and different behavioral choices, encourage hospitals to conclude a balanced psychological contract with physicians, and provide governance and intervention strategies for hospital human resource management.

Methods

Stratified cluster sampling was used to select 321 physicians from four public hospitals in Beijing for questionnaire surveys. Descriptive statistical analysis, t-test, ANOVA, correlation analysis, and regression models were performed using Stata 15.0 and SPSS 26.0 to analyze the relationship between psychological contract violations, physicians' EVLN behaviors and organizational justice.

Results

Psychological contract violation had a positive effect on exit behavior and neglect behavior, and a negative effect on voice behavior and loyalty behavior. Organizational justice plays a mediating role between psychological contract violation and physicians' exit, voice and loyalty behaviors.

Conclusion

Psychological contract violation can drive negative behavior among physicians, and organizational justice can play a mediating role in this. Public hospitals should establish a healthy psychological contract with physicians and place a premium on organizational justice to promote constructive behaviors and prevent destructive behaviors. This study constructs a more complete theoretical framework to explain physicians' behavior, and further dynamic tracking investigations are necessary because the evolution of physicians' behavior is a dynamic and long-term process.

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.

The Experiences of Motherhood in Female Surgeons: A Scoping Review

OBJECTIVE

The objective of this study is to systematically synthesize the existing literature on the experiences of motherhood in female surgeons both during surgical training and as staff physicians, to identify knowledge gaps, and to provide recommendations for institutional changes to better support pregnant female surgeons.

BACKGROUND

There are disproportionately fewer medical students pursuing surgical specialties, as surgery is often seen as incompatible with childbearing and pregnancy. However, no review has summarized the published literature on the collective experiences of female surgeons in navigating motherhood.

METHODS

Four databases were searched and 1106 abstracts were identified. Forty-two studies were included and a thematic analysis was performed.

RESULTS

Four themes were identified: path toward motherhood (n=18), realities of motherhood (n=25), medical culture and its impact on career and family life (n=24), and institutional reproductive wellness policies (n=21). Female surgeons are more likely to delay motherhood until after training and have high rates of assisted reproductive technology use. Pregnancy during surgical training is associated with negative perception from peers, pregnancy complications, and scheduling challenges. Maternity leave policies and breastfeeding and childcare facilities are variable and often inadequate. Many female surgeons would agree that greater institutional support would help support women in both their roles as mothers and as surgeons.

CONCLUSIONS

Both female residents and staff surgeons experience significant and unique barriers before, during, and after motherhood that impact their personal and professional lives. Understanding the unique challenges that mothers face when pursuing surgical specialties is critical to achieving gender equity.

Representation of women in orthopaedic surgery: perception of barriers among undergraduate medical students in Saudi Arabia

BACKGROUND

While female participation has improved in several surgical specialties over time globally, no such increase has been observed in orthopaedic surgery over the past decades. The potential barriers to female participation are likely present from the beginning of medical education. Therefore, this study assessed the apparent lag in equal representation among men and women in orthopaedic surgery in the Kingdom of Saudi Arabia.

METHODS

This cross-sectional study used a questionnaire survey to investigate medical students' and interns' perceptions of women participating in orthopaedic surgery, their subspeciality preferences, and barriers preventing them from pursuing an orthopaedic career. The responses were analysed to understand general perceptions, gender-based differences, impact of clinical experiential learning, and exposure to orthopaedic surgery.

RESULTS

Approximately 565 medical students (49% females, 51% males) participated in the survey. Only 17% of students (11% females, 23% males) considered orthopaedic surgery as their future career option. While 31% of female and 17% of male students disagreed with the concept of female-appropriate orthopaedic subspecialties, most of the remaining male and female students perceived paediatric orthopaedics as a female-appropriate subspecialty. Concerning equal representation of women, gender bias and lack of a strong physique were the most frequently selected barriers by female and male students, respectively. Patient preference for male orthopaedicians, gender discrimination, social and family commitments, and need for physical strength were all perceived as barriers for women in orthopaedics. Overall, clinical experience and orthopaedic exposure did not significantly improve the likelihood of female students in choosing orthopaedic surgery as a career.

CONCLUSIONS

The bias against women in orthopaedic careers is prevalent among medical students early in their academic years. Clinical experience and exposure to orthopaedic surgery should be improved to make a significant impact on female participation in orthopaedic careers. Career building efforts in terms of improved career opportunities, career counselling, flexible working hours, social and family related adjustments and implementation of mentorship/research/fellowship programmes for females are needed to reduce gender discrimination and improve female orthopaedic participation. Furthermore, process improvements may yield greater flexibility for women pursuing the challenging field while accommodating other barriers faced by women in orthopaedic surgery.

Assessment of Sex Diversity Among Craniofacial Academic Faculty

Sex diversity among plastic surgery and its subspecialties faculties lags behind many medical specialties. Despite the significant evidence in favor of diversity in leadership, female presence in high-ranking positions in medicine is lacking across multiple specialties. In this study, we aim to evaluate sex disparity among faculty across craniofacial fellowship programs by comparing the disparities among total number of faculty, program directors, years in practice, and academic rank. Our sample included 354 individuals including 193 craniofacial surgery journal editorial board members, 130 craniofacial surgery academic faculty members, and 31 craniofacial surgery association board members. A significant difference (P-value <0.0001) was seen among male and female craniofacial surgery faculty with 84.6% males. Faculty members were further subdivided by academic rank. A significant difference was found between the number of male and female faculty members at all academic positions (P-value =0.043). Of 41 full professors, 2.4% were female. There were 42 associate professors queried with 14.3% female. Similarly, 43 assistant professors were identified with 32.0% female. Years in practice after completing terminal training were analyzed across the academic faculty. There was a significant difference in the number of male and female faculty members across all experience levels (P-value =0.0037). Among the faculty with <10 years since completion of terminal training, 32.4 % were female. For faculty with 10 to 20 years after post-terminal training, 19.6% were female. For those with 20 to 30 years of experience, 0% were female. Finally, for the faculty with over 30 years since graduation, 5.9% were female. Board membership in 2 craniofacial surgery organizations was analyzed: the American Cleft Palate-Craniofacial Association and the American Society of Maxillofacial Surgeons. Among the 17 board members of the American Cleft Palate-Craniofacial Association, 8 (47.1%) were female. For the American Society of Maxillofacial Surgeons, 5 (35.7%) were female. Data were collected for 193 editorial board members from 2 craniofacial surgery journals. There was a significant difference between the number of male and female members across both journals (χ2 value: 33.3570; P-value <0.0001). Among 56 editorial board members from Cleft Palate-Craniofacial Journal, 26 (46.4%) members were female. In comparison, Journal of Craniofacial Surgery has 24.8% female editorial board members. Sex diversity among faculty members is really important and should be brought into light to highlight and improve areas of particular importance and of tremendous potential impact. Given our results, surgical residencies and fellowship programs should begin to show concrete commitment and increase their efforts to recruit and retain a diverse faculty not only for the educational benefit but more importantly to achieve a higher level of care for all.

Disparity in female and Asian representation amongst cardiology journal editorial boards members: a call for empowerment

BACKGROUND

While progress is evident in gender and ethnic representation in the workplace, this disparity remains prevalent in academic positions.

OBJECTIVES

We examined gender and Asian ethnic representation in editorial boards of cardiology journals.

METHODS

A cross-sectional analysis was conducted using publicly available data on Cardiology and Cardiovascular medicine journals in the first quartile of the 2020 Scimago Journal & Country Rank indicator. The proportions of female and Asian editorial board members, associate editors and editors-in-chief were assessed. Subgroup analyses were conducted based on the journal's geographical origin, subspecialty and demographic of the editor-in-chief.

RESULTS

Seventy-six cardiology journals, involving 8915 editorial board members, were included. Only 19.6% of editorial board members were female, 20.8% Asians and 4.0% Asian females. There were less female representation amongst editors-in-chief (9.9%) compared to associate editors (22.3%). European (18.1%) and North American-based journals (21.1%) had higher female representation compared to Asian-based journals (8.7%). There was lower Asian representation in European (18.1%) and North American-based journals (19.9%) compared to Asian-based journals (72.3%). Females were underrepresented in interventional (14.5%) journals, while Asians were underrepresented in general cardiology (18.3%) and heart failure (18.3%) journals. Journals led by female editors-in-chief had significantly higher female representation compared to male-led ones, while journals with Asian editors-in-chief had greater Asian representation compared to non-Asian led ones.

CONCLUSION

This study highlights the female and Asian ethnic underrepresentation in academic roles in cardiology journal editorial boards. Further analysis is needed for other ethnicities, while the community pushes towards gender-balanced and ethnic diversity across editorial boards.

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.

Diversity bias in colorectal surgery: a global perspective

There is a specific lack of data on equity and injustices among colorectal surgeons regarding diversity. This study aimed to explore colorectal surgeon’s lived experience of diversity bias with a specific focus on gender, sexual orientation or gender identity and race or religion. A bespoke questionnaire was designed and disseminated to colorectal surgeons and trainees through specialty association mailing lists and social media channels. Quantitative and qualitative data points were analysed. 306 colorectal surgeons responded globally. 58.8% (n = 180) identified as male and 40.5% (n = 124) as female. 19% were residents/registrars. 39.2% stated that they had personally experienced or witnessed gender inequality in their current workplace, 4.9% because of sexual orientation, and 7.5% due to their race or religion. Sexist jokes, pregnancy-related comments, homophobic comments, liberal use of offensive terms and disparaging comments and stereotypical jokes were commonly experienced. 44.4% (n = 135) did not believe their institution of employer guaranteed an environment of respect for diversity and only 20% were aware of society guidelines on equality and diversity. Diversity bias is prevalent in colorectal surgery. It is necessary to work towards real equality and inclusivity and embrace diversity, both to promote equity among colleagues and provide better surgical care to patients.

Gender Disparity in Surgical Device Patents: A 5-year Trend From Canada and the United States

INTRODUCTION

Despite an increasing number of women pursuing careers in science, engineering, and medicine, gender disparities in patents persist. This study sought to analyze trends in inventor's gender for surgical device patents filed and granted in Canada and the United States from 2015 to 2019.

METHODS

This study analyzed patents filed and granted by the Canadian Intellectual Property Office (CIPO) in the category of "Diagnosis; Surgery; Identification" and the United States Patent and Trademark Office (USPTO) in the category of "Surgery" from 2015 to 2019. The gender of the patent applicants was determined using a gender algorithm that predicts gender based on first names. Gender matches with names having a probability of less than 95% were excluded.

RESULTS

We identified 14,312 inventors on patents filed and 12,737 inventors on patents granted by the CIPO for "Diagnosis; Surgery; Identification". In the USPTO category of "Surgery," we identified 75,890 inventors on patents filed and 44,842 inventors on patents granted. Female inventors accounted for 7%-10% of inventors from 2015 to 2019 for both patents filed and granted. The proportion of female inventors on patents granted was significantly lower than for patents filed for four of the 5 y analyzed for both the USPTO and CIPO.

CONCLUSIONS

Female representation in surgical device patenting has stagnated, between 7 and 10%, from 2015 to 2019 in Canada and the United States. This underrepresentation of female inventors in surgical device patenting represents sizable gender disparity.

Experiences of Canadian Female Orthopaedic Surgeons in the Workplace: Defining the Barriers to Gender Equity

BACKGROUND

Only 13.6% of orthopaedic surgeons in Canada are women, even though there is nothing inherent to the practice of orthopaedic surgery that favors men over women. Clearly, there is a need to identify, define, and measure the barriers faced by women in orthopaedic surgery.

METHODS

An electronic survey was distributed to 330 female-identifying Canadian orthopaedic surgeons and trainees and included the validated Gender Bias Scale (GBS) and questions about career burnout. The barriers for women in Canadian orthopaedics were identified using the GBS. The relationships between the GBS and burnout were investigated. Open-text questions explored the barriers perceived by female orthopaedic surgeons.

RESULTS

The survey was completed by 220 female orthopaedic surgeons and trainees (66.7%). Five barriers to gender equity were identified from the GBS: Constrained Communication, Unequal Standards, Male Culture, Lack of Mentoring, and Workplace Harassment. Career burnout correlated with the GBS domains of Male Privilege (r = 0.215; p < 0.01), Disproportionate Constraints (r = 0.152; p < 0.05), and Devaluation (r = 0.166; p < 0.05). Five main themes emerged from the open-text responses, of which 4 linked closely to the barriers identified in the GBS. Work-life integration was also identified qualitatively as a theme, most notably the difficulty of balancing disproportionate parental and childcare responsibilities alongside career aspirations.

CONCLUSIONS

In this study, 5 barriers to workplace equity for Canadian female orthopaedic surgeons were identified using the validated GBS and substantiated with qualitative assessment using a mixed-methods approach. Awareness of these barriers is a necessary step toward dismantling them and changing the prevailing culture to be fair and equitable for all.

CLINICAL RELEVANCE

A just and equitable orthopaedic profession is imperative to have healthy and thriving surgeons who are able to provide optimal patient care.

Gender profile of principal investigators in a large academic clinical trials group

Introduction

Gender equity in medicine has become a significant topic of discussion due to consistently low female representation in academia and leadership roles. Gender imbalance directly affects patient care. This study examined the gender and craft group of the Principal Investigators (PI) of clinical trials run by the Australasian Gastro-Intestinal Trials Group (AGITG)

Methods

Publicly available data was obtained from the AGITG website. Trials were divided into upper, lower gastrointestinal cancer, miscellaneous (neuroendocrine and gastrointestinal stromal tumours). Where multiple PIs were listed, all were counted. Craft group was assigned as surgical, medical, radiation oncology or other.

Results

There were 69 trials with 89 PI, where 52 trials were represented exclusively by male PIs. Of all PIs, 18 were women (20.2%); all were medical oncologists. Prior to 2005, all PIs were male. The craft group distribution of PIs was: 79% medical oncologists, 12% surgical oncologists, 8% radiation oncologist, 1% nuclear medicine physicians. Regarding trials with multiple PI's, there were 19 in total. Of these, 11 had only male PIs, which included 5 surgeons. Females were more likely to be a co-PI (42%) as opposed to sole PI (18%). There was no gender policy publicly available on the AGITG website.

Conclusions

There is a low percentage of female PIs in academic oncology trials in the portfolio of this large international trials group. No trial was led by a female surgical or radiation oncologist. There is a need to understand the reasons driving the disparity so that specific strategies can be put in place.

Gender discrimination in surgical oncology: An in-house appraisal

Introduction

Gender discrimination (GD) though rarely blatant, may present indirectly within a surgical department in the form of subtle inequities, differing standards, and bias. GD encompasses a wide spectrum including academic development, surgical opportunities and sexual harassment.

Methods

We conducted an online survey to analyse the perceived incidence of GD in the surgical oncology department at a tertiary care cancer centre in India. The questionnaire consisted of 15 questions and was mailed to the entire department including trainees and faculty. Anonymity was maintained while collecting the data only of the participants' gender and whether they were faculty or trainee. Collated responses were analysed using proportions.

Results

The questionnaire was sent out to 200 recipients of whom 56% (112/200) responded via an online survey. Respondents included 84% of faculty (42/50) and 46.6% of trainees (70/150). GD was perceived by 28% of female trainees (7/25) as compared to 6.6% of male trainees (3/45), whereas amongst faculty, GD was perceived by 26.6% of female faculty (4/15) compared to 14.8% of male faculty (3/27). Approximately 13% of our trainees and 12% of our faculty mentioned that GD affected their professional performance or mental well-being. GD was experienced in terms of work experience and opportunities by a majority of trainees (13%) and faculty (9.5%). There was a significant lack of awareness about recourse to an institutional grievance committee by trainees (47%) compared to faculty (14%). About 7% of trainees and 12% of faculty acknowledged that they may have been responsible for intentional/unintentional GD.

Conclusion

Gender discrimination can present in subtle or overt fashion in surgical departments and requires active sustained efforts to allow both genders to feel equally empowered. Establishing a system to objectively evaluate gender equity while avoiding stereotyping for certain roles can help minimize GD.

The Challenges Experienced By Female Surgeons in Africa: A Systematic Review

BACKGROUND

There are many challenges faced by female surgeons in Africa. These challenges, when brought to the forefront, can be tackled by the necessary stakeholders to increase the participation of women in surgery. This paper will review the existing literature, across the African continent, to bring to light the challenges experienced by women currently practicing as surgeons.

METHODS

We conducted a search using keywords 'Challenges' 'Female' 'Surgeon' 'Africa' and 'Bias' on PubMed, Google Scholar, and AJOL from inception till the 21st of January 2022. We then searched the same keywords on the Google search engine in addition to the names of each of the 54 African countries.

RESULTS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in conducting this systematic review. Out of the 10 published papers that were deemed eligible, four (n = 4) originated from South Africa. Other countries that were represented include Nigeria, Rwanda, Zimbabwe and Ghana. 8 of the articles were cross-sectional studies. Underrepresentation was the most common challenge (n = 4 articles). Disrespect from colleagues, poor work-life balance, harassment, and stereotypes were also challenges identified in these articles.

CONCLUSION

Despite the increasing participation, female surgeons continue to face different challenges ranging from the unfavorable work environment to the pressures put on them by society. This narrative review serves as a stimulant for major health stakeholders in Global surgery to promote gender inclusivity in the African surgical workforce.

Hegemonic masculinity: representation of women surgeons in leadership positions in Pakistan

PURPOSE

Surgery is predominantly a masculine profession worldwide and has largely excluded women in leadership positions. This paper aims to examine the representation of women surgeons in leadership positions in Pakistan.

DESIGN/METHODOLOGY/APPROACH

Data were drawn from larger qualitative research examining the experiences of women surgeons in Pakistani hospitals. The data comprises in-depth interviews with ten doctors working in the Rawalpindi and Islamabad cities. The participants were selected by using the purposive sampling method and data were analyzed using thematic analysis.

FINDINGS

This study included participants from diverse surgical specialties from different stages of their career with two having leadership experience. Based on participants' perspectives several factors are responsible for this exclusion of women in leadership positions. The most prominent among these were long working hours for surgical leaders, greater responsibilities assigned to leadership positions, gender stereotypes and work-family conflict. Due to masculine hegemony, women were considered less capable and they were expected to have masculine traits to work as successful leaders. Interestingly, some participants had internalized such stereotypes and showed a lack of interest and lack of capabilities for surgical leadership as evident from their narratives.

RESEARCH LIMITATIONS/IMPLICATIONS

The findings of this paper are drawn from the perspectives of ten women surgeons working in Islamabad and Rawalpindi cities of Pakistan who were selected using a convenient sampling method. Hence, the results cannot be generalized to the larger population of women surgeons working in other cities of the country. Nevertheless, this study is unique in the sense that it provides useful insight into the experiences of the women surgeons and their perspectives on surgical leadership in Pakistani hospitals. Academically, it contributes to the global debates on surgical leadership by providing empirical evidence from Pakistan.

ORIGINALITY/VALUE

This paper contributes to the larger debates on the under-representation of women in leadership positions in surgery by unveiling the experiences of female surgeons from Pakistan. It calls for the need for structural changes in health management and policy to accommodate women surgeons. Organizational efforts could minimize some hurdles and encourage more women to take on more formal leadership roles. The authors also call for an increasing number of women in surgery to pave the way for creating new leadership opportunities.