Trends in Race/Ethnicity Among Applicants and Matriculants to US Surgical Specialties, 2010-2018

Dissecting Diversity: A Comprehensive Look at the Present Landscape and Future Challenges in Surgical Specialties

BACKGROUND

As the US demographic evolves, surgical fields must adapt to ensure equitable healthcare. Healthcare disparities notably affect minority populations, with communities of color often facing physician shortages and higher rates of diseases such as coronary disease, stroke, and cancer. Research shows that minority physicians significantly improve patient satisfaction and outcomes in underserved communities, highlighting the need for increased physician diversity to enhance cultural competency and patient centered care. Data from the Association of American Medical Colleges (AAMC) reveals minimal increases in underrepresented minorities (URM) in surgical residency and academic careers over the past thirty-six years, with little change URM applicants and matriculants in the nine surgical specialties recognized by the American College of Surgeons from 2010 to 2018.

OBJECTIVE

This review aims to critically evaluate the current landscape of racial and gender diversity in six out of the nine defined surgical specialties (general surgery, plastic surgery, neurosurgery, orthopedic surgery, cardiothoracic surgery, and vascular surgery) in the US.

DESIGN

We conducted a comprehensive literature review to assess of the state of diversity within surgical specialties in the United States. By analyzing the benefits of diversity in surgical fields, evaluating the effectiveness of various diversity programs and initiatives, examining the comparative diversity between surgical subspecialties, and assessing the impact of diversity on patient outcomes, our aim is to highlight the critical importance of enhancing diversity in surgical fields.

RESULTS

While nuances in representation and diversity vary across surgical specialties, all fields persistently exhibit underrepresentation of certain racial/ethnic groups and persistent gender disparities. These disparities manifest throughout various phases, including in residency, and in the recruitment and retention of URM individuals in surgery and surgical subspecialties. While interventions over the past decade have contributed to improving diversity in surgical fields, significant disparities persist. Limitations include the time required for recent interventions to show significant impacts and the inability of established interventions to eliminate disparities.

CONCLUSIONS

Despite the clear benefits, diversity within surgical specialties remains an uphill battle. Addressing the diversity gap in surgical fields is crucial for improving patient outcomes, healthcare access, and workplace environments, requiring strategies such as targeted recruitment, mentorship programs, and addressing systemic biases. This review highlights the undeniable imperative for change and serve a call to action.

How Does Lacking a Home Program Impact Otolaryngology Applicants?

OBJECTIVES

To compare otolaryngology interview and match outcomes between applicants with and without home residency programs.

METHODS

Otolaryngology applicants from US allopathic medical schools during the 2019-2023 cycles who responded to the Texas Seeking Transparency in Application to Residency (STAR) survey were identified. Students were stratified based upon whether their medical school had an affiliated otolaryngology residency program. The primary outcomes were number of interviews and match rate. Wilcoxon-rank sum and χ2 testing was used to assess associations between home program status and interview and match outcomes.

RESULTS

Of the 633 fourth-year medical students applying to otolaryngology during the 2019-2023 application cycles, 89 had no home program (NHP) and 544 had a home program (HP). Applicants with NHP completed significantly more away rotations than applicants with a HP (2.2 vs. 1.5; p < 0.01). There was no difference in mean number of applications submitted between applicants with NHP and applicants with a HP. However, applicants with a HP received a significantly greater number of interviews (14.7 vs. 11.8; p < 0.01), attended more interviews (12.4 vs. 11.3; p = 0.02), attended a lower percentage of their offered interviews (84.4% vs. 95.8%), and had a higher match rate (81.8% vs. 70.8%; p = 0.02) than applicants with NHP. Applicants with NHP interviewed at (1.9 vs. 1.3; p < 0.01) and matched at (33.7% vs. 23.9%; p = 0.048) significantly more away rotation institutions than applicants with a HP.

CONCLUSION

Applicants with NHP received fewer interviews and had lower match rates. Away rotations may be especially important for applicants with NHP.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Investigating racial/ethnic differences in procedure experience in obstetrics & gynecology trainees at a single academic institution: a retrospective cohort study

BACKGROUND

Discrimination is common in medical education. Resident physicians of races and ethnicities underrepresented in medicine experience daily discrimination which has been proven to negatively impact training. There is limited data on the impact of resident race/ethnicity on OB/GYN surgical training. The objective of this study was to investigate the impact of race/ethnicity on procedural experience in OB/GYN training.

METHODS

A retrospective analysis of graduated OB/GYN resident case logs from 2009 to 2019 was performed at a single urban academic institution. Self-reported race/ethnicity data was collected. Association between URM and non-URM were analyzed using t-tests. Trainees were categorized by self-reported race/ethnicity into underrepresented in medicine (URM) (Black, Hispanic, Native American) and non-URM (White, Asian).

RESULTS

The cohort consisted of 84 residents: 19% URM (N = 16) and 79% non-URM (n = 66). Difference between URM and non-URM status and average case volume was analyzed using t-tests. There was no difference between non-URM and URM trainees and reported mean number of Total GYN (349 vs. 334, p = 0.31) and Total OB (624 vs. 597, P = 0.11) case logs. However, compared with non-URM, on average URM performed fewer Total procedures (1562 vs. 1469, P = 0.04). Analyzing individual procedures showed a difference in average number of abortions performed between URM and non-URM (76 vs. 53, P = 0.02). There were no other statistically significant differences between the two groups.

CONCLUSIONS

This single institution study highlights potential differences in trainee experience by race/ethnicity. Larger national studies are warranted to further explore these differences to identify bias and discrimination, and to ensure equitable experience for all trainees.

The Future State of Race/Ethnicity in Urology: Urology Workforce Projection From 2021-2061

OBJECTIVE

To project the proportion of the urology workforce that is from under-represented in medicine (URiM) groups between 2021-2061.

METHODS

Demographic data were obtained from AUA Census and ACGME Data Resource Books. The number of graduating urology residents and proportion of URiM graduating residents were characterized with linear models. Stock and Flow models were used to project future population numbers and proportions of URiM practicing urologists, contingent on assumptions regarding trainee demographics, retirement trends, and growth in the field.

RESULTS

Currently, there is an increase in the percentage of URiM graduates by 0.145% per year. If historical trends continue, URiM urologists will likely comprise 16.2% of urology residency graduates and 13.3% of the practicing urological workforce in 2061. These percentages would constitute an underrepresentation of URiM urologists relative to the projected 44.2% of the U.S. population who would identify as American Indian/Alaskan Native, Black/African American, Latinx/Hispanic and Native Hawaiian/Pacific Islander by 2060.1 An increase in the percentage of URiM graduates by 0.845% per year would result in 44.2% URiM urology residency graduates and 26.1% URiM practicing urologists by 2061. An interactive app was designed to allow for a range of assumptions to be explored and for future data to be incorporated.

CONCLUSION

URiM physician representation within urology over the next 40years will remain disproportionately low compared to that of the projected share of people of color in the general U.S.

POPULATION

In order to achieve the AUA's Diversity, Equity and Inclusion goals, a concerted effort to implement interventions to recruit, train, and retain a generation of racially diverse urologists appears necessary.

Racial and Ethnic Disparities in Otolaryngology Applicants and Residents: Recruiting a Diverse Workforce

OBJECTIVE

The purpose of this study is to examine the racial and ethnic representation of otolaryngology applicants and residents and determine if there have been any improvements in recruiting a diverse workforce over the past several years.

METHODS

A retrospective study was conducted on self-reported race and ethnicity data of otolaryngology applicants to United States residency programs from 2016 to 2022 from the Association of American Medical Colleges (AAMC) and residents from 2011 to 2022 from the Accreditation Council for Graduate Medical Education (ACGME). The changes in proportions of applicants and residents by race and ethnicity separately was compared as well as the proportion of applicants to residents. Descriptive analyses and chi-square tests were used to compare proportions of groups by race and ethnicity.

RESULTS

There was no statistically significant difference in the proportion of applicants by race or ethnicity from 2016-2017 to 2021-2022. There was a decrease in the proportion of White residents from 58.1% to 54.5% from 2011-2012 to 2018-2019. There were higher proportions of White residents than applicants and lower proportions of Black residents than applicants in the two cycles analyzed. In the most recent cycle analyzed, the proportion of Hispanic or Latino residents was higher than the proportion of Hispanic or Latino applicants.

CONCLUSION

While there may be improvements to increase representation of otolaryngology applicants and residents, there continues to be inequalities and a lack of diversity. Further initiatives are needed to ensure diversity in the field improves moving forward.

National Comparison of Burnout for a Cohort of Surgical and Nonsurgical Female Trainees

INTRODUCTION

Studies have shown that female physician trainees have an increased risk of burnout. We describe the current state of surgical and nonsurgical female trainee well-being and examine differences between surgical and nonsurgical specialties.

METHODS

Survey responses were received from 1017 female identifying trainees from 26 graduate medical education institutions across the United States. These survey responses included demographic data and well-being measures. Specifically, burnout was assessed using the Maslach Burnout Inventory. Data were analyzed using Wilcoxon rank sum test, Fisher's exact test, and Pearson's Chi-squared test data with significance defined as a P < 0.05. This survey was reported in line with strengthening the reporting of cohort studies in surgery criteria.

RESULTS

Nine-hundred ninety-nine participants completed the demographic and well-being section of the surveys and were included in analysis. Demographic data between the surgical versus nonsurgical group were similar, aside from surgeons being slightly older. Burnout was prevalent among all surveyed trainees with 63% scoring positive. Trainees also scored high in imposter syndrome and moral injury with low levels of self-compassion, although respondents also reported themselves flourishing. Surgical trainees scored higher than nonsurgical trainees in the personal accomplishment domain of burnout (P < 0.048). There was no difference between surgical and nonsurgical trainees in measures of the emotional exhaustion or depersonalization domains of burnout, or in impostor syndrome, self-compassion, moral injury, or flourishing.

CONCLUSIONS

While personal accomplishment was noted to be higher in surgical trainees as compared to nonsurgical trainees, overall rates of burnout are high among both groups. Targeted interventions for well-being, such as coaching, can help decrease the levels of burnout experienced by female physician trainees and do not need to be specialty specific.

Delivering Diversity and Inducing Inclusion: Evidence-Based Perspectives on Charting a Future of Equity in Obstetrics and Gynecology Residency Programs

An active implementation of principles encompassed by the terms diversity, equity, and inclusion (DEI) is critical to the success of obstetrics and gynecology (OB/GYN) residency programs. The patients served by our specialty come from a vast array of backgrounds, identities, and experiences. Preparing OB/GYN providers for the reality of this practice requires commitment to DEI principles in training programs nationwide through evidence-based policies and practices while empowering the next generation to chart the path forward to equity.

Are our actions matching our words? A review of trainee ethnic and gender diversity in orthopaedic surgery

Background

There is a lack of physician ethnic and gender diversity amongst surgical specialties. This study analyzes the literature that promotes diversity amongst surgical trainees. Specifically, this study sought to answer (i) how the number of publications regarding diversity in orthopaedic surgery compares to other surgical specialties, (ii) how the number of publications amongst all surgical subspecialties trends over time and (iii) which specific topics regarding diversity are discussed in the surgical literature.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to query articles from PubMed, Web of Science, Embase and the Cumulative Index to Nursing and Allied Health Literature. Broad inclusion criteria for both ethnic and gender diversity of any surgical specialty were utilized.

Results

Our query resulted 1429 publications, of which 408 duplicates were removed, and 701 were excluded on title and abstract screening, leaving 320 to be included. The highest number of related publications was in orthopaedic surgery (n = 73) followed by general surgery (n = 56). Out of 320 total articles, 260 (81.3 %) were published after 2015, and 56 of 73 (76.7 %) orthopaedic-specific articles were published after 2015.

Conclusion

Orthopaedic surgery published the most about ethnic and gender diversity, however, still remains one of the least diverse surgical specialties. With the recent increase in publications on diversity in surgical training, close attention should be paid to ethnic and gender diversity amongst surgical trainees over the coming years. Should diversity remain stagnant, diversification efforts may need to be restructured to achieve a diverse surgeon workforce.

Key message

Orthopaedic surgery is the surgical subspecialty that publishes the most about trainee ethnic and gender diversity followed by general surgery. With most of this literature being published over the last eight years, it is imperative to pay close attention to the ethnic and gender landscape of the surgeon workforce over the coming years.

Sexual Orientation and Racial Bias in Relation to Medical Specialty

Physician explicit and implicit biases involving race and sexual orientation (SO) affect patient and provider experiences in healthcare settings. An anonymous survey was disseminated nationally to graduating medical students, residents, and practicing physicians to evaluate SO and racial biases across medical specialties. SO explicit and implicit bias were measured with the Attitudes toward Lesbians and Gay Men Scale, short form (ATLG-S) and Gay-Straight Implicit Association Test (IAT). Racial explicit and implicit bias were measured with the Quick Discrimination Index (QDI) and the Black-White IAT. Medical specialty was associated with racial explicit bias and specialty prestige with Black-White IAT score. Medical specialty and specialty prestige were not associated with SO bias. Female sex, sexual and gender minority (SGM) identity, and decreased religiosity were associated with reduced SO and racial bias. Provider race was associated with racial implicit and explicit bias.

Identifying Gender and Racial Bias in Pediatric Fellowship Letters of Recommendation: Do Word Choices Influence Interview Decisions?

OBJECTIVES

To describe linguistic differences in letters of recommendation (LORs) for pediatric fellowship candidates based on applicant and letter writer demographics and to examine if these differences influenced the decision to interview a candidate for a fellowship position.

STUDY DESIGN

LORs for applicants to 8 pediatric subspecialty fellowships at a single academic center from the 2020 Match were analyzed in this cross-sectional study. Frequency of validated agentic and communal terms in each letter were determined by a language processing web application. Bias was determined as having a >5% surplus of agentic or communal terms.

RESULTS

We analyzed 1521 LORs from 409 applicants: 69% were women, 28% were under-represented minorities in medicine (URM), and 50% were invited to interview. Overall, 66% of LORs were agentic biased, 16% communal biased, and 19% neutral. There was no difference in bias in LORs by an applicant's gender (woman 67% agentic vs man 62% agentic; P = .058), race, or ethnicity (non-URM 65% agentic vs URM 67% agentic; P = .660). Despite a lower frequency of agentic terms in LORs for applicants invited for interviews, when accounting for other components of an application and applicant demographics, no significant association was made between language bias in LORs and fellowship interview status.

CONCLUSIONS

The frequency of agentic and communal terms in LORs for pediatric subspecialty fellowship candidates were not found to influence the decision to invite a candidate to interview. However, raising awareness of potential areas of bias within the pediatric fellowship selection process might lead to a more equitable and holistic approach to application review.

Racial disparities in the selection of chief resident: A cross-sectional analysis of a national sample of senior residents in the United States

INTRODUCTION

Part of the difficulty in recruiting and retaining a diverse physician workforce, as well as within medical leadership, is due to racial disparities in medical education. We investigated whether self-identified race-ethnicity is associated with the likelihood of selection as chief resident (CR).

MATERIALS AND METHODS

We performed a cross sectional analysis using de-identified person-level data from the GME Track, a national resident database and tracking system, from 2015 through 2018. The exposure variable, self-identified race-ethnicity, was categorized as African American or Black, American Indian or Alaskan Native, Asian, Hispanic, Latino or of Spanish Origin, Native Hawaiian or Pacific Islander, White, and Multi-racial. The primary study outcome was CR selection among respondents in their final program year. Logistic regression was used to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (CI) of CR selection for each racial group, as compared to the White referent group.

RESULTS

Among the study population (N=121,247), Black, Asian and Hispanic race-ethnicity was associated with a significantly decreased odds of being selected as CR in unadjusted and adjusted analyses. Black, Asian and Hispanic residents had a 26% (aOR=0.74, 95% CI 0.66-0.83), 29% (aOR=0.71, 95% CI 0.66-0.76) and 28% (aOR=0.72, 95% CI 0.66-0.94) decreased likelihood of becoming CR, respectively. Multi-racial residents also had a decreased likelihood, but to a lesser degree (aOR=0.92, 95% CI 0.89-0.95).

CONCLUSIONS

In as much as CR is an honor that sets one up for future opportunity, our findings suggest that residents of color are disproportionately disadvantaged compared to their White peers.

Climate change and cancer: the Environmental Justice perspective

Despite advances in cancer control-prevention, screening, diagnosis, treatment, and survivorship-racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population.

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.

At the Intersection of Intersectionality: Race and Gender Diversity Among Surgical Faculty and Trainees

OBJECTIVE

To compare the representation of intersectional (ie, racial/ethnic and gender) identities among surgical faculty versus medical students.

BACKGROUND

Health disparities are pervasive in medicine, but diverse physicians may help the medical profession achieve health equity.

METHODS

Data from the Association of American Medical Colleges for 140 programs (2011/2012-2019/2020) were analyzed for students and full-time surgical faculty. Underrepresented in medicine (URiM) was defined as Black/African American, American Indian/Alaskan Native, Hispanic/Latino/Spanish Origin, or Native Hawaiian/Other Pacific Islander. Non-White included URiM plus Asian, multiracial, and non-citizen permanent residents. Linear regression was used to estimate the association of year and proportions of URiM and non-White female and male faculty with proportions of URiM and non-White students.

RESULTS

Medical students were comprised of more White (25.2% vs 14.4%), non-White (18.8% vs 6.6%), and URiM (9.6% vs 2.8%) women and concomitantly fewer men across all groups versus faculty (all P < 0.01). Although the proportion of White and non-White female faculty increased over time (both P ≤ 0.001), there was no significant change among non-White URiM female faculty, nor among non-White male faculty, regardless of whether they were URiM or not. Having more URiM male faculty was associated with having more non-White female students (estimate = +14.5% students/100% increase in faculty, 95% CI: 1.0% to 8.1%, P = 0.04), and this association was especially pronounced for URiM female students (estimate = +46.6% students/100% increase in faculty, 95% CI: 36.9% to 56.3%, P < 0.001).

CONCLUSIONS

URiM faculty representation has not improved despite a positive association between having more URiM male faculty and having more diverse students.

Evaluating Diversity Promotion on Integrated Plastic Surgery Residency Program Websites and Instagram Accounts

BACKGROUND

Medical students applying to residency, including those from underrepresented groups, strongly value cultural fit and program diversity. Program websites and social media are thus an influential information source for prospective applicants and recruitment tool for residencies. We evaluated whether and how integrated plastic surgery residency program websites and social media display commitments to diversity online.

METHODS

We evaluated program websites for 8 predetermined diversity elements, (1) nondiscrimination and (2) diversity statements, (3) community resources, (4) faculty and (5) resident biographies, (6) faculty and (7) resident photographs, and (8) resident resources, and assessed Instagram accounts for diversity-related images, captions, and hashtags. Our analysis used Mann-Whitney U , chi-squared, and t tests; significance level was P < 0.05.

RESULTS

We reviewed 82 program websites with a mean of 3.4 ± 1.4 diversity elements. Resident (n = 76, 92.7%) and faculty photographs (n = 65, 79.3%) and resident biographies (n = 43, 52.4%) were the most common. Seventy programs (85.4%) had Instagram accounts, the majority of which (n = 41, 58.6%) shared content related to diversity in race, ethnicity, gender, and/or sexual orientation. Programs located in smaller cities were more likely to have ≥4 website diversity elements ( P = 0.014) and mention diversity on Instagram ( P = 0.0037). Programs with women chairs/chiefs were more likely to mention diversity on Instagram ( P = 0.007).

CONCLUSIONS

In the age of virtual recruitment, program websites and social media should provide sufficient information, described in our diversity element checklist, to help prospective applicants determine fit from a diversity perspective. Residents, who often contribute to program social media, and women chairs/chiefs may be critical to driving diversity promotion.

Racial and Gender Representation Trends Among National Obstetrics and Gynecology Society Leadership

STUDY OBJECTIVE

The purpose of this study is to review the trends in racial and gender representation among the various national obstetrics and gynecology societies' presidents over the past 15 years.

DESIGN

A retrospective cross-sectional study.

SETTING

Data obtained from publicly available information on official websites of the professional societies studied.

PATIENTS

Presidents of national societies in obstetrics and gynecology.

INTERVENTIONS

The study was performed by obtaining publicly available data for past presidents from the official websites of the professional societies studied. Gender and race were inferred based on name and image. Racial classification was selected using the United States Census classification system. Educational background, residency training, and practice type were also collected. Assessment of 15-year trends was completed using linear regression analysis and differences in representation was assessed using analysis of variance and post hoc analysis.

MEASUREMENTS AND MAIN RESULTS

Over 15 years, there were 134 presidents elected for the 10 obstetrics and gynecology societies. Of those leaders, 85.2% were white, 8.2% Asian, and 5.2% black; 59% were men and 41% were women. During the study period, there was a significantly increasing slope for representation of women (+2.3% per year; 95% confidence interval, 0.4-4.2; p = .016). The representation of nonwhite presidents (+1.5% per year; 95% confidence interval, 0.2-2.8; p = .028) increased significantly during the same time period.

CONCLUSION

Over the last 15 years, less than 50% of obstetrics and gynecology national societies' presidents were women and most were of white race. However, there has been an increasing trend in the ratio of women to men and nonwhite to white representation among presidents of obstetrics and gynecology national societies.

A Pathway for Increased Diversity, Equity, and Inclusion in the Surgical Infection Society

Background: With the rise of diversity, equity, and inclusion (DEI) efforts across medicine, the Surgical Infection Society (SIS) leadership undertook a several-year mission to evaluate DEI issues within the SIS, through the formation of a DEI Ad Hoc Committee to guide the application of best practices. The purpose of this article is to describe the work of the DEI committee since its inception, as well as report on advances made during that time. Methods: Beginning in September 2020, 26 volunteer committee members met monthly to explore the current state of science and best practices around DEI, identify opportunities for the SIS, and translate opportunities into recommendations. As part of this initiative, a survey of the SIS membership was conducted. Survey results, published best practices from business and medicine, and experiences of committee members were utilized collaboratively to outline specific opportunities and recommendations. These findings were presented to the SIS Executive Council and to the membership at the SIS Annual Business Meeting. Results: Committee-identified opportunities and recommendations fell into broad categories of Membership, Leadership and Society Structure, the Annual Meeting, and Research Priorities. Several recommendations were immediately enacted, and a standing DEI committee was established to continue this work. Conclusions: Beyond the main mission of the SIS to advance the science of surgical infections, the SIS can also have a major impact on DEI within society and academic surgery at large.

Geographic Reach of Surgery Residency Applicants During In-Person and Virtual Interviews

Background Virtual interviews for surgery residency may improve interview opportunities for applicants from underrepresented in medicine (UIM) and lower socioeconomic backgrounds. Objective To compare the geographic reach of surgical residency applicants during in-person versus virtual interviews. Methods This study compared applicants for the 2019 (in-person) and 2020 (virtual interviews) application cycle for surgery residency. Geographic reach (GR) was defined as the distance between applicants' current location and the program. Federal Financial Institutions Examination Council's website supplied socioeconomic data using applicants' geographic locations. Applicant demographics, United States Medical Licensing Examination (USMLE) scores, and geographic distance to program were collected. Multivariable analyses examined GR with interaction terms between interview type, UIM status, and socioeconomic status, while controlling for USMLE scores. Results A total of 667 (2019) and 698 (2020) National Resident Matching Program applications were reviewed. Overall, there was no difference in GR for applicants during in-person and virtual interviews in multivariable testing. UIM status had no association with GR for in-person interviews, but virtual interviews were associated with an increased GR for UIM applicants compared to non-UIM applicants (235.17; 95% CI 28.87-441.47; P=.02). For in-person interviews, applicants living in communities with poverty levels ≥7% had less GR vs those in communities with levels <7% (-332.45; 95% CI -492.10, -172.79; P<.001), an effect not observed during virtual interviews. Conclusions There was no difference in overall GR, or the proportion of UIM applicants or those from higher poverty level communities, but virtual survey interviews during the COVID-19 pandemic were associated with increased GR for UIM and from lower socioeconomic backgrounds applicants.

What are the Trends in Racial Diversity Among Orthopaedic Applicants, Residents, and Faculty?

BACKGROUND

Orthopaedic surgery has recruited fewer applicants from underrepresented in medicine (UIM) racial groups than many other specialties, and recent studies have shown that although applicants from UIM racial groups are competitive for orthopaedic surgery, they enter the specialty at lower rates. Although previous studies have measured trends in orthopaedic surgery applicant, resident, or attending diversity in isolation, these populations are interdependent and therefore should be analyzed together. It is unclear how racial diversity among orthopaedic applicants, residents, and faculty has changed over time and how it compares with other surgical and medical specialties.

QUESTIONS/PURPOSES

(1) How has the proportion of orthopaedic applicants, residents, and faculty from UIM and White racial groups changed between 2016 and 2020? (2) How does representation of orthopaedic applicants from UIM and White racial groups compare with that of other surgical and medical specialties? (3) How does representation of orthopaedic residents from UIM and White racial groups compare with that of other surgical and medical specialties? (4) How does representation of orthopaedic faculty from UIM and White racial groups compare with that of other surgical and medical specialties?

METHODS

We drew racial representation data for applicants, residents, and faculty between 2016 and 2020. Applicant data on racial groups was obtained for 10 surgical and 13 medical specialties from the Association of American Medical Colleges Electronic Residency Application Services report, which annually publishes demographic data on all medical students applying to residency through Electronic Residency Application Services. Resident data on racial groups were obtained for the same 10 surgical and 13 medical specialties from the Journal of the American Medical Association Graduate Medical Education report, which annually publishes demographic data on residents in residency training programs accredited by the Accreditation Council for Graduate Medical Education. Faculty data on racial groups were obtained for four surgical and 12 medical specialties from the Association of American Medical Colleges Faculty Roster United States Medical School Faculty report, which annually publishes demographic data of active faculty at United States allopathic medical schools. UIM racial groups include American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native American or Other Pacific Islander. Chi-square tests were performed to compare representation of UIM and White groups among orthopaedic applicants, residents, and faculty between 2016 and 2020. Further, chi-square tests were performed to compare aggregate representation of applicants, residents, and faculty from UIM and White racial groups in orthopaedic surgery to aggregate representation among other surgical and medical specialties with available data.

RESULTS

The proportion of orthopaedic applicants from UIM racial groups increased between 2016 to 2020 from 13% (174 of 1309) to 18% (313 of 1699, absolute difference 0.051 [95% CI 0.025 to 0.078]; p < 0.001). The proportion of orthopaedic residents (9.6% [347 of 3617] to 10% [427 of 4242]; p = 0.48) and faculty (4.7% [186 of 3934] to 4.7% [198 of 4234]; p = 0.91) from UIM racial groups did not change from 2016 to 2020. There were more orthopaedic applicants from UIM racial groups (15% [1151 of 7446]) than orthopaedic residents from UIM racial groups (9.8% [1918 of 19,476]; p < 0.001). There were also more orthopaedic residents from UIM groups (9.8% [1918 of 19,476]) than orthopaedic faculty from UIM groups (4.7% [992 of 20,916], absolute difference 0.051 [95% CI 0.046 to 0.056]; p < 0.001). The proportion of orthopaedic applicants from UIM groups (15% [1151 of 7446]) was greater than that of applicants to otolaryngology (14% [446 of 3284], absolute difference 0.019 [95% CI 0.004 to 0.033]; p = 0.01), urology (13% [319 of 2435], absolute difference 0.024 [95% CI 0.007 to 0.039]; p = 0.005), neurology (12% [1519 of 12,862], absolute difference 0.036 [95% CI 0.027 to 0.047]; p < 0.001), pathology (13% [1355 of 10,792], absolute difference 0.029 [95% CI 0.019 to 0.039]; p < 0.001), and diagnostic radiology (14% [1635 of 12,055], absolute difference 0.019 [95% CI 0.009 to 0.029]; p < 0.001), and it was not different from that of applicants to neurosurgery (16% [395 of 2495]; p = 0.66), plastic surgery (15% [346 of 2259]; p = 0.87), interventional radiology (15% [419 of 2868]; p = 0.28), vascular surgery (17% [324 of 1887]; p = 0.07), thoracic surgery (15% [199 of 1294]; p = 0.94), dermatology (15% [901 of 5927]; p = 0.68), internal medicine (15% [18,182 of 124,214]; p = 0.05), pediatrics (16% [5406 of 33,187]; p = 0.08), and radiation oncology (14% [383 of 2744]; p = 0.06). The proportion of orthopaedic residents from UIM groups (9.8% [1918 of 19,476]) was greater than UIM representation among residents in otolaryngology (8.7% [693 of 7968], absolute difference 0.012 [95% CI 0.004 to 0.019]; p = 0.003), interventional radiology (7.4% [51 of 693], absolute difference 0.025 [95% CI 0.002 to 0.043]; p = 0.03), and radiation oncology (7.9% [289 of 3659], absolute difference 0.020 [95% CI 0.009 to 0.029]; p < 0.001), and it was not different from UIM representation among residents in plastic surgery (9.3% [386 of 4129]; p = 0.33), urology (9.7% [670 of 6877]; p = 0.80), dermatology (9.9% [679 of 6879]; p = 0.96), and diagnostic radiology (10% [2215 of 22,076]; p = 0.53). The proportion of orthopaedic faculty from UIM groups (4.7% [992 of 20,916]) was not different from UIM representation among faculty in otolaryngology (4.8% [553 of 11,413]; p = 0.68), neurology (5.0% [1533 of 30,871]; p = 0.25), pathology (4.9% [1129 of 23,206]; p = 0.55), and diagnostic radiology (4.9% [2418 of 49,775]; p = 0.51). Compared with other surgical and medical specialties with available data, orthopaedic surgery had the highest proportion of White applicants (62% [4613 of 7446]), residents (75% [14,571 of 19,476]), and faculty (75% [15,785 of 20,916]).

CONCLUSION

Orthopaedic applicant representation from UIM groups has increased over time and is similar to that of several surgical and medical specialties, suggesting relative success with efforts to recruit more students from UIM groups. However, the proportion of orthopaedic residents and UIM groups has not increased accordingly, and this is not because of a lack of applicants from UIM groups. In addition, UIM representation among orthopaedic faculty has not changed and may be partially explained by the lead time effect, but increased attrition among orthopaedic residents from UIM groups and racial bias likely also play a role. Further interventions and research into the potential difficulties faced by orthopaedic applicants, residents, and faculty from UIM groups are necessary to continue making progress.

CLINICAL RELEVANCE

A diverse physician workforce is better suited to address healthcare disparities and provide culturally competent patient care. Representation of orthopaedic applicants from UIM groups has improved over time, but further research and interventions are necessary to diversify orthopaedic surgery to ultimately provide better care for all orthopaedic patients.

The Home Program Advantage in the Otolaryngology Residency Match

OBJECTIVE

To evaluate the effect of home residency programs on outcomes in the otolaryngology residency match DESIGN: A retrospective online survey study during the 2015, 2018, 2019, 2020, and 2021 match cycles was conducted. All available otolaryngology residency positions listed by the National Resident Matching Program were compared with publicly available spreadsheets containing the following information: matriculated applicant name, medical school, whether the final match institution was the matriculated applicant's home program (HP), whether the matriculated applicant had completed an away rotation at their final matched institution (designated away institution, AI), or neither (designated Other Institution, OI).

SETTING

Nonclinical survey study using publicly available spreadsheets containing The Match data from 2015 to 2021 located online at Otomatch.com.

PARTICIPANTS

Newly matched United States otolaryngology-head and neck surgery residents completing the Otomatch.com survey RESULTS: A total of 1771 matched OHNS applicants were identified. Fifty-one percent of students were affiliated with their matched institution, with 25% of students matching at HPs, and 26% matching at AIs. Students with home programs had an increased likelihood of remaining in the same geographic region compared to students without home programs (OR 1.742 95% CI [1.21-2.506], p = 0.003). Applicants with HPs matched at significantly larger residency programs (p < 0.001).

CONCLUSIONS

This study found that a majority of residents match at an institution with which they were affiliated, either their home program or away institution. Applicants with HPs are more likely to remain in the same geographic region as their medical school, and to match into larger residency programs compared to applicants without HPs.

The Intersection of Race and Sex: A New Perspective Into Diversity Trends in Orthopaedic Surgery

INTRODUCTION

Studies on diversity in orthopaedic surgery have exclusively examined challenges from a race or sex perspective. This study examines trends in the diversity of entering orthopaedic surgery residents from the intersection of race and sex.

METHODS

The American Association of Medical Colleges was queried for individuals entering orthopaedic surgery residencies in the United States from 2001 to 2020. Deidentified data on self-reported sex and race were collected. Proportions by the intersection of sex and race were calculated for 5-year intervals.

RESULTS

From 2001 to 2020, most of the new female residents identified as White (mean, 71.0%). The average proportion of White female residents was lower in 2016 to 2020 than in 2001 to 2005 (71.0% vs. 73.2%) but higher than that in 2011 to 2015 (66.8%). The 2016 to 2020 average was lower than that of 2001 to 2005 for those who identified as Asian (11.7% vs. 14.9%), Black (4.1% vs. 4.8%), Hispanic (3.0% vs. 4.4%), and American Indian/Alaska Native (0.0% vs. 1.5%). Most of the new male orthopaedic surgery residents from 2001 to 2020 identified as White (mean, 74.1%), but the average decreased across every 5-year interval from 2001 to 2005 (76.1%) to 2016 to 2020 (71.1%). The 2016 to 2020 average was lower than that of 2001 to 2005 for those who identified as Asian (12.2% vs. 13.6%), Black (3.5% vs. 4.2%), Hispanic (3.0% vs. 3.4%), American Indian/Alaska Native (0.0% vs. 0.6%), and Native Hawaiian/Other Pacific Islander (0.1% vs. 0.3%). In 2020, White male residents made up to 54.2% of new residents. White female residents were the second highest group represented (12.1%).

CONCLUSION

Increases in representation were observed for some subgroups of new orthopaedic surgery residents from 2001 to 2020. Although the proportion of both White female and male residents decreased by 11.5% during the 20-year study period, these individuals still made up most of the trainees in 2020. These results underscore the need for conversations and recruitment practices to take into consideration the intersectionality of identities.

Divisions of health equity in departments of obstetrics and gynecology

Disparities in maternal morbidity and mortality remain vivid reminders of the role of racism in obstetrics and gynecology. If a serious attempt is to be made to purge medicine of its ongoing role in unequal care, then departments must commit the same intellectual and material resources as they would to the other health challenges in their remit. A division that understands the unique needs and complexities of the specialty, including translating theory into practice, is uniquely positioned to keep health equity as a focus of clinical care, education, research, and community engagement. To achieve reproductive justice, an approach addressing the intersectionality of race, ethnicity and gender identity is critical. In this article, we detailed the ways in which divisions of health equity within departments of obstetrics and gynecology can dismantle impediments to progress and can move our discipline closer to optimal and equitable care for all. We described the unique educational, clinical, research, and innovative community-based activities of these divisions.

Diversity in Radiology Residents Relative to Other Specialties- Trends Over the Past Decade

RATIONALE AND OBJECTIVES

The objective of this study was to assess diversity among radiology residents relative to other specialties and compare it with historical trends.

MATERIALS AND METHODS

The Graduate Medical Education results from 2010-2011 to 2020-2021 were accessed for demographic information for major medical specialties (number of residents > 500 as of the 2020-2021 report). Subspecialties and fellowship programs were not included in this analysis. The racial and ethnicity breakdowns were extracted, including Black, White/Caucasian, Asian, Hispanic, and others. The changes in racial and ethnicity composition of residents in radiology was compared to other specialties using the Chi Squared test using a significance level of p < 0.05.

RESULTS

In 2020-2021, radiology ranked ninth in total resident enrollment among the 21 largest ACGME training programs, unchanged when compared to 2010-2011. Amongst all specialties, Radiology ranked 10th for Black and 9th for Hispanic representation in 2020-2021.The percentage of Black residents increased from 3.07% in 2010-2011 to 3.83% in 2020-2021. The percentage of Hispanic Radiology residents increased from 4.83% to 7.35%, constituting the third largest increase amongst all specialties.

CONCLUSION

The representation of Blacks and Hispanics in Radiology has improved relative to other medical specialties in the last decade.

Understanding Current Demographics, Practice Patterns, and Concerns of Women in Urology: Analysis From the 2022 Society of Women in Urology Census Task Force

OBJECTIVE

To describe the current demographics, needs, and challenges of women in Urology throughout the United States, including active Urologists as well as urologic trainees.

METHODS

An electronic survey was distributed via email and social media sites to all members of the Society of Women in Urology, including residents, fellows, and female urologists practicing in the US and its territories, between February 2022 and May 2022. The survey collected information on demographics, practice type, workplace, personal, family issues, barriers, and career plans from all respondents.

RESULTS

Of the estimated 1375 women urologists and trainees based on AUA census data, 379 responses (27.6% response rate) were received. Almost all respondents (98%) are members of the AUA. The average age was 42.9years (SD 18.6). In terms of ethnicity, most self-reported as White 71.0%, followed by 16.4% Asian or Asian American, and 6.3% African American. The majority reported practicing in urban locations (63.5%) at an academic setting (55.7%), followed by similar distribution between private practice and hospital-employed settings (17.0% and 16.7%, respectively). The vast majority, 89.6%, reported working full-time, while only 10.4% worked part-time. The average hours of work per week were 56.7 (SD 14.5). In terms of personal demographics, 81.9% were married, 17.3% were single and 1% did not answer. 68.8% of responders had children, with the majority of these children being born during or after training.

CONCLUSION

Based on the findings, although female urologists have increased in numbers, certain ethnicities are under-represented. Additional surveys and engagement of current trainees and practitioners are needed to identify further areas of intervention for specific needs.

Trends in Racial and Gender Diversity Among Complex General Surgical Oncology Fellowship Trainees

BACKGROUND

This study examines trends in racial and gender diversity of trainees within Complex General Surgical Oncology Fellowships, and compares the racial and gender proportions of trainees across different fields to assess potential barriers to increasing diversity within surgical oncology training programs.

METHODS

Accredited Council for Graduate Medical Education (ACGME) data were queried to identify surgical trainees between 2013 and 2021. Trainees were identified based on self-reported race and gender and were stratified based on residency type and fellowship program type if applicable. Chi-square tests were used to assess differences between groups and trends.

RESULTS

A significantly lower proportion of individuals who are underrepresented in medicine (URMs) trained in surgical oncology fellowships (8.9%) compared with both the overall trainee pool (12.8%) and general surgery residency programs (13.1%) [p < 0.05]. There was no significant increase in URM representation in surgical oncology fellowships across the study period. Furthermore, there was a significantly lower proportion of females training in surgical oncology fellowships (38.6%) compared with the overall trainee pool (45.6%) [p < 0.05]. Despite a significant increase in female representation in general surgery residency and other surgical fellowships, there was no significant increase in female representation in surgical oncology fellowships across the study period.

CONCLUSIONS

This study identifies disparities in gender and racial minority representation within ACGME-accredited Complex General Surgical Oncology Fellowship training programs. While steps have been taken to expand diversity, more needs to be done to combat the systemic barriers that both racial minorities and women face during their training.

Assessing the Complex General Surgical Oncology Pipeline: Trends in Race and Ethnicity Among US Medical Students, General Surgery Residents, and Complex General Surgical Oncology Trainees

BACKGROUND

Cancer incidence is expected to increase in coming decades, disproportionately so among minoritized communities. Racially and ethnically concordant care is essential to addressing disparities in cancer outcomes within at-risk groups. Here, we assess trends in racial and ethnic representation of medical students (MS), general surgery (GS) residents, and complex general surgical oncology (CGSO) fellows.

METHODS

This is a retrospective review of data from the American Association of Medical Colleges and the Accreditation Council of Medical Education (ACGME) from 2015 to 2020. Self-reported race and ethnicity was obtained for MS, GS, and CGSO trainees. Race and ethnicity proportions were compared with respective representation in the 2020 US Census. Mann-Kendall, Wilcoxon rank sum, and linear regression were used to assess trends, as appropriate.

RESULTS

A total of 316,448 MS applicants, 128,729 MS matriculants, 27,574 GS applicants, 46,927 active GS residents, 710 CGSO applicants, and 659 active CGSO fellows were included. With every progressive stage in training, there was a smaller proportion of URM active trainees than applicants. Further, URM, Hispanic/Latino, and Black/African American trainees were significantly underrepresented compared with 2020 Census data. While the proportion of White CGSO fellows increased over time (54.5-69.2%, p = 0.009), the proportion of Black/African American and Hispanic/Latino (URM) CGSO fellows did not significantly change over the study period, though URM representation was lower in 2020 as compared with 2015.

DISCUSSION

From 2015 to 2020, minority representation decreased at every advancing stage in surgical oncology training. Efforts to address barriers for URM applicants to CGSO fellowships are needed.

Perceptual Barriers to Becoming a Plastic Surgeon among Underrepresented Medical Students

Background

The field of plastic surgery has experienced difficulty increasing diversity among trainees, despite significant efforts. Barriers to recruitment of underrepresented in medicine (URM) students are poorly understood. This study assesses URM students' exposure to plastic surgery, access to mentors and research opportunities, and the importance of diversity in the field.

Methods

A survey was designed and distributed to members of the Student National Medical Association over 3 months. Survey data were collected using Qualtrics and descriptive statistics, and logistical regressions were performed using SAS.

Results

Of the 136 respondents, 75.0% identified as Black (n = 102/136), and 57.4% (n = 66/115) reported a plastic surgery program at their home institution. Of the total respondents, 97.7% (n = 127/130) were concerned about racial representation in plastic surgery, and 44.9% (n = 53/114) would be more likely to apply if there were better URM representation. Most respondents disagreed that there was local (73.4%, n = 58/79) or national (79.2%, n = 57/72) interest in URM recruitment. Students whose plastic surgery programs had outreach initiatives were more likely to have attending (OR 11.7, P < 0.05) or resident mentors (OR 3.0 P < 0.05) and access to research opportunities (OR 4.3, P < 0.05).

Conclusions

URM students feel there is an evident lack of interest in recruiting URM applicants in plastic surgery. Programs with outreach initiatives are more likely to provide URM students access to mentorship and research opportunities, allowing students to make informed decisions about pursuing plastic surgery.

Racial diversity amongst Otolaryngology-Head and Neck Surgery programs in Canada

BACKGROUND

The Canadian landscape of racial diversity in academic OHNS programs is currently unknown, as to date Canadian medical organizing bodies have refrained from collecting race-based data. However, new policy guidelines by the Canadian Medical Association support the collection of data that may be used to support equity, diversity and inclusion programs. This study aims to describe the representation of visible minorities amongst academic OHNS departments and divisions in Canada at various levels of academic seniority.

METHODS

An online survey was distributed to members of the 13 academic OHNS department in Canada in 2022. The survey collected demographic data as well as each participant's self-reported race and gender. The primary outcome was the comparison of the racial demographics of Canadian academic OHNS programs to Canadian census data. Secondary outcome measures assessed how demographics varied based on academic position and gender. Simple descriptive statistics were tabulated for all demographic variables. Chi-square goodness of fit analysis was used to compare survey results to anticipated demographics based on 2016 Canadian census data.

RESULTS

Of 545 surveys distributed, 224 surveys were completed (response rate of 41%); 67.9% or respondents were male and 32.1% were female. Of these respondents, 71 were residents, 26 lecturers, 54 assistant professors, 39 associate professors, and 34 full professors. There was significantly greater minority representation amongst residents (47.9%), assistant professors (39.6%), and lecturers (40.7%) compared to the Canadian population (25.3%) p < 0.001. Results also showed that there were significantly fewer female lecturers (25.9%, p = 0.01), assistant professors (31.5%, p = 0.006), and full professors (2.9%, p < 0.001) compared to an assumed even proportion of men and women in the population.

CONCLUSIONS

Academic OHNS programs in Canada are more racially diverse than the Canadian population. However, women continue to be under-represented in more senior positions, especially women who are visible minorities. Further investigation into the systemic factors that may contribute to this disparity is needed as well as effective ways to promote diversity amongst academic OHNS departments at all levels of academic seniority.

Continued underrepresentation of historically excluded groups in the neurosurgery pipeline: an analysis of racial and ethnic trends across stages of medical training from 2012 to 2020

OBJECTIVE

US allopathic medical schools have experienced improvements in racial and ethnic diversity among matriculants in the past decade. It is not clear, however, whether better representation of historically excluded racial and ethnic groups at medical school entry impacts subsequent stages of the medical training pipeline leading into a specific field. The aim of this study was to examine these trends as they relate to the neurosurgical medical education pipeline and consider the drivers that sustain barriers for underrepresented groups.

METHODS

Race and ethnicity reports from the American Association of Medical Colleges were obtained on allopathic medical school applicants, acceptees, and graduates and applicants to US neurosurgical residency programs from 2012 to 2020. The representation of groups categorized by self-reported race and ethnicity was compared with their US population counterparts to determine the representation quotient (RQ) for each group. Annual racial composition differences and changes in representation over time at each stage of medical training were evaluated by estimating incidence rate ratios (IRRs) and 95% confidence intervals (CIs) using non-Hispanic Whites as the reference group.

RESULTS

On average, Asian and White individuals most frequently applied and were accepted to medical school, had the highest graduation rates, and applied to neurosurgery residency programs more often than other racial groups. The medical school application and acceptance rates for Black individuals increased from 2012 to 2020 relative to Whites by 30% (95% CI 1.23-1.36) and 42% (95% CI 1.31-1.53), respectively. During this same period, however, inequities in neurosurgical residency applications grew across all non-Asian racialized groups relative to Whites. While the incidence of active Black neurosurgery residents increased from 2012 to 2020 (0.6 to 0.7/100,000 Black US inhabitants), the prevalence of White neurosurgery residents grew in the active neurosurgery resident population by 16% more.

CONCLUSIONS

The increased racial diversity of medical school students in recent years is not yet reflected in racial representation among neurosurgery applicants. Disproportionately fewer Black relative to White US medical students apply to neurosurgery residency, which contributes to declining racial representation among all active neurosurgery resident physicians. Hispanic individuals are becoming increasingly represented in neurosurgery residency but continue to remain underrepresented relative to the US population. Ongoing efforts to recruit medical students into neurosurgery who more accurately reflect the diversity of the general US population are necessary to ensure equitable patient care.

Minority Resident Physicians' Perspectives on the Role of Race/Ethnicity, Culture, and Gender in Their Surgical Training Experiences

BACKGROUND

Female and racial/ethnic minority representation in surgical programs continues to trail behind other medical specialties. Various structural and perceived obstacles which contribute to a difficult path for underrepresented minority (URM) trainees have been identified, and efforts to reduce these hurdles are underway. Gaining perspective and insight from current surgical minority trainees may add valuable insight to aid with improving and innovating strategies to recruit and retain URM surgeons.

OBJECTIVE

To characterize how race/ethnicity, cultural background, and gender affect the surgical training experience of URM surgical residents in all areas of surgery a focus on the field of Orthopedic Surgery, given its particularly poor rates of diversity.

METHODS

Authors conducted semi-structured video interviews on current surgical residents or fellows who were members of underrepresented populations including Female, African-American/Black, Latino, Asian, Native American, and First or Second-generation immigrant status. Recruitment was achieved through a combination of voluntary, convenience, and snowball sampling procedures. Interview transcripts were then coded using conventional thematic analysis. Themes were iteratively expanded into subthemes and subsequently categorized utilizing a pile-sorting methodology.

RESULTS

Among 23 surgical trainees 12 self-identified as Black (60.9%), 5 as Asian (17.4%), 1 as Hispanic (4.4%), and 5 as Caucasian (17.4%). Twelve residents identified as male (52%) and 11 as female (48%). Six surgical specialties were represented with the majority of participants (83%) being trainees in surgical subspecialties, among those orthopedic surgery was most strongly represented (57%). Analysis of their responses revealed 4 major themes: positive experiences, problems related to minority status, coping strategies, and participant suggested interventions. Themes were distilled further to sub-themes. Positive experiences' sub-themes included finding a supportive community, pride in minority status, and being able to better relate to patients. Negative experiences related to minority status' subthemes included perceived microaggressions and additional pressures, such as greater scrutiny and harsher punishments relative to their nonminority counterparts, which negatively impacted their surgical training. Most respondents did not feel there were dedicated resources to help alleviate these additional burdens, so some sought help outside of their training programs while others tried to assimilate, and others felt isolated. Recommended proposed interventions included validating the URM resident experience, providing education/training, and creating opportunities for mentorship.

IMPLICATIONS/CONCLUSIONS

URM surgical trainees face numerous challenges related to their minority status. Recruitment and retention of URM in medicine would benefit from individual early and longitudinal mentorship, mitigating imposter syndrome, acknowledging the challenges faced by residents, and seeking feedback from both past and current residents.

A Review of OB/GYN, Internal Medicine, Family Medicine, and Pediatrics Residency Program Websites for Diversity, Equity, and Inclusion Elements

Background

Residency program websites have become a central source of information for applicants due to a shift toward virtual interviewing. Applicants, particularly those from diverse backgrounds, place strong value on programs that present commitments to diversity, equity, and inclusion (DEI). The DEI content of residency program websites for primary care specialties has been largely unexplored.

Objective

The objective of this study is to review, in an exploratory manner, family medicine, internal medicine, obstetrics and gynecology, and pediatrics residency program websites for number of DEI elements present. By identifying lacking DEI content, we hope to give residency programs that are seeking to increase diversity among applicants some direction for improving their websites.

Methods

We reviewed all available residency program websites (1814) in the Fellowship and Residency Electronic Interactive Database (FREIDA) from August to December 2021. Each website was evaluated for the presence of 10 DEI elements chosen from previously published website reviews and informal applicant surveys. Some elements included the presence of resident and faculty photos/biographies, patient population descriptions, and dedicated DEI curricula. Program demographic information was collected, and summative statistics were performed.

Results

The average number of DEI elements displayed per program ranged from 3.5 (internal medicine) to 4.9 (pediatrics). The most common elements were resident and faculty photographs/biographies. Internal medicine programs displayed significantly fewer elements than the other 3 specialties. This difference remained significant after controlling for program size, location, and type.

Conclusions

This study highlights a lack of DEI elements available for residency program website visitors to review.

Ethnic and Gender Diversity in Pathology: A Dream Deferred

Background Equity, diversity, and inclusion (EDI) remain an elusive dream in the physician workforce in the United States of America (USA). Many studies have documented the tangible and intangible benefits of EDI, including the caregiver, patients, and healthcare organizations. Objective We aim to examine the ethnic and gender diversity trends of the active residents in pathology in United States residency programs. Methods A retrospective cross-sectional study was conducted on the ethnicity and gender distribution of pathology residency trainees from the academic year 2007-2018. The data was compiled from the American Association of Medical Colleges (AAMC) annual report. Data was entered and analyzed using Microsoft Excel 2013 (Microsoft Corporation, Redmond, WA, USA). Frequencies and percentages were calculated, and bar charts and pie charts were used for graphical representation. Results Almost 35,000 US pathology residents were enrolled according to AAMC during this particular period. The highest trend of enrolling in the field of pathology was observed in 2010 and remained the same for years. This shows that the field of pathology in the USA had some acceptance all these years. The most popular speciality in which most residents were enrolled was anatomic/clinical pathology (80%) in which females were dominant over other fields. Conclusion Over the years, we have failed to overcome gender and ethnicity diversity. Gender and ethnicity have a significant influence on leadership positions, academic ranks, and research productivity among pathology faculty members in the USA.

Analysis of Racial and Gender Distribution of US-Doctor of Medicines Graduates Entering Into General Surgery and Surgical Subspecialties' Residencies: The Need for Effective & Sustainable Diversity, Equity, and Inclusion Strategies

INTRODUCTION

We aim to investigate disparities & inequities based on race, sex, graduating age, and the number of peer-reviewed publications among allopathic U.S. Doctor of Medicine graduates who reported entering a surgical training program over a span of 5 y.

METHODS

A retrospective cohort analysis of the Association of American Medical Colleges student records system and Electronic Residency Application Service for graduates entering a surgical specialty residency during graduate medical education training cycles 2015-2020.

RESULTS

African American, Asian, and Hispanic applicants each accounted for less than 1% of graduates who reported entering a surgical training program. Asians (OR = 0.58, P = 0.01) and those identifying as other races (OR = 0.74, P = 0.01) were significantly less likely to enter a surgical subspecialty when compared to Caucasians. Orthopedic surgery contained the lowest proportion of minorities; African Americans 0.5% (n = 18), Asians 0.3% (n = 11), Hispanics 0.1% (n = 4), and others with 2% (n = 68). Females who reported entering Orthopedic surgery training represented the smallest female population in surgical specialties (17%, n = 527). The number of peer-reviewed publications was significantly associated with male sex (β = 0.28, P < 0.01), age between 30 and 32 at graduation (β = 1.76, P < 0.01), and identification as other races (β = 1.53, P < 0.01).

CONCLUSIONS

Racial minorities represented only 5.1% of graduates who reported entering a surgical specialty graduate medical education training program. Minority races and females were significantly less likely to enter a surgical subspecialty training program compared to Caucasian graduates and males, especially in orthopedic surgery. Implementation of specialty-specific programs and diversity, equity, and inclusion departments that promote mentorship and guidance toward residency programs is needed to combat continued race and sex disparities.

Trends in Race and Sex Representation Among Entering Orthopaedic Surgery Residents: A Continued Call for Active Diversification Efforts

INTRODUCTION

Multiple studies have analyzed the diversity of surgical subspecialties, in which orthopaedic surgery consistently lags behind in female and minority representation. This study aims to examine contemporary data on trends in sex and racial representation among entering orthopaedic surgery residents.

METHODS

The American Association of Medical Colleges' Graduate Medical Education Track data set was queried for all individuals entering surgical residencies in the United States from 2001 to 2020. Deidentified data on self-reported sex and race (American Indian or Alaska Native [AIAN]; Asian; Black or African American, Hispanic, Latino, or of Spanish Origin; Native Hawaiian or Other Pacific Islander [NHOPI]; White; and Other) for individuals across all surgical subspecialties were collected. Sex and race proportions for newly matriculating surgical residents were analyzed and aggregated across the study period.

RESULTS

From 2001 to 2020, there was a 9.2% increase in the proportion of new female orthopaedic surgery residents, with approximately one in five identifying as such in 2020. By contrast, surgical specialties in aggregate saw a 16.3% increase. A 11.7% decrease was observed in entering orthopaedic residents who identified as White with a corresponding increase in representation by multiracial (9.2%) individuals and those identifying as "Other" (1.9%). The proportion of Asian (range: 10.4 to 15.4%), Black (2.5 to 6.2%), Hispanic (0.3 to 4.4%), AIAN (0.0 to 1.2%), and NHOPI (0.0 to 0.5%) new trainees has largely remained unchanged throughout the study period. A similar trend was observed among surgical specialties in aggregate. Of the identities most represented by the multiracial cohort, the most common were Asian (range: 7.0 to 50.0%), Hispanic (0.0 to 53.5%), and White (30.2 to 50.0%).

CONCLUSION

Although orthopaedic surgery has improved in sex diversity in its entering class of residents, measures to increase racial diversity have been less successful. Efforts at improving the recruitment of a diverse class of trainees are necessary and will require acknowledging the importance of both racial and sex representation diversity metrics.

Racial and Ethnic Bias in Letters of Recommendation and Personal Statements for Application to Otolaryngology Residency

INTRODUCTION

The persistent lack of racial and ethnic diversity within the field of otolaryngology calls for an analysis of potential bias within the residency application system. Letters of recommendation (LORs) and personal statements (PSs) are the most important subjective application constituents. This subjectivity predisposes these components to implicit bias. In applications to various surgical subspecialties, prior linguistic studies assessing bias in reviews of LOR show race-based differences. Thus far, racial and ethnic linguistic differences in LORs for otolaryngology applicants have not been analyzed in the literature.

METHODS

LORs and PSs were abstracted from otolaryngology - head and neck surgery applications in the Electronic Residency Application Service for the 2019-20 and 2020-21 application cycles. Linguistic Inquiry and Word Count 2015 was used for quantitative analysis of emotional, cognitive, and structural components of written text.

RESULTS

Race-pair analysis of the 2019-2021 application cycles revealed higher mean "teaching" scores for LORs for Asian, black, Hispanic, and white applicants when compared to applicants who self-identified as Other. White applicants had lower scores for the terms "research" and "analytic" when compared to Asian and black applicants, respectively. Analysis of PSs revealed greater scores for an "authentic" writing style for white versus Asian applicants. White applicants were found to have higher scores for "tone" compared to black applicants.

CONCLUSION

Minor racial and ethnic language differences exist in both LORs and PSs. A statistically significant difference was observed among LORs, with the "teaching" term used more frequently for Asian, black, Hispanic, and white applicants compared to self-identified Other individuals. For PSs, statistically significant differences were observed among white applicants, who wrote about themselves using more "authentic" language when compared with Asian applicants and who also had higher scores for "tone" compared to black applicants. Although these differences were statistically significant, the practical impact of the variances is likely small.

Evaluating Match and Attrition Rates for Women and African Americans in Neurosurgery

BACKGROUND

Previous efforts to increase diversity in neurosurgery have been aimed primarily at female inclusion while little analysis of other under-represented groups has been performed.

OBJECTIVE

To evaluate match and retention rates of under-represented groups in neurosurgery, specifically Black and female applicants compared with non-Black and male applicants.

METHODS

Match lists, Electronic Residency Application Service data, and National Resident Matching Program data were retrospectively reviewed along with publicly available residency program information for successful matriculants from 2017 to 2020. Residents were classified into demographic groups, and analysis of match and retention rates was performed.

RESULTS

For 1780 applicants from 2017 to 2020, 439 identified as female while 1341 identified as male. Of these 1780 applicants, 128 identified as Black and 1652 identified as non-Black. Male and female applicants matched at similar rates ( P = .76). Black applicants matched at a lower rate than non-Black applicants ( P < .001). From 2017 to 2020, neither race nor sex was associated with retention as 94.1% of male applicants and 93.2% of female applicants were retained ( P = .63). In total, 95.2% of Black residents and 93.9% of non-Black residents were retained ( P = .71). No intraregional or inter-regional differences in retention were found for any group.

CONCLUSION

Although sex parity has improved, Black applicants match at lower rates than non-Black applicants but are retained after matriculation at similar rates. Neurosurgery continues to recruit fewer female applicants than male applicants. More work is needed to extend diversity to recruit under-represented applicants. Future studies should target yearly follow-up of retention and match rates to provide trends as a measure of diversification progress within the field.

Racial and Sex Disparities in Resident Attrition Among Surgical Subspecialties

Importance

Racial and sex disparities are prevalent in surgical trainees. Although retrospective studies on resident attrition have been conducted for individual specialties, this study analyzes racial and sex differences in resident attrition among all surgical subspecialties over an 18-year period.

Objective

To evaluate the racial and sex differences in resident attrition among surgical specialties over an 18-year period.

Design, Setting, and Participants

This was a large, cross-sectional, database study that analyzed program-reported resident censuses (program information, resident demographics, and attrition status) obtained by the Association of American Medical Colleges from 2001 to 2018 for trainees in surgical residency programs. Data were analyzed from March 20, 2021, to June 8, 2022.

Main Outcomes and Measures

Demographic trends (including race and ethnicity and sex) for all surgical subspecialty training programs over an 18-year period. Resident attrition includes all-cause withdrawals, dismissals, and transfers to another specialty. Unintended attrition encompasses all withdrawals, dismissals, and transfers except for changing career plans.

Results

This study included 407 461 program-reported resident years collected from 112 205 individual surgical residents (67 351 male individuals [60.0%]). The mean percentage of female trainees was 40.0% (44 835) and increased over the study period. Sex disparity remained greatest in orthopedic surgery. Residents who were underrepresented in medicine (URiM) comprised 14.9% (16 695) of all surgical trainees but demonstrated a 2.1% decrease over the study period. Overall attrition rate among all specialties was 6.9% (7759), with an unintended attrition rate of 2.3% (2556). Female residents had a significantly higher relative risk (RR) of attrition (RR, 1.16; 95% CI, 1.11-1.22; P < .001) and unintended attrition (RR, 1.17; 95% CI, 1.08-1.26; P < .001) compared with their male counterparts. URiM residents were at significantly higher RR for attrition (RR, 1.40; 95% CI, 1.32-1.48; P < .001) and unintended attrition (RR, 1.92; 95% CI, 1.75-2.11; P < .001) compared with non-URiM residents. The highest attrition (10.6% [746 of 7043]) and unintended attrition (5.2% [367 of 7043]) rates were in Black/African American residents. The lowest attrition and unintended attrition rates were seen in White residents at 6.2% (4300 of 69 323) and 1.8% (1234 of 69 323), respectively. Black/African American residents were at disproportionate risk for attrition (RR, 1.66; 95% CI, 1.53-1.80; P < .001) and unintended attrition (RR, 2.59; 95% CI, 2.31-2.90; P < .001) compared with all other residents. Orthopedic surgery had the highest attrition (RR, 3.80; 95% CI, 2.84-5.09; P < .001) and unintended attrition (RR, 7.20; 95% CI, 4.84-10.71; P < .001) for Black/African American residents.

Conclusions and Relevance

Results of this cross-sectional study suggest that the percentage of female residents in surgical specialties has improved over the last 18 years, and the percentage of URiM residents has remained relatively unchanged. Risk for attrition and unintended attrition was significantly elevated for female and URiM residents, specifically Black/African Americans. These results highlight current racial and sex disparities in resident attrition and demonstrate the importance of developing strategies to recruit, retain, and support residents.

Effects of race and test preparation resources on standardized test scores, a pilot study

BACKGROUND

Little research exists on the relationship between pre-examination resources, race, and standardized test outcomes. This study aimed to determine the effect of test preparation resources and race on test scores.

METHODS

We surveyed medical students at an allopathic institution on the use of test preparation materials and their test scores. Students were grouped by self-identified race. Underrepresented in Medicine (URiM) students were defined as Black/African American (AA), Hispanic/Latino (HL), Native American (NA) and multiple races. Univariate analysis and linear regression were used for statistical analysis.

RESULTS

192 students completed the survey (response rate = 33%). URiM students reported more MCAT attempts than other students. No differences between scores existed between races. There was no association between scores and the use of test preparation resources.

CONCLUSIONS

We found that URiM students took the MCAT more times than their peers; however, we found no racial/ethnic differences in examination preparation resources or scores.

Analyzing Diversity Elements on Otolaryngology Residency Program Websites

OBJECTIVE

To investigate how the internet presence of Otolaryngology residency programs influences recruitment of diverse applicants.

STUDY DESIGN

Retrospective cohort study.

SETTING

Website, Instagram, and AAMC Residency Explorer data from all US, non-military, allopathic otolaryngology residency programs.

METHODS

We identified 10 common ways in which residency programs communicate their commitment to diversity through web-based platforms. We then analyzed program websites and Instagram pages for the presence of these 10 diversity elements. Univariate and multivariate linear regression were used to evaluate the association between presence of a diversity elements and the proportion of underrepresented minority residents in the program.

RESULTS

Review of 106 Otolaryngology residency program websites and Instagram pages was completed from February to May 2021. Most programs (69.8%) satisfied at least one diversity element. Of the programs reviewed, 83 had demographic information available for comparison. After adjusting for Doximity ranking, multivariate linear regression demonstrated that several elements were positive predictors of program diversity. Diversity and inclusion message (p < 0.0001), statement encouraging URM applicants (p < 0.0001), dedicated diversity chair/committee (p = 0.005), and diversity related articles/blog posts (p = 0.006) were independently associated with a greater proportion of URM residents in a given program.

CONCLUSION

These data demonstrate that providing diversity related information on residency program websites may play a role in improving program diversity. The large percentage of programs that lack the presence of any diversity element (30.2%) demonstrates that there is significant room for improvement. This study presents a promising strategy through which programs can improve recruitment of diverse residents.

National trends in distribution of underrepresented minorities within United States general surgery residency programs: A longitudinal panel study

BACKGROUND

Cultural affinity with a provider improves satisfactoriness of healthcare. We examined 2005-2019 trends in racial/ethnic diversity/inclusion within general surgery residency programs.

METHODS

We triangulated 2005-2019 race/ethnicity data from Association of American Medical Colleges surveys of 4th-year medical students, the Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education-affiliated general surgery residencies. Temporal trends in minority representation were tested for significance.

RESULTS

Underrepresented racial/ethnic minorities in medicine (URiMs) increased among graduating MDs from 7.6% in 2005 to 11.8% in 2019 (p < 0.0001), as did their proportion among surgery residency applicants during 2005-2019 (p < 0.0001). However, proportions of URiMs among general surgery residents (≈8.5%), and of programs without URiMs (≈18.8%), stagnated.

CONCLUSIONS

Growing URiM proportions among medical school graduates and surgery residency applicants did not improve URiM representation among surgery trainees nor shrink the percentage of programs without URiMs. Deeper research into motivators underlying URiMs' residency program preferences is warranted.

Gender and Race Demographics of Fellowships After General Surgery Training in the United States: A Five-Year Analysis in Applicant and Resident Trends

INTRODUCTION

The gender and minority gap in general surgery residency is narrowing; however, literature lacks comprehensive data regarding the demographics of fellowship programs following general surgery training.

METHODS

Data from 2017 to 2021 for gender, ethnicity, and surgical subspecialty are publicly available from the ERAS database and ACGME yearly data reports. Cochran-Armitage trend tests were used to determine statistical significance in trends for female and minority applicants and trainees.

RESULTS

The overall trend of female applicants to surgical specialties remained stagnant. However, female applicants to vascular surgery increased significantly from 25% to 35% (P = .045). There was no significant increase in female trainees in any surgical specialties evaluated. Furthermore, the overall trend of minority applicants to surgical specialties also remained stagnant, except for pediatric surgery, which showed significantly fewer minority applicants. Despite pediatric surgery having fewer applicants, minority trainees in this specialty increased significantly from 8% to 19% (P = .008).

CONCLUSION

Several current initiatives, such as intentional mentorship, are being reported to promote diverse and equal representation among female and minority applicants and trainees. However, the current overall margin of increase in diversity among surgical specialty applicants and trainees is minimal, indicating that continued efforts are needed to diversify surgical specialty training programs.

Practical Strategies for Underrepresented Minority Recruitment in General Surgery Residency

OBJECTIVE

To analyze the effects of diversification efforts on underrepresented minority in medicine (URiM) resident recruitment in general surgery residency at a single large southeastern United States academic institution with five categorical positions.

METHODS

A retrospective review of applications from the 2016 to 2022 ACGME match cycles was conducted. In an effort to diversify resident recruitment, multiple new strategies were enacted in 2021. URiM candidates were identified via a more laborious review of individual applications to the program. In addition, a holistic review process was conducted, URiM faculty and residents were prominently featured, previous underperformance in diversity was openly addressed, and URiM applicants were contacted with follow up emails. Cohorts pre- and post-implementation of these strategies were analyzed. The proportion of URiM applicants invited, interviewed, ranked, and matched were compared.

RESULTS

Pre-intervention during the 2016to 20 match cycles, URiM candidates represented 4% of total applicants invited. Post-intervention during the 2021to 22 match cycles, URiM candidates represented 27% of total applicants invited. Over the past 5 years under the present program director, 1 URiM resident of 24 (4%) matched into the categorical program. Over the past 15 years under the direction of 3 program directors, a total of 6 out of 69 matched residents (9%) identified as URiM. Post intervention, the program matched on average 30% of its incoming categorical class from URiM candidates.

CONCLUSION

Recruitment and selection of diverse medical school applicants is an ongoing concern of general surgery residency program directors. Historically, URiM candidates are underrepresented in applicants selected for interview. Interventions aimed at increasing the matriculation of URiM include concentrated efforts to identify more URiM candidates for interview. However, importantly, transparency of ongoing diversity efforts and diversifying both faculty and trainees involved in the selection process may also improve general surgery URiM recruitment.

Demographic Factors Associated With Research and Career Interests in Aspiring Academic Surgeons: What are the Implications for Tomorrow's Workforce?

OBJECTIVE

To evaluate the research and career interests of aspiring academic surgeons and determine the influence of demographic factors.

DESIGN

Cross-sectional survey SETTING: Single institution, academic general surgery residency program PARTICIPANTS: Medical students invited to interview during 2019-2020 and 2020-2021 residency cycle RESULTS: One hundred fifty-four of 160 (96%) potential respondents representing 63 medical schools completed the survey, American Association for Public Opinion Research Response Rate 6. Fifty-three percent of the study population was female. Seventeen percent identified as Black, 14% Asian, 13% Latinx, 50% white, and 6% other. Respondents were most interested in education, professional development, and surgical culture (32%) followed by basic and translational science (23%), global and community health (20%), and health services (18%). On multiple logistic regression, interest in global/community health was associated with identifying as Black (OR 5.9 [2.0, 17.8] p = 0.001) and female (OR 2.7 [1.0, 7.0] p = 0.044). A plurality of participants were undecided on future specialty (n = 63, 41%). The most common specialty interests were surgical oncology (n = 28, 18%); trauma, acute care, or surgical critical care (n = 21, 14%); pediatric and cardiothoracic surgery (n = 20 for each, 13%); and abdominal transplant (n = 15, 10%).

CONCLUSIONS

In this cross-sectional survey of highly competitive academic general surgery applicants, respondents who were underrepresented in medicine (URiM) and women were more interested in research fields with a history of lower relative NIH funding. In light of these findings, academic programs seeking a more diverse residency workforce should consider strategies beyond recruitment to promote the scholarly achievement of women and URiM residents.