Evolution of Workforce Diversity in Surgery✰

Does gender disparity exist in neurosurgery training? Evidence from a nationwide survey from Pakistan

Gender disparities are prevalent in the neurosurgical field, particularly for female trainees, despite the growing demand for neurosurgeons. The situation is bleaker in low-and middle-income countries, where gender disparities among neurosurgical trainees have not been evaluated. We aimed to gauge the gender differences in opportunities and perceptions of neurosurgery training in Pakistan by comparing responses between males and females. A nationwide web-based survey was conducted in Pakistan, covering 22 College of Physicians and Surgeons of Pakistan (CPSP) accredited neurosurgery training programs. Convenience sampling was used with a pilot-tested questionnaire. Data analysis was performed using SPSS version 26. A total of 120 trainees participated in our survey. The mean age of the participants was 30.4 ± 4.1 years, with 29.2% females and 70.8% males. Concerns about gender equity were more among females (34.3%) than males (27.1%). Poor work-life balance was reported by more females (34.3%) than males (30.6%). Burnout due to working hours was strongly agreed by more females (54.3%) than males (35.3%). More females (40%) acknowledged sufficient mentorship opportunities versus males (25%). Female respondents (65.7%) worked 50-100 hours per week, less than males (69.4%). Satisfaction with surgical exposure was lower among females (2.9%) compared to males (18.8%). More females reported access to teaching courses (82.9% vs. 77.6% males) and neurosurgical conferences (85.7% vs. 80.0% males), cadaver workshops (17.1% vs. 12.9% males), morbidity and mortality meetings (88.6% vs. 82.4% males), case-based sessions (82.9% vs. 75.3% males), and radiology discussions (82.9% vs. 74.1% males). Our study highlights substantial gender gaps in neurosurgical training, concerns over working hours, burnout, mentorship, work-life balance, and gender equity. These findings underscore the necessity for interventions to rectify these disparities and foster gender equity in neurosurgical training.

Surgeon and Surgical Trainee Experiences After Adverse Patient Events

Importance

Adverse patient events are inevitable in surgical practice.

Objectives

To characterize the impact of adverse patient events on surgeons and trainees, identify coping mechanisms, and assess whether current forms of support are sufficient.

Design, Setting, and Participants

In this mixed-methods study, a validated survey instrument was adapted and distributed to surgical trainees from 7 programs, and qualitative interviews were conducted with faculty from 4 surgical departments in an urban academic health system.

Main Outcomes and Measures

The personal impact of adverse patient events, current coping mechanisms, and desired forms of support.

Results

Of 216 invited trainees, 93 (43.1%) completed the survey (49 [52.7%] male; 60 [64.5%] in third postgraduate year or higher; 23 [24.7%] Asian or Pacific Islander, 6 [6.5%] Black, 51 [54.8%] White, and 8 [8.6%] other race; 13 [14.0%] Hispanic or Latinx ethnicity). Twenty-three of 29 (79.3%) invited faculty completed interviews (13 [56.5%] male; median [IQR] years in practice, 11.0 [7.5-20.0]). Of the trainees, 77 (82.8%) endorsed involvement in at least 1 recent adverse event. Most reported embarrassment (67 of 79 trainees [84.8%]), rumination (64 of 78 trainees [82.1%]), and fear of attempting future procedures (51 of 78 trainees [65.4%]); 28 of 78 trainees (35.9%) had considered quitting. Female trainees and trainees who identified as having a race and/or ethnicity other than non-Hispanic White consistently reported more negative consequences compared with male and White trainees. The most desired form of support was the opportunity to discuss the incident with an attending physician (76 of 78 respondents [97.4%]). Similarly, faculty described feelings of guilt and shame, loss of confidence, and distraction after adverse events. Most described the utility of confiding in peers and senior colleagues, although some expressed unwillingness to reach out. Several suggested designating a departmental point person for event debriefing.

Conclusions and Relevance

In this mixed-methods study of the personal impact of adverse events on surgeons and trainees, these events were nearly universally experienced and caused significant distress. Providing formal support mechanisms for both surgical trainees and faculty may decrease stigma and restore confidence, particularly for underrepresented groups.

Matching Against Men: 5 Years of Residency Match Data Show Disparities Still Exist

OBJECTIVES

Despite progress toward equal representation by sex in medical practice, women remain underrepresented in many specialties. This study sought to examine the current state of gender equality among recently graduated doctors in multiple specialties.

METHODS

Deidentified demographics, standardized examination scores, and Match results were gathered for 829 graduates. Participants were selected from an allopathic medical school between 2016 and 2020. Nineteen students (2.29%) were excluded from the study. Descriptive statistics were calculated, and χ2 tests for independence were used to compare proportions between reported sex and specialty and program Match results. One-way analysis of variance was then performed to test for differences in US Medical Licensing Examination Step 1 and Step 2 scores between sexes. P < 0.05 was considered statistically significant.

RESULTS

Of the 829 individuals studied, 44.6% were women. A significantly smaller proportion of women matched into the most competitive specialties, despite no significant difference in US Medical Licensing Examination Step 1 scores between sexes. Furthermore, there was an overall significant trend of women matching into more competitive programs for any given specialty.

CONCLUSIONS

In this study, we found that men matched into more highly competitive specialties, whereas women matched into more competitive residency program locations. Further research is needed to determine why women matched into specific specialties at lower rates than their male peers and seek to understand how sex affects the narrative of specialty choice.

Representation of Women Authorship in the Top 5 Transplantation Journals in the United States

BACKGROUND

In the United States, only 13% of transplant surgeons are women. We evaluated gender distribution and trends of American authorship over the past 10 y in high-impact solid organ transplantation journals to gain insight into the current status of women authorship in transplantation.

METHODS

Original articles from 2012 to 2021 from the 5 highest-impact solid organ transplantation journals were extracted from Scopus. First and last author's gender was predicted using Genderize.io. Data of first and last authors, article type and topic, location, citation, and funding metrics were analyzed. Chi-square, logistic regression, and trend tests were performed where appropriate. Statistical significance was set at <0.05.

RESULTS

Women's first and last authorship increased over time among all journals. There was an increase in women first authors in the American Journal of Transplantation and in senior women authors in Liver Transplantation and Transplantation . Significant differences in gender authorship in lung, intestine, pancreas, general, and islet cell transplantation were found. Women's last authorship was associated with 1.69 higher odds of having a woman first author when adjusting for year and journal. There was an increase in the rate of women's first and last author collaborations over the years. Women last authors had 1.5 higher odds of being funded by the National Institutes of Health over the years.

CONCLUSIONS

Despite an increase in women transplant surgeons and physicians, the gap in women authorship in transplantation persists. Women's last authorship was associated with higher odds of having a woman first author, pointing to the importance of mentorship for women joining the transplant academia.

When I Don't see me, Am I seen? Race and student perception of the surgery clerkship

INTRODUCTION

Increasing interest in general surgery from students who are Under-Represented in Medicine (URiM) is imperative to advancing diversity, equity, and inclusion efforts. We examined medical student third year surgery clerkship evaluations quantitatively and qualitatively to understand the experiences of URiM and non-URiM learners at our institution.

METHODS

Evaluations from 235 graduated medical students between the years of 2019 and 2021 were analyzed. T-tests were used to compare numerical data. Free-text comments were qualitatively analyzed using inductive thematic analysis by two independent reviewers with conflicts resolved by a third.

RESULTS

Evaluations were completed by 214 non-URiM students (91.1 ​%) and 21 (8.9 ​%) URiM students. There were no significant differences between URiM and non-URiM students in ratings of faculty and resident teaching. When asked whether residents were positive role models for patient care, non-URiM students were more likely than URiM students to agree (3.284 vs. 2.864, p ​= ​0.040). When asked whether they considered faculty to be positive role models, non- URM students were also more likely to answer affirmatively than URiM students (3.394 vs. 2.909 p ​= ​0.013). Qualitative comments were similar between the two groups. When asked what the strengths of the clerkship were, the most commonly evoked theme was "interactions with team" with subthemes of "team integration" "feeling valued" and positive "faculty" or "resident" interactions. "Operative experience" was the second most commonly evoked strength of the clerkship. The most common criticisms of the clerkship involved "negative interactions with team" with subthemes of "not prioritized above other learners" and "ignored." Negative "academic experience" was the next most commonly evoked weakness, with an affiliated theme of "lack of teaching."

CONCLUSIONS

URiM students are less likely than non-URiM students to see surgical residents and faculty as positive role models. Integrating medical students into the team, taking time to teach, and allowing students to feel valued in their roles improves the clerkship experience for trainees and can contribute to recruitment efforts.

Importance of Diversity, Equity, and Inclusion in the Hepatopancreatobiliary Workforce

Diversity is a catalyst for progress that prevents institutional stagnation and, by extension, averts descent to mediocrity. This review focuses on the available data concerning hepatopancreatobiliary (HPB) surgical workforce demographics and identifies evidence-based strategies that may enhance justice, equity, diversity, and inclusion for HPB surgeons and their patients. We report that the current United States HPB surgical workforce does not reflect the population it serves. We review data describing disparity-perpetuating hurdles confronting physicians from minority groups underrepresented in medicine at each stage of training. We further examine evidence showing widespread racial and socioeconomic disparities in HPB surgical care and review the effects of workforce diversity and physician-patient demographic concordance on healthcare outcomes. Evidence-based mitigators of structural racism and segregation are reviewed, including tailored interventions that can address social determinants of health toward the achievement of true excellence in HPB surgical care. Lastly, select evidence-based data driving surgical workforce solutions are reviewed, including intentional compensation plans, mentorship, and sponsorship.

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.

Working Through the Pain: A Cross-Sectional Survey on Musculoskeletal Pain Among Surgeons and Residents

INTRODUCTION

While prior studies have reported that over 80% of surgeons report musculoskeletal pain, to our knowledge, the degree of care required to manage these symptoms has not been discussed. Here, we present granular data on musculoskeletal treatment modalities used by surgeons and residents at a single institution.

METHODS

We distributed a survey to assess the prevalence of musculoskeletal pain and treatment utilization to surgery attending and residents at a single institution.

RESULTS

Fifty-five out of 115 residents and attending (47.8%) responded to our survey. Among the respondents, 87.3% reported pain within the past week and 76.4% (42/55) of respondents required treatment for musculoskeletal pain and injuries: 63.6% had taken over the counter pain medication, 10.9% had taken prescription pain medication, 25.5% required physical therapy, 14.5% required orthopedic surgery, 23.6% made an appointment with a specialist, and 21.8% required additional testing (i.e., imaging, labs). Interestingly, treatment utilization overall and by modality was similar between residents and attending surgeons.

CONCLUSIONS

Our study mirrors the high prevalence of musculoskeletal pain in surgeons that has been previously reported in the literature. Among survey respondents, 76.5% of surgeons and 76.2% of residents required some form of treatment. These findings suggest a significant burden of musculoskeletal disorders of likely multifactorial etiologies including operating room ergonomics. Therefore, comprehensive ergonomics programs to measure, prevent, and treat musculoskeletal injury may help to fulfill a compelling need to ensure health and career longevity of the surgical workforce.

Building Approachable Surgical Experiences (BASE) in High School Populations

OBJECTIVE

Pipeline programs are often set up to bring more diverse candidates to medical schools with the goal of diversifying the physician workforce in the years to come. All too often, these programs begin in college, long after many students of diverse backgrounds have been left behind through a myriad of barriers that exist between entering high school and matriculating to medical school. The Building Approachable Surgical Experiences (BASE) outreach program was designed to showcase healthcare careers, with an emphasis on surgical subspecialties, to historically underserved high school students. This pilot program's goal was to increase high school students' interest and confidence in pursuing future medical and surgical careers and provide a platform to initiate mentorship.

DESIGN

Local high school students from underrepresented in medicine (URiM) populations or medically underserved communities were invited to spend the day at an academic medical school campus. These students engaged in hands-on clinical and basic operative skill workshops led by third- and fourth-year medical students. They also engaged in small group conversations centered on mentorship with surgical residents and faculty.

SETTING

Program implementation took place at an academic medical center school of medicine in an urban city.

PARTICIPANTS

Forty high school students, 16 medical students, and 2 surgery faculty participated in this pilot program.

CONCLUSIONS

This event allowed early exposure for high school students to surgical and medical specialties, clinical techniques, and surgical mentorship. From the connections made, students have developed mentorship relationships and have felt comfortable reaching out with questions regarding the steps required to seek entrance to medical school. Mentors are currently resident or attending physicians, which provides students from underrepresented populations an opportunity for direct insight and guidance to and through the path to becoming a physician. Based on qualitative feedback from students, their high school teachers, and administrators, this pilot program succeeded in providing a window into healthcare, using a format that was encouraging to students long beyond their time on the school of medicine campus.

Advocacy for Diversity in Hand Surgery

Diversity in the Hand Surgery workforce improves the quality of care delivered, advances a wider variety of innovation within the field and leads to higher patient satisfaction, greater access to care and patient adherence to advice. An understanding of the data makes a compelling argument for change. Advocacy is necessary to stop the "leaky pipeline" of the loss of diversity in more senior and leadership roles. Hand surgeons who are both women and from underrepresented minority groups are especially vulnerable to bias from the health-care system, with focused support and mentoring required throughout their training and career.

Gender trends in applicants to general surgery residency programs in Canada

BACKGROUND

Surgical disciplines lag behind non-surgical disciplines in attracting female trainees. Female representation of Canadian General Surgeons has not been evaluated in recent years in the literature. The objectives of this study were to assess gender trends in applicants to Canadian General Surgery residency programs and practicing general surgeons and subspecialists.

METHODS

This retrospective cross-sectional study analyzed gender data for residency applicants ranking General Surgery as their first-choice discipline from publicly-available annual Canadian Residency Matching Service (CaRMS) R-1 match reports from 1998 to 2021. Aggregate gender data for practicing female physicians in General Surgery and related subspecialties, including Pediatric Surgery, obtained from annual Canadian Medical Association (CMA) census from 2000 to 2019 was also analysed.

RESULTS

There was a significant increase in the proportion of female applicants from 34% in 1998 to 67% in 2021 (p < 0.001) and of successfully matched candidates from 39% to 68% (p = 0.002) from 1998 to 2021. Success rates between male and female candidates were significantly different in 1998 (p < 0.001), but not in 2021 (p = 0.29). The proportion of practicing female General Surgeons also significantly increased from 10.1% in 2000 to 27.9% in 2019 (p = 0.0013), with variable trends in subspecialties.

CONCLUSION

Gender inequality in General Surgery residency matches has normalized since 1998. Despite females representing more than 40% of applicants and successfully matched candidates to General Surgery since 2008, a gender gap still exists amongst practicing General Surgeons and subspecialists. This suggests the need for further cultural and systemic change to mitigate gender disparities.

TYPE OF STUDY

Original research article, clinical research.

LEVEL OF EVIDENCE

Level III (Retrospective cross-sectional study).

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.

An Analysis of Underrepresented in Medicine Away Rotation Scholarships in Surgical Specialties

BACKGROUND

Underrepresented in medicine (UIM) visiting student clerkship scholarships provide an opportunity for supporting diversity. Although these scholarships have become a popular initiative to recruit diverse surgical applicants, they have not been thoroughly analyzed regarding which programs offer scholarships and the characteristics of the scholarships. UIM scholarship opportunity disparities may exist depending on location, funding, reputation, and program size among different specialties.

OBJECTIVE

To describe the characteristics and prevalence of UIM visiting student scholarships by examining institutional and program websites for the surgical specialties.

METHODS

Using the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System for 2021, residency training and diversity websites were identified and evaluated for the availability of UIM visiting student scholarships in July 2021. Eight surgical specialties were examined. Scholarships were categorized by how UIM was defined, the funding amount provided, and scholarship application requirements. We analyzed the association of the program's National Institutes of Health funding, size, type, region, reputation, and population density of the program's area via Doximity on scholarship availability using chi-square and multivariate analysis.

RESULTS

Of the 1058 analyzed programs, 314 (29.7%) had a UIM visiting student scholarship. There were 4 different definitions of UIM used among the analyzed programs. The average scholarship amount offered was $1,852.25 ($500-$4,000). Depending on the specialty, different variables were associated with whether a program had a UIM scholarship.

CONCLUSIONS

Currently, UIM scholarship offerings were variable between programs and surgical specialties.

Diversity in surgery: the perceptions of aspiring surgeons

Background/Aims

This study aimed to explore definitions of diversity, and views and attitudes towards diversity in healthcare among future generations of surgical trainees.

Methods

This was a prospective, cohort study via an online questionnaire during a virtual, nationwide surgical course, targeted at aspiring surgeons.

Results

Out of 202 participants, 166 met the inclusion criteria. Participants' definitions of diversity most frequently included race, gender and ethnicity, with fewer than 50.0% recognising pregnancy, communication style or political preference in their definition. Of the respondents, 56.0% (93/166) believed that the surgical community did not do enough to encourage diversity. The rising cost of training, lack of diverse role models and dated ideologies were identified as barriers to achieving greater diversity within surgery.

Conclusions

Important components of diversity continue to be under-recognised. Surgery must maximise diversity to attract, support and motivate the next generation of surgeons, for the benefit of the health service and the populations it serves.

Does Diversity of Authorship Matter? An Analysis of Plastic Surgery's Top 100 Articles

Diversity, whether related to age, gender, ethnicity, race, geography, or experience, is increasing in all realms of medicine, including plastic surgery. Research has also become more diverse in those who conduct studies and those who participate in them. Fittingly, surgeons who produce prominent research are likely to come from diverse backgrounds. This study was designed to analyze the diversity of authorship in peer-reviewed plastic surgery journals.

Diversity, Equity, and Inclusion: A Current Analysis of General Surgery Residency Programs

BACKGROUND

Local, regional, and national diversity, equity, and inclusion (DEI) initiatives have been established to combat barriers to entry and promote retention in surgery residency programs. Our study evaluates changes in diversity in general surgery residency programs. We hypothesize that diversity trends have remained stable nationally and regionally.

MATERIALS AND METHODS

General surgery residents in all postgraduate years were queried regarding their self-reported sex, race, and ethnicity following the 2020 ABSITE. Residents were then grouped into geographic regions. Data were analyzed utilizing descriptive statistics, Kruskal-Wallis test, and chi-square analyses.

RESULTS

A total of 9276 residents responded. Nationally, increases in female residents were noted from 38.0 to 46.0% (P < .001) and in Hispanic or Latinx residents from 7.3 to 8.3% (P = .031). Across geographic regions, a significant increase in female residents was noted in the Northwest (51.9 to 58.3%, P = .039), Midwest (36.9 to 43.3%, P = .006), and Southwest (35.8 to 47.5%, P = .027). A significant increase in black residents was only noted in the Northwest (0 to 15.8%, P = .031). The proportion of white residents decreased nationally by 8.9% and in the Mid-Atlantic, Southeast, and Southwest between 5.5 and 15.9% (P < .05).

DISCUSSION

In an increasingly diverse society, expanding the numbers of underrepresented surgeons in training, and ultimately in practice, is a necessity. This study shows that there are region-specific increases in diversity, despite minimal change on a national level. This finding may suggest the need for region-specific DEI strategies and initiatives. Future studies will seek to evaluate individual programs with DEI plans and determine if there is a correlation to changing demographics.

Experiences and Perceptions of Gender Discrimination and Equality among Korean Surgeons: Results of a Survey of the Korean Surgical Society

BACKGROUND

Previous studies that have focused on the challenges faced by female surgeons, such as the gender pay gap, gender biases, lower likelihood of promotion, and gender differences in the perception of discrimination against women, are reviewed. A more comprehensive understanding of explicit and implicit gender discrimination and experiences and perceptions of discrimination is needed. This study aims to determine the current prevalence and degree of gender discrimination in the Korean Surgical Society and to compare the experiences and perceptions of gender discrimination between male and female surgeons.

METHODS

We analyzed 400 responses from a survey sent to all members of the Korean Surgical Society. This electronic survey included 16 items on experiences of gender discrimination and 17 items on perceptions of gender discrimination. We conducted χ² tests and binary logistic regression on the data regarding these experiences and perceptions of gender discrimination.

RESULTS

Adjusted analyses found that female surgeons were more likely to experience gender discrimination than their male counterparts across all categories of discrimination. Further, adjusted analyses showed that female surgeons were more likely to confirm the presence of gender discrimination than male surgeons.

CONCLUSION

Female surgeons were more likely to experience implicit and explicit gender biases and discrimination throughout all stages of their career progression. We also discovered significant gender differences in the perception of gender discrimination, as well as the experience of it. Changing the male-dominated culture and raising awareness of gender biases and discrimination among male surgeons are crucial steps toward addressing gender discrimination in surgery.

Diversity Matters: A 21-Year Review of Trends in Resident Recruitment into Surgical Specialties

Background

Diversity within the healthcare workforce is essential to improve quality of care, although evaluation of diversity within surgical training remains limited. This study analyzed diversity in recruitment of residents into surgical subspecialties at a large academic medical institution and national trends.

Methods

A 21-year cross-sectional study of medical school graduates accepted into all surgical subspecialty training programs was performed. The institutional cohort was divided into two groups (1997-2006, 2007-2017). Subspecialty acceptance rates were determined between 2011 and 2018. Data on candidate demographics including gender, race, ethnicity, citizenship, and origin of medical education at a single institution and nationally were extracted.

Results

Two thousand found hundred seventy-two residents were included in this study. From 1997 to 2018, female acceptances increased from 21.1% to 29.7% (p < 0.01), non-White increased from 27.9% to 31.8% (p = 0.01), and international medical graduates decreased from 28.8% to 25.5% (p = 0.02). There was no significant change in accepted Hispanic and Non-US candidates. Female subspecialty rates for subspecialties increased nationally and was comparable to our cohort, except in general surgery. Hispanic subspecialty acceptance rates were less than 10% and Black/African American acceptance rates remained less than 5% across subspecialties nationally and at our institution.

Conclusion

Diversity in surgical training has modestly progressed over the last two decades, but the degree of positive change has not been universal and highlights the critical need for improvement and action. Continued institution driven and collaborative strategies are essential to promote diversity in recruitment across all surgical specialties that has implications on our future workforce and surgical leadership.

National Trends in Gender Diversity Among Trainees and Practicing Physicians in Otolaryngology-Head and Neck Surgery in Canada

Importance

Monitoring the evolution of gender diversity within medicine is essential to understanding the medical workforce and anticipating its future.

Objective

To evaluate gender distribution and trends among trainees and practicing physicians in the field of otolaryngology-head and neck surgery (OHNS) across Canada.

Design, Setting, and Participants

This cross-sectional study collected demographic data on the Canadian population, medical students, resident physicians, fellows, practicing physicians, and full-time professors from the following publicly available databases: the Canadian Post-MD Education Registry, the Canadian Medical Education Statistics from the Association of Faculties of Medicine of Canada, the Canadian Medical Association Masterfile, the Canadian Resident Matching Service archives, and the Canadian Institute for Health Information from 2000 to 2019. Information about the gender distribution in leadership positions and fellowships was obtained through publicly available websites where gender was either listed or assigned by authors.

Main Outcomes and Measures

The primary outcomes were the proportion of women in OHNS and the evolution of gender diversity over time.

Results

In 2019, 65 of 155 of OHNS trainees were female (41.9%), whereas female representation among all surgical trainees combined was 1225 of 2496 (49.1%). Female OHNS trainees and practicing physicians are underrepresented despite a 13.3% increase in female trainees and a 14.3% increase in female staff physicians from 2000 to 2019. Proportionally fewer female graduates pursued a fellowship during a 10-year period compared with their male counterparts, with otology and neurotology having the lowest female representation (6 of 27 [22.2%]). A minimal increase occurred in the number of women holding academic leadership positions (eg, 4 of 13 residency training programs had a previous or current female director).

Conclusions and Relevance

Despite the overall increase in the representation of women in the field of OHNS in Canada, these findings suggest that persistent gender gaps remain with respect to academic leadership positions and fellowship training. Continuous monitoring of the surgical workforce is important to highlight and address gender disparities within OHNS.

Transplant surgery departmental leaders do not represent workforce demographics especially among women and underrepresented minorities - A retrospective analysis

INTRODUCTION

The diversity among surgical directors for liver, kidney, and pancreas transplant departments has not been previously evaluated. We aim to quantify the sex and racial demographics of transplant department leaders and assess the impact on patient outcomes.

METHODS

Demographics were collected for 116 liver, 192 kidney, and 113 pancreas transplant directors using Organ Procurement and Transplantation Network (OPTN) directory and program websites. Scientific Registry of Transplant Recipients (SRTR) 5-tier program outcomes rankings were obtained for each program and matched to leader demographics. A retrospective analysis of transplant recipients from 2010 to 2019 was performed using the United Network for Organ Sharing (UNOS) database.

RESULTS

91.5% of transplant surgical directors were male. 55% of departments had a Non-Hispanic White leader. Asian, Hispanic and Black transplant chiefs were at the helm of 23.3%, 9%, and 5% of divisions respectively. Multivariate cox regression analysis did not identify any differences in patient outcomes by transplant director demographics.

CONCLUSION

There is a paucity of female and URM leaders in transplant surgery. Initiatives to promote research, mentorship, and career advancement opportunities for women and URM are necessary to address the current leadership disparity.

Gender and racial disparities in the transplant surgery workforce

PURPOSE OF REVIEW

This review explores trends in the United States (US) transplant surgery workforce with a focus on historical demographics, post-fellowship job market, and quality of life reported by transplant surgeons. Ongoing efforts to improve women and racial/ethnic minority representation in transplant surgery are highlighted. Future directions to create a transplant workforce that reflects the diversity of the US population are discussed.

RECENT FINDINGS

Representation of women and racial and ethnic minorities among transplant surgeons is minimal. Although recent data shows an improvement in the number of Black transplant surgeons from 2% to 5.5% and an increase in women to 12%, the White to Non-White transplant workforce ratio has increased 35% from 2000 to 2013. Transplant surgeons report an average of 4.3 call nights per week and less than five leisure days a month. Transplant ranks 1st among surgical sub-specialties in the prevalence of three well-studied facets of burnout. Concerns about lifestyle may contribute to the decreasing demand for advanced training in abdominal transplantation by US graduates.

SUMMARY

Minimal improvements have been made in transplant surgery workforce diversity. Sustained and intentional recruitment and promotion efforts are needed to improve the representation of women and minority physicians and advanced practice providers in the field.

Diversity and Inclusion: A Review of Effective Initiatives in Surgery

OBJECTIVE

Surgery lacks women and racial minorities that are underrepresented in medicine (UIM). This systematic review evaluates interventions used to promote diversity in surgery.

DESIGN

The PubMed (MEDLINE), EMBASE, and Cochrane databases were searched for studies (1) describing interventions for increasing UIM and gender diversity, (2) within surgery, and (3) targeting any learner prior to residency.

SETTING

Nine surgical specialties were searched: general, neurosurgery, plastics, orthopedics, otolaryngology, urology, cardiothoracic, vascular, and ophthalmology.

RESULTS

Of the 982 studies identified, 16 were included. Awards, clerkships, and workshops were each described by three studies; awards funded research or travel to national meetings, clerkships referred to a third- or fourth-year rotation that provided exposure to surgery, and workshops were hands-on skills sessions for learners. Two studies proposed a holistic review of residency applications, which involves emphasizing an individual's attributes and life experiences rather than strictly academics. Two studies detailed a longitudinal mentoring program comprised of mentorship throughout medical school plus opportunities for research, lectures, and workshops. One study described a combination of interventions and the remaining 2 presented interventions that were characterized as "other." Longitudinal mentoring programs significantly increased the likelihood of women and UIM applying to surgical residency, while holistic review significantly increased the numbers of women and UIM being interviewed and ranked by residency programs. One award increased the number of female residents matriculating into surgical residency. Clerkships significantly increased the number of women applying to surgical residency. The mere mention of diversity initiatives on a program's website was associated with more female surgical residents, but not UIM residents. Workshops led to a higher, but not statistically significant, proportion of women applying to surgery.

CONCLUSION

Holistic review and longitudinal mentoring programs are the most effective interventions for increasing UIM and female representation among surgical trainees.

Women in Leadership and Their Influence on the Gender Diversity of Academic Plastic Surgery Programs

BACKGROUND

Women seldom reach the highest leadership positions in academic plastic surgery. Contributing factors include lack of female role models/mentors and lack of gender diversity. Studies show that female role models and mentors are critical for recruiting and retaining female surgeons and that gender diversity within organizations more strongly influences women's career choices. The authors therefore sought to determine the current gender diversity of academic plastic surgery programs and investigate influences of gender and leadership on program gender composition.

METHODS

A cross-sectional study of U.S. plastic surgery residency programs was performed in December of 2018. Genders of the leadership were collected, including medical school dean, department of surgery chair, department/division of plastic surgery chair/chief, plastic surgery program director, plastic surgery faculty, and plastic surgery residents. Gender relationships among these groups were analyzed.

RESULTS

Ninety-nine residency programs were identified (79 integrated with or without independent and 20 independent). Women represented a smaller proportion of academic plastic surgeons in more senior positions (38 percent residents, 20 percent faculty, 13 percent program directors, and 8 percent chairs). Plastic surgery chair gender was significantly correlated with program director gender, and plastic surgery faculty gender was significantly associated with plastic surgery resident gender. Although not statistically significant, female plastic surgery chair gender was associated with a 45 percent relative increase in female plastic surgery residents.

CONCLUSIONS

Women in leadership and gender diversity influence the composition of academic plastic surgery programs. Gender disparity exists at all levels, worsening up the academic ladder. Recruitment, retention, and promotion of women is critical, as such diversity is required for continued progress in innovation and problem-solving within plastic surgery.

Trending diversity: Reviewing four-decades of graduating fellows and the current leadership in pediatric surgery

PURPOSE

Diversity in the physician workforce remains a priority in healthcare as it has been shown to improve outcomes. Decisions for choosing specific fields in medicine are partly influenced by mentors, which tend to be the same sex or ethnicity. Females are starting to outnumber males in medical school and minorities are targeted for recruitment. We hypothesized that diversity in pediatric surgery has increased over time.

METHODS

The recently published A Genealogy of North American Pediatric Surgery was utilized to identify graduating pediatric surgery fellows from 1981 to 2018. Organization websites were used to identify past and current leaders. A web-based analysis, including online facial recognition software, was performed. A year-to-year and decade-to-decade demographic comparison was completed.

RESULTS

1217 pediatric surgery fellows graduated between 1981 and 2018. When comparing graduates from the first and last decades, an increase from 16.9% to 39.5% for female graduates was observed (p = 0.046). A significant increase in nonwhite graduates was seen for all races (p < 0.05). Representation in leadership was White and male dominant.

CONCLUSION

There was a significant increase in diversity in pediatric surgery fellowship graduates. There were increasing trends in female graduates and all nonwhite racial groups. Focusing on enhancing the pipeline and mentoring underrepresented minorities will continue to enhance this trend for the field of pediatric surgery.

LEVEL OF EVIDENCE

III; Retrospective Review.

The evolving sex, race, and ethnic composition of the surgical workforce: North Carolina is a bellwether of national change

BACKGROUND

North Carolina, as a state with a significant Black population and fast-growing Hispanic population, serves as bellwether of demographic changes nationally and the challenges facing the nation to recruit and retain a general surgery workforce that mirrors the population.

METHODS

Annual licensure data from the North Carolina Medical Board were analyzed between 2004 and 2019. Physicians self-reporting a specialty of abdominal surgery, critical care surgery, colon and rectal surgery, general surgery, trauma surgery, proctology, and surgical oncology were categorized as general surgeons.

RESULTS

Female surgeons made the most gains from 2004, at just 8% of the workforce in 2004 to 26% of the workforce in 2019. Over the same period, Black surgeons increased from just 5% to 6% of the workforce, with those gains largely represented by Black female surgeons. Almost half of North Carolina's Black physicians are aged 46 and 55 and will be nearing retirement in the coming decade. Nearly two-thirds (64%) of Hispanic general surgeons were 45 or younger, and one-third of these young surgeons were international medical graduates.

CONCLUSION

Although the general surgery workforce in North Carolina is slowly diversifying, growth in the Black surgeon workforce has stagnated in the last 15 years at levels much lower than their representation in the population. More research is needed on the individual and life course phenomena that drive this underrepresentation.

An Approach to Diversity and Inclusion in Cardiothoracic Surgery

EXECUTIVE SUMMARY

While the United States (US) population at large is rapidly diversifying, cardiothoracic surgery is among the least diverse specialties in terms of racial and gender diversity. Lack of diversity is detrimental to patient care, physician well-being, and the relevance of cardiothoracic surgery on our nation's health. Recent events, including the coronavirus disease 2019 pandemic and the Black Lives Matter protests, have further accentuated the gross inequities that underrepresented minorities face in our country and have reignited conversations on how to address bias and systemic racism within our institutions. The field of cardiothoracic surgery has a responsibility to adopt a culture of diversity and inclusion. This kind of systemic change is daunting and overwhelming. With bias ubiquitously entangled with everyday experiences, it can be difficult to know where to start. The Society of Thoracic Surgeons Workforce on Diversity and Inclusion presents this approach for addressing diversity and inclusion in cardiothoracic surgery. This framework was adapted from a model developed by the National Institute on Minority Health and Health Disparities and includes information and recommendations generated from our literature review on diversity and inclusion. A MEDLINE search was conducted using keywords "diversity," "inclusion," and "surgery," and approaches to diversity and inclusion were drawn from publications in medicine as well as non-healthcare fields. Recommendations were generated and approved by The Society of Thoracic Surgeons Executive Committee. We present an overarching framework that conceptualizes diversity and inclusion efforts in a series of concentric spheres of influence, from the global environment to the cardiothoracic community, institution, and the individual surgeon. This framework organizes the approach to diversity and inclusion, grouping interventions by level while maintaining a broader perspective of how each sphere is interconnected. We include the following key recommendations within the spheres of influence: It is important to note that each of the spheres of influence is interconnected. Interventions to improve diversity must be coordinated across spheres for concerted change. Altogether, this multilevel framework (global environment, cardiothoracic community, institution, and individual) offers an organized approach for cardiothoracic surgery to assess, improve, and sustain progress in diversity and inclusion.

Gender and ethnic diversity in academic general surgery department leadership

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intersectionality of Gender and Visible Minority Status Among General Surgery Residents in Canada

Importance

Within medical specialties, surgical disciplines disproportionately and routinely demonstrate the greatest underrepresentation of women and individuals from racial/ethnic minority groups. Understanding the role that diversity plays in surgical resident training may identify strategies that foster resident resiliency, optimize surgical training, and improve patient outcomes.

Objective

To examine the implication of gender and visible minority (VM [ie, nonaboriginal people who are not White individuals]) status for resiliency and training experiences of general surgery residents in Canada.

Design, Setting, and Participants

In this survey study, a 129-item questionnaire was emailed from May 2018 to July 2018 to all residents enrolled in all Canadian general surgery training programs during the 2017-2018 training year. Survey responses were extracted and categorized into 5 major themes. The survey was designed by the Resident Committee and reviewed by the Governing Board of the Canadian Association of General Surgeons. French and English versions of the survey were created, distributed, and administered using Google Forms.

Main Outcomes and Measures

Survey questions were formulated to characterize resident diversity and training experience. Self-perceptions of diversity, mentorship, and training experience were evaluated using a 5-point Likert scale (1 for strongly disagree, 2 for disagree, 3 for neither agree or disagree, 4 for agree, and 5 for strongly agree) and open-ended responses. The frequency of perceived unprofessional workplace encounters was evaluated using a 5-point scale (1 for daily, 2 for weekly, 3 for monthly, 4 for annually, and 5 for never).

Results

Of the 510 general surgery residents invited, a total of 210 residents (40.5%) completed the survey. Most respondents were younger than 30 years (119 [56.7%]), were women (112 [53.3%]), reported English as their first language (133 [63.3%]), did not identify as a VM (147 [70.0%]), had no dependents (184 [87.6%]), and were Canadian medical graduates (178 [84.8%]). Women residents who identified as VM compared with male residents who did not identify as a VM were less likely to agree or strongly agree that they had a collegial relationship with staff, (21 [63.6%] vs 61 [89.7%]; P = .01), to feel like they fit in with their training programs (21 [63.6%] vs 56 [82.3%]; P = .003), and to feel valued at work (15 [45.4%] vs 47 [69.1%]; P = .03). Both female residents and female residents who identified as VM described significant concerns about receiving fewer training opportunities because of their gender vs their male peers (54 [48.2%] vs 3 [3.0%]; P < .001). Ninety-one of 112 female residents (81.2%) reported feeling that their medical expertise was dismissed because of their gender at least once annually, with 37 women (33.0%) experiencing dismissal of their expertise at least once every week (P < .001). In contrast, 98% of male residents reported never experiencing dismissal of their medical expertise because of their gender. Similarly, residents with VM status vs those without VM status reported at least monthly dismissal of their expertise because of their race/ethnicity (9 of 63 [14.3%] vs 1 of 147 [0.7%]; P < .001).

Conclusions and Relevance

In this study, female sex and VM status appeared to be associated with adverse implications for the training experience of general surgery residents. These findings suggest that new strategies focused on the intersectionality of gender and race/ethnicity are needed to improve the training experience of at-risk residents.

Medical Student Values Inform Career Plans in Service & Surgery-A Qualitative Focus Group Analysis

BACKGROUND

Diversifying the surgical workforce is a critical component of improving care for underserved patients. To recruit surgeons from diverse backgrounds, we must understand how medical students choose their specialty. We investigate how preclinical students contemplate entering a surgical field.

MATERIALS AND METHODS

We conducted semistructured focus groups during two iterations of a seminar class called Service Through Surgery. Discussion goals included identifying student values and assessing how they inform early career decisions. We used a systematic, collaborative, and iterative process for transcript analysis, including developing a codebook, assessing inter-rater reliability, and analyzing themes.

RESULTS

Twenty-four preclinical medical students from diverse backgrounds participated in seven focus groups; most were women (16; 67%), in their first year of medical school (19; 79%), and interested in surgery (17; 71%). Participants ranked professional fulfillment, spending time with family, and serving their communities and/or underserved populations among their most important values and agreed that conducting groundbreaking research, working long hours, and finding time for leisure activities were the least important. We constructed a framework to describe student responses surrounding their diverse visions for service in future surgical careers through individual doctoring interactions, roles in academia, and broader public service.

CONCLUSIONS

Our framework provides a basis for greater understanding and study of the ways in which preclinical medical students think about their personal values and visions for service in potential future surgical careers. This research can guide early interventions in medical education to promote diversity and care for the underserved in surgery.

Women Continue to Be Underrepresented in Surgery: A Study of AMA and ACGME Data from 2000 to 2016

OBJECTIVE

In the past decade women have comprised nearly half of U.S. medical school graduates. However, women remain underrepresented among surgical residents and practicing surgeons. We conducted the current study to assess recent trends in the female-to-male (F:M) ratios among residents and physicians pursuing careers in surgery.

DESIGN

We used retrospective population statistics published by the American Medical Association and the Accreditation Council for Graduate Medical Education from 2000 to 2016. We compared trends of female-to-male ratios among residents and surgeons in surgical subspecialties to evaluate for potential differences over time.

SETTING

Published online population statistics.

PARTICIPANTS

We stratified both board-certified surgeons and surgical residents by sex and specialty.

RESULTS

From 2000 to 2013, the proportion of female surgeons among all female physicians remained constant (12%-13%). The proportion of board-certified female surgeons to all surgeons increased (from 15% in 2000 to 25% in 2013). The F:M ratios of board-certified surgeons in neurosurgery and orthopedic surgery were 1:10.6 and 1:13.9, with resident ratios 1:4.8 and 1:5.9, respectively. One specialty with increasingly equivalent ratios is plastic surgery with integrated resident F:M ratios of 1:3.1 in 2008 to 1:1.4 in 2015, and board-certified plastic surgeons of 1:9.2 in 2008 to 1:5.3 in 2013.

CONCLUSION

Although the gender gap is narrowing, women continue to be underrepresented in surgical specialties. It is important for fields with disproportionate representation to be aware of these differences and take steps toward creating and supporting a more diverse workforce.