Persistent racial discrimination among vascular surgery trainees threatens wellness

The impact of intersectionality on the experience of medical trainees

Diverse trainees have different training experiences than non-diverse trainees; however, it has not been demonstrated if the number of diverse traits (DTs) (i.e. intersectionality) contributes to worse experiences. Our objective was to understand if the number of DTs a trainee has impacts their training experience. We distributed a survey to medical trainees at Mass General Brigham from 15/12/23 to 15/4/24. DTs were based on race/ethnicity, gender-identity, sexual orientation, birthplace, disability, and highest parental education. A total of 134 responses were obtained. Respondents with 1 DT were more likely to report dissatisfaction with the quality of their training compared to those with 0 DT (P = 0.03). However, this did not remain true for those with 2 or 3+ DT (P = 0.39, P = 0.59). Only respondents with 1 DT disagreed that they had similar opportunities for academic success to those of their peers (P = 0.03) and agreed that they had to work harder than others to be valued equally (P < 0.01). Respondents with 3+ DTs felt that their institution was not diverse (P < 0.01) and racist (P < 0.01) compared to respondents with zero DTs. Therefore, trainees with DTs had different training experiences than trainees with zero DTs, but the number of DTs did not consistently correlate with the quality of their experience. We believe this data is important for administrators to understand how intersectionality effects the trainee experience. Additionally, we believe this data can be used to gauge disparities in education and create an avenue to address issues, such as discrimination, microaggressions, and low retention rate of diverse applicants.

A multi-institutional study from the United States Resident OPerative Experience Consortium examining factors influencing vascular surgery specialization among general surgery residents

OBJECTIVE

There remains a progressive projected deficit in the vascular surgery (VS) workforce for decades. Despite the expanding integrated VS residency pathway, the fellowship training model remains critical in supporting our future workforce. Therefore, it is imperative to understand the resident and program-specific factors that influence VS specialization among general surgery (GS) residents.

METHODS

Data from the United States Resident OPerative Experience (ROPE) Consortium, which comprises 20 Accreditation Council for Graduate Medical Education-accredited GS residency programs across the United States, were queried for resident demographics and residency program-related details. Logistic regression analysis was used to identify factors associated with VS specialization.

RESULTS

From 2010 to 2020, a total of 1343 graduating GS residents were included in the study. Of these, 135 (10.1%) pursued VS fellowship training. Residents pursuing VS were more frequently male (80.7% vs 62.8%; P < .0001) and younger (median age, 32 vs 33 years; P = .03) compared with other GS residents. Racial and ethnic group, underrepresented in medicine status, and international medical graduate status were similar between the VS and non-VS groups. Residency program-level details were also similar between groups, including program type (university vs community-based), region, size, resident volume, dedicated research experience, and National Institutes of Health funding. Dedicated vascular rotations were common among all GS programs (95.4%), and total months spent on a VS rotation (median, 4 vs 4.5 months; P = .11) did not differ among residents pursuing VS and all other residents. The presence of a collocated traditional (5 + 2) VS fellowship (91.1% vs 90.4%; P = .79) or integrated (0 + 5) VS residency (56.3% vs 55.0%; P = .77) were also similar between groups. On multivariate analysis, only male sex (odds ratio, 2.34; 95% confidence interval, 1.50-3.81; P < .001) was associated with pursuing VS fellowship. Factors that did not impact VS specialization included resident age, underrepresented in medicine status, international medical graduate status, program volume, dedicated research experience, or total months spent on a VS rotation.

CONCLUSIONS

In this multi-institutional study, we did not find any program-specific factors that influence VS specialization among GS residents. Notably, the presence of a collocated 0 + 5 residency or 5 + 2 fellowship program did not appear to deter GS residents from pursuing a VS fellowship. These data suggest that individual factors, such as mentorship, may be more impactful in recruiting GS residents to the VS specialty.

Burnout is not associated with trainee performance on the Vascular Surgery In-Training Exam

OBJECTIVE

The Vascular Surgery In-Training Examination (VSITE) is a yearly exam evaluating vascular trainees' knowledge base. Although multiple studies have evaluated variables associated with exam outcomes, few have incorporated training program-specific metrics. The purpose of this study is to evaluate the impact of the learning environment and burnout on VSITE performance.

METHODS

Data was collected from a confidential, voluntary survey administered after the 2020 to 2022 VSITE as part of the SECOND Trial. VSITE scores were calculated as percent correct then standardized per the American Board of Surgery. Generalized estimating equations with robust standard errors and an independent correlation structure were used to evaluate trainee and program factors associated with exam outcomes. Analyses were further stratified by integrated and independent training paradigms.

RESULTS

A total of 1385 trainee responses with burnout data were collected over 3 years (408 in 2020, 459 in 2021, 498 in 2022). On average, 46% of responses reported at least weekly burnout symptoms. On unadjusted analysis, burnout symptoms correlated with a 14 point drop in VSITE score (95% confidence interval [CI], -24 to -4; P = .006). However, burnout was no longer significant after adjusted analysis. Instead, higher postgraduate year level, being in a relationship, identifying as male gender with or without kids, identifying as non-Hispanic white, larger programs, and having a sense of belonging within a program were associated with higher VSITE scores.

CONCLUSIONS

Despite high rates of burnout, trainees generally demonstrate resilience in gaining the medical knowledge necessary to pass the VSITE. Performance on standardized exams is associated with trainee and program characteristics, including availability of support systems and program belongingness.

Examiner-examinee gender concordance does not impact ratings on the American Board of Surgery Vascular Surgery Certifying Examination

OBJECTIVE

Implicit bias is a potential factor in the severity of examinee rating during oral examinations. Ratings may be impacted by examinee characteristics, such as gender, that are independent of examinee knowledge base, clinical judgment, or test-taking ability. The effects of examiner-examinee gender concordance in the Vascular Surgery Certifying Examination (VCE) have not been previously studied. We explored whether examiner ratings and likelihood of passing the examination were influenced by gender concordance among examiners and examinees.

METHODS

Data collected from examinees who first attempted the VCE between 2018 and 2023 were analyzed. There were 1005 examinees (69.3% male and 30.1% female) and 121 examiners (71.9% male, and 28.1% female). Linear mixed-effects models and generalized linear mixed-effects models were used to evaluate the effects of examinee and examiner gender on VCE ratings and likelihood of passing the examination.

RESULTS

Examiner-examinee gender concordance had no significant impact on examiner ratings or likelihood of passing the examination. In addition, examinee gender alone had no significant impact on VCE rating or pass rates. Only Vascular Qualifying Examination scores explained more than 1% of the variance in total VCE scores for the gender model (F(1, 1003.5) = 71.08, P < .01, R2 = 3%). Vascular Qualifying Examination scores were positively related to total VCE scores.

CONCLUSIONS

Although implicit bias has the potential to impact examiner scoring, there is no evidence that this is the case with respect to gender in the VCE of the American Board of Surgery.

The Diversity of Surgical Trainees Index identifies racial and ethnic disparities among surgical specialties

OBJECTIVE

Racial and ethnic disparities have been well-described among surgical specialties; however, variations in underrepresented in medicine (URiM) representation between these specialties have not previously been quantified.

METHODS

Data collected from Accreditation Council for Graduate Medical Education (ACGME) annual reports were used to derive the Diversity of Surgical Trainee Index (DoSTI), which was calculated as the proportion of URiM residents and fellow physicians within a given surgical specialty, relative to the overall proportion of URiM trainees within all surgical and non-surgical ACGME-accredited programs in the same academic year.

RESULTS

From 2013 to 2022, a total of 108,193 ACGME-accredited residency programs trained 1,296,204 residents and fellows in the United States. Of these, 14.1% (n = 182,680) of trainees self-identified as URiM over the study period. The mean DoSTI among all surgical specialties was 0.80 (standard error, 0.01) compared with all ACGME-accredited programs. High DoSTI specialties incorporated significantly higher proportions of trainees who identify as Hispanic (8.7% vs 6.3%) and Black or African American (5.2% vs 2.5%) when compared with low DoSTI specialties (P < .0001 each). General surgery (1.06 ± 0.01), plastic surgery (traditional) (1.12 ± 0.06), vascular surgery (integrated) (0.96 ± 0.03), and vascular surgery (traditional) (0.94 ± 0.06) had the highest DoSTI (P < .05 each vs composite). On linear regression analysis, only ophthalmology (+0.01/year; R2 = 0.41; P = .019), orthopedic surgery (+0.01/year; R2 = 0.33; P = .047), otolaryngology (+0.02/year; R2 = 0.86; P < .001), and pediatric surgery (+0.06/year; R2 = 0.33; P = .048) demonstrated an annual increase in DoSTI.

CONCLUSIONS

The DoSTI is a novel metric used to quantify the degree of URiM representation among surgical specialties. DoSTI has revealed specialty-specific variations in racial/ethnic minority representation among surgical training programs. This metric may be used to improve provider awareness and identify high performing DoSTI specialties to highlight best practices to ultimately recruit a more diverse surgical workforce.

Perception of shared learning environment differs between vascular surgery and general surgery residents

BACKGROUND

An enriching learning environment is integral to resident wellness and education. Integrated vascular (VS) and general surgery (GS) residents share 18 months of core GS rotations during the postgraduate years 1-3 (PGY1-3); differences in their experiences may help identify practical levers for change.

METHODS

We used a convergent mixed-methods design. Cross-sectional surveys were administered after the 2020 American Board of Surgery In-Training Examination and Vascular Surgery In-Training Examination, assessing eight domains of the learning environment and resident wellness. Multivariable logistic regression models identified factors associated with thoughts of attrition between categorical PGY1-3 residents at 57 institutions with both GS and VS programs. Resident focus groups were conducted during the 2022 Vascular Annual Meeting to elicit more granular details about the experience of the learning environment. Transcripts were analyzed using inductive and deductive logics until thematic saturation was achieved.

RESULTS

Surveys were completed by 205 VS and 1198 GS PGY1-3 residents (response rates 76.8% for VS and 82.5% for GS). After adjusting for resident demographics, PGY level, and program type, GS residents were more likely than their VS peers to consider leaving their programs (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.37-4.99). This finding did not persist after adjusting for differences in perceptions of the learning environment, specifically: GS residents had higher odds of mistreatment (OR: 1.99, 95% CI: 1.36-2.90), poorer work-life integration (OR: 2.88, 95% CI: 1.41-5.87), less resident camaraderie (OR: 3.51, 95% CI: 2.26-5.45), and decreased meaning in work (OR: 2.94, 95% CI: 1.80-4.83). Qualitative data provided insight into how the shared learning environment was perceived differently: (1) vascular trainees expressed that early specialization and a smaller, more invested faculty allow for an apprenticeship model with early operative exposure, hands-on guidance, frequent feedback, and thus early skill acquisition (meaning in work); (2) a smaller program is conducive to closer relationships with co-residents and faculty, increasing familiarity (camaraderie and work-life integration); and (3) due to increased familiarity with program leadership, vascular trainees feel more comfortable reporting mistreatment, allowing for prompt responses (mistreatment).

CONCLUSIONS

Despite sharing a learning environment, VS and GS residents experience training differently, contributing to differential thoughts of attrition. These differences may be attributable to intrinsic features of the integrated training paradigm that are not easily replicated by GS programs, such as smaller program size and higher faculty investment due to early specialization. Alternative strategies to compensate for these inherent differences should be considered (eg, structured operative entrustment programs and faculty incentivization).

Reported pain at work is a risk factor for vascular surgery trainee burnout

BACKGROUND

Work-related pain is a known risk factor for vascular surgeon burnout. It risks early attrition from our workforce and is a recognized threat to the specialty. Our study aimed to understand whether work-related pain similarly contributed to vascular surgery trainee well-being.

METHODS

A confidential, voluntary survey was administered after the 2022 Vascular Surgery In-Service Examination to trainees in all Accreditation Council for Graduate Medical Education-accredited vascular surgery programs. Burnout was measured by a modified, abbreviated Maslach Burnout Inventory; pain after a full day of work was measured using a 10-point Likert scale and then dichotomized as "no to mild pain" (0-2) vs "moderate to severe pain" (3-9). Univariable analyses and multivariable regression assessed associations of pain with well-being indicators (eg, burnout, thoughts of attrition, and thoughts of career change). Pain management strategies were included as additional covariables in our study.

RESULTS

We included 527 trainees who completed the survey (82.2% response rate); 38% reported moderate to severe pain after a full day of work, of whom 73.6% reported using ergonomic adjustments and 67.0% used over-the-counter medications. Significantly more women reported moderate to severe pain than men (44.3% vs 34.5%; P < .01). After adjusting for gender, training level, race/ethnicity, mistreatment, and dissatisfaction with operative autonomy, moderate-to-severe pain (odds ratio, 2.52; 95% confidence interval, 1.48-4.26) and using physiotherapy as pain management (odds ratio, 3.06; 95% confidence interval, 1.02-9.14) were risk factors for burnout. Moderate to severe pain was not a risk factor for thoughts of attrition or career change after adjustment.

CONCLUSIONS

Physical pain is prevalent among vascular surgery trainees and represents a risk factor for trainee burnout. Programs should consider mitigating this occupational hazard by offering ergonomic education and adjuncts, such as posture awareness and microbreaks during surgery, early and throughout training.

Vascular Surgery Training Positions and Applicant 10-Year Trends with Consideration for Further Expansion

BACKGROUND

There is a significant shortage of vascular surgeons in the United States and projections for these practicing surgical specialists continue to worsen. Annual appraisal of our workforce recruitment and growth is imperative.

MATERIALS AND METHODS

Retrospective data were analyzed using the National Resident Matching Program from 2012-2022 applicant appointment years (specialty code for vascular surgery 450). Simple linear trend analysis was performed for the number of positions available and the number of applicants, stratified by fellowship or residency.

RESULTS

Over the 10-year study period, the total vascular surgery trainee positions expanded from 161 to 202. Integrated residency positions increased (41 positions in 2012 vs. 84 in 2022) while available fellowship positions remained stagnant (120 in 2012 vs. 118 in 2022). Total applicants rose as well, from 213 to 311. In 2022, unmatched applicants have increased for both paradigms (25 fellowship and 84 residency applicants) and 100% of programs filled. On average, the number of residency positions offered increased by 4 each year (P < 0.0001) and the number of fellowship positions increased by 0.5 each year (P = 0.1617). The number of integrated residency applicants increased by approximately 9 per year (P = 0.001), while the number of fellowships applicants increased by approximately 1.5 per year (P = 0.121).

CONCLUSIONS

Applicants for both vascular tracks have increased since 2012 indicating successful recruitment; however, all 2022 programs filled, leaving many applicants unmatched. Residency positions have continued to expand while fellowship positions have not. With the demonstrated surge among applicants, the disproportionate lack of increasing training positions, and the existing shortage of vascular surgeons, there is an urgency to meet the increasing demand. A concerted effort should be made toward adding additional residency and fellowship positions where feasible.

Racial discrimination in surgery: A systematic review

INTRODUCTION

Racial/ethnic discrimination indicates the stereotyped or unkind conduct of superiority towards other persons based on their race or skin color. The UK General Medical Council published a statement supporting zero-tolerance approach to racism in the workplace. We aimed to systematically review racial discrimination in surgery and answer the following questions: (1) Does racial/ethnic discrimination in surgery exist in citations from the last 5 years. (2) If yes, are ways suggested to reduce racial/ethnic discrimination in surgery?

METHODS

The systematic review was performed in compliance with the PRISMA guidelines along AMSTAR 2. A 5-year literature search was carried out on PubMed for articles published from 1/1/2017 to 01/11/2022. Search terms were 'racial discrimination and surgery', 'racism OR discrimination AND surgery', 'racism OR discrimination AND surgical education'. The retrieved citations were quality assessed by MERSQI and evidence graded by GRADE.

RESULTS

A total of 9116 participants responded with a mean of 1013 (SD = 2408) responses per citations reported in 9 studies from a final list of 10 included citations. Nine studies were from USA and 1 from South Africa. There was evidence of racial discrimination in the last 5 years and the results were justified on strong scientific evidence constituting the basis for evidence grade I. The second question's answer was 'yes' which was defendable on moderate scientific recommendation and thereby establishing the basis for evidence grade II.

CONCLUSION

There was sufficient evidence for the presence of racial discrimination in surgical practice in the last 5 years. Ways to decrease racial discrimination in surgery exist. Healthcare and training systems must increase the awareness of these issues to eliminate the harmful effect on the individual as well as on the level of the surgical team performance. The existence of the discussed problems must be managed in more countries with diverse healthcare systems.