The effect of gender on operative autonomy in general surgery residents

doi:10.1016/j.surg.2019.06.006

Surgery

Volume 166, Issue 5, November 2019, Pages 738-743

Presented at the Society of University Surgeons 14th Annual Academic Surgical Congress, Houston TX.

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https://doi.org/10.1016/j.surg.2019.06.006 Get rights and content

Abstract

Background

Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees.

Methods

A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

Results

A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training.

Conclusion

There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents’ experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

Introduction

Autonomy in the operating room is a key aspect of surgical training because it allows residents to explore their limits and develop confidence in their skills. Despite its importance, surgery residents receive less operative autonomy in training than either they or faculty expect for common operations.1, 2 There are known procedural and surgeon factors that contribute to the operative autonomy allowed, including resident clinical skill, level of training and contact time, and attending confidence and operative complexity or difficulty.³ Additional social and cultural factors, however, may also influence operative autonomy, such as productivity demands, the medical-legal climate, and the gender of the resident and/or faculty surgeon.

A survey conducted by members of the Association of Women Surgeons found that 67% of female residents reported experiencing discrimination, most commonly as lack of respect from the medical team and inappropriate verbal exchanges.4, 5 Participants reported that events which were more common in past decades, such as inappropriate firing, barriers to hiring, and sexual harassment, are perceived to be less common now. Although overt discrimination has become less socially and corporately acceptable, implicit or unconscious bias still may be driving persistent discrimination. Implicit bias is unrecognized by the holder and may even contradict their stated beliefs.⁶ For example, despite a growing number of women in medicine, leadership roles are predominantly filled by men.⁷ In addition, women are paid less for the same work upon completion of their training, even after accounting for age, experience, specialty, faculty rank, and clinical and research productivity.8, 9 This study explored differences in the degree of autonomy granted to male and female general surgery residents as perceived by both residents and faculty.

Section snippets

Study design and participants

The Procedural Learning and Safety Collaborative is a group of over 50 surgical training programs working to improve resident education and patient safety. As part of this mission, categorical general surgery residents and surgery faculty at 14 university-affiliated, general surgery programs were recruited to use a smartphone app (SIMPL [System for Improving and Measuring Procedural Learning], Procedural Learning and Safety Collaborative, Ann Arbor, MI, USA) to evaluate resident autonomy in the

Results

In total, 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period, from September 2015 to June 2016 (Table I). Of those, 5,107 cases were evaluated by both the resident and the faculty surgeon for a 57.4% response rate. An additional 760 cases were evaluated by the faculty surgeon only, and 3,033 cases were evaluated by the resident only. Residents evaluated a mean (± standard deviation) of 22 ± 26 (range 1–184) cases. There was no

Discussion

These data were from the largest study of the autonomy of surgery residents reported to date, and they demonstrate that women continue to receive less autonomy in the operating room than men. This difference in granting resident autonomy continues despite substantial progress toward gender equality in surgery. From the perspective of the faculty, male and female interns received equivalent autonomy, with >80% of cases performed at the "active help" or "show and tell" levels, as would be

Funding/Support

The initial development of SIMPL was funded by grants from Massachusetts General Hospital, Northwestern University, and Indiana University. Later development was funded by contributions from the 36 institutional members of the Procedural Learning and Safety Collaborative and from grants from the American Board of Surgery and the Association of Program Directors in Surgery.

Conflict of interest/Disclosure

The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

Acknowledgements

The authors thank Niloufar Safaeinili and Michael Clark for their work on the statistical analysis of this data. The authors also thank the faculty and residents at the participating institutions: Brigham and Women’s Hospital, Indiana University, Massachusetts General Hospital, Northwestern University, State University of New York Upstate, University of Kentucky, University of Minnesota, University of Nebraska College of Medicine, University of New Mexico, University of Texas Southwestern,

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We found heterogeneity in the tools used to "measure" the autonomy of a resident in the operating room. The SIMPL tool or the Zwisch Scale appear to be the most frequently used tools. The relationship between autonomy, performance, confidence, and knowledge may require multidimensional tools that encompass various areas of competence, but this could make their daily application more challenging. The factors influencing autonomy are numerous; and understanding them would improve teaching in the operating room. There is a significant lack of data on surgical autonomy in France, as well as a lack of evaluation in the field of gynecology-obstetrics worldwide.
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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.
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).
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EducationPresented at the Academic Surgical Congress 2019The effect of gender on operative autonomy in general surgery residents

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study design and participants

Results

Discussion

Funding/Support

Conflict of interest/Disclosure

Acknowledgements

J Surg Educ

Ann Thorac Surg

J Am Coll Surgeons

J Surg Educ

J Surg Educ

J Surg Educ

Patient Educ Couns

Sexual harassment in medical education: A review of the literature with comments from the law

Acad Med

Perceptions of gender-based discrimination during surgical training and practice

Med Educ Online

Understanding and overcoming implicit gender bias in plastic surgery

Plast Reconstr Surg

Stuck in the out-group: Jennifer can’t grow up, Jane’s invisible, and Janet’s over the hill

J Womens Health

Education
Presented at the Academic Surgical Congress 2019
The effect of gender on operative autonomy in general surgery residents