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