Autonomy in the Operating Room: A Multicenter Study of Gender Disparities During Surgical Training

Abstract

Background Gender disparities are prevalent in medicine, but their impact on surgical training is not well studied. Objective To quantify gender disparities in trainee intraoperative experiences and explore the variables associated with ratings of surgical autonomy and performance. Methods From September 2015 to May 2019, attending surgeons and trainees from 71 programs assessed trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale after surgical procedures. Multivariable regression models were used to examine the association of trainee gender with autonomy and performance evaluations. Results A total of 3255 trainees and attending surgeons completed 94 619 evaluations. Attendings gave lower ratings of operative autonomy to female trainees than male trainees when controlling for training level, attending, and surgical procedure (effect size B = −0.0199, P = .008). There was no difference in ratings of autonomy at the beginning of training (P = .32); the gap emerged as trainees advanced in years (B = −0.0163, P = .020). The gender difference in autonomy was largest for the most complex cases (B = −0.0502, P = .002). However, there was no difference in attending ratings of surgical performance for female trainees compared to male trainees (B = −0.0124, P = .066). Female trainees rated themselves as having less autonomy and worse performance than males when controlling for training level, attending, procedure, case complexity, and attending ratings (autonomy B = −0.0669, P < .001; performance B = −0.0704, P < .001). Conclusions While there was no significant difference in ratings of operative performance, a small difference between ratings of operative autonomy for female and male surgical trainees was identified.

Factors affecting operative autonomy and performance during otolaryngology training: A multicenter trial

“…In this study, resident gender was not associated with either attending evaluations or resident self‐assessments. This is particularly interesting because in previous studies pooling SIMPL OR data across surgical specialties, trainee gender was found to be a source of disparities in attending ratings of surgical autonomy and performance 16 . Many other studies using a range of self‐assessment instruments have also found that female residents are more self‐critical than male residents 16–18 .…”

“…This is particularly interesting because in previous studies pooling SIMPL OR data across surgical specialties, trainee gender was found to be a source of disparities in attending ratings of surgical autonomy and performance. 16 Many other studies using a range of self-assessment instruments have also found that female residents are more self-critical than male residents. [16][17][18] One possible explanation for the difference in findings between this multicenter study of otolaryngology residents compared to studies that pooled data across surgery programs nationwide could be the nearly equal numbers of male and female trainees in the present study.…”

“…16 Many other studies using a range of self-assessment instruments have also found that female residents are more self-critical than male residents. [16][17][18] One possible explanation for the difference in findings between this multicenter study of otolaryngology residents compared to studies that pooled data across surgery programs nationwide could be the nearly equal numbers of male and female trainees in the present study. In this study of large academic training programs where female trainees were no longer in the minority, female residents did not exhibit historically gender-based psychological phenomena like imposter syndrome.…”

Surgical Education: Disparities in Education May Impact the Quality and Likelihood of Completion of Training

“…Multiple recent singleand multicenter studies demonstrate that women get less operative autonomy as trainees. [28][29][30][31] One study conducted in 2019 reviewed almost 9,000 cases at 14 general surgery programs and found that female surgical residents received less operative autonomy even when controlled for training level, case complexity, faculty sex, and program environment. This gap in autonomy was seen at every level of training and was most pronounced in the fourth year of training, which is when most trainees experience autonomy in intraoperative decision making and patient care.…”

Proceed, With Caution: Unconscious Bias in Technical Assessment

“…Chen et al report a multicenter review of nearly 95 000 assessments and identified the development of a gap in autonomy ratings for women over the course of surgical trainees, with the largest gap occurring in the most complex cases. 5 Additionally, women trainees self-rated as having less autonomy and worse performance than men, even after controlling for most other potential confounding elements. Cooney et al's review of 8377 assessments of plastic surgery residents in 3 different programs found women trainees were scored significantly lower than men in the first 4 years of residency when rated by men attending surgeons, but not when rated by women attending surgeons.…”