Comments on Surgeon-Patient Sex Concordance and Postoperative Outcomes—Reply

Abstract

In Reply As Bai et al note, general surgery has historically been a (White, cisgendered, heterosexual) male-dominated field. Our data indicate lack of inclusion is experienced by many with minoritized identities in surgery, including lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) physicians. We agree that this lack of inclusion likely leads LGBTQ+ residents to withhold their identity. In our survey of 85.6% of all residents training in accredited general surgery programs, 305 (4.8%) self-identified as LGBTQ+, and 394 residents did not answer or selected "prefer not to answer." Based on US Census data and prior work 1 demonstrating that more than half of LGBTQ+ surgery residents choose not to disclose their identity, we too suspect our study undercounts LGBTQ+ surgery residents and therefore underestimates LGBTQ+-based mistreatment. Even if residents are able to avert mistreatment by withholding LGBTQ+ identity, the inability to authentically express one's identity causes psychological distress and difficulty connecting with colleagues. 2 Therefore, an environment in which it is safe to disclose identity is essential to the well-being of LGBTQ+ trainees.A growing body of literature supports improved patient outcomes with physician diversification. Physicians from minoritized groups are more likely to work with underserved communities, improving access to care. 3 Patient-physician identity concordance reduces morbidity and mortality for patients with minoritized identities. 4,5 Even care provided by physicians who are not from minoritized groups likely improves because exposure to colleagues from minoritized groups durably reduces their biases. 6 Thus, developing strategies to foster and support a diverse surgical workforce is our moral imperative, not only for the sake of LGBTQ+ surgeons, but for all patients.We are currently working with programs across the US to develop targeted interventions to address mistreatment and well-being for the Surgical Education Culture Optimization Through Targeted Interventions Based on National Comparative Data (SECOND) Trial. Although we urge all programs, and certainly those in other countries, to be mindful of their local cultural context (eg, in the acceptance and construction of LGBTQ+ identities) as they implement our interventions within their training environments, we submit that the following principles are universal: (1) Representation matters. Many training and/or physician organizations do not query sexual orientation or gender identity, making disparities challenging to scope and normalizing invisibility. Diversification of training programs, from both a resident and faculty standpoint, is critical. To this end, resources that support the work, well-being, and therefore recruitment and retention of LGBTQ+ surgeons should be made available. (2) As Bai et al highlight, more education is needed for both trainees and faculty. Content should address basic vocabulary and rules of respectful conduct (eg, Why do pronouns matter? Wha...

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