Comparison of Performance Score for Female and Male Residents in General Surgery Doing Supervised Real‐Life Laparoscopic Appendectomy: Is There a Norse Shield‐Maiden Effect?

Abstract

Background Gender bias may represent a threat to resident assessment during surgical training, and there have been concerns that women might be disadvantaged. There is a lack of studies investigating gender differences in ‘entry-level’ real-life procedures, such as laparoscopic appendectomy. We aimed to explore potential gender disparities in self-evaluation and faculty evaluation of a basic surgical procedure performed by junior surgical residents in general surgery. Methods A structured training program in laparoscopic appendectomy was implemented before undertaking evaluation of real-life consecutive laparoscopic appendectomies by junior residents in general surgery. Resident and faculty gender-pairs were assessed. Intraclass correlation coefficient (ICC) was calculated using a single-rater, consistency, 2-way mixed-effects model. Results A total of 165 paired sessions were completed to evaluate resident–faculty scores for the procedure. Overall, 19 residents participated (43% women) and 26 faculty (42% women) were involved. The overall correlation between faculty and residents was good (ICC > 0.8). The female–female pairs scored higher for most steps, achieving excellent (ICC ≥ 0.9) for several steps and for overall performance. Female residents were more likely to give a higher self-evaluated score on own performance particularly if evaluated by a female faculty. Also, female trainees had highest correlation-score with male faculty. Conclusions This study found higher performance scores in female surgical residents evaluated during real-time laparoscopic appendectomy. No negative gender bias toward women was demonstrated. Better insight into the dynamics of gender-based interaction and dynamics in both training, feedback and influence on evaluation during training is needed when evaluating surgical training programs.

Early Barriers to Career Progression of Women in Surgery and Solutions to Improve Them

“…Female residents’ tended to underestimate their abilities compared with faculty assessment has been the main topic in 3 papers,70,72,73 with male residents’ self-assessment scores demonstrating a stronger correlation with the attending score 72. On the contrary, in a study conducted in Norway71 assessing residents during laparoscopic appendicectomy, no negative gender bias toward women trainees was demonstrated.…”

A multilevel, step-based model to evaluate progress in procedure efficiency for laparoscopic appendicectomy in surgical training: structured evaluation using ‘ebb-and-flow’ and ‘string-of-pearls’ concepts

“…In a structured training programme described previously 16 , and in which both trainee and trainer have specific obligations and preparations to consider for enhanced learning during laparoscopic appendicectomy, we have previously shown that there was no difference between male or female trainees’ performance during surgical training 9 . A previous study also demonstrated that most trainees became proficient in laparoscopic appendicectomy when having completed around 30 procedures 10 ; however, the same investigation also found that the mastery of each of the procedure steps varied considerably, which led to the current in-depth analyses of the connectivity between each of the steps.…”

“…To further explore the weight of each step to the final procedure evaluation, an artificial neural network model was created using a multilayer perceptron. As we have previously demonstrated equal outcomes between trainee sex and described the association of absolute number on performance metrics 9 , we performed the analyses across the eight steps without covariates to specifically investigate the procedure steps influence on overall evaluation of the junior residents. To control for experience, a sensitivity analysis was performed for 20 or fewer, 30 or fewer, or more than 30 laparoscopic appendectomies.…”

“…Also, little data exist on what parts of procedures are considered stumbling blocks to performance and which are steppingstones to mastery. In a training programme for trainees and trainers in general surgery evaluating real-life surgery, we have previously demonstrated that there are no differences in trainee performance according to sex 9 . Previous study data have also demonstrated that the cut-off for mastering any given step of a laparoscopic appendicectomy is widely different 10 , suggesting that a fixed procedure number is insufficient to demonstrate ‘experience’.…”

Next Steps: Advocating for Women in Orthopaedic Surgery

“…41 A recent study performed at a surgical training program in Norway found that female surgical trainees received higher performance scores during real-time laparoscopic appendectomy than their male counterparts. 42 As more women enter specialties across all of medicine, growing evidence affirms that training and experience predict competence in medicine and surgery, not gender.…”