The Gender Gap in Surgical Residencies Bennett, Christopher L; Baker, Olesya; Rangel, Erika L ...
JAMA surgery,
09/2020, Letnik:
155, Številka:
9
Journal Article
Recenzirano
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This cross-sectional study identifies surgical specialties with the greatest gender inequities among resident physicians and examines how long it will take for women in these specialties to reach ...parity with the overall resident and US population.
IMPORTANCE: While surgeons often delay pregnancy and childbearing because of training and establishing early careers, little is known about risks of infertility and pregnancy complications among ...female surgeons. OBJECTIVE: To describe the incidence of infertility and pregnancy complications among female surgeons in the US and to identify workplace factors associated with increased risk compared with a sociodemographically similar nonsurgeon population. DESIGN, SETTING, AND PARTICIPANTS: This self-administered survey questionnaire was electronically distributed and collected from November 2020 to January 2021 through multiple surgical societies in the US and social media among male and female attending and resident surgeons with children. Nonchildbearing surgeons were asked to answer questions regarding the pregnancies of their nonsurgeon partners as applicable. EXPOSURES: Surgical profession; work, operative, and overnight call schedules. MAIN OUTCOMES AND MEASURES: Descriptive data on pregnancy loss were collected for female surgeons. Use of assisted reproductive technology was compared between male and female surgeons. Pregnancy and neonatal complications were compared between female surgeons and female nonsurgeon partners of surgeons. RESULTS: A total of 850 surgeons (692 women and 158 men) were included in this survey study. Female surgeons with female partners were excluded because of lack of clarity about who carried the pregnancy. Because the included nonchildbearing population was therefore made up of male individuals with female partners, this group is referred to throughout the study as male surgeons. The median (IQR) age was 40 (36-45) years. Of 692 female surgeons surveyed, 290 (42.0%) had a pregnancy loss, more than twice the rate of the general population. Compared with male surgeons, female surgeons had fewer children (mean SD, 1.8 0.8 vs 2.3 1.1; P < .001), were more likely to delay having children because of surgical training (450 of 692 65.0% vs 69 of 158 43.7%; P < .001), and were more likely to use assisted reproductive technology (172 of 692 24.9% vs 27 of 158 17.1%; P = .04). Compared with female nonsurgeon partners, female surgeons were more likely to have major pregnancy complications (311 of 692 48.3% vs 43 of 158 27.2%; P < .001), which was significant after controlling for age, work hours, in vitro fertilization use, and multiple gestation (odds ratio OR, 1.72; 95% CI, 1.11-2.66). Female surgeons operating 12 or more hours per week during the last trimester of pregnancy were at higher risk of major pregnancy complications compared with those operating less than 12 hours per week (OR, 1.57; 95% CI, 1.08-2.26). Compared with female nonsurgeon partners, female surgeons were more likely to have musculoskeletal disorders (255 of 692 36.9% vs 29 of 158 18.4%; P < .001), nonelective cesarean delivery (170 of 692 25.5% vs 24 of 158 15.3%; P = .01), and postpartum depression (77 of 692 11.1% vs 9 of 158 5.7%; P = .04). CONCLUSIONS AND RELEVANCE: This national survey study highlighted increased medical risks of infertility and pregnancy complications among female surgeons. With an increasing percentage of women representing the surgical workforce, changing surgical culture to support pregnancy is paramount to reducing the risk of major pregnancy complications, use of fertility interventions, or involuntary childlessness because of delayed attempts at childbearing.
IMPORTANCE: Although family priorities influence specialty selection and resident attrition, few studies describe resident perspectives on pregnancy during surgical training. OBJECTIVE: To directly ...assess the resident experience of childbearing during training. DESIGN, SETTING, AND PARTICIPANTS: A self-administered 74-question survey was electronically distributed in January 2017 to members of the Association of Women Surgeons, to members of the Association of Program Directors in Surgery listserv, and through targeted social media platforms. Surgeons who had 1 or more pregnancies during an Accreditation Council for Graduate Medical Education–accredited US general surgery residency program and completed training in 2007 or later were included. Important themes were identified using focus groups of surgeons who had undergone pregnancy during training in the past 7 years. Additional topics were identified through MEDLINE searches performed from January 2000 to July 2016 combining the keywords pregnancy, resident, attrition, and parenting in any specialty. MAIN OUTCOMES AND MEASURES: Descriptive data on perceptions of work schedule during pregnancy, maternity leave policies, lactation and childcare support, and career satisfaction after childbirth. RESULTS: This study included 347 female surgeons (mean SD age, 30.5 2.7 years) with 452 pregnancies. A total of 297 women (85.6%) worked an unmodified schedule until birth, and 220 (63.6%) were concerned that their work schedule adversely affected their health or the health of their unborn child. Residency program maternity leave policies were reported by 121 participants (34.9%). A total of 251 women (78.4%) received maternity leave of 6 weeks or less, and 250 (72.0%) perceived the duration of leave to be inadequate. The American Board of Surgery leave policy was cited as a major barrier to the desired length of leave by 268 of 326 respondents (82.2%). Breastfeeding was important to 329 (95.6%), but 200 (58.1%) stopped earlier than they wished because of poor access to lactation facilities and challenges leaving the operating room to express milk. Sixty-four women (18.4%) had institutional support for childcare, and 231 (66.8%) reported a desire for greater mentorship on integrating a surgical career with motherhood and pregnancy. A total of 135 (39.0%) strongly considered leaving surgical residency, and 102 (29.5%) would discourage female medical students from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood with training. CONCLUSIONS AND RELEVANCE: The challenges of having children during surgical residency may have significant workforce implications. A deeper understanding is critical to prevent attrition and to continue recruiting talented students. This survey characterizes these issues to help design interventions to support childbearing residents.
Frailty is associated with poor surgical outcomes in elderly patients but is difficult to measure in the emergency setting. Sarcopenia, or the loss of lean muscle mass, is a surrogate for frailty and ...can be measured using cross-sectional imaging. We sought to determine the impact of sarcopenia on 1-year mortality after emergency abdominal surgery in elderly patients.
Sarcopenia was assessed in patients 70 years or older who underwent emergency abdominal surgery at a single hospital from 2006 to 2011. Average bilateral psoas muscle cross-sectional area at L3, normalized for height (Total Psoas Index TPI), was calculated using computed tomography. Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was mortality at 1 year. Secondary outcomes were in-hospital mortality and mortality at 30, 90, and 180 days. The association of sarcopenia with mortality was assessed using Cox proportional hazards regression and model performance judged using Harrell's C-statistic.
Two hundred ninety-seven of 390 emergency abdominal surgery patients had preoperative imaging and height. The median age was 79 years, and 1-year mortality was 32%. Sarcopenic and nonsarcopenic patients were comparable in age, sex, race, comorbidities, American Society of Anesthesiologists classification, procedure urgency and type, operative severity, and need for discharge to a nursing facility. Sarcopenic patients had lower body mass index, greater need for intensive care, and longer hospital length of stay (p < 0.05). Sarcopenia was independently associated with increased in-hospital mortality (risk ratio, 2.6; 95% confidence interval CI, 1.6-3.7) and mortality at 30 days (hazard ratio HR, 3.7; 95% CI, 1.9-7.4), 90 days (HR, 3.3; 95% CI, 1.8-6.0), 180 days (HR, 2.5; 95% CI, 1.4-4.4), and 1 year (HR, 2.4; 95% CI, 1.4-3.9).
Sarcopenia is associated with increased risk of mortality over 1 year in elderly patients undergoing emergency abdominal surgery. Sarcopenia defined by TPI is a simple and objective measure of frailty that identifies vulnerable patients for improved preoperative counseling, setting realistic goals of care, and consideration of less invasive approaches.
Prognostic study, level III.
IMPORTANCE: Although pregnancy during surgical residency is increasingly common, studies of surgical residents have identified challenges associated with pregnancy and motherhood. These include ...perceptions of different maternity leave policies among institutions, lack of mentorship, stigma, and desire for greater lactation support. OBJECTIVE: To describe the perspective and experience of US surgical program directors regarding maternity leave and postpartum support for surgical residents. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study included surgical program directors of US general surgery residency programs who were selected using purposive-stratified, criterion-based sampling. Transcripts were collected from semi-structured interviews, which were audio-recorded and transcribed verbatim, from October 21, 2018, to June 1, 2019. EXPOSURES: Maternity leave and postpartum support. MAIN OUTCOMES AND MEASURES: Perspectives of program directors regarding maternity leave and postpartum support were categorized into common themes identified using content analysis. RESULTS: A total of 40 US general surgical programs directors (28 70.0% male; mean SD age, 49.7 6.8 years) were interviewed, of whom 36 (90.0%) were from university-based programs. All reported having maternity leave policies allowing a duration of leave of 6 weeks or longer. Analysis of program director interviews identified 5 themes: (1) residents are reluctant to extend training despite being offered multiple leave options; (2) childbearing negatively impacts the quality of work of certain residents; (3) lack of formal lactation policies creates practical challenges in supporting residents who are nursing; (4) resentment from coresidents who are asked to provide maternity leave coverage varies based on the prepregnancy reputation of the resident on leave; and (5) lack of salary support limits the practicality of extended leave options. Complex interpersonal issues affected residents differently, including stigma, reluctance to change established surgical training patterns, and challenges with work-life balance. CONCLUSIONS AND RELEVANCE: This qualitative study found that sociopolitical issues within surgical training culture and fiscal constraints created obstacles against program directors supporting pregnant residents. These findings suggest that a multidimensional approach to supporting residents through written maternity and lactation policies, structured mentorship and coaching programs, and efforts by leadership to enforce family priorities is needed to promote a surgical culture that normalizes pregnancy and motherhood during training.
IMPORTANCE: Although men are increasingly involved in childrearing, little is known about paternity leave in surgical residency. Conflict between professional and family duties contribute to burnout ...and decreased career satisfaction for surgeons of both sexes. With men more likely than women to have children during their clinical years of surgical training, understanding the issues surrounding paternity leave is imperative to ensuring the longevity of our workforce. OBJECTIVE: To explore surgical program directors’ perspectives on the challenges of providing paternity leave. DESIGN, SETTING, AND PARTICIPANTS: This qualitative descriptive study of transcripts collected from semistructured interviews of US surgical program directors was performed from October 2018 to June 2019. Program directors were selected using purposive-stratified criterion-based sampling. Interviews were audio-recorded and transcribed verbatim, with emergent themes identified using content analysis. EXPOSURE: Paternity leave. MAIN OUTCOMES AND MEASURES: Program directors’ perspectives on paternity leave were categorized into common themes. RESULTS: A total of 40 US general surgery program directors were interviewed (28 male 70%; mean SD age, 49.7 6.8 years; 36 90% were university-based programs). Twenty (50%) reported providing paternity leave of 1-week duration. Five major themes were identified: (1) paternity leave policies are poorly defined by many programs and require self-initiation by residents; (2) residents often do not take the full amount of time offered for leave; (3) stigma against male residents taking parental leave is common and may be even greater than that facing women taking maternity leave; (4) paternity leave has little to no impact on colleagues’ workload owing to the brevity of time taken; and (5) men desire longer leave than what they are currently offered and wish to receive equal time off compared with childbearing parents. CONCLUSIONS AND RELEVANCE: Surgical program directors report male residents take brief paternity leave despite a desire for more time off, which may be influenced by fear of stigma and surgical culture that avoids handing off work, even for short periods of time. A cultural shift toward supporting family planning as a normal part of young adult life, rather than a medical condition to be accommodated, is necessary to promote life balance and behaviors that will sustain a long career in surgery. Implementation of defined leave policies at individual programs for the nonchildbearing parent is critical to make parental leave socially acceptable among surgical residents.
Although surgical training programs have nearly reached gender parity, pregnancy and parenthood remain challenging for female surgeons, with obstetric risks related to occupational demands, stigma, ...inconsistent and brief parental leaves, a paucity of postpartum support for lactation and childcare, and little mentorship on work-family integration. This work environment causes many to postpone starting a family, which leads to higher risks of infertility among female surgeons compared to their male peers. Perception of work-family incompatibility jeopardizes recruitment and retention of our surgical workforce, as it deters medical students from the profession, increases risk of resident attrition, and leads to burnout and career dissatisfaction. The challenges of parenthood for female surgeons was the focus of a Hot Topics session during the 2022 Academic Surgical Congress, the discussion of which is presented herein with recommendations for policy change to better support maternal-fetal health and the needs of surgeons with young children.
IMPORTANCE: Previous work shows women who have children during surgical residency face difficulty balancing childbearing with training, which negatively affects residency and career satisfaction. ...Little is known about the factors that drive professional discontent. OBJECTIVE: To determine factors associated with professional dissatisfaction for childbearing residents. DESIGN, SETTING, AND PARTICIPANTS: Self-administered survey questionnaire electronically distributed through the Association of Program Directors in Surgery, the Association of Women Surgeons, and targeted Twitter and Facebook platforms. The survey was distributed in January 2017 to surgeons who delivered at least 1 child during a US general surgery residency and was available online for 4 weeks. MAIN OUTCOMES AND MEASURES: Respondents were reported to be dissatisfied with their residency if they indicated agreement that they considered leaving residency owing to challenges surrounding childbearing (considered leaving). Respondents were reported to be unhappy with their career if they indicated agreement with statements that (1) given an opportunity to revisit their job choice, they would choose a nonsurgical career more accommodating of motherhood (revisit career choice) or (2) they would advise a female medical student against a surgical career owing to difficulties balancing motherhood with the profession (advise against surgery). Logistic regression was used to determine predictors of agreement with each of the 3 statements of professional dissatisfaction. RESULTS: In total, 347 women responded to the survey and reported 452 pregnancies, and the mean (SD) age was 30.5 (2.7) years. One hundred seventy-nine respondents (51.6%) agreed with at least 1 statement of residency or career dissatisfaction. Lack of a formal maternity leave policy was associated with “considered leaving” (odds ratio OR, 1.83; 95% CI, 1.07-3.10). Perception of stigma during pregnancy was associated with “revisit career choice” (OR, 1.79; 95% CI, 1.01-3.19). Changing fellowship plans owing to perceived difficulty balancing motherhood with the originally chosen subspecialty was associated with all 3 markers of residency and career dissatisfaction (“considered leaving” OR, 2.68; 95% CI, 1.30-5.56; “revisit career choice” OR, 2.23; 95% CI, 1.13-4.43; and “advise against surgery” OR, 2.44; 95% CI, 1.23-4.84). CONCLUSIONS AND RELEVANCE: Surgery residents who perceived stigma during pregnancy, did not have a formal institutional maternity leave policy, or altered their fellowship training plans because of challenges of childbearing expressed greater professional dissatisfaction. Mentorship in subspecialty selection and work-life integration, interventions to reduce workplace bias, and identification of obstacles to establishment of maternity leave policies are needed to enhance professional fulfillment for childbearing residents.
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