April 2020 - Equity, Quality and Inclusion

April 2020
EAST Monthly Literature Review

"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee

This issue was prepared by EAST Manuscript and Literature Review Committee Members Rondi Gelbard, MD, Mark Hoofnagle, MD, PhD, and John Bliton, MD.

Thank you to Haemonetics for supporting the EAST Monthly Literature Review.

In This Issue: Equity & Inclusion

Scroll down to see summaries of these articles

Article 1 reviewed by John Bliton, MD
Gender Disparity in Trauma Surgery: Compensation, Practice Patterns, Personal Life, and Wellness. Sangji NF, Fuentes E, Donelan K, Cropano C, King D. J Surg Res. 2020 Jun;250:179–187.

Article 2 reviewed by Rondi Gelbard, MD, FACS
#EAST4ALL: An introduction to the EAST equity, quality, and inclusion task force. Bonne S, Williams BH, Martin M, Kaafarani H, Weaver WL, Rattan R, Byers PM, Joseph DK, Ferrada P, Joseph B, Santos A, Winfield RD, DiBrito S, Bernard A, Zakrison TL. J Trauma Acute Care Surg. 2019 Jul;87(1):225-233.

Article 3 reviewed by Mark H. Hoofnagle, MD, PhD
Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. Hu YY, Ellis RJ, Hewitt DB, Yang AD, Cheung EO, Moskowitz JT, Potts JR 3rd, Buyske J, Hoyt DB, Nasca TJ, and Bilimoria, KY. N Engl J Med. 2019 Oct 31;381(18):1741-1752.

Article 1
Gender Disparity in Trauma Surgery: Compensation, Practice Patterns, Personal Life, and Wellness. Sangji NF, Fuentes E, Donelan K, Cropano C, King D. J Surg Res. 2020 Jun;250:179–187.

Gender disparities persist throughout medicine, surgery, and trauma surgery.  This study seeks to quantify aspects of the disadvantages and disincentives faced by women in trauma surgery. The authors compared numerous factors related to work and quality of life between male and female trauma surgeons.
In the introduction, the authors provide a useful summary of the current state of representation of women in academic surgery and share evidence of ongoing discrimination. They highlight that, despite significant increases in the representation of women among trainees, only 10% of full professors are women. Furthermore, 88% of women in surgery experienced gender-based discrimination during residency, and 91% during practice. By quantifying aspects of the work/life tradeoff in men and women, this study responds to those who defend these disparities as natural consequences of differences in what men and women want from their career and personal life.
The study consists of a survey of 497 surgeons, drawn from EAST membership in 2014 - a 37.4% response rate. Chi-square testing was used to identify relationships between the variables and self-reported, binary gender. 105 of the respondents (21.1%) were women. Women were less likely to be married (66.7% vs 86.8%, p <0.001), more likely to work longer hours in academic surgery, and slept more on average (28.6% of women slept under 6 hours vs 34.0% of men), p<0.001). After age stratification, women were significantly less likely to have income > $300,000 compared to men (57.1% vs 83.1%, p<0.001). Self-reported health status was more likely to be ‘excellent’ or ‘very good’ among women (82.8% vs 74.1%, p<0.001), and women were more likely to have had a physical exam in the last 2 years (72.4% vs 65.4%, p<0.001). Women had higher prevalence of obesity (25.7% vs 19.9%) and lung conditions (10.5% vs 5.3%) and lower prevalence of hypertension (6.7% vs 19.7%) and arthritis (7.65% vs 12.1% p<0.001). It should be noted that these values may be shaped by the respondents’ age and self-evaluations; women were on average 5 years younger (43.3 vs 48.3) and 1 point lower in BMI (27.2 vs 28.1). Differences in profiles of physical activity, dietary patterns and cancer screening were also noted, but no testing was performed.
Limitations include the use of binary gender only, the potential for response and recall biases, and the lack of adjustment for factors other than age. Nonetheless, these findings suggest a persistent pay gap, and raise questions about disproportionate effects of a surgical career on female trauma surgeons' personal lives.

Article 2
#EAST4ALL: An introduction to the EAST equity, quality, and inclusion task force. Bonne S, Williams BH, Martin M, Kaafarani H, Weaver WL, Rattan R, Byers PM, Joseph DK, Ferrada P, Joseph B, Santos A, Winfield RD, DiBrito S, Bernard A, Zakrison TL. J Trauma Acute Care Surg. 2019 Jul;87(1):225-233.

In this well written manuscript, the authors highlight the proceedings of a plenary session conducted by the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force at the EAST 2019 Annual Scientific Assembly. This timely glimpse into the longstanding history of inequity within the trauma surgery profession sheds light on the prevalence and character of inequity among trauma surgeons, and challenges us to open our minds, identify and combat our biases, and collectively change the future of trauma surgery.
The authors discuss how implicit (unconscious) bias not only influences clinical decisions that impact patient outcomes, but also affects how we interact with colleagues and trainees. They discuss gender bias against childbearing women in surgery, the pay gap that results from occupational segregation (i.e. the notion that women's earnings are lower due to their exclusion from primarily male occupations and segregation into female-dominated occupations), and bias against working mothers. The paper goes on to highlight the pervasiveness of harassment and discrimination within training programs, not only towards women, but those with different religious backgrounds, countries of origin, and gender identities or sexual orientation.
The authors call upon us to create a non-threatening environment that supports all surgeons, including those from different religious, ethnic or racial backgrounds equally; an environment where women surgeons who choose to have both a family and a demanding career do not have to worry about the long-term consequences of parental leave such as slower advancement or a decline in academic productivity; where International Medical Graduates do not have to worry about being perceived as inferior or less qualified for an academic career. LGBTQ+ surgeons and trainees can have their lifestyle normalized. There is a call to start blinding residency applications, engage in empathy-building exercises and make a conscious effort to focus on individual attributes to minimize the impact of implicit bias and microaggressions on our profession.
Exclusion and discrimination very clearly exist today, and EAST is the first trauma surgery organization to develop toolkits and best practice recommendations directly addressing these topics, with the hope that it will lead to further awareness, stimulate deeper scientific inquiry, and perhaps translate into improved patient outcomes. This is just the tip of the iceberg in terms of what #EAST4ALL will undoubtedly accomplish.  We will continue to disseminate knowledge about equity and inclusion and engage both membership and the general trauma community in active dialogue to affect individual and structural change. As surgeons, scientists, educators, mentors, and leaders who represent the intersection of gender, race, ethnicity, and sexual orientation, they are inspiring us all to acknowledge and eradicate inequities within our profession.
Article 3
Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. Hu YY, Ellis RJ, Hewitt DB, Yang AD, Cheung EO, Moskowitz JT, Potts JR 3rd, Buyske J, Hoyt DB, Nasca TJ, and Bilimoria, KY. N Engl J Med. 2019 Oct 31;381(18):1741-1752.

This paper is a timely and powerful study of the state of equitable treatment in our surgical training programs in the United States that should be read by all program directors (PDs) and leaders of surgical training programs. This study presents the results of a survey given to all US residents immediately following their ABSITE exam. Questions were asked about experiences of discrimination, abuse, harassment, suicidality and burnout, as well as the sources of these experiences and basic demographic information about the subject.
Female residents experienced particularly high levels of abuse. 65% of women surveyed reported discrimination (vs 10% of men) and 20% reported harassment (vs 4% of men). Although patients are sometimes the source of sexual harassment for residents, attendings were equally likely to be the source of harassment for women (31% each). While some may feel abuse from patients and visitors is beyond the control of surgical training programs, institutions like the Mayo Clinic have instituted policies respond to bias from patients and families here (2). Residents experienced discrimination primarily from co-residents or faculty: 44% came from attendings and 24% from co-residents. Patients and patients’ families were the most frequent sources of gender discrimination (as reported by 43.6% of residents) and racial discrimination (47.4%), whereas attending surgeons were the most frequent sources of sexual harassment (27.2%) and abuse (51.9%).
A quick review of the literature shows that this discrimination takes place in an environment that is often unsupportive of residents’ family lives. A previous national survey of program directors in surgery found that only 2/3 of programs have a maternity leave policy, and only half have a paternity leave policy (usually only 1 week). Worse, 61% of PDs report the perception that childbirth negatively affects female trainees by burdening other residents, and male trainees do not experience nearly the same perception (3).
These experiences of discrimination and abuse are not absorbed by the residents without placing a strain on their mental health. The final part of the study creates multivariate models to identify relationships among discrimination, abuse, burnout and suicidal thoughts.  Work hour violations and mistreatment were associated with significant increases in burnout symptoms (odds ratios 2.91, 2.52 – 3.35 and 2.94, 2.58 – 3.36, respectively) and suicidal thoughts (2.12, 1.56 – 2.88 and 3.07, 2.25 – 4.19). As background, burnout occurs at high frequency among surgeons (between 28% and 42% of surgeons report symptoms) with trauma surgery independently associated with higher rates of burnout,(4-7) it is associated with medical error and worse patient outcomes, (8-9) and is strongly related to suicidal intent in physicians where it is consistently and notably higher in female trainees.(10) Surgeons are also less likely to seek help for mental illness, despite surgeons having suicidal ideation 2-3x higher than the general population, only 26% of surgeons with suicidal ideation seek help.(11) National Suicide Prevention Lifeline
Three factors elevate this study to a critical level of significance for leaders in academic surgery.  First, the authors surveyed virtually all surgical residents and achieved a 99.3% response rate; it is impossible to dismiss as too small or biased to be accepted as an accurate reflection of residents’ experiences. Second, it is consistent with similar smaller studies and surveys research in the past 30 years, revealing unchanged levels of mistreatment of trainees since the 1980s (1).  Finally, the program-level variation in mistreatment shows that the abuse and mistreatment experienced does not have to be an intrinsic feature of surgical training. Since the differential prevalence among programs indicates some programs have succeeded in creating cultures without abuse of residents (eg. Residents experiencing verbal and physical abuse varied from 0 to 66.7% and 0 to 100% of residents by program).  It follows that the poorly-performing leaders cannot rely on the tired excuse of tradition or the unique nature of surgical training to justify hostile conditions for trainees.
The data are now clear and glaring, without a doubt, inequity and abuse occur in our workforce. Mistreatment cannot be defended on grounds of tradition or necessity. It contributes to the ongoing shortage of surgeons, and cause tragic, unnecessary harm to our friends and colleagues. We all deserve better.

  1. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Academic Medicine. 2014;89(5):817-827  
  2. Warsame, R. M., & Hayes, S. N. (2019). Mayo Clinic’s 5-Step Policy for Responding to Bias Incidents. AMA journal of ethics21(6), 521-529.
  3. Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and parenthood among surgery residents: results of the first nationwide survey of general surgery residency program directors. Journal of the American College of Surgeons. 2016;222(6):1090-1096.
  4. Kuerer HM, Eberlein TJ, Pollock RE, et al. Career Satisfaction, Practice Patterns and Burnout among Surgical Oncologists: Report on the Quality of Life of Members of the Society of Surgical Oncology. Annals of Surgical Oncology. 2007;14(11):3043-3053.
  5. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and Career Satisfaction Among American Surgeons. Annals of Surgery. 2009;250(3):463-471.
  6. Balch CM, Freischlag JA, Shanafelt TD. Stress and Burnout Among Surgeons: Understanding and Managing the Syndrome and Avoiding the Adverse Consequences. JAMA Surgery. 2009;144(4):371-376.
  7. Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Annals of surgery. 2011;254(4):558-568.
  8. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. Jama. 2006;296(9):1071-1078. 11. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
  9.  Dyrbye LN, Burke SE, Hardeman RR, et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA. 2018;320(11):1114-1130.
  10. Lindeman S, Läärä E, Hakko H, Lönnqvist J. A systematic review on gender-specific suicide mortality in medical doctors. The British Journal of Psychiatry. 1996;168(3):274-279.
  11. Shanafelt TD, Balch CM, Dyrbye L, et al. Special Report: Suicidal Ideation Among American Surgeons. JAMA Surgery. 2011;146(1):54-62.
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 This Literature Review is being brought to you by the EAST Manuscript and Literature Review Committee. Have a suggestion for a review or an additional comment on articles reviewed? Please email litreview@east.orgPrevious issues available on the EAST website.