October 2021 - Equity, Diversity and Inclusion

October 2021
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 Equity, Diversity and Inclusion in Trauma Surgery Practice Committee Members Maraya Camazine, MS, Cristina Feather, MD, MHS, Aimee LaRiccia, DO and Mark Hoofnagle, MD, PhD.

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


In This Issue: Equity, Diversity and Inclusion

Scroll down to see summaries of these articles

Article 1 reviewed by Maraya Camazine, MS and Cristina Feather, MD, MHS
Gender perception bias of operative autonomy evaluations among residents and faculty in general surgery training. Cookenmaster C, Shebrain S, Vos D, Munene G, Miller L, Sawyer R. Am J Surg. 2021 Mar;221(3):515-520.

Article 2 reviewed by Maraya Camazine, MS and Cristina Feather, MD, MHS
Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US. Schlick CJR, Ellis RJ, Etkin CD, et al. JAMA Surg. 2021 Jul 28;e213195.

Article 3 reviewed by Aimee LaRiccia, DO
Is There Color or Sex Behind the Mask and Sterile Blue? Examining Sex and Racial Demographics within Academic Surgery. Aggarwal A, Rosen CB, Nehemiah A, Maina I,  Kelz RR,  Aarons CB,  Roberts SE. Ann Surg. 2021 Jan 1;273(1):21-27.

Article 4 reviewed by Mark Hoofnagle, MD, PhD
A national analysis of pediatric firearm violence and the effects of race and insurance status on risk of mortality. Rosenbaum K,  Grigorian A, Yeates E, Kuza C, Kim D, Inaba K, Dolich M, Nahmias J. Am J Surg. 2021 Sep;222(3):654-658.

Article 5 reviewed by Mark Hoofnagle, MD, PhD
Call to Action on the Categorization of Sex, Gender, Race, and Ethnicity in Surgical Research. Nahmias J, Zakrison TL, Haut ER, Onaona G, Joseph B, Hendershot K, Ghneim M, Stey A, Hoofnagle MH, Zinzi B, Rishi R, Richardson JB, Santos AP, Zarzaur B. J Am Coll Surg. 2021 Aug;233(2):316-319.

Article 1
Gender perception bias of operative autonomy evaluations among residents and faculty in general surgery training. Cookenmaster C, Shebrain S, Vos D, Munene G, Miller L, Sawyer R. Am J Surg. 2021 Mar;221(3):515-520.

As surgical residents progress through training, the overarching goal of their education is to obtain a diverse skill set and operative autonomy. Previous research indicates that multiple socioeconomic and cultural factors affect level of autonomy; however, there is mixed data on the impact of gender within this area. Cookenmaster et al. discuss operative autonomy in terms of two components: sound medical and surgical knowledge, and procedural skills driven by a sound decision-making process. In this investigation, the authors sought to evaluate the impact of gender on resident and faculty perceived level of operative autonomy. Over a 5 year period, operative autonomy was evaluated using the Zwisch score in addition to paired evaluations by both faculty and residents. 

Thirty-nine surgeons and forty-two residents participated in the study to complete 2,360 evaluations over a 5-year period. Residents from all levels of training submitted evaluations. ACGME defined-category cases performed were variable (49.1% abdominal), as was procedural complexity. An odds ratio of higher level of autonomy granted by faculty was determined using logistic regression including variables such as resident and faculty gender, postgraduate level, case complexity and faculty years of experience. When evaluated by faculty, resident gender did not affect the level of granted autonomy. Interestingly, female faculty evaluations had an overall lower odds ratio of higher level of autonomy for both female and male residents when compared to male faculty. Analysis of resident self-evaluations showed the female residents rated their degree of autonomy to be lower than that of their male counterparts. Faculty experience had an inverse relation to degree of autonomy granted, showing faculty with experience of 10 or more years were less likely to score a higher level of autonomy. The authors conclude that when evaluating the entire study cohort, gender did not impact the level of perceived autonomy at all PGY levels. Limitations cited by Cookenmaster et al. include a single center study, with voluntary participation in evaluations leading to a possible selection bias. Additionally, case evaluations included in this study were all elective or non-emergent cases, leading to a reduction in the potential case complexity. At the individual program level, efforts should be taken to evaluate what bias may exist within their curriculum and resident feedback protocols to ensure equity in education among residents. In addition, differences in gender perception may be a contributing factor that should be considered when understanding evaluation and feedback. 

Article 2
Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US. Schlick CJR, Ellis RJ, Etkin CD, et al. JAMA Surg. 2021 Jul 28;e213195.

Gender discrimination and sexual harassment is a well-established contributor to career dissatisfaction, decreased self-confidence and mental health issues amongst female professionals. Schlick et al. aim to define prevalence and further characterize types of harassment within surgical residency programs in the United States, with hopes of promoting awareness and change.  The authors present survey results administered to clinically active US surgery residents after the ABSITE exam. Questions address different aspects of gender discrimination and sexual harassment including types of behavior, frequency, and source of behavior.

A total of 6,764 resident responses were included in this study, with a response rate of 85.6%.  Female residents experienced higher rates of gender discrimination compared to male (80% of women vs. 17% of men), and higher rates of sexual harassment (43% of women vs. 22% of men). Interestingly, rates of both categories are increased from previous research published in 2019 by Ellis et al. that was obtained in a similar fashion and evaluating similar parameters, indicating that despite knowledge of ongoing discrimination, behaviors are potentially unchanged. Source of harassment differed between groups with females more frequently reporting discrimination from patients and/or families, whereas male residents reported the most common source was from co-residents and/or fellows. Gender discrimination was associated with pregnancy and higher ABSITE scores in females, while parenthood and lower ABSITE scores were associated with gender discrimination reported in males.  Lastly, in accordance with previous studies, attending physicians were the most common source of gender discrimination based on opportunities and evaluation. Harassment and discrimination is still an alarmingly common occurrence reported by surgical residents, and could play a large part in career dissatisfaction, depression, burnout, and suicidal ideation. This study posits several areas for additional interventions and improvement that would lead to improved equity among male and female surgeons and promote a healthier and sustainable workforce.   

Article 3
Is There Color or Sex Behind the Mask and Sterile Blue? Examining Sex and Racial Demographics within Academic Surgery. Aggarwal A, Rosen CB, Nehemiah A, Maina I,  Kelz RR,  Aarons CB,  Roberts SE. Ann Surg. 2021 Jan 1;273(1):21-27.

In this call to action cross sectional survey, racial and gender disparities that exist across the surgical pipeline are clearly displayed. The authors highlight the fact more females are entering medical schools than males, but the leadership of department chairs continues to skew male dominated. This study aimed to capture the current racial and demographic data of the surgical trainee pipeline as well as the current surgical leadership in order to understand why certain populations are underrepresented. Data on racial and sex demographics were obtained using the AAMC database for medical students, surgical residents/fellows and surgical faculty. Compared to the US Census data from 2018, Whites made up 69.8% of surgical faculty compared to 60.4% of the overall population. Both Blacks and Hispanics were underrepresented compared to population percentage with 4.2% of surgical faculty identifying as Black (12.5% of the US population identified as Black) and 3.4% of surgical faculty identifying as Hispanic (18.3% of the US population identified as Hispanic). For gender reported data, Women make up 51.7% of medical students, 43.7% of surgical residents and 34.3% of surgical faculty. The surgical faculty ranks continue to demonstrate a sharp decrease in both underrepresented minorities and women from residency into faculty positions. Black women makeup 1.6 % of assistant professors, 0.9% of associate professors and only 0.4% of full professors. Broken down by race, 4.5% of residents identified as Black compared to just 4.2% of surgical faculty, 4.4% of residents identified as Hispanic/Latino compared to just 3.4% of surgical faculty. On the other hand, while 64.7% of residents identified as White, that percentage increases to 69.8% of surgical faculty. 

This study gathered a robust amount of data on sex and racial demographics within the surgical population from residents to full professor surgical faculty. The disparities are clearly laid out in this study and the authors identify strategies to improve equity amongst the surgical field. The data highlights attrition of women as well as underrepresented minorities at all levels: surgical trainees, assistant, associate and full surgical professors. Authors point to previously reported work on the multifactorial etiology that could explain the attrition including work-life balance, lack of minority mentorship and the traditional culture of male dominated leadership (1-3). Promoting surgical diversity does not have a simple path, but as this study points out surgical faculty demographics closely mirror surgical resident demographics so by recruiting and retaining underrepresented minorities the leadership could reflect the population. 

Article 4
A national analysis of pediatric firearm violence and the effects of race and insurance status on risk of mortality. Rosenbaum K,  Grigorian A, Yeates E, Kuza C, Kim D, Inaba K, Dolich M, Nahmias J. Am J Surg. 2021 Sep;222(3):654-658.

Health outcomes disparities by race in the United States are well documented and in the field of trauma surgery are directly relevant to provision of quality care to all patients, and in pediatric firearm violence disparity in mortality for Black patients has been found to be as much as ten times higher than for white patients while Black youths represent almost two thirds of pediatric firearm violence patients.  Rosenbaum et al. use the Pediatric Trauma Quality Improvement Program (TQIP) data for retrospective analysis on all trauma patients that were 16 years of age or younger between January 2014 and December 2016 to examine the differences between mortality observed by race and insurance status in the United States when older teenagers are excluded from analysis.  Clinical outcomes of length of stay (LOS), days in the intensive care unit (ICU), and days on a ventilator and complications of acute kidney injury, acute respiratory distress syndrome, cardiac arrest with cardiopulmonary resuscitation (CPR), deep site infection, superficial infection, organ space infection, deep vein thrombosis, compartment syndrome, pneumonia, cerebrovascular accident, unplanned intubation, urinary tract infection, unplanned return to operating room, unplanned ICU admission, and severe sepsis were analyzed. Using univariable and multivariate logistic regression.  In univariate regression race and insurance status were not associated with increased mortality in this population, however, when high head AIS was excluded a significant racial disparity exists with Black youths with 5x risk of mortality (OR 5.26, CI 1.00–27.47, p = 0.049) while being uninsured was not associated with risk of mortality although a trend maybe apparent (OR 4.13, CI 0.94–18.06, p = 0.059).  The authors hypothesize that in this subset of patients “mortality rate may be influenced by variations in quality and availability of interventions rather than just mechanism of injury.”

Black patients are close to 90% of pediatric firearm violence victims, and as many as two thirds of pediatric patients under the age of 16 despite being 20% of pediatric trauma patients in the TQIP. Evidence of higher mortality in this population represents a quality improvement challenge in trauma, and does not appear to be simply related to presence or absence of insurance status or socioeconomic factors.  Additional study is needed to determine what other risks may be modified or needs addressed in this population to address a persistent racial disparity in mortality present in the literature. 

Article 5
Call to Action on the Categorization of Sex, Gender, Race, and Ethnicity in Surgical Research. Nahmias J, Zakrison TL, Haut ER, Onaona G, Joseph B, Hendershot K, Ghneim M, Stey A, Hoofnagle MH, Zinzi B, Rishi R, Richardson JB, Santos AP, Zarzaur B. J Am Coll Surg. 2021 Aug;233(2):316-319.

A recent review of the quality of reporting of race and ethnicity in the surgical literature found reporting was low at 33% independent of journal adherence to International Committee of Medical Journal Editors guidelines on reporting(1).  However, beyond low rates of reporting of racial and ethnic makeup of surgical populations, our current reporting structure standardized and encoded into our databases is woefully-inadequate to address the complexity of demographic population variables including sex, gender, race and ethnicity. Nahmias et al. have issued a call to action on behalf of EAST for higher quality reporting on sex, gender, race, and ethnicity bringing in the additional expertise of a medical anthropologist, and a social epidemiologist to help guide conclusions about these deficiencies in our literature. 

Surgical databases, such as NSQIP and TQIP have vague or absent definitions of sex and gender and typically do not distinguish between the two likely contributing to the noted problem of infrequent data analysis of variables by sex and gender in the surgical literature and the paucity of data on the transgender population.  Additionally racial and ethnic categorization in our databases is frankly antiquated, based on divisions that may capture effects of racialization but have limited biologic meaning as compared to ancestry.  Racial categorizations in the US are not predictive of genetic similarity, with the majority of variation within populations and only a tiny minority of the variation existing between groups delimited by these blunt racial and ethnic categorizations. Further, variables that may capture the important effects of structural racism and inequality are not included.  Ethnicity reporting is often reported as “Hispanic or non-Hispanic” despite a more complex definition of ethnicity as “defined as large groups of people classified by common racial, national, tribal, religious, linguistic, cultural origin, and background.”  The authors’ conclusions and recommendations include better adherence to best practices of existing standards of reporting on sex, gender, race and ethnicity, as well as improved mechanisms for capture of these data beyond existing limited and binary categories. Ultimately this is a structural problem and requires development of a standardized tools for gathering more complex data on sex, gender, race, and ethnicity (eg EQUATOR tool) in our surgical databases.

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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.