Workplace microaggressions: results of a survey of the American College of Surgeons members.

BACKGROUND: Workplace microaggressions are a longstanding but understudied problem in the surgical specialties. Microaggressions in health care are linked to negative emotional and physical health outcomes and can contribute to burnout and suboptimal delivery of patient care. They also negatively impact recruitment, retention, and promotion, which often results in attrition. Further attrition at the time of an impending surgical workforce shortage risks compromising the delivery of health care to the diverse US population, and may jeopardize the financial stability of health care organizations. To date, studies on microaggressions have consisted of small focus groups comprising women faculty or trainees at a single institution. To our knowledge, there are no large, multiorganizational, gender-inclusive studies on microaggressions experienced by practicing surgeons. OBJECTIVE: This study aimed to examine the demographic and occupational characteristics of surgeons who do and do not report experiencing workplace microaggressions and whether these experiences would influence a decision to pursue a career in surgery again. STUDY DESIGN: We developed and internally validated a web-based survey to assess surgeon experiences with microaggressions and the associated sequelae. The survey was distributed through a convenience sample of 9 American College of Surgeons online Communities from November 2022 to January 2023. All American College of Surgeons Communities comprised members who had completed residency or fellowship training and had experience in the surgical workforce. The survey contained demographic, occupational, and validated microaggression items. Analyses include descriptive and chi-square statistics, t tests, and bivariable and multivariable logistic regression. RESULTS: The survey was completed by 377 American College of Surgeons members with the following characteristics: working as a surgeon (80.9%), non-Hispanic White (71.8%), general surgeons (71.0%), aged ≥50 years (67.4%), fellowship-trained (61.0%), and women (58.4%). A total of 254 (67.4%) respondents reported experiencing microaggressions. Younger surgeons (P=.002), women (P<.001), and fellowship-trained surgeons (P=.001) were more likely to report experiencing microaggressions than their counterparts. Surgeons working in academic medical centers or health care systems with teaching responsibilities were more likely to experience microaggressions than those in private practice (P<.01). Surgeons currently working as a surgeon or those who are unable to work reported more experience with microaggressions (P=.003). There was no difference in microaggressions experienced among respondents based on surgical specialty, race/ethnicity, or whether the surgeons reported having a disability. In multivariable logistic regression, women had higher odds of experiencing microaggressions compared with men (adjusted odds ratio, 15.9; 95% confidence interval, 7.7-32.8), and surgeons in private practice had significantly lower odds of experiencing microaggressions compared with surgeons in academic medicine (adjusted odds ratio, 0.3; 95% confidence interval, 0.1-0.8) or in health care systems with teaching responsibilities (adjusted odds ratio, 0.2; 95% confidence interval, 0.1-0.6). Among surgeons responding to an online survey, respondents reporting microaggressions were less likely to say that they would choose a career in surgery again (P<.001). CONCLUSION: Surgeons reporting experience with microaggressions represent a diverse range of surgical specialties and subspecialties. With the continued expansion of surgeon gender and race/ethnicity representation, deliberate efforts to address and eliminate workplace microaggressions could have broad implications for improving recruitment and retention of surgeons.

Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry.

OBJECTIVE: The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research. STUDY DESIGN: This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy). RESULTS: A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036). CONCLUSION: Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.

Surgeon Counseling Regarding Return to Sexual Activity After Pelvic Reconstructive Surgery.

IMPORTANCE: Patients highly value surgeon counseling regarding the first sexual encounters after pelvic reconstructive surgery. OBJECTIVES: We performed a qualitative analysis of usual surgeon counseling regarding return to sexual activity after surgery for pelvic organ prolapse and/or urinary incontinence. METHODS: Participating surgeons provided a written description of their usual patient counseling regarding return to sexual activity after pelvic organ prolapse or urinary incontinence surgery. Counseling narratives were coded for major themes by 2 independent reviewers; disagreements were arbitrated by the research team. Analysis was performed utilizing Dedoose software and continued until thematic saturation was reached. RESULTS: Twenty-two surgeons participated, and thematic saturation was reached. Six major themes were identified: "Safety of Intercourse," "Specific Suggestions," "Surgical Sequelae," "Patient Control," "Partner Related," "Changes in Experience," and "No Communication." Nearly all participating surgeons included counseling on the safety of intercourse and reassurance that intercourse would not harm the surgical repair. Specific suggestions included different positions, use of lubrication, vaginal estrogen use, specific products/vendors, alternatives to (vaginal) intercourse, and the importance of foreplay. Surgical sequelae discussion included possible interventions for complications, such as persistent sutures in the vagina, abnormal bleeding, or de novo dyspareunia. Counseling regarding changes to the patient's sexual experience ranged from suggestion of improvement to an anticipated negative experience. Surgeons more commonly advised patients that their sexual experience would be worsened or different from baseline; discussion of improvement was less frequent. CONCLUSIONS: Surgeon counseling regarding the postoperative return to sexual activity varies among pelvic reconstructive surgeons. Most reassure patients that intercourse is safe after surgery.

Fecal Incontinence and the Risk of Urinary Tract Infection in Patients Presenting for Urogynecological Consultation.

IMPORTANCE: Urinary tract infection (UTI) is common in urogynecology patients. Patients with fecal incontinence (FI) often attribute their UTIs to FI, but this association has not been evaluated. OBJECTIVES: The objectives of this study were to compare the prevalence of UTI in urogynecology patients with and without FI and to characterize factors associated with UTI and recurrent UTI. STUDY DESIGN: This retrospective cohort study included all new adult patients who presented to an academic female pelvic medicine and reconstructive surgery practice with FI from January 2014 through December 2017. Patients were age-matched to new adult patients with stage <2 pelvic organ prolapse without FI. All urine culture results from 1 year before and 1 year after the first visit were identified. Logistic regression identified factors associated with UTI. RESULTS: Among 399 patients, 106 (27%) had a culture-confirmed UTI in the year before or after their first urogynecology visit; the prevalence of UTI was 23% (45/198) in patients with FI and 30% (61/201) in those without FI (P = 0.09). The rate of recurrent UTI was 11.5% overall and did not differ among those with and without FI. In multivariate models, variables that were statistically significantly associated with UTI included age, diabetes mellitus, anterior vaginal wall prolapse, and sexual activity. Fecal incontinence was not associated with any or recurrent UTI. CONCLUSIONS: The prevalence of UTI and recurrent UTI was similar in urogynecology patients with and without FI. Variables that were associated with UTI risk included older age, sexual activity, diabetes mellitus, and anterior vaginal wall prolapse.

Evaluation of a Structured Female Pelvic Medicine and Reconstructive Surgery Resident Rotation Curriculum.

IMPORTANCE: Residency education is moving toward competency-based learning, which requires novel educational methods. One solution is structured learning through a formalized curriculum. OBJECTIVE: The purpose of this study is to evaluate the educational aspects of a novel structured curriculum in female pelvic medicine and reconstructive surgery. STUDY DESIGN: This was a prospective cohort study of third-year obstetrics and gynecology residents who rotated on the female pelvic medicine and reconstructive surgery service. The curriculum was organized into 7 specific topics with weekly required reading, key specialty articles, and reviewed quizzes on subspecialty topics adapted from the American Board of Obstetrics and Gynecology Guide to Learning. A prerotation and postrotation self-assessment of pelvic anatomy and pelvic floor dysfunction content comprehension was assessed using a Likert scale (0-10) for each domain. RESULTS: Obstetrics and gynecology residents from 4 academic years resulted in a total of 17 paired assessments for analysis. Each of the 7 domains showed significant improvement among all academic years, with a mean increase of 4.9 ± 0.8 points ( P < 0.001). The 2 domains that showed the greatest improvement were stress urinary incontinence (5.5 ± 1.3, P < 0.001) and pelvic organ prolapse (5.5 ± 1.9, P < 0.001). There was no significant association between score improvement and the number of previous surgical rotations or having the rotation in the first or second half of the academic year. CONCLUSIONS: This study demonstrated that a structured curriculum in female pelvic medicine and reconstructive surgery was associated with significant improvement in self-assessed perceived resident knowledge during the subspecialty rotation. This approach could be applied to other rotations and direct education curriculum development.

Money Matters: Anticipated Expense of In-Person Obstetrics and Gynecology Fellowship Interviews Has Greater Impact for Underrepresented in Medicine and Women Applicants.

Background: Much of the expense of pursuing subspecialty training in obstetrics and gynecology (ObGyn) is due to in-person fellowship interviews. Although interviews were converted to a virtual platform for the 2020 fellowship interview season in response to the COVID-19 pandemic, candidates anticipated in-person interview expenses at the time of their application. It is unknown whether financial considerations influenced candidates' decision to pursue fellowship training. This study aimed to evaluate the financial impact of anticipated in-person fellowship interviews among applicants of ObGyn subspecialties. Materials and Methods: This was a planned secondary analysis of a survey administered during the 2020 interview season to evaluate the effectiveness of virtual ObGyn fellowship subspecialty interviews in creating a rank list. Information was obtained about anticipated and actual interview costs, the need for securing additional funding and whether financial considerations influenced the decision to apply for fellowship. Results: In total, 158 participants enrolled in the 2020 National Resident Matching Program for ObGyn fellowship programs (48%) completed the web-based survey. Women and Black fellowship applicants were more likely than men (p = 0.044) and White applicants (p = 0.014) to endorse a need to secure additional funding for in-person fellowship interviews. In addition, Hispanic and Black applicants were more likely than White applicants to report that the financial impact of fellowship interviews influenced the decision to apply "somewhat" or "to a great extent" (p = 0.025 and p < 0.001, respectively). Conclusions: The costs of applying to ObGyn fellowship programs may disproportionately affect women and underrepresented in medicine applicants. By reducing a financial barrier, virtual interviews may help promote greater gender and racial and ethnic diversity in ObGyn subspecialty pursuit.

Virtual Interviews Improve Equity and Wellbeing: Results of a Survey of Applicants to Obstetrics and Gynecology Subspecialty Fellowships.

BACKGROUND: Nationwide restrictions and recommendations from the Association of American Medical Colleges mandated program directors to conduct all graduate medical education interviews virtually in the Spring of 2020 in response to the COVID-19 pandemic. This study was conducted to assess the impact of virtual interviews on a candidates' ability to effectively create a rank list. OBJECTIVE: The primary objective of this study was to evaluate Obstetrics and Gynecology (ObGyn) subspecialty fellowship applicants' perspectives regarding the effectiveness of virtual interviews for creating a rank list. Secondary outcomes included perceived advantages and disadvantages of the process and costs of the process. METHODS: This was a cross-sectional IRB-exempt study, using an electronic survey administered to a convenience sample of applicants to ObGyn subspecialty fellowship programs. The survey was administered via RedCap between the rank list submission deadline and the Match. Descriptive statistics were used. RESULTS: Response rate was 158/330 (48%). Overall, 129/158 (82%) percent of respondents felt confident in making their rank list based on the virtual interviews, and 146/158 (92%) were "very satisfied" or "somewhat satisfied" with the process. Of those who expressed an interview style preference, 65/149(44%) of respondents preferred virtual interviews; 49/149(33%) had no preference or were not sure. Nearly all 146/148(99%) applicants cited cost-savings as a distinct advantage of virtual interviews. CONCLUSION: Applicants to ObGyn subspecialty fellowships felt comfortable to create a rank list based on the virtual interview. This study indicates that the virtual format is effective, less stressful and less costly for ObGyn subspecialty interviews and should be considered beyond the pandemic to remove barriers and burdens for applicants.

A Cost-Effectiveness Analysis of Post-Void Residual Bladder Scan Thresholds in the Postoperative Setting.

INTRODUCTION AND HYPOTHESIS: To identify the optimal cost-effectiveness threshold of post-void residual (PVR) by bladder scan in postoperative urogynecologic patients. METHODS: A cost-effectiveness analysis was performed as a secondary analysis of a previously published study of patients undergoing urogynecologic procedures with planned voiding trials, setting thresholds for postoperative PVR bladder scan volumes at 100 ml, 150 ml, and 200 ml. Patient-based scenarios were modeled for ambulatory office or emergency department (ED) resource utilization and to determine the cost-effectiveness of each threshold. Costs were obtained from a southeastern academic medical center, only utilizing direct medical costs and hospital costs, not including societal costs. Quality-adjusted life years (QALY's) were used as health outcomes determining the incremental cost-effectiveness ratio (ICER). RESULTS: A total of 151 patients from the original study were included. A willingness to pay threshold of $100,000 per QALY was assumed. A PVR of 100 ml exceeded this at $373,824. A PVR threshold of 150 ml was dominant (-$1,211,716), while minimizing ED visits for postoperative urinary retention (POUR) and unnecessary clinic appointments. While a PVR of 200 ml appeared a cost-effective strategy (-$488,389), there was increased ED utilization and under-detection of postoperative urinary retention (POUR). CONCLUSION: A PVR threshold of 100 ml created a healthcare system burden due to increased office voiding trials. Both PVR thresholds of 150 ml and 200 ml were cost-effective strategies; however, ED utilization for POUR increased with 200 ml. Utilizing 150 ml as the PVR cut-off proved the most cost-effective strategy, avoiding POUR under-detection and undue health costs.

A telehealth intervention to increase patient preparedness for surgery: a randomized trial.

INTRODUCTION AND HYPOTHESIS: Methods to increase surgical preparedness in urogynecology are lacking. Our objective was to evaluate the impact of a preoperative provider-initiated telehealth call on surgical preparedness. METHODS: This was a multicenter randomized controlled trial. Women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence were randomized to either a telehealth call 3 (± 2) days before surgery plus usual preoperative counseling versus usual preoperative counseling alone. Our primary outcome was surgical preparedness, as measured by the Preoperative Prepardeness Questionnaire. The Modified Surgical Pain Scale, Pelvic Floor Distress Inventory-20, Patient Global Impressions of Improvement, Patient Global Impressions of Severity, Satisfaction with Decision Scale, Decision Regret Scale, and Clavien-Dindo scores were obtained at 4-8 weeks postoperatively and comparisons were made between groups. RESULTS: Mean telehealth call time was 11.1 ± 4.11 min. Women who received a preoperative telehealth call (n = 63) were significantly more prepared for surgery than those who received usual preoperative counseling alone (n = 69); 82.5 vs 59.4%, p < 0.01). A preoperative telehealth call was associated with greater understanding of surgical alternatives (77.8 vs 59.4%, p = 0.03), complications (69.8 vs 47.8%, p = 0.01), hospital-based catheter care (54 vs 34.8%, p = 0.04) and patient perception that nurses and doctors had spent enough time preparing them for their upcoming surgery (84.1 vs 60.9%, p < 0.01). At 4-8 weeks, no differences in postoperative and patient reported outcomes were observed between groups (all p > 0.05). CONCLUSIONS: A short preoperative telehealth call improves patient preparedness for urogynecological surgery.

Can We Trust the Math? Correlation of Objective Postvoid Residual With Calculated Subtraction Postvoid Residual.

OBJECTIVE: The aim of the study was to determine the accuracy of postvoid residual (PVR) by subtraction as compared with objective measurement by bladder scan or catheterization. METHODS: This is a secondary analysis of postoperative patients who underwent avoiding trial by retrograde bladder instillation. Fill volume, spontaneous voided volume, and PVR were objectively measured; PVR was also calculated. Pearson correlation compared PVR by subtraction versus objective measurement. We then defined postoperative urinary retention (POUR) at 3 different PVR values (100 mL, 150 mL, and 200 mL) to compare the sensitivity, specificity, and positive and negative predictive values of subtraction for detecting urinary retention at these 3 thresholds. RESULTS: Data were available for 155 patients after urogynecologic surgery. Median PVR by objective measurement was 46 mL (interquartile range = 11-146 mL). Median calculated PVR by subtraction was 10 mL (interquartile range = 0-100 mL). Objective measure and subtraction PVR values were strongly correlated (Pearson coefficient = 0.78, P < 0.001). Using a threshold of 200 mL to define POUR resulted in the highest negative predictive value and the lowest absolute number of both false negatives and false positives. Even using this threshold, 11 (48%) of 23 women with POUR by measurement were misclassified as not having POUR when ascertained by subtraction. CONCLUSIONS: Although subtraction PVR correlates well with objective PVR measurement, almost half of women with a PVR volume of greater than 200 mL by objective measurement are miscategorized as voiding normally by subtraction PVR. Based on these findings, reliance on objective PVR measurement in postoperative patients is preferable to subtraction PVR.

Urinary Tract Injury During Gynecologic Surgery: Prevention, Recognition, and Management.

Lower urinary tract (LUT) injuries may occur during gynecologic surgery due to the close proximity of pelvic organs and vary by procedure, surgical indication, and route. Prevention of LUT injury should be a primary goal of gynecologic surgery. LUT injuries are more common in patients with aberrant anatomy, during difficult procedures, and with surgeons with less experience. Immediate recognition and management of LUT injuries is optimal, although delayed postoperative diagnoses may be unavoidable. Surgical management is based on the size and location of injury and should be performed by an experienced surgeon with thorough knowledge of pelvic anatomy, surgical technique, and postoperative management.

Professional Address during Obstetrics and Gynecology Grand Rounds Introductions: Setting the Stage, Setting the Standard.

OBJECTIVE: This study aimed to assess gender dynamics during Obstetrics and Gynecology (Ob/Gyn) Grand Rounds. DESIGN: This was an observational cohort study of Ob/Gyn Grand Rounds introductions at a large academic center. Ob/Gyn Grand Rounds introductions from December 2016 to February 2020 were included. Audio and video components of introductions for those with doctorate degrees were reviewed. Each named reference to the presenter and use of descriptors were collected. Statistical analyses included Fisher's exact test for categorical variables and Student's t-test for continuous variables. SETTING: This study was completed at the University of Wisconsin in the Department of Ob/Gyn PARTICIPANTS: Ob/Gyn Grand Rounds introducers who had complete audio and video components of introductions for those with doctorate degrees. RESULTS: Sixty-four Grand Rounds introductions were reviewed; 57 met inclusion criteria. The majority of introducers and presenters were women. Consistent use of "doctor" was similar by men and women introducers (50% vs. 29%, p = 0.427). Assistant professors were more likely to maintain professional address during introductions, compared to associate or full professors (86% vs. 0% vs. 10%, p < 0.001). Trainees were less likely than faculty to be addressed professionally at any time during introductions (42% vs. 81%, p = 0.017). Descriptors were used for men and women presenters, though men received more female-gendered descriptors than women (5 vs. 1, p = 0.011). Women introducers used productivity descriptors less often than men introducers (8 [15.1%] vs. 5 [55.6%] (p = 0.015)). CONCLUSIONS: Use of professional address was associated with academic rank, but not gender. Men endorsed and received more descriptors emphasizing accomplishments, highlighting qualifications as an expert. Given the professional environment, all Grand Rounds presenters should be introduced using professional titles.

Enterocele manifesting as recurrent anterior rectal prolapse: A case report.

INTRODUCTION AND IMPORTANCE: An enterocele is a true herniation of small bowel through the rectovaginal septum, most commonly occurring transvaginally. Although the prevalence of enterocele is not as low as previously thought, enteroceles manifesting transrectally or with rectal prolapse are exceedingly rare and without established surgical guidance. CASE PRESENTATION: A medically complex, oxygen-dependent patient presented with full fecal incontinence and transrectal enterocele associated with recurrent anterior rectal prolapse. This was diagnosed via defecography and repaired under regional anesthesia through an open transabdominal approach of posterior cul-de-sac obliteration, uterosacral ligament vaginal vault suspension and simplified ventral suture rectopexy. Surgical planning was determined through a multidisciplinary care-conference, with preference for an approach with minimal respiratory compromise and repair durability. Short-term, this patient has complete resolution of bulge symptoms, and improved fecal continence. CLINICAL DISCUSSION: In addition to history and examination, dynamic imaging of the pelvic floor, specifically defecography, is particularly useful in identifying enteroceles that present as a component of pelvic organ or anorectal prolapse. As there are no established standard surgical treatment approaches for these rare conditions, surgeons must consider several points prior to proceeding: the repair of the defect, the symptoms the repair targets, and repair durability. CONCLUSIONS: Complete assessment and specialist consultation should be pursued prior to surgical repair for anorectal pathology. For this patient, an open transabdominal native tissue repair under regional anesthesia was successful, emphasizing that approaches to surgical correction of such rare presentations must be individualized.

The Current Status of Women in Surgery: How to Affect the Future.

Importance: Despite women composing half of current medical school classes, surgical specialties still struggle to attract and retain women. Even after successful recruitment into training, women surgeons continue to face gender bias and various obstacles to career advancement, including lower rates of surgical residency completion, board certification, and professional advancement. Gender inequality in medicine has drawn attention; particular consideration regarding the status of women in surgery is warranted. We review research delineating disparities and investigating the causes underlying such issues, and most importantly, we propose recommended action. Observations: Recruitment of women into surgery is increasing as more women are visible in the specialty, and forthcoming measures to encourage mentorship and rectify issues related to pregnancy and burnout will likely improve this. However, obstacles to career development for women surgeons, including residency/fellowship support, mentorship/sponsorship, leadership, work-life balance, and pay equity remain. More importantly, gender discrimination continues, originating from conscious and unconscious bias, which is remedied only by recognition and deliberate correction. Several organizations have proactively recommended measures to cultivate gender equity for women surgeons, which require implementation to effect meaningful change. While the first step is recognition of the issues and underlying etiologies, further action is needed in combating such disparities and establishing a culture of equity for women in surgery. Conclusions and Relevance: Opportunities for women in surgery have improved, although much work remains to make the surgical workplace supportive of women, empowering them to optimally contribute. These efforts will benefit organizations, the community, future generations of surgeons, and most importantly, profoundly and positively affect the care of patients.

Leading from Behind: Paucity of gender equity statements and policies among professional surgical societies.

BACKGROUND: The availability and utility of public statements and policies on gender equity from professional surgical societies has not been studied. METHODS: Professional surgical society websites were searched for publicly available statements and policies related to gender equity. These were compiled and assessed for critical components. RESULTS: Publicly available statements/policies were published in every surgical society, though few pertained specifically to gender. Nearly all were recently written or revised. The most common statement/policy addressed discrimination and harassment. The only policies/statements that reliably contained all four key components pertained to professional conduct at national meetings. All policies that provided consequences also contained specific reporting processes. CONCLUSIONS: Gender equity statements and policies are deficient among professional surgical societies. Prioritization of publicizing statements/policies that describe the challenges and provide potential solutions to well-documented gender inequities within surgical fields allows professional societies to promote a diverse and equitable workforce.

Has a critical mass of women resulted in gender equity in gynecologic surgery?

Gender equity in medicine and surgery has recently received widespread attention. Unlike surgical specialties that remain predominantly male, the majority of obstetrician-gynecologists have been women for nearly a decade, and women have composed the majority of trainees since the 1990s. Despite a critical mass of women, biases related to gender persist in the field. Professional and behavioral expectations of men and women gynecologists remain different for patients and workplace colleagues. Gender discrimination and sexual harassment are still experienced at high rates by both trainees and obstetrician-gynecologists in practice. In addition, in other surgical fields, women gynecologic surgeons face a gender wage gap that is unexplained by differences in experience, hours worked, or subspecialty training. Academic advancement and the attainment of leadership positions remain a challenge for many women. Policies related to pregnancy and parenting may disproportionately affect the careers of women gynecologists. This article presents peer-reviewed evidence relevant to gender equity in the workplace and suggests proactive interventions to ensure diversity and inclusion for gynecologic surgeons.

Take me to your leader: Reporting structures and equity in academic gynecologic oncology.

OBJECTIVE: Gynecologic oncology includes increasing percentages of women. This study characterizes representation of faculty by gender and subspecialty in academic department leadership roles relevant to the specialty. METHODS: The American Association of Medical Colleges accredited schools of medicine were identified. Observational data was obtained through institutional websites in 2019. RESULTS: 144 accredited medical schools contained a department of obstetrics and gynecology with a chair; 101 a gynecologic oncology division with a director; 98 a clinical cancer center with a director. Women were overrepresented in academic faculty roles compared to the US workforce (66 vs 57%, p < 0.01) but underrepresented in all leadership roles (p < 0.01). Departments with women chairs were more likely to have >50% women faculty (90.2 vs 9.8%, p < 0.01); and have larger faculties (80.4 vs 19.6% >20 faculty, p = 0.02). The cancer center director gender did not correlate to departmental characteristics. A surgically focused chair was also associated with >50% women faculty (85.7 vs 68.3%, p = 0.03); faculty size >20 (85.7 vs 61.4%, p < 0.01); and a woman gynecologic oncology division director (57.6 vs 29.4%, p < 0.01; 68.4 vs 31.7%, p < 0.01) and gynecologic oncology fellowship (50 vs 30.4%, p < 0.01; 59.1 vs 32%, p < 0.01). Gynecologic oncology leadership within cancer centers was below expected when incidence and mortality to leadership ratios were examined (p < 0.01, p < 0.01). CONCLUSION: Within academic medical schools, women remain under-represented in obstetrics and gynecology departmental and cancer center leadership. Potential benefits to gynecologic oncology divisions of inclusion women and surgically focused leadership were identified.

Utility of intraoperative cystoscopy in detecting ureteral injury during vaginal hysterectomy.

OBJECTIVES: The aim of this study was to determine the utility of intraoperative cystoscopy in detecting and managing ureteral injury among women undergoing vaginal hysterectomy. METHODS: We performed a secondary analysis of a retrospective cohort study of 593 patients who underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor reconstructive surgery, from January 2, 2004, through December 30, 2005. A logistic regression model determining the propensity to undergo intraoperative cystoscopy was constructed. Comparisons of ureteral injury and cost between patients with and without cystoscopy were adjusted for the cystoscopy propensity score. We further explored the feasibility of using perioperative change in creatinine level to detect ureteral injury. RESULTS: In total, 230 (38.8%) of 593 patients underwent cystoscopy. Six patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group had ureteral injuries (odds ratio, 1.92; 95% confidence interval [CI], 0.58-6.36). This association was further attenuated after adjusting for the propensity to undergo cystoscopy (odds ratio, 1.31; 95% CI, 0.19-9.09). Four injuries detected cystoscopically were managed intraoperatively. Adjusted mean-predicted costs for patients undergoing cystoscopy were $10,686 (95% CI, $7500-$13,872) versus $10,217 (95% CI, $6894-$13,540). In the no-cystoscopy group, patients with ureteral injury had a median increase in creatinine level of 0.2 mg/dL, whereas patients without injury had a median decrease of 0.1 mg/dL (P < 0.001). CONCLUSIONS: The level of selection for cystoscopy did not significantly increase the mean predicted costs for patients. Reliance on postoperative creatinine level to detect ureteral injury, while highly sensitive, is limited by a low positive predictive value and variable range.