Barriers to neurosurgery for medical students: a national study focused on the intersectionality of gender and race.

OBJECTIVE: Despite 51.2% of medical school graduates being female, only 29.8% of neurosurgery residency applicants are female. Furthermore, only 12.6% of neurosurgery applicants identify as underrepresented in medicine (URM). Evaluating the entry barriers for female and URM students is crucial in promoting the equity and diversity of the neurosurgical workforce. The objective of this study was to evaluate barriers to neurosurgery for medical students while considering the interaction between gender and race. METHODS: A Qualtrics survey was distributed widely to US medical students, assessing 14 factors of hesitancy toward neurosurgery. Likert scale responses, representing statement agreeability, converted to numeric values on a 7-point scale were analyzed by Mann-Whitney U-test and ANOVA comparisons with Bonferroni correction. RESULTS: Of 540 respondents, 68.7% were female and 22.6% were URM. There were 22.6% male non-URM, 7.4% male URM, 53.5% female non-URM, and 15.2% female URM respondents. The predominant reasons for hesitancy toward neurosurgery included work/life integration, length of training, competitiveness of residency position, and perceived malignancy of the field. Females were more hesitant toward neurosurgery due to maternity/paternity needs (p = 0.005), the absence of seeing people like them in the field (p < 0.001), and opportunities to pursue health equity work (p < 0.001). Females were more likely to have difficulties finding a mentor in neurosurgery who represented their identities (p = 0.017). URM students were more hesitant toward neurosurgery due to not seeing people like them in the field (p < 0.001). Subanalysis revealed that when students were stratified by both gender and URM status, there were more reasons for hesitancy toward neurosurgery that had significant differences between groups (male URM, male non-URM, female URM, and female non-URM students), suggesting the importance of intersectionality in this analysis. CONCLUSIONS: The authors highlight the implications of gender and racial diversity in the neurosurgical workforce on medical student interest and recruitment. Their findings suggest the importance of actively working to address these barriers, including 1) maternity/paternity policy reevaluation, standardization, and dissemination; and 2) actively providing resources for the creation of mentorship relationships for both women and URM students in an effort to create a workforce that aligns with the changing demographics of medical graduates to continue to improve diversity in neurosurgery.

Missing Black males among preterm births in the US, 1995 to 2019.

BACKGROUND: In the US, non-Hispanic (NH) Black birthing persons show a two-fold greater risk of fetal death relative to NH white birthing persons. Since males more than females show a greater risk of fetal death, such loss in utero may affect the sex composition of live births born preterm (PTB; <37 weeks gestational age). We examine US birth data from 1995 to 2019 to determine whether the ratio of male to female preterm (i.e., PTB sex ratios) among NH Black births falls below that of NH whites and Hispanics. METHODS: We acquired data on all live births in the US from January 1995 to December 2019. We arrayed 63 million live births into 293 "conception cohort" months of which 2,475,928 NH Black, 5,746,953 NH white, and 2,511,450 Hispanic infants were PTB. We used linear regression methods to identify trend and seasonal patterns in PTB sex ratios. We also examined subgroup differences in PTB sex ratios (e.g., advanced maternal ages, twin gestations, and narrower gestational age ranges). RESULTS: The mean PTB sex ratio for NH Black births over the entire test period (1.06, 95% Confidence Interval [CI]: 1.05, 1.07) is much lower than that for NH white births (1.18, 95% CI: 1.17, 1.19). NH Black PTB sex ratios are especially low for twins and for births to mothers 35 years or older. Only NH white PTB sex ratios show a trend over the test period. CONCLUSIONS: Analysis of over 10 million PTBs reveals a persistently low male PTB frequency among NH Black conception cohorts relative to NH white cohorts. Low PTB sex ratios among NH Black births concentrate among subgroups that show an elevated risk of fetal death. PTB sex ratios may serve as an indicator of racial/ethnic and subgroup differences in fetal death, especially among male gestations.

A Systematic Review of the State of Neurosurgical Disparities Research: Past, Present, and Future.

BACKGROUND: The social determinants of health, which influence healthcare access, patient outcomes, and population-level burden of disease, contribute to health disparities experienced by marginalized patient populations. In the present study, we sought to evaluate the landscape of health disparities research within neurosurgery. METHODS: Embase, Ovid-MEDLINE, Scopus, Web of Science, Cochrane Library, and ProQuest Dissertations databases were queried for original research on health disparities regarding access to, outcomes of, and/or postoperative management after neurosurgical procedures in the United States. RESULTS: Of 883 studies screened, 196 were included, of which 144 had a neurosurgery-affiliated author. We found a significant increase in the number of neurosurgical disparities reports beginning in 2010, with only 10 studies reported before 2010. Of the included studies, 3.1% used prospective methods and 63.8% used data from national registries. The disparities analyzed were racial/ethnic (79.6%), economic/socioeconomic (53.6%), gender (18.9%), and disabled populations (0.5%), with 40.1% analyzing multiple or intersecting disparities. Of the included reports, 96.9% were in phase 1 (detecting phase of disparities research), with a few studies in phase 2 (understanding phase), and none in phase 3 (reducing phase). The spine was the most prevalent subspecialty evaluated (34.2%), followed by neuro-oncology (19.9%), cerebrovascular (16.3%), pediatrics (10.7%), functional (9.2%), general neurosurgery (5.1%), and trauma (4.1%). Senior authors with a neurosurgical affiliation accounted for 79.2% of the reports, 93% of whom were academically affiliated. CONCLUSIONS: Although a recent increase has occurred in neurosurgical disparities research within the past decade, most studies were limited to the detection of disparities without understanding or evaluating any interventions for a reduction in disparities. Future research in neurosurgical disparities should incorporate the latter 2 factors to reduce disparities and improve outcomes for all patients.

Mass Probation: Effects of Sentencing Severity on Mental Health for Black and White Individuals.

BACKGROUND: Incarceration is associated with negative impacts on mental health. Probation, a form of community supervision, has been lauded as an alternative. However, the effect of probation versus incarceration on mental health is unclear. Our objective was to estimate the impact on mental health of reducing sentencing severity at individuals' first adult criminal-legal encounter. METHODS: We used the US National Longitudinal Survey on Youth 1997, a nationally representative dataset of youth followed into their mid-thirties. Restricting to those with an adult encounter (arrest, charge alone or no sentence, probation, incarceration), we used parametric g-computation to estimate the difference in mental health at age 30 (Mental Health Inventory-5) if (1) everyone who received incarceration for their first encounter had received probation and (2) everyone who received probation had received no sentence. RESULTS: Among 1835 individuals with adult encounters, 19% were non-Hispanic Black and 65% were non-Hispanic White. Median age at first encounter was 20. Under hypothetical interventions to reduce sentencing, we did not see better mental health overall (Intervention 1, incarceration to probation: RD = -0.01; CI = -0.02, 0.01; Intervention 2, probation to no sentence: RD = 0.00; CI = -0.01, 0.01) or when stratified by race. CONCLUSION: Among those with criminal-legal encounters, hypothetical interventions to reduce sentencing, including incremental sentencing reductions, were not associated with improved mental health. Future work should consider the effects of preventing individuals' first criminal-legal encounter.

Medical student specialty decision-making and perceptions of neurosurgery. Part 2: Role of race/ethnicity.

OBJECTIVE: Although individuals underrepresented in medicine (URM) make up 33% of the United States population, only 12.6% of medical school graduates identify as URM; the same percentage of URM students comprises neurosurgery residency applicants. More information is needed to understand how URM students are making specialty decisions and their perceptions of neurosurgery. The authors aimed to evaluate the differences between URM and non-URM medical students and residents in terms of the factors that contribute to specialty decision-making and perceptions of neurosurgery. METHODS: A survey was administered to all medical students and resident physicians at a single Midwestern institution to assess factors influencing medical student specialty decision-making and perceptions of neurosurgery. Likert scale responses converted to numerical values on a 5-point scale (strongly agree was the high score of 5) were analyzed with the Mann-Whitney U-test. The chi-square test was performed on the binary responses to examine associations between categorical variables. Semistructured interviews were conducted and analyzed using the grounded theory method. RESULTS: Of 272 respondents, 49.2% were medical students, 51.8% were residents, and 11.0% identified as URM. URM medical students considered research opportunities more than non-URM medical students in specialty decision-making (p = 0.023). When specialty decision-making factors were assessed, URM residents less strongly considered the technical skill required (p = 0.023), their perceived fit in the field (p < 0.001), and seeing people like them in the field (p = 0.010) than their non-URM counterparts when making specialty decisions. Within both medical student and resident respondent cohorts, the authors found no significant differences between URM and non-URM respondents in terms of their specialty decision-making being affected by medical school experiences such as shadowing, elective rotations, family exposure, or having a mentor in the field. URM residents were more concerned about the opportunity to work on health equity issues in neurosurgery than non-URM residents (p = 0.005). The predominant theme that emerged from interviews was the need for more intentional efforts to recruit and retain URM individuals in medicine and specifically neurosurgery. CONCLUSIONS: URM students may make specialty decisions differently than non-URM students. URM students were more hesitant toward neurosurgery due to their perceived lack of opportunity for health equity work in neurosurgery. These findings further inform optimization of both new and existing initiatives to improve URM student recruitment and retention in neurosurgery.

Medical student specialty decision-making and perceptions of neurosurgery. Part 1: Role of gender.

OBJECTIVE: Although women account for 50% of medical school graduates, less than 30% of neurosurgery residency applicants and less than 10% of neurosurgeons are female. In order to diversify the field of neurosurgery and recruit more women, it is necessary to understand why there is a disproportionately low entry rate into neurosurgery by female medical students. Factors contributing to specialty decision-making and perceptions of neurosurgery among medical students and residents, specifically differences by gender, have not been studied. The authors aimed to investigate these differences using quantitative and qualitative methods. METHODS: A Qualtrics survey was administered at the authors' institution to all medical students and resident physicians to assess factors influencing medical specialty decision-making and perceptions of neurosurgery. Likert scale responses converted to numerical values on a 5-point scale were analyzed with the Mann-Whitney U-test. The chi-square test was performed on binary responses. Semistructured interviews were conducted in a subset of survey respondents and were analyzed by using the grounded theory method. RESULTS: Of the 272 survey respondents, 48.2% were medical students and 61.0% were female. When making specialty decisions, female medical students considered maternity/paternity leave more (p = 0.028) than their male counterparts. Female medical students were more hesitant toward neurosurgery due to maternity/paternity needs (p = 0.031) and the technical skill required (p = 0.020) than male medical students. Across both genders, the majority of medical students were hesitant toward neurosurgery due to opportunities for work/life integration (93%), length of training (88%), malignancy of the field (76%), and perceived happiness of the people in the field (76%). Female residents indicated they were more likely than male residents to consider the perceived happiness of the people in the field (p = 0.003), shadowing experiences (p = 0.019), and elective rotations (p = 0.004) when making specialty decisions. Two major themes emerged from the semistructured interviews: 1) maternity needs were more of a concern for women and 2) length of training was a concern for many individuals. CONCLUSIONS: Compared with their male counterparts, female students and residents consider different factors and experiences when choosing a medical specialty and have different perceptions of neurosurgery. Exposure to and education within neurosurgery, specifically maternity needs, may help address hesitancy in pursuing a neurosurgical career among female medical students. However, cultural and structural factors may need to be addressed within neurosurgery in order to ultimately increase representation of women.

Policing and Population Health: Past, Present, and Future.

Policy Points A growing body of research suggests that policing, as a form of state-sanctioned racial violence, operates as a social determinant of population health and racial or ethnic health disparities. A lack of compulsory, comprehensive data on interactions with police has greatly limited our ability to calculate the true prevalence and nature of police violence. While innovative unofficial data sources have been able to fill these data gaps, compulsory and comprehensive data reporting on interactions with police, as well as considerable investments in research on policing and health, are required to further our understanding of this public health issue.

State-Level Variation in the Cumulative Prevalence of Child Welfare System Contact, 2015-2019.

Background: Prior estimates of the cumulative risks of child welfare system contact illustrate the prominence of this system in the lives of children in the United States (U.S.). However, these estimates report national data on a system administered at the state and local levels and are unable to detail potential simultaneous geographic and racial/ethnic variation in the prevalence of these events. Methods: Using 2015-2019 data from the National Child Abuse and Neglect Data System and Adoption and Foster Care Analysis and Reporting System, we use synthetic cohort life tables to estimate cumulative state- and race/ethnicity-specific risks by age 18 of experiencing: (1) a child protective services investigation, (2) confirmed maltreatment, (3) foster care placement, and (4) termination of parental rights for children in the U.S. Results: In the U.S., state-level investigation risks ranged from 14% to 63%, confirmed maltreatment risks from 3% to 27%, foster care placement risks from 2% to 18%, and risks of parental rights termination from 0% to 8%. Racial/ethnic disparities in these risks varied greatly across states, with larger disparities at higher levels of involvement. Whereas Black children had higher risks of all events than white children in nearly all states, Asian children had consistently lower risks. Finally, ratios comparing risks of child welfare events show these prevalences did not move in parallel, across states or racial/ethnic groups. Contribution: This study provides new estimates of spatial and racial/ethnic variation in children's lifetime risks of maltreatment investigation, confirmed maltreatment, foster care placement, and termination of parental rights in the U.S., as well as relative risks of these events.

Racial/ethnic differences in the relationship between wealth and health across young adulthood.

•Wealth attenuated racial differences in self-rated health during young adulthood.•Wealth had consistent incremental effect on health among White & Hispanic Americans.•For Black Americans, wealth was protective of health in the highest wealth quartile.•Individual wealth, not parental wealth was associated with health among Hispanics.

Racial and Ethnic Disparities in Housing Instability During the COVID-19 Pandemic: the Role of Assets and Income Shocks.

Stable and adequate housing is critical to sound public health responses in the midst of a pandemic. This study explores the disproportionate impact of the COVID-19 pandemic on housing-related hardships across racial/ethnic groups in the USA as well as the extent to which these disparities are mediated by households' broader economic circumstances, which we operationalized in terms of prepandemic liquid assets and pandemic-related income losses. Using a longitudinal national survey with more than 23,000 responses, we found that Black and Hispanic respondents were more vulnerable to housing-related hardships during the pandemic than white respondents. These impacts were particularly pronounced in low- and moderate-income households. We found that liquid assets acted as a strong mediator of the housing hardship disparities between white and Black/Hispanic households. Our findings imply that housing became less stable for minority groups as a result of the pandemic, particularly those households with limited liquid assets. Such housing-related disparities demonstrate the need for policies and practices that target support to economically marginalized groups and families of color in particular.

Vicarious Exposure to the Criminal Legal System Among Parents and Siblings.

Objective: This study documents life course patterns of vicarious exposure to the criminal legal system among parents and siblings in the United States. Background: The criminal legal system shapes family outcomes in important ways. Still, life course patterns of vicarious exposure to the system-especially to lower-level contacts-among parents and siblings are not well documented. Method: Using longitudinal data from the Panel Study of Income Dynamics, Kaplan-Meier survival curves, and Cox regression models, we estimate cumulative risks of vicarious exposure to arrest, probation, and incarceration among parents (n=3,885 parents; 185,444 person-years) and siblings (n=1,875; 44,766 person-years) and examine disparities by race-ethnicity, gender, and education, and at their intersections. Results: Vicarious exposure to the system is common-but highly unequal-among parents and siblings. Racially minoritized parents and siblings had greater levels and earlier risks of exposure. For example, by age 50, an estimated one in five Black parents experienced having a child incarcerated, a risk about twice as high as White and 50% higher than Latinx parents. By age 26, an estimated six in 10 Black young people with brothers experienced having a brother arrested; more than four in 10 experienced a brother on probation; and more than three in 10 experienced brother incarceration. For many estimates, racialized inequities in risks of vicarious system exposure widened at higher levels of education. Conclusion: These findings provide essential context for understanding the role of the criminal legal system in maintaining and exacerbating family inequality.

Remembering St. Louis individual-structural violence and acute bacterial infections in a historical anatomical collection.

Incomplete documentary evidence, variable biomolecular preservation, and limited skeletal responses have hindered assessment of acute infections in the past. This study was initially developed to explore the diagnostic potential of dental calculus to identify infectious diseases, however, the breadth and depth of information gained from a particular individual, St. Louis Individual (St.LI), enabled an individualized assessment and demanded broader disciplinary introspection of ethical research conduct. Here, we document the embodiment of structural violence in a 23-year-old Black and/or African American male, who died of lobar pneumonia in 1930s St. Louis, Missouri. St.LI exhibits evidence of systemic poor health, including chronic oral infections and a probable tuberculosis infection. Metagenomic sequencing of dental calculus recovered three pre-antibiotic era pathogen genomes, which likely contributed to the lobar pneumonia cause of death (CoD): Klebsiella pneumoniae (13.8X); Acinetobacter nosocomialis (28.4X); and Acinetobacter junii (30.1X). Ante- and perimortem evidence of St.LI's lived experiences chronicle the poverty, systemic racism, and race-based structural violence experienced by marginalized communities in St. Louis, which contributed to St.LI's poor health, CoD, anatomization, and inclusion in the Robert J. Terry Anatomical Collection. These same embodied inequalities continue to manifest as health disparities affecting many contemporary communities in the United States.

Highly public anti-Black violence and preterm birth odds for Black and White mothers.

Highly public anti-Black violence may increase preterm birth in the general population of pregnant women via stress-mediated paths, particularly Black women exposed in early gestation. To examine spillover from racial violence in the US, we included a total of 49 high publicity incidents of the following types: police lethal force toward Black persons, legal decisions not to indict/convict officers involved, and hate crime murders of Black victims. National search interest in these incidents was measured via Google Trends to proxy for public awareness of racial violence. Timing of racial violence was coded in relation to a three-month preconception period and subsequent pregnancy trimesters, with the primary hypothesis being that first trimester exposure is associated with higher preterm birth odds. The national sample included 1.6 million singleton live births to US-born Black mothers and 6.6 million births to US-born White mothers from 2014 to 2017. Using a preregistered analysis plan, findings show that Black mothers had 5% higher preterm birth odds when exposed to any high publicity racial incidents relative to none in their first trimester, and 2-3% higher preterm birth odds with each log10 increase in national interest. However, post hoc sensitivity tests that included month fixed effects attenuated these associations to null. For White mothers, associations were smaller but of a similar pattern, and were attenuated when including month fixed effects. Highly public anti-Black violence may act as a national stressor, yet whether racial violence is associated with reproductive outcomes in the population is unknown and merits further research.

Early life patterns of criminal legal system involvement: Inequalities by race/ethnicity, gender, and parental education.

BACKGROUND: Contacts with the criminal legal system have consequences for a host of outcomes. Still, early life age patterns of system involvement remain to be better understood. OBJECTIVE: We estimate cumulative risks of arrest, probation, and incarceration from childhood through early adulthood and assess disparities by race/ethnicity, gender, and parental education. METHODS: Data come from the Transition to Adulthood Supplement of the Panel Study of Income Dynamics (n = 2,736). We use Kaplan-Meier curves and Cox regression models to estimate cumulative risks of arrest, probation, and incarceration across the early life course and document disparities by race/ethnicity, gender, and parental education, as well as at their intersections. RESULTS: Criminal legal system involvement is common among recent cohorts, but Black and Latinx boys and young men face especially high risks. Among Black men whose highest-educated parent completed high school or less, an estimated six in ten had been arrested, four in ten had experienced probation, and four in ten had been incarcerated by age 26. Among Latinx men whose highest-educated parent completed high school or less, an estimated four in ten had been arrested and one in four had been incarcerated by age 26. Black women also experienced high risks, with an estimated one in four arrested by age 26. CONTRIBUTION: We document early life patterns of criminal legal system involvement among young people who came of age during the expansion of proactive policing and mass incarceration in the United States, providing important context for understanding the role of the system in generating and exacerbating life course inequalities.

Representation of female neurosurgeons as abstract authors at neurological surgery conferences.

OBJECTIVE: Female neurosurgeon representation has increased, but women still represent only 8.4% of neurosurgeons in the US. Women are significantly underrepresented as authors in neurosurgical and spine journals, a key indicator of professional success in academic medicine. In this study, the authors aimed to assess the gender diversity of first and last authors of accepted abstracts at neurosurgical conferences in 2015 and 2019. METHODS: Annual meeting abstracts for 2015 and 2019 of the American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), and pediatrics, spine, stereotactic and functional surgery, and cerebrovascular AANS/CNS subspecialty sections were obtained and analyzed for gender. Partial data were obtained for tumor and pain sections. Composite gender data were obtained from the societies. Percentage differences were calculated using comparison of proportions testing. RESULTS: Overall, female neurosurgeons accounted for only 8.3% of first and 5.8% of last authors, and 7.2% of authors overall. The pediatrics section had the highest proportion of female neurosurgeons as first (13.7%) and last (12.4%) abstract authors, while the spine section had the lowest proportions of female neurosurgeon first (4.6%) and last (2.0%) authors. Qualitatively, a higher proportion of women were first authors, while a higher proportion of men were last authors. Overall, there was no significant change in female neurosurgeon authorship between 2015 and 2019. With regard to society demographics, female neurosurgeons accounted for only 6.3% of AANS membership. The pediatrics section had the highest proportion of female neurosurgeons at 18.1% and the stereotactic and functional surgery section had the lowest of the subspecialty sections (7.6%). While female neurosurgeons represented 12.6% of spine section membership, they represented only 4.7% of first authors (-7.9% difference; p < 0.0001) and 2.4% of last authors (-10.2% difference; p < 0.0001). For the 2019 cerebrovascular section, female neurosurgeons were underrepresented as presenting authors (5.8%) compared with their membership representation (14.8%, -9.0% difference; p = 0.0018). CONCLUSIONS: Despite an increase in the number of female neurosurgeons, there has not been a corresponding increase in the proportion of female neurosurgeons as abstract authors at annual neurosurgery conferences, and female neurosurgeons remain underrepresented as authors compared with their male colleagues.

Assessing mass incarceration's effects on families.

In this Review, we assess how mass incarceration, a monumental American policy experiment, has affected families over the past five decades. We reach four conclusions. First, family member incarceration is now common for American families. Second, individuals who will eventually have a family member incarcerated are worse off than those who never will, even before the incarceration takes place. Third, family member incarceration has negative effects on families above and beyond these preexisting disadvantages. And finally, policy interventions that address the precursors to family member incarceration and seek to minimize family member incarceration would best enhance family well-being. If the goal is to help all American families thrive, then the importance of simultaneous changes in social and criminal justice policy cannot be overstated.

Theory and empiricism: A comment on "Interrogating the environmental affordances model" by Pamplin and colleagues.

We strongly support efforts to generate, rigorously test, and falsify hypotheses derived from the Environmental Affordances (EA) Model of Health Disparities, as originated by the late Dr. James S. Jackson (1940-2020). Such efforts are critical to establishing robust, theoretically grounded scientific frameworks that explain the fundamental causes of racial disparities in health and wellbeing. Pamplin et al. (2021) fundamentally misrepresents the EA Model as a framework that (falsely) reifies the role of race as a determinant of health behaviors and health outcomes. Further, both their study design and analytic approach are inappropriate for testing predictions of this framework. We address these issues with the goal of recentering the scholarly conversation about how stress contributes to health, and disparities in health, over the life course.

Systematic review and meta-analysis of depression, anxiety, and suicidal ideation among Ph.D. students.

University administrators and mental health clinicians have raised concerns about depression and anxiety among Ph.D. students, yet no study has systematically synthesized the available evidence in this area. After searching the literature for studies reporting on depression, anxiety, and/or suicidal ideation among Ph.D. students, we included 32 articles. Among 16 studies reporting the prevalence of clinically significant symptoms of depression across 23,469 Ph.D. students, the pooled estimate of the proportion of students with depression was 0.24 (95% confidence interval [CI], 0.18-0.31; I2 = 98.75%). In a meta-analysis of the nine studies reporting the prevalence of clinically significant symptoms of anxiety across 15,626 students, the estimated proportion of students with anxiety was 0.17 (95% CI, 0.12-0.23; I2 = 98.05%). We conclude that depression and anxiety are highly prevalent among Ph.D. students. Data limitations precluded our ability to obtain a pooled estimate of suicidal ideation prevalence. Programs that systematically monitor and promote the mental health of Ph.D. students are urgently needed.