Microaggressions and Implicit Bias in Surgical Training: An Undocumented but Pervasive Phenomenon.

OBJECTIVE: To examine the prevalence, nature, and source of microaggressions experienced by surgical residents during training. SUMMARY AND BACKGROUND DATA: The role of microaggressions in contributing to workplace culture, individual performance, and professional satisfaction has become an increasingly studied topic across various fields. Little is known about the prevalence and impact of microaggressions during surgical training. METHODS: A 46-item survey distributed to current surgical residents in training programs across the United States via the Association of Program Directors in Surgery listserv and social media platforms between January and May 2020. Survey questions explored the frequency and extent of events of experiencing, witnessing, and responding to microaggressions in the workplace. The primary outcome was the occurrence of microaggressions experienced by surgical residents. Secondary outcomes included the nature, impact, and responses to these events. RESULTS: A total of 1624 responses were collected, with an equal distribution by self-identified gender (female, n = 815; male, n = 809). The majority of trainees considered themselves heterosexual (n = 1490, 91.7%) and White (n = 1131, 69.6%). A majority (72.2%, n = 1173) of respondents reported experiencing microaggressions, most commonly from patients (64.1%), followed by staff (57.5%), faculty (45.3%), and co-residents (38.8%). Only a small proportion (n = 109, 7.0%) of residents reported these events to graduate medical education office/program director. Nearly one third (30.8%) of residents said they experienced retaliation due to reporting of micro-aggressions. CONCLUSIONS: Based on this large, national survey of general surgery and surgical subspecialty trainees, microaggressions appear to be pervasive in surgical training. Microaggressions are rarely reported to program leadership, and when reported, can result in retaliation.

Development and Assessment of a Systematic Approach for Detecting Disparities in Surgical Access.

Importance: Although optimal access is accepted as the key to quality care, an accepted methodology to ascertain potential disparities in surgical access has not been defined. Objective: To develop a systematic approach to detect surgical access disparities. Design, Setting, and Participants: This cross-sectional study used publicly available data from the Health Cost and Utilization Project State Inpatient Database from 2016. Using the surgical rate observed in the 5 highest-ranked counties (HRCs), the expected surgical rate in the 5 lowest-ranked counties (LRCs) in North Carolina were calculated. Patients 18 years and older who underwent an inpatient general surgery procedure and patients who underwent emergency inpatient cholecystectomy, herniorrhaphy, or bariatric surgery in 2016 were included. Data were collected from January to December 2016, and data were analyzed from March to July 2020. Exposures: Health outcome county rank as defined by the Robert Wood Johnson Foundation. Main Outcomes and Measures: The primary outcome was the proportional surgical ratio (PSR), which was the disparity in surgical access defined as the observed number of surgical procedures in the 5 LRCs relative to the expected number of procedures using the 5 HRCs as the standardized reference population. Results: In 2016, approximately 1.9 million adults lived in the 5 HRCs, while approximately 246 854 lived in the 5 LRCs. A total of 28 924 inpatient general surgical procedures were performed, with 4521 being performed in those living in the 5 LRCs and 24 403 in those living in the 5 HRCs. The rate of general surgery in the 5 HRCs was 13.09 procedures per 1000 population. Using the 5 HRCs as the reference, the PSR for the 5 LRCs was 1.40 (95% CI, 1.35-1.44). For emergent/urgent cholecystectomy, the PSR for the 5 LRCs was 2.26 (95% CI, 2.02-2.51), and the PSR for emergent/urgent herniorrhaphy was 1.83 (95% CI, 1.33-2.45). Age-adjusted rate of obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 30), on average, was 36.6% (SD, 3.4) in the 5 LRCs vs 25.4% (SD, 4.6) in the 5 HRCs (P = .002). The rate of bariatric surgery in the 5 HRCs was 33.07 per 10 000 population with obesity. For the 5 LRCs, the PSR was 0.60 (95% CI, 0.51-0.69). Conclusions and Relevance: The PSR is a systematic approach to define potential disparities in surgical access and should be useful for identifying, investigating, and monitoring interventions intended to mitigate disparities in surgical access that effects the health of vulnerable populations.

Associations Between Career Satisfaction, Personal Life Factors, and Work-Life Integration Practices Among US Surgeons by Gender.

Importance: Burnout among US surgeons is alarmingly high, particularly among women, and work-life integration conflicts contribute to career dissatisfaction. Objective: To evaluate associations between surgical career satisfaction and personal life factors such as time requirements for outside interests, household chores, and parenting responsibilities and to explore similarities and differences between men and women. Design, Setting, and Participants: This cross-sectional survey study of practicing US surgeons was conducted between June 4 and August 1, 2018. The 257-item online survey was sent to 25 748 fellows of the American College of Surgeons. A 31-item subanalysis was performed from August 13 to November 4, 2019. Main Outcomes and Measures: Degree of career satisfaction was measured on a 5-point Likert scale. Professional and personal life factors associated with career satisfaction were evaluated with gender-stratified multivariable proportional odds models. Results: Among 3807 respondents, 3166 self-identified as male (83%) and 639 (17%) as female. Fewer women reported career satisfaction (483 [77%] vs 2514 [82%]) and relatively more women reported problematic interruption of personal life owing to work (315 [50%] vs 1381 [45%]). A higher proportion of women reported being primarily responsible for meal preparation (282 [46%] vs 355 [12%]) and housekeeping (149 [24%] vs 161 [5%]). On multivariable analyses, factors independently associated with career satisfaction were generally similar between genders. Stronger collegial support of work-life integration efforts was significantly associated with higher career satisfaction for both genders (P < .001), although the odds ratio (OR) for women was higher than for men (OR, 4.52; 95% CI, 2.60-7.87 vs OR, 2.45; 95% CI, 1.88-3.21). For men and women, increasing age was significantly associated with higher career satisfaction (men: OR, 1.04; 95% CI, 1.03-1.05; P < .001; women: OR, 1.04; 95% CI, 1.02-1.06; P = .001), and insufficient time for family owing to work was associated with lower satisfaction (men: OR, 0.66; 95% CI, 0.49-0.90; P = 009; women: OR, 0.49; 95% CI, 0.30-0.81; P = .006). For women only, there was a significant association between primary responsibility for at least 1 household chore and lower career satisfaction (OR, 0.66; 95% CI, 0.45-0.98; P = .04). Conclusions and Relevance: In this study, although women had relatively lower surgical career satisfaction than men, the associations between career satisfaction and personal life factors were largely similar. Collegial support of work-life integration efforts appeared to be the most influential factor, particularly for women. Optimization of work-life integration may not only decrease physician burnout but also promote gender equity in surgery.