Resident perspectives on the role of gender in operative experience during general surgery residency training: A mixed-methods study.

BACKGROUND: It remains unclear why female general surgery residents perform fewer cases than male peers. This exploratory study investigated possible contributors to gender-based disparities and solutions for improving equity in operative experience. METHODS: Surveys, including Likert scale and free-text questions, were distributed to 21 accredited general surgery residency programs. RESULTS: There were 96 respondents, of whom 69% were female. 22% of females personally experienced barriers to operative experience versus 13% of males (p â€‹= â€‹0.41), while 52% of female residents believed operative training was affected by gender (p â€‹= â€‹0.004). Inductive analysis revealed the most common barrier to operating room participation was floor work/clinical tasks. The most common barrier for female residents was perceived sexism/gender bias, with subthemes of "misidentification," "feeling unwelcome," and "poor trust/autonomy." To improve parity, residents proposed structured program-level review, feedback, and transparent expectations about case assignments. CONCLUSION: Female general surgery residents believe gender bias impacts training. Further mixed-methods research is crucial to determine the cause of gender-based disparities in operative experience.

Decision-Making Confidence of Clinical Competency Committees for Entrustable Professional Activities.

Importance: A competency-based assessment framework using entrustable professional activities (EPAs) was endorsed by the American Board of Surgery following a 2-year feasibility pilot study. Pilot study programs' clinical competency committees (CCCs) rated residents on EPA entrustment semiannually using this newly developed assessment tool, but factors associated with their decision-making are not yet known. Objective: To identify factors associated with variation in decision-making confidence of CCCs in EPA summative entrustment decisions. Design, Setting, and Participants: This cohort study used deidentified data from the EPA Pilot Study, with participating sites at 28 general surgery residency programs, prospectively collected from July 1, 2018, to June 30, 2020. Data were analyzed from September 27, 2022, to February 15, 2023. Exposure: Microassessments of resident entrustment for pilot EPAs (gallbladder disease, inguinal hernia, right lower quadrant pain, trauma, and consultation) collected within the course of routine clinical care across four 6-month study cycles. Summative entrustment ratings were then determined by program CCCs for each study cycle. Main Outcomes and Measures: The primary outcome was CCC decision-making confidence rating (high, moderate, slight, or no confidence) for summative entrustment decisions, with a secondary outcome of number of EPA microassessments received per summative entrustment decision. Bivariate tests and mixed-effects regression modeling were used to evaluate factors associated with CCC confidence. Results: Among 565 residents receiving at least 1 EPA microassessment, 1765 summative entrustment decisions were reported. Overall, 72.5% (1279 of 1765) of summative entrustment decisions were made with moderate or high confidence. Confidence ratings increased with increasing mean number of EPA microassessments, with 1.7 (95% CI, 1.4-2.0) at no confidence, 1.9 (95% CI, 1.7-2.1) at slight confidence, 2.9 (95% CI, 2.6-3.2) at moderate confidence, and 4.1 (95% CI, 3.8-4.4) at high confidence. Increasing number of EPA microassessments was associated with increased likelihood of higher CCC confidence for all except 1 EPA phase after controlling for program effects (odds ratio range: 1.21 [95% CI, 1.07-1.37] for intraoperative EPA-4 to 2.93 [95% CI, 1.64-5.85] for postoperative EPA-2); for preoperative EPA-3, there was no association. Conclusions and Relevance: In this cohort study, the CCC confidence in EPA summative entrustment decisions increased as the number of EPA microassessments increased, and CCCs endorsed moderate to high confidence in most entrustment decisions. These findings provide early validity evidence for this novel assessment framework and may inform program practices as EPAs are implemented nationally.

Evaluating Patients' Health Literacy to Improve Thyroid Pathology Reports.

INTRODUCTION: As our growing population demonstrates a significant increase in the incidence of thyroid cancer, so does patient access to their medical records. Poor health literacy and understanding of disease severity, underscores the importance of effective and accessible patient-doctor communication. No previous studies on patient understanding of thyroid pathology reports exist; therefore, we sought to characterize health literacy in this population. METHODS: Using a modified Delphi technique, a 12-question multiple-choice survey regarding common pathology terms with possible definitions for each term was synthesized and administered to patients in a high-volume endocrine surgery clinic. Survey results, patient demographics, history of prior thyroid procedure (biopsy or surgery), and self-reported health literacy were collected. Data analysis included t tests, chi-squared, and multivariable linear regression using R. RESULTS: The survey was completed by 54 patients (response rate: 69.8%). On univariate analysis, White race, previous thyroid procedure, and at least a high school level education were all more likely to score higher on the survey than their counterparts (P < 0.05). On multivariable logistic regression for predicting a higher survey score, only race (est: 2.48 [95% confidence interval: 1.01-3.96]) and higher educational attainment (est: 3.98 [95% confidence interval: 2.32-5.64]) remained predictive (P < 0.05). The remaining demographic groups (age, health literacy confidence, and previous thyroid procedure) did not show a statistically significant difference. CONCLUSIONS: Overall, terms on a thyroid pathology report are poorly understood by patients. This is exacerbated by non-White race and low educational attainment. There is a need for patient-facing pathology education.

Young and resilient: Unraveling papillary thyroid cancer outcomes in males under 40.

BACKGROUND: While males present with more adverse clinicopathologic features in papillary thyroid carcinoma (PTC), younger age has previously been shown to be a favorable prognostic factor. We examined the combined effect of male sex and young age on PTC outcomes. METHODS: We conducted a retrospective analysis of a prospectively maintained database of thyroid cancer surgery patients (2000-2020) at a single quaternary care institution. We included papillary thyroid carcinoma cases and excluded those with prior cancer-related thyroid surgery. We examined demographics, cancer stage, surgical outcomes, and complications by age and sex, analyzing groups below and above the age of 40 years. RESULTS: A total of 680 patients with PTC were included. Females constituted 68% (age ≥40 years: 44% and <40 years: 24%) and males 32% (≥40 years: 24% and <40 years: 8%). A significant difference (p < 0.001) of N1 disease distribution was found between the groups. N1a metastasis was greater in patients younger than 40 regardless of sex ((M < 40 (15%), F < 40 (15%), M ≥ 40 (12%), and F ≥ 40 (9%)). While, M < 40 had greater N1b metastasis (36%) than all other groups (M ≥ 40 (28%), F < 40 (22%), and F ≥ 40 (10%)). There was no significant difference in the distribution of T stages between groups. Groups showed no differences in 30-day outcomes, recurrence at 1 year, reoperation, mortality, nerve injury, or hypocalcemia. CONCLUSIONS: Young males with PTC face increased occurrence of nodal metastasis yet experience similar recurrence rates as their female and older counterparts. Subgroup analysis underscores the predictive role of sex and age in advanced PTC cases.

Racial implications of time to surgery in disparities in thyroid cancer survival.

INTRODUCTION: The influence of time to surgery on racial/ethnic disparities in papillary thyroid carcinoma (PTC) survival remains unstudied. MATERIALS AND METHODS: The National Cancer Database (2004-2017) was queried for patients with localized PTC. Survival data was compared by time to surgery, patient demographics, and multivariable Cox regression was performed. RESULTS: Of 126,708 patients included, 5% were Black, 10% Hispanic. Of all patients, 85% had no comorbidities. Non-Hispanic White (NHW) patients had a shorter median time to surgery than Black and Hispanic patients (36 vs. 43 vs. 42 days, respectively p â€‹< â€‹0.001). In multivariable analysis, longer time to surgery (>90 days vs â€‹< â€‹30 days) and Black race vs NHW, were associated with worse survival (HR: 1.56, (95%CI, 1.43-1.70), p â€‹< â€‹0.001 and HR: 1.21, (1.08-1.36), p â€‹= â€‹0.001), respectively. CONCLUSION: Delaying surgery for thyroid cancer is associated with worse survival. However, independent of time to surgery and other confounders, there remains a disparity as black patients have poorer outcomes.

The overtreatment of papillary thyroid microcarcinoma in the community.

INTRODUCTION: Total thyroidectomy is the traditional primary approach for papillary thyroid cancer. However, recent evidence supports conservative management for low-risk tumors like papillary thyroid microcarcinomas (PTMCs). This study explores the adoption of these practices in our community, using a cancer database to analyze treatment strategies. METHODS: A retrospective review of a 1433-patient institutional database identified 258 â€‹PTMC cases. Outcomes, including 30-day mortality, reoperation rate, postoperative hypocalcemia, and recurrent laryngeal nerve (RLN) injury, were assessed. RESULTS: Of PTMC patients, 63.4% underwent total thyroidectomy, with higher rates of RLN injury (8.8% vs. 2.3%) and hypocalcemia (12.4% vs. 0.0%) compared to lobectomy. Non-endocrine surgeons had higher postoperative radioactive iodine administration rates (28.6% vs. 6.1%). Subgroup analysis revealed a shift in total thyroidectomy rates based on tumor size and surgery period. CONCLUSION: Our community favors total thyroidectomy for PTMC, despite associated complications. Enhanced awareness and adherence to PTMC best practice guidelines are warranted.

Validity of Entrustable Professional Activities in a National Sample of General Surgery Residency Programs.

BACKGROUND: The American Board of Surgery has endorsed competency-based education as vital to the assessment of surgical training. From 2018 to 2020, a national pilot study was conducted at 28 general surgery programs to evaluate feasibility of implementing entrustable professional activities (EPAs) for 5 common general surgical conditions. ACGME core competency Milestones were also rated for each resident by program clinical competency committees. This study aimed to evaluate the validity of general surgery EPAs compared with Milestones. STUDY DESIGN: Prospectively collected, de-identified EPA Pilot Study data were analyzed. EPAs studied were EPA-1 (gallbladder), EPA-2 (inguinal hernia), EPA-3 (right lower quadrant pain), EPA-4 (trauma), and EPA-5 (consult). Variables abstracted included levels of EPA entrustment (1 to 5) and corresponding ACGME Milestone subcompetency ratings (1 to 5) for the same study cycle. Spearman's correlations were used to evaluate the relationship between summative EPA scores and corresponding Milestone ratings. RESULTS: A total of 493 unique residents received a summative entrustment decision. EPA summative entrustment scores had moderate-to-strong positive correlation with mapped Milestone subcompetencies, with median rho value of 0.703. Among operation-focused EPAs, median rho values were similar between EPA-1 (0.688) and EPA-2 (0.661), but higher for EPA-3 (0.833). EPA-4 showed a strong positive correlation with diagnosis and communication competencies (0.724), whereas EPA-5, mapped to the most Milestone subcompetencies, had the lowest median rho value (0.455). CONCLUSIONS: Moderate-to-strong positive correlation was noted between EPAs and patient care, medical knowledge, and communication Milestones. These findings support the validity of EPAs in general surgery and suggest that EPA assessments can be used to inform Milestone ratings by clinical competency committees.

An Evaluation of Health Literacy in Patients Undergoing Surgical Evaluation for Thyroid Disease.

INTRODUCTION: Health literacy (HL) is the ability to comprehend and apply health information to make informed health-care decisions. Poor HL results in the inability to provide informed consent, medication noncompliance, inconsistent follow-up, and delayed seeking of care. Data about HL in endocrine surgery is currently lacking. In this study, we aimed to evaluate the HL of patients with thyroid disease and identify risk factors for limited HL. METHODS: We evaluated a total of 172 patients with thyroid disease in a single endocrine surgery clinic. HL was determined by the Brief Health Literacy Screening Tool, a validated HL screening questionnaire in which patient scores correlate to limited, marginal, or adequate HL. Demographic data including age, sex, race, diagnosis, employment status, and median annual income were obtained. Analysis of variance, t-test, and Chi-square test were used to compare HL between and within each demographic domain. P < 0.05 was considered significant. RESULTS: Of the 172 patients, 77% had adequate HL, 16% had marginal HL, and 7% had limited HL. Patients with higher education exhibited greater HL (P < 0.001). Ninety-three percent of patients with college/postgraduate degree had adequate HL, while of those with some college only 79% had adequate HL and of those with high school or less only 48.6% had adequate HL. There was minimal variation among age, sex, race, diagnosis, employment status, or income. CONCLUSIONS: Most patients with thyroid diseases from the endocrine surgery clinic at our institution have adequate HL. Limited education is a risk factor for low HL.

Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium.

OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

Patient perspectives on barriers to obtaining surgery for primary hyperparathyroidism: A qualitative review.

BACKGROUND: The purpose of this study was to qualitatively explore patient-reported barriers to surgery for primary hyperparathyroidism (PHPT) and identify actionable interventions to improve access to surgical care. METHODS: We recruited forty-nine patients in an endocrine surgery clinic at a large, academic medical to participate in an 11- question phone interview. All interviewees underwent parathyroidectomy for primary hyperparathyroidism. Responses were recorded and a codebook of qualitative themes, blinded to patient race and sex, was created by 3 independent reviewers. Comments were subsequently sorted into the codebook with patient demographic information. RESULTS: Patients that experienced delays in parathyroidectomy most commonly cited "issues with the referral process" and "missed diagnosis" as the cause. Patients were asked to identify the most challenging part about the surgery process. Commonly evoked themes among patients of both races and sexes included "transportation" and "financial" with subthemes of "no ride," "distance from surgeon," "insurance," and "difficulty taking time off work." Patients were asked to name actionable interventions to improve access to surgical care. The most commonly evoked theme involved "support systems," with subthemes of "transportation assistance," "financial," and "patient advocacy." Physician factors were also commonly evoked among patients of both races with subthemes of "knowledge", "communication," and "listening." CONCLUSION: PHPT patients cited multiple barriers to undergoing surgery. Future work can focus on examining these questions with a larger patient cohort and examining delays at the referral and diagnosis stage, which was most commonly cited by our respondents.

When I Don't see me, Am I seen? Race and student perception of the surgery clerkship.

INTRODUCTION: Increasing interest in general surgery from students who are Under-Represented in Medicine (URiM) is imperative to advancing diversity, equity, and inclusion efforts. We examined medical student third year surgery clerkship evaluations quantitatively and qualitatively to understand the experiences of URiM and non-URiM learners at our institution. METHODS: Evaluations from 235 graduated medical students between the years of 2019 and 2021 were analyzed. T-tests were used to compare numerical data. Free-text comments were qualitatively analyzed using inductive thematic analysis by two independent reviewers with conflicts resolved by a third. RESULTS: Evaluations were completed by 214 non-URiM students (91.1 â€‹%) and 21 (8.9 â€‹%) URiM students. There were no significant differences between URiM and non-URiM students in ratings of faculty and resident teaching. When asked whether residents were positive role models for patient care, non-URiM students were more likely than URiM students to agree (3.284 vs. 2.864, p â€‹= â€‹0.040). When asked whether they considered faculty to be positive role models, non- URM students were also more likely to answer affirmatively than URiM students (3.394 vs. 2.909 p â€‹= â€‹0.013). Qualitative comments were similar between the two groups. When asked what the strengths of the clerkship were, the most commonly evoked theme was "interactions with team" with subthemes of "team integration" "feeling valued" and positive "faculty" or "resident" interactions. "Operative experience" was the second most commonly evoked strength of the clerkship. The most common criticisms of the clerkship involved "negative interactions with team" with subthemes of "not prioritized above other learners" and "ignored." Negative "academic experience" was the next most commonly evoked weakness, with an affiliated theme of "lack of teaching." CONCLUSIONS: URiM students are less likely than non-URiM students to see surgical residents and faculty as positive role models. Integrating medical students into the team, taking time to teach, and allowing students to feel valued in their roles improves the clerkship experience for trainees and can contribute to recruitment efforts.

Surgical Treatment of Hyperthyroidism Can Be Performed Safely Before a Euthyroid State is Achieved.

Background: The 2016 American Thyroid Association guidelines recommend that hyperthyroid patients should be euthyroid before thyroidectomy. This recommendation is based on low-quality evidence. In this retrospective cohort study, we compare peri- and post-operative outcomes of patients with hyperthyroidism who were controlled versus uncontrolled at the time of thyroidectomy. Methods: A retrospective cohort study was performed on 275 hyperthyroidism patients at a single institution from December 2015 to November 2022. Patients were defined as hyperthyroid if they had a diagnosis of hyperthyroidism with at least one suppressed thyrotropin (TSH). Patients were considered uncontrolled if triiodothyronine or thyroxine (T4) was elevated immediately before surgery. Patient demographics, perioperative data, and postoperative outcomes were compared with Chi-square and Wilcoxon Rank Sum tests, as appropriate. Results: Of the 275 patients, 84.3% were women and 51.3% were uncontrolled at time of surgery. Controlled patients had higher median [interquartile range] TSH (0.4 [0.0, 2.4] mIU/L vs. 0.0 [0.0, 0.0] mIU/L, p < 0.001) and lower free T4 (fT4) (0.9 [0.7, 1.1] ng/dL vs. 3.1 [1.9, 4.4] ng/dL, p < 0.001), respectively. Uncontrolled patients were more likely to be diagnosed with Grave's disease (85.1% vs. 67.9%, p < 0.001) and to undergo surgery due to medication intolerance (12.1% vs. 6%) or history of thyroid storm (6.4% vs. 1.5%) (p = 0.008). Uncontrolled patients were also more likely to take a larger number of preoperative medications (2.3 vs. 1.4, p < 0.001). No patient in either group experienced thyroid storm precipitated by surgery. Controlled patients had shorter operative times (7.3% vs. 19.8% <1 hour, p < 0.014) and decreased median estimated blood loss (15.0 [5.0, 30.0] mL vs. 20.0 [10.0, 50.0] mL, p = 0.002). Both groups experienced similar, low rates of postoperative complications, apart from an increase in temporary hypocalcemia in the uncontrolled group (13.4% vs. 4.7%, p = 0.013). Conclusion: Our study is the largest to date examining the postoperative outcomes of patients with uncontrolled hyperthyroidism who undergo thyroidectomy. Our results affirm that thyroidectomy in actively thyrotoxic patients is safe and will not precipitate thyroid storm.

The Impact of a Job Crafting Intervention on Wellbeing in Health Care Leaders.

BACKGROUND: Job Crafting is a strategy undertaken by highly motivated individuals to modify their own work. Educating individuals about the benefits of this approach has recently been explored in other professions as a wellbeing intervention. OBJECTIVE: We aimed to demonstrate that a Job Crafting intervention for health care leaders would result in improved wellbeing, lower burnout, and enhanced job resources. METHODS: Fourteen health care leaders across 6 departments at one academic medical center participated in a two-part workshop on Job Crafting between January 1, 2019 and December 31, 2020. Participants completed electronic surveys before and 4-6 weeks after the sessions. Pre- and post-intervention scores were compared using Wilcoxon signed rank sum tests. RESULTS: Eighty-six percent of participants stated the sessions were useful and applicable to their jobs, with 93% stating they were a valuable use of time and would recommend sessions to others. Participant Job Crafting behaviors increased following the intervention, with 46% increasing structural and social resources (P = .03) and 85% decreasing Hindrance Demands (P = .02). Increased meaning in work was identified by 38% post-intervention (P = .04). No statistically significant differences were identified in Distress Scores at high risk for burnout pre- and post-intervention (86% for both), but 30% of participants had an absolute improvement (decrease) in their Distress Score. CONCLUSIONS: A Job Crafting intervention was associated with high rates of satisfaction among participants and was successful in increasing Job Crafting behaviors and perceptions of meaningful work, but did not result in a change in risk for burnout in the short follow-up period.

Postoperative Hypocalcemia in Hyperthyroid Patients: The Parathyroids Aren't Always to Blame.

INTRODUCTION: Hypocalcemia is commonly reported after thyroidectomy and has multiple possible etiologies including: parathyroid devascularization, reactive hypoparathyroidism from relative hypercalcemia in thyrotoxicosis, and abrupt reversal of thyrotoxic osteodystrophy. In patients that are actively hyperthyroid and undergoing thyroidectomy, it is not known how many experience hypocalcemia from nonhypoparathyroidism etiologies. Therefore, our aim was to examine the relationship among thyrotoxicosis, hypocalcemia, and hypoparathyroidism. METHODS: A retrospective review was performed of prospectively-collected data from all patients undergoing thyroidectomy for hyperthyroidism by 4 surgeons from 2016 to 2020. All patients carried a diagnosis of Graves' disease or toxic multinodular goiter. Patient demographics, preoperative medications, laboratory reports, and postoperative medications were reviewed. Hypocalcemia within the first month of surgery despite a normal parathyroid hormone (PTH) level was the primary outcome of interest and was compared between patients with and without thyrotoxicosis. Secondary outcomes were duration of postoperative calcium use and the relationship between preoperative calcium supplementation and postoperative calcium supplementation. Descriptive statistics, Wilcoxon rank-sum, and chi-square tests were used for bivariate analysis, as appropriate. RESULTS: A total of 191 patients were identified, with mean age of 40.5 y (range 6-86). Most patients were female (80%) and had Graves' disease (80%). At the time of surgery, 116 (61%) had uncontrolled hyperthyroidism (thyrotoxic group, Free Thyroxine >1.64 ng/dL or Free Triiodothyronine > 4.4 ng/dL), with the remaining 75 (39%) considered euthyroid. Postoperative hypocalcemia (calcium < 8.4 mg/dL) developed in 27 (14%), while hypoparathyroidism (PTH < 12 pg/mL) was observed in 39 (26%). Thyrotoxic patients comprised a majority of those with hypocalcemia (n = 22, 81%, P = 0.01) and hypoparathyroidism immediately following surgery (n = 14, 77%, P = 0.04). However, a majority of initially hypocalcemic, thyrotoxic patients had normal PTH values within the first month after surgery (n = 17, 85%), pointing to a potential nonparathyroid etiology. On bivariate analysis, no significant relationship was found for thyrotoxic patients with initial postoperative hypocalcemia (18%) and hypoparathyroidism <1-month after surgery (29%, P = 0.29) or between 1 and 6 mo after surgery (2%, P = 0.24). Of the 19 patients in the nonhypoparathyroidism group, 17 (89%) were off all calcium supplements by 6 mo postop. CONCLUSIONS: In patients with hyperthyroidism, those in active thyrotoxicosis at time of surgery have a higher rate of postoperative hypocalcemia compared to euthyroid patients. When hypocalcemia lasts >1 mo postoperatively, data from this study suggest that hypoparathyroidism may not be the primary etiology in many of these patients, who typically require calcium supplementation no more than 6 mo postoperatively.

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium.

OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.