Racial Differences in Cardiothoracic Surgery Letters of Recommendation.

OBJECTIVE: Cardiothoracic surgery lacks racial diversity. Attracting the best candidates requires valuing diversity and advancing a recruitment process that minimizes racial bias. Implicit bias in recommendation letters has been identified as an influential mechanism for lack of diversity in cardiothoracic surgery. We aim to investigate how applicant race impacts language used in cardiothoracic surgery fellowship recommendation letters. METHODS: We examined applications to an accredited cardiothoracic surgery fellowship program between 2017 and 2021. Recommendation letter authors were categorized as cardiothoracic and non-cardiothoracic surgeons. Applicant self-reported race was dichotomized as White and non-White. Applicant characteristics were described using standard descriptive statistics and compared between applicant race. Recommendation letters were examined with linguistic analysis software and higher-level analysis to assess language associations between applicant race and author specialty. RESULTS: 597 recommendation letters were analyzed from 158 individual applications. Cardiothoracic surgeons composed 334 (55.9%) recommendation letters. 95 (60.1%) applicants were categorized as White. White applicants were described as more driven (p=0.03), while letters for non-White applicants were more authentic (p=0.02) and highlighted past experiences (p=0.05). Cardiothoracic surgeons wrote longer letters (p=0.04) with standout adjectives (p=0.03) more frequently for White applicants, and emphasized perceptiveness (p=0.02) more often when writing for non-White applicants. CONCLUSIONS: We demonstrate that authors' recommendation letters are influenced by applicant race. Letters written for White candidates are significantly longer and more descriptive of drive and outstanding characteristics than letters written for non-White candidates, particularly when written by cardiothoracic surgeons. Addressing this bias is crucial for recruiting the best candidates for cardiothoracic surgery.

The Cost of Being a Woman in Academic Cardiothoracic Surgery: Joint Collaboration of The Society of Thoracic Surgeons Workforces on Diversity, Equity, and Inclusion and Cardiothoracic Surgery Practice Models.

BACKGROUND: Gender disparity in the cardiothoracic surgery workforce is challenging to enumerate and quantify. The purpose of our work is to use the most current data to quantify the percentage of women in academic cardiothoracic surgery and salary disparity between women and men. METHODS: We performed a cross-sectional analysis of data collected by the Accreditation Council for Graduate Medical Education Data Resource Book 2021 and Association of American Medical Colleges Faculty Data for U.S. Medical School Faculty 2019, 2020, and 2021. We used descriptive analysis of the number of faculty and mean salaries of academic cardiothoracic surgeons according to academic rank and gender. Salary disparity in cardiothoracic surgery was compared with salary disparities seen among surgical specialties and academic clinicians. RESULTS: Over the past 3 years, women comprised 11.5% of the cardiothoracic workforce. In 2021, cardiothoracic surgeons who were women earned $0.71 to $0.86 for every $1.00 earned by cardiothoracic surgeons who were men. Ascending academic rank correlated with greater gender salary disparity; women professors earned less than men of equal and lower academic rank. From 2019 to 2021, women of the academic ranks of associate professor, professor, and chief of cardiothoracic surgery experienced a decrease in mean salaries, whereas men of equivalent academic ranks experienced an increase in mean salaries. CONCLUSIONS: Gender disparity in cardiothoracic surgery persists, with low representation of women and salary disparity at every academic rank.

Gender differences in cardiothoracic surgery letters of recommendation.

OBJECTIVE: To investigate whether or not gender influences letters of recommendation for cardiothoracic surgery fellowship. METHODS: From applications to an Accreditation Council Graduate Medical Education cardiothoracic surgery fellowship program between 2016 and 2021, applicant and author characteristics were examined with descriptive statistics, analysis of variance, and Pearson χ2 tests. Linguistic software was used to assess communication differences in letters of recommendation, stratified by author and applicant gender. An additional higher-level analysis was then performed using a generalized estimating equations model to examine linguistic differences among author-applicant gender pairs. RESULTS: Seven hundred thirty-nine recommendation letters extracted from 196 individual applications were analyzed; 90% (n = 665) of authors were men and 55.8% (n = 412) of authors were cardiothoracic surgeons. Compared with women authors, authors who are men wrote more authentic (P = .01) and informal (P = .03) recommendation letters. When writing for women applicants, authors who are men were more likely to display their own leadership and status (P = .03) and discuss women applicants' social affiliations (P = .01), like occupation of applicant's father or husband. Women authors wrote longer letters (P = .03) and discussed applicants' work (P = .01) more often than authors who are men. They also mentioned leisure activities (P = .03) more often when writing for women applicants. CONCLUSIONS: Our work identifies gender-specific differences in letters of recommendation. Women applicants may be disadvantaged because their recommendation letters are significantly more likely to focus on their social ties, leisure activities, and the status of the letter writer. Author and reviewer awareness of gender-biased use of language will aid in improvements to the candidate selection process.

Implementation of Staging Guidelines in Early Esophageal Cancer: A Study of the Society of Thoracic Surgeons General Thoracic Surgery Database.

OBJECTIVE: To evaluate the adoption and clinical impact of endoscopic resection (ER) in early esophageal cancer. BACKGROUND: Staging for early esophageal cancer is largely inaccurate. Assessment of the impact of ER on staging accuracy is unknown, as is the implementation of ER. METHODS: We retrospectively reviewed 2608 patients captured in the Society of Thoracic Surgeons General Thoracic Surgery Database between 2015 and 2020. Patients with clinical T1 and T2 esophageal cancer without nodal involvement (N0) who were treated with upfront esophagectomy were included. Staging accuracy was assessed by clinical-pathologic concordance among patients staged with and without ER. We also sought to measure adherence to National Comprehensive Cancer Network staging guidelines for esophageal cancer staging, specifically the implementation of ER. RESULTS: For early esophageal cancer, computed tomography/positron emission tomography/endoscopic ultrasound (CT/PET/EUS) accurately predicts the pathologic tumor (T) stage 58.5% of the time. The addition of ER to staging was related to a decrease in upstaging from 17.6% to 10.8% ( P =0.01). Adherence to staging guidelines with CT/PET/EUS improved from 58.2% between 2012 and 2014 to 77.9% between 2015 and 2020. However, when ER was added as a staging criterion, adherence decreased to 23.3%. Increased volume of esophagectomies within an institution was associated with increased staging adherence with ER ( P =0.008). CONCLUSIONS: The use of CT/PET/EUS for the staging of early esophageal cancer is accurate in only 56.3% of patients. ER may increase staging accuracy as it is related to a decrease in upstaging. ER is poorly utilized in staging of early esophageal cancer. Barriers to the implementation of ER as a staging modality should be identified and corrected.