Key Points
Question
What are the barriers and facilitators to clinical practice development for men and women surgeons?
Findings
In this qualitative study with 45 surgeons, participants reported barriers and facilitators to surgical practice development related to their colleagues, department, institution, and environment; women surgeons also described barriers related to gender discrimination and additional demands. Surgeons proposed several strategies to better facilitate clinical practice development.
Meaning
The findings of this study suggest that interpersonal, departmental, and institutional support structures may facilitate surgical practice development and improve workplace equity for women in surgery.
Abstract
Importance
Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons.
Objective
To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender.
Design, Setting, and Participants
A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience.
Main Outcomes and Measures
Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons.
Results
A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals.
Conclusions and Relevance
The findings of this qualitative study suggest that a surgeon’s external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.
This qualitative study examines surgeons’ perspectives on external barriers and facilitators of clinical practice development, with a focus on gender differences.
Introduction
A robust clinical practice is fundamental for early-career surgeons to build confidence and solidify their professional identity. However, some surgeons struggle to develop a practice that matches their professional goals, leading to dissatisfaction, burnout, and attrition.1,2,3,4,5,6 In one survey of new fellows of the American College of Surgeons, 44% reported having left their first job at the time of the survey after an average of 3.3 years.4 Attrition is not only disruptive to the individual surgeon, but also threatens their department’s financial solvency through recruitment and onboarding costs.3,7
Female surgeons report more difficulty when transitioning into practice than male surgeons8 and perform fewer operative cases early in their careers.9 Among the many challenges faced by women surgeons,10 inequities in referrals have emerged as a contributing barrier to equitable employment, compensation, and academic advancement.11,12,13,14,15 Several studies using administrative data report that referring physicians send fewer referrals to female surgeons than male surgeons,11,12 and referrals to female surgeons are often less complex, specialized, and remunerative.11,12,16,17 These case mix differences may contribute to known wage gaps, with male surgeons earning an additional $30 000 to $40 000 annually after adjustment for experience and productivity.17,18 However, claims-based studies have limited ability to identify the mechanisms that underlie these phenomena, including specific barriers faced by surgeons as they establish clinical practices, which is essential to developing interventions to eliminate inequities.
In this study, we aimed to identify the barriers and facilitators of clinical practice development with attention to differences related to surgeon gender. Potential strategies to support practice development were elicited to inform policy recommendations and guide future interventions.
Methods
Study Design and Participants
This multi-institutional qualitative study consisted of semistructured interviews analyzed using a grounded theory framework to better understand the barriers and facilitators of clinical practice development among academic surgeons. Institutional review boards at all participating institutions approved the study (Mass General Brigham; University of California, San Francisco; University of Michigan; University of Pennsylvania; and Weill Cornell Medicine). Participants provided verbal informed consent before each interview; there was no financial compensation. Study reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.
To account for possible regional variation, we included surgeons from 5 academic medical centers in the Northeast, Mid-Atlantic, Midwest, and Western regions of the US. Institutions were chosen based on geographic diversity and preexisting research partnerships.19,20,21 Purposeful sampling22 was used to recruit surgeons representing a range of specialties and experiences. Our criteria for inclusion were (1) affiliation with a participating medical center, including affiliated community and Veterans Affairs hospitals, (2) 1 year or more of independent practice experience, and (3) specialty that performs predominantly elective procedures. We excluded nonelective specialties (eg, trauma). Potential participants were identified by researchers at their institution and invited to participate via email. Participants’ gender was self-identified. Race and ethnicity data were not collected to protect participant identities.
Data Collection
Data collection occurred between July 12, 2022, and January 31, 2023. An interview guide was developed and iteratively refined with a qualitative methods expert (J.A.S.) (eAppendix in Supplement 1). Participants were informed the purpose of the study was to identify barriers and facilitators of practice development and strategies to support surgeons. Open-ended questions focused on the personal and institutional challenges experienced as participants built their practices at their current and prior institutions. Participants were prompted to discuss their clinical partners, relationships with referring physicians, and the impact of their personal attributes on practice development. The same interview guide was used for men and women. Each interview was conducted virtually using Zoom (Zoom Video Communications Inc, version 5.13.11) and lasted 20 to 60 minutes. Interviews were recorded, transcribed verbatim, and deidentified before analysis.
Interviews were conducted by women researchers trained in qualitative interviewing (C.B.F., S.S., D.E.B., and A.M.M.). Initial interviews were conducted in pairs to ensure consistency of style between interviewers. Interviewers were employed as surgical residents in research fellowships (C.B.F. and A.M.M.), a medical student (D.E.B.), and a research coordinator (S.S.). The resident researchers had prior professional relationships with fewer than 10 participants.
Data Analysis
Thematic analysis was performed between September 12, 2022, and March 28, 2023. We followed a modified grounded theory framework to inductively identify and iteratively refine themes throughout data collection.23 A codebook containing thematic codes and definitions was developed using the initial 5 interviews. The codes were organized into domains with additional codes, and themes were added throughout the interview process until saturation was reached.24 Thematic analysis was performed by the principal investigator (R.R.K.), interviewers, and an additional surgical resident with qualitative research training (E.B.). Interviews were coded in duplicate using NVivo (QSR International, version 1.6.1). Disagreements were resolved through discussion and consensus. Following thematic coding, all coded quotations were stratified by surgeon gender to detect thematic differences. Participants were emailed a summary of the domains, themes, subthemes, and exemplary quotations for qualitative member checking.
Results
Of 73 surgeons invited to participate, 45 (61.6%) completed semistructured interviews (eTable 1 in Supplement 1). Participants self-identified as women (23 [51%]) and men (22 [49%]) (Table 1). Participants represented a variety of surgical specialties, including colorectal (8 [18%]); breast, endocrine, or oncologic (23 [51%]); gastrointestinal, minimally invasive, or general surgery (8 [18%]); and other surgical subspecialties (6 [13%]). Eighteen participants (40%) were in their first 5 years of practice (women: 12 [52%]; men: 6 [27%]), and 20 (44%) had 10 years or more experience (women: 5 [22%]; men: 15 [68%]). Women were more often assistant professors or instructors (women, 14 [61%]; men, 6 [28%]). Participants reported mean (SD) similar weekly clinical days by gender (women, 3.7 [0.8]; men, 4.0 [1.1]).
Table 1. Surgeon Characteristics and Practice Experience by Gender.
| Characteristic | No. (%) | |
|---|---|---|
| Women (n = 23) | Men (n = 22) | |
| Surgical specialty | ||
| Colorectal | 7 (30) | 1 (5) |
| GI, MIS, or general | 2 (9) | 6 (27) |
| Surgical oncology, breast, or endocrine | 11 (48) | 12 (55) |
| Othera | 3 (13) | 3 (14) |
| Academic rank | ||
| Instructor or assistant professor | 14 (61) | 6 (27) |
| Associate professor | 7 (30) | 6 (27) |
| Professor | 2 (9) | 10 (45) |
| Years of experience | ||
| ≤5 | 12 (52) | 6 (27) |
| 6-9 | 6 (26) | 1 (5) |
| ≥10 | 5 (22) | 15 (68) |
| No. of clinical partners, mean (SD) | 5.9 (3.4) | 4.6 (4.3) |
| Clinical days per week, mean (SD) | 3.7 (0.8) | 4.0 (1.1) |
| Continuing to practice at training institution | 6 (26) | 8 (36) |
| Changed institutions at least once following training | 7 (30) | 10 (45) |
Abbreviations: GI, gastrointestinal; MIS, minimally invasive surgery.
Other includes surgical specialties such as otolaryngology, plastic surgery, urology, and vascular surgery.
Thematic abstraction of the surgeon interviews identified 20 themes reflecting the different barriers and facilitators of practice development, which acted within 4 domains of the external context: (1) colleagues, (2) department, (3) institution, and (4) environment (Figure). Women surgeons additionally identified gender-related barriers and facilitators.
Figure. Proposed Framework of Barriers and Facilitators of Clinical Practice Development Among Academic Surgeons.
OR indicates operating room.
Colleagues
Participants reported that colleagues played important roles in their practice development (eTable 2 in Supplement 1). Dominant themes related to the distribution of patients across surgeons with similar specialties. Some participants described feeling supported by group practice models, in which centralized referrals were distributed according to surgeon availability. Alternatively, in practices with referrals directed to individual surgeons, senior surgeons facilitated practice development by redirecting excess volume to junior surgeons. Other participants lacked these elements of structural support and described competing with colleagues or feeling overshadowed, especially in volume-based compensation models.
Mentorship and sponsorship emerged as major facilitators of practice development. Colleagues supported junior surgeons by providing proctorship for decision-making and challenging operations, advice on practice-building, and sponsorship when interacting with referring physicians.
Department of Surgery
Participants described several departmental barriers including lacking resources for patient care and concerns regarding departmental culture (eTable 3 in Supplement 1). Critical resources for practice-building included operating room (OR) time and support staff. A lack of dedicated OR time hindered some surgeons’ ability to provide high-quality, timely care. Participants reported dedicating substantial effort to advocating for additional OR time to accommodate their growing practices. Conversely, adequate OR availability facilitated clinical practice for other participants by alleviating time pressure when operating. Additionally, participants reported that administrative and clinical support staff facilitated patient care and optimized efficiency.
Participants were also impacted by their perceived departmental culture. Some surgeons reported struggling with a lack of community, unfairness in treatment of different surgeons by staff, or resistance to cultural change. Other surgeons described the process of adjusting to a new culture as being necessary to effectively advocate for oneself when hired at a new institution. Several women noted a positive cultural shift in recent years with increasing awareness of biases and acceptance of women and traditionally underrepresented racial and ethnic groups. Responsiveness to issues was a facilitator of practice development.
Institution
Surgeons identified several barriers and facilitators at the institutional level (eTable 4 in Supplement 1). Dominant facilitators included market expansion, advertising, institutional reputation, and collaborative care. Surgeons noted that expansion of the institution’s reach to new markets provided a distinct source of patients in which they could build referral patterns independent of their partners. Similarly, advertising was believed to increase visibility among referring physicians. Surgeons noted that a strong institutional reputation for providing high-quality care lent credibility when establishing their practice. Similarly, the presence of experienced clinicians outside of surgery improved multidisciplinary collaboration. Several surgeons reported that aligning their clinics with those of corresponding medical specialists (eg, endocrinology and endocrine surgery) facilitated practice development by strengthening relationships with frequent referral partners and providing a natural referral pipeline.
The institution’s centralized patient schedulers (eg, call center) were often seen as a barrier to practice development for new surgeons. Several surgeons questioned the objectivity of the central schedulers, who were sometimes perceived as biased against women surgeons. Others commented that schedulers favored familiar surgeons to the detriment of newer surgeons. Several surgeons added these centralized scheduling processes lacked transparency, leading to concerns over equitability.
Environment
Surgeons reported that their broader environment contributed to practice development (eTable 5 in Supplement 1). Environmental barriers and facilitators related to the social, cultural, and economic conditions of the surgeon’s geographic area. Several surgeons practicing in urban locations noted that market saturation posed a barrier to increasing their patient volume. Other surgeons, particularly those entering practice in 2019 and 2020, identified the COVID-19 pandemic as a substantial barrier to building elective volume. One surgeon expressed that increasing awareness of racism in the US facilitated practice development by improving others’ understanding of microaggression and macroaggression.
Surgeon Gender
Participants identified several barriers and facilitators related to gender specifically (eTable 6 in Supplement 1). Women surgeons related experiences in which they were treated differently from their colleagues. One of the most common barriers was questioning the experience, abilities, or judgment of women surgeons by colleagues, trainees, staff, and patients. For example, one surgeon described feeling continually second-guessed by her residents. Similarly, participants noted that patients often questioned the qualifications and experience of women surgeons or misidentified the surgeon’s role. One surgeon described being unwilling to attend marketing sessions alongside male surgeons because referring physicians often mistook her for a nurse or administrator. Some surgeons perceived that resources for patient care, such as OR time, were allocated unequally between men and women. Women noted that additional work was frequently required to establish credibility and build confidence in an environment in which they experienced these frequent discriminatory experiences.
Several surgeons described the burdens of additional demands due to their performed gender. Some women described the pressure to maintain a professional physical appearance to build credibility, such as the need to wear makeup or style their hair. Additionally, one surgeon described seeing a substantially higher proportion of patients who did not require surgery than her male colleagues, which required self-advocacy, a formal audit, and structural changes to her schedule.
Contrastingly, men and women participants noted that gender concordance with patients and referring physicians could also facilitate practice development. Both men and women described patients seeking gender-concordant surgeons for sensitive surgical care, such as treatment of breast, colorectal, and urologic conditions. Furthermore, several women surgeons described purposefully and preferentially building relationships with women referring physicians.
Several women discussed the roles of pregnancy and parental leave in practice building. While surgeons reported that pregnancy sometimes slowed practice growth, it was not seen as a major barrier, particularly when their colleagues were supportive. However, multiple women discussed a lack of consideration for parental leave on a departmental and institutional level when setting productivity targets and allocating OR resources.
Strategies for Supporting Surgeons
Participants proposed numerous suggestions for colleagues, departments, and institutions to facilitate practice development for surgeons (Table 2). Improving clinical support and mentorship for junior surgeons was a dominant theme for both men and women. Surgeons suggested that an ideal system would involve support for clinical decisions and difficult cases. Surgeons advocated for operating on the same day as a senior partner to lower barriers to seeking help. Additionally, surgeons desired social support from colleagues to better cope with the transition to practice, loneliness of junior attending life, and burden of complications.
Table 2. Suggestions to Support Practice Development for New Surgical Faculty.
| Topic | Interview response |
|---|---|
| Target: colleagues | |
| Clinical support and mentorship | They actually need a little bit of support with decision-making. They often also need support in the OR… we don’t do this at [my institution], but I think we suffer because of it. I think that the practices that have really good clinical outcomes will actually… scrub with a new faculty [hire] for the first year. |
| One big key thing is the mentorship, having someone available that’s able to devote some time to assisting you and being able to answer questions, or join for an OR case, or be able to collaborate without that distracting from their clinical practice. | |
| Social support | I remember before I started, some junior faculty said it’s just kind of lonely… I think some intentional structure, whether it’s like coffee every Wednesday morning, with so-and-so, or whatever… so, I think ironically, putting some structure in is helpful. |
| I don’t think we prepare ourselves well emotionally for dealing with really difficult complications and patient deaths and that sort of thing, and so I think that could be part of the curriculum. | |
| Case mix management | I recently came to this realization that I’m sort of the catch-all for a lot of things. And I don’t know if that’s what I want to be, and so potentially scheduling in annual or semiannual check-ins to be like, “okay, let’s look at your case mix for the last 6 months, 12 months. Is this sort of [what you want]?” |
| Target: department of surgery | |
| Needs assessment | But it would be great for institutions to have a very streamlined methodology of analyzing when a surgeon needs that help and is generating enough revenue to justify hiring another [physician assistant], hiring another nurse to change robot arms, whatever it is, figuring out a way to get that additional help. |
| Access to operative resources | I think what’s important in supporting new faculty is not just helping them get patients in, but actually helping them get patients through, right? Because even if you can get a patient in to see their physician, if the physician does not have block time, does not have time to do surgeries… then they cannot grow their practice. |
| I think about my faculty... is making sure that they don’t get the worst OR teams… they arguably should get the best OR teams…. Because they’re by definition, probably going to be slower. | |
| Administrative support | And then, just basic resources to maximize physicians doing clinical work and not being burdened with a lot of the other stuff. So, a lot of like paperwork and prior authorizations, really could be done by a nurse, or a medical assistant, having a scribe in clinic. |
| Financial and clinical operations onboarding | But really sitting down with clinic people and the finance people to really figure out how the numbers work... having a formal onboarding process with people who actually keep track of the numbers. |
| I think also understanding how clinics work.... In reality, I don’t know anything about the administrative or the business end of making anything happen. | |
| Community building | If there were periodic events to make sure people meet other members of the department, because, unlike training…there’s no embedded network of people that you’ll instantly know. |
| Target: institution | |
| Market research | If the institution can identify, this is where Dr X gets all of his referrals, there are the other markets you can catch. You should be targeting those specific groups to get referrals. That would be useful because you do outreach within those groups, and then you build your own referral pattern. |
| Transparency in referral process | There’s very little transparency about how that’s divvied up in terms of nondirected patients… because even within my own schedule, I will have a slot for something benign and then patient gets scheduled really far out…. They would have loved a sooner appointment. |
| Call center education | I would give them the technical name of what I did. And then all the little nicknames that it could have as well… made sure they knew my name and number, and my admin’s name and number, so that if they had somebody who wanted to be seen or had questions, they would know. |
On the departmental level, several surgeons advocated for a streamlined, objective process for assessing and addressing issues with resource allocation. For example, departments can track operative volumes and wait times to assess when a surgeon can sustain increased OR time or administrative support. Surgeons also desired formal onboarding regarding clinical and financial operations. In addition, surgeons suggested that departments host community-building events to foster connections between newer surgeons, who often felt isolated.
Surgeons suggested the institution could facilitate practice development through market research and optimizing the referral process. For example, institutions can track referral patterns for established surgeons to identify opportunities for new surgeons to grow the practice through market expansion. Additionally, institutions can optimize their central scheduling process. In some cases, surgeons provided direct education to schedulers to improve the appropriateness of their scheduling decisions. Surgeons stated that central schedulers would benefit from increased transparency and objective criteria to guide distribution of patients across surgeons.
Discussion
In this multi-institutional qualitative study, academic surgeons identified several barriers and facilitators encountered while building their clinical practices. Dominant barriers included competition with partners, insufficient patient-care resources, and geographic market saturation. Dominant facilitators included mentorship, group practice models, and market expansion. Women also described barriers related to gender discrimination and additional demands but identified gender concordance with patients and referring physicians as facilitators of practice growth. Participants suggested several strategies for improving practice development for new surgeons by amplifying facilitators (eg, mentorship) and creating standardized and objective processes for addressing barriers related to resource allocation and distribution of referrals.
The barriers and facilitators described by the participants are consistent with those reported in prior studies of burnout, satisfaction, and attrition among surgeons.25,26 For example, in surveys of practicing surgeons at academic medical centers, the strongest predictors of workplace satisfaction were departmental leadership, collegiality and collaboration, and relationships with partners.25 Similarly, in a qualitative study of early-career colorectal surgeons, market competition and inadequate mentorship were identified as barriers to career advancement.26 The present study adds to the literature by describing several additional barriers on the departmental and institutional level, including the availability of OR time and support staff. Limitations in patient care resources may be worsening following the COVID-19 pandemic, which increased attrition across health care.27,28 Limited resources may be particularly detrimental for new surgeons, who are dependent on patient volume to build self-confidence and establish their practices. Departmental leadership should consider how their policies surrounding resource allocation may negatively impact early-career surgeons.
Several of the gender-specific barriers described by women surgeons have been identified in previous studies of academic promotion and retention. Female surgeons have reported difficulty when transitioning from residency to independent practice, describing less institutional support and mentorship.8 In one single-institution qualitative study, women surgeons cited barriers to academic advancement including negative departmental culture, interactional biases, and a lack of mentorship.29 Another survey describing barriers to a career in academic surgery found women were more likely than men to report experiencing different treatment, negative comments, or discrimination due to gender.30 Furthermore, prior studies report unequal demands for men and women surgeons in the context of work-life integration31 and nonoperative patient care.12 The mirrored experiences between the participants in the present and those of earlier studies suggest that these barriers are real, widely applicable, and consequential.10
However, women surgeons identified gender concordance between surgeons, patients, and referring physicians as an underrecognized facilitator of clinical practice development. Gender concordance between surgeons and patients is associated with improved patient outcomes.32,33 Additionally, gender homophily is common among referrals to surgeons,34 and closer relations between collaborating physicians may also benefit patients.35,36 Within the constraints of patient preferences, building alliances and strengthening relationships between women surgeons, referring physicians, and their mutual patients may improve outcomes and facilitate practice development for women surgeons.
The study participants suggested several strategies targeted toward their colleagues, departments, and institutions to improve practice development for new surgeons. Surgeons advocated for many potential forms of mentorship, including decision support, proctoring, career advice, and interpersonal support. Mentors can also guide junior surgeons to consider the described barriers and facilitators during their job search and contract negotiation. However, few departments of surgery have structured faculty mentorship programs, and most lack mentor-mentee training or evaluation and recognition of mentorship efforts.37 Surgeons also suggested structures and policies to make practice development more objective and transparent, particularly for referrals and resource allocation. For example, single-entry referral models, in which centralized referrals are distributed among clinical partners,38 may allow newer surgeons to accelerate volume growth. Additionally, departments can compare case mix and conversion rate to evaluate for referral biases. When allocating resources to surgeons, hospitals should implement data-informed policies that prioritize transparency and equity with regular reassessments to ensure that practices are upholding institutional values.39
Limitations
Our findings should be interpreted in the context of several limitations. First, themes may not generalize to other institutions or nonacademic settings. However, we included surgeons from 5 regionally diverse institutions to increase geographic generalizability and encouraged surgeons to discuss experiences at prior institutions. Second, while we included both junior and senior surgeons to increase the breadth of experience captured, these themes do not capture the experiences of other stakeholders, such as referring physicians, patients, administrators, or trainees. Third, most women participants were in earlier career stages than many men participants, reflecting the unbalanced composition of the surgical workforce.40 Fourth, themes may not generalize to surgeons with other gender identities, such as nonbinary, as all participants identified as men and women. Fifth, interviews and informed consent occurred over Zoom, and social desirability biases may have impacted results. Sixth, we chose not to collect race and ethnicity data to protect participant confidentiality. The impact of surgeon race and ethnicity on practice development, as well as intersectionality between race and ethnicity and gender, are important topics of further investigation given established disparities in promotion and retention for surgeons belonging to historically marginalized groups.41,42,43,44
Conclusions
The barriers and facilitators identified in this qualitative study suggest that a surgeon’s external context influences their clinical practice. Policies to improve mentorship, standardization, and transparency may facilitate practice development by removing potential sources of bias in referrals and resource allocation. The experiences of the participants in this study illuminate strategies to support the longevity of the surgical workforce and achieve equity in clinical practice.
eAppendix. Study Introduction, Informed Consent, and Interview Guide
eTable 1. Response Rate by Participating Institution
eTable 2. Themes, Subthemes, and Representative Quotations Related to Colleagues
eTable 3. Themes, Subthemes, and Representative Quotations Related to Department of Surgery
eTable 4. Themes, Subthemes, and Representative Quotations Related to Institution
eTable 5. Themes, Subthemes, and Representative Quotations Related to Environment
eTable 6. Themes, Subthemes, and Representative Quotations Related to Surgeon Gender
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eAppendix. Study Introduction, Informed Consent, and Interview Guide
eTable 1. Response Rate by Participating Institution
eTable 2. Themes, Subthemes, and Representative Quotations Related to Colleagues
eTable 3. Themes, Subthemes, and Representative Quotations Related to Department of Surgery
eTable 4. Themes, Subthemes, and Representative Quotations Related to Institution
eTable 5. Themes, Subthemes, and Representative Quotations Related to Environment
eTable 6. Themes, Subthemes, and Representative Quotations Related to Surgeon Gender
Data Sharing Statement