The Role of Inclusion in Increasing Diversity and Retention Across Surgical Residencies: a Literature Review

Abstract

Purpose of Review

Across surgical specialties, residencies are incentivized to improve program diversity, most often through recruitment of underrepresented minority (URM), women, LGBTQ, and disabled applicants. However, residency attrition remains high in these groups, highlighting the need for specific inclusion initiatives to improve retention and support for these cohorts. A better understanding of previous efforts at retention is paramount. This paper reviews the existing literature on inclusion and retention efforts in surgical residencies.

Recent Findings

A literature search was conducted using PubMed Central. Published articles were filtered based on date (2018–2023) and relevancy. Articles were evaluated holistically and focused on methods in increasing diversity and inclusion in residency retention. Through formal literature review focusing on pertinent research topic terms (i.e., inclusion, diversity, residency, surgery, retention), efforts that included inclusion initiatives, improving residency retention, and diversifying leadership were overarching themes.

Summary

In recent years, there have been marked strides and improvements in encouraging resident diversity and inclusion. However, more widespread efforts with proven efficacy are needed in order to improve residency retention and to increase and maintain diversity in leadership in surgery.

Introduction

The conversation around increasing diversity across surgical subspecialties is continuously expanding. In an effort to grow diversity, equity, inclusion, and belonging (DEIB) among practicing residents and attendings within surgical subspecialties, several efforts are reported in the current literature, the majority of which start at the medical school level. In 2009, the Liaison Committee on Medical Education (LCME) introduced standards which aim to enhance overall institutional diversity and increase investments in bridge programs in order to increase the number of qualified applicants of underrepresented in medicine (URiM) backgrounds [1]. An almost universally adopted approach has been the use of a holistic admissions process which looks more into an applicant’s potential contributions to the clinical learning environment, rather than relying solely on academic benchmarks. Despite these efforts, a number of URiMs such as Black/African American and American Indian or Alaska Native medical school applicants have remained dormant, and Black/African American male applicants have decreased since 1978 [1].

Ultimately, it is important for surgical programs to recognize these issues in order to promote work environments that are inclusive, equitable, and health-promoting. Particularly in orthopaedic surgery residency programs, there continues to be a lag in females and overall diversity, with female representation increasing from 10.9 to 14.4% between 2006 and 2015, which was significantly lower compared to other specialties (P < 0.05), except for urology (P = 0.64) [2]. Furthermore, in surgical subspecialties such as vascular surgery, there have been marked increases in the number of women and Hispanic trainees in recent years; however, Hispanic trainees only enter the surgical field at a higher rate than their proportion in medical school and not relative to the general population [3]. A 2022 study, Powell et al. revealed that there was no improvement of gender diversity or representation of African Americans and Hispanic residents in integrated cardiothoracic programs [4]. The above literature points to a “leaky pipeline” scenario where URiM trainees are not as likely to matriculate into certain specialties due to lack of early exposure [4]. Thus, it appears that there are issues at all levels—at the beginning, duration and end of the residency journey, of which more research is needed to address the latter.

Although research is aimed at addressing discrepancies across these specialties, it is important to consider other aspects such as institutional biases, as well as inclusion and retention, which ultimately play a role in the success and promotion of diversity in applications and help reduce the gap that we see today. Here, we define these terms as they affect residents and review the existing literature to offer ideas and possible solutions to optimize inclusion and retention in surgical residency programs.

Threats to Inclusion in Surgical Residency

It is essential to set the historical landscape regarding the lack of inclusion and belonging among diverse individuals in medical training. In 2019, the National Evaluation of Racial/Ethnic Discrimination in US Surgical Residency Programs determined that a high percentage of non-white general surgery residents experienced racial/ethnic discrimination which causes considerable distress that can lead to decreased productivity, increased alcohol consumption, depression, attrition, and suicidal ideation or intent [5]. Furthermore, with residents that hold multiple medically underrepresented identities (such as women, African American, Native American, Latino, lesbian, gay, bisexual, transgender, queer (LGBTQ +), and disabled populations), there is a direct relationship with these residents experiencing worsened conditions. Currently, white men make up 37% of all surgical residents, and Black men make up 1.9% of all surgical residents, whereas Black women make up 2.6%. The lowest percentage of Black women in any surgical subspecialty is orthopaedics at 0.6%, while obstetrics and gynecology have the highest representation of Black women at 6.2% [6]. This overall low percentage of URiM women in surgery is ultimately magnified as surgeons advance from resident to attending physician [6]. Lack of representation allows biases to manifest typically as microaggressions, which can typically be conveyed as intentional or unintentional verbal, behavioral, and environmental insults that demonstrate hostile, derogatory, or negative slights and insults that can result in an unpleasant psychological impact on the target person or group. In comparison to overt racism, microaggressions are often less identified and mitigated [7].

In surgery and across subspecialties, widespread implicit and explicit biases also create segregated environments. Ashton-James et al. found that female surgeons received higher warmth ratings than male surgeons, while male surgeons received higher competence ratings compared to female surgeons [8]. Although this may not inherently seem like a harmful observation, perceived competency may correlate with resident inclusion and retention. Aryee et al. revealed that URiM and female trainees have significantly increased residency attrition rates when compared to their counterparts [9]. Previous studies in orthopaedic surgery and general surgery found that attrition occurs disproportionally with female and male minority trainees, which highlights that carrying certain identities can drastically lead to a diminished residency training experience. Additionally, previous studies have also found that orthopaedic residents who are female, single, or without children are statistically more likely to leave residency [10]. As of 2019, women account for 41% of general surgery residents, but gender discrimination and sexual harassment during training were reported by 65% and 20% of female trainees, respectively. Previous studies also show that female trainees had decreased surgical autonomy by completing fewer complex cases during surgical training compared to their male counterparts [11]. Furthermore, the gender gap in self-assessments can translate to a decrease in surgical confidence in female trainees. However, these studies do not consider the experiences of female-identifying residents or non-binary residents. While LGBTQ + residents make up a small percentage of surgical residents (approximately 5–11%), a significant proportion report harassment and mistreatment throughout their training, which could translate to impacting retention in academia after residency completion [12]. A survey conducted among 6381 LGBTQ + general surgery residents (response rate of 85%) revealed that people who identify as lesbian, gay, bisexual, transgender, or queer experienced higher rates of discrimination, harassment, and bullying than their non-LGBTQ + peers, with attending surgeons as the most common source [13]. LGBTQ + residents were twice as likely to consider leaving their training program and/or suicidality even though reports of career satisfaction were similar [13]. Thus, it is paramount to ensure that initiatives designed to increase diversity are actually targeted toward inclusive environments to improve the quality of resident experiences and retention across fields [14].

Initiatives to Improve Inclusion in Surgical Residency

Academic institutions and surgical societies carry a responsibility to improve diversity and inclusivity in surgical residency as they are largely responsible for constructing the systems in place that ultimately shape the careers and experiences of URiM students, trainees, and faculty that act to gatekeep such individuals from medical school, residency, fellowship, and academic positions [15]. Organizations such as the J. Robert Gladden Orthopaedic Society, Ruth Jackson Orthopaedic Society, Nth Dimensions, Pride Ortho, the Association of Women Surgeons (AWS), the Latino Surgical Society (LSS), the Society of Asian Academic Surgeons (SAAS), the Society of Black Academic Surgeons (SBAS), and the Society of Out Surgeons and Allies (SOSA), work to support the professional and emotional development and success of their members, especially in members unable to identify mentors/sponsors in home institutions at both the medical school and residency level [15]. The Association for Academic Surgery (AAS) and the Society of University Surgeons (SUS) are two institutions that aim to improve inclusion in academic surgery by supporting associated societies and increasing diversity of its members through targeted courses, programs, and antiracist educational content [15]. These efforts demonstrate that true diversity, equity, and inclusion can only be met with intentional, focused initiatives and long-term financial and professional investment.

An example of targeted inclusion initiatives can be seen in research conducted by the University of Pennsylvania (UPenn) Health Systems [14]. A three-facet program was implemented that first featured a URiM-focused, 4-week visiting clerkship with provided stipends for lodging and travel expenses. Secondly, residency applicants were then reviewed holistically, and finally, they received targeted outreach on behalf of the URiM-focused faculty, staff, and medical student mentorship network, who provided communication and support to candidates before their residency interview, during interview day, and interview day follow-up. From this multifaceted approach, URiM representation among surgical applicants of the UPenn Health Systems more than doubled in four years [14]. Barriers to make this program approach more scalable included relying on human capital, in addition to commitments from leadership and administration of programs nationwide.

Further strategies for continued DEIB growth within surgical residency programs include targeted surveys evaluating the workplace culture at training institutions. Understanding of the unique challenges at each institution is a critical first step to then develop a multilayered approach to mitigate reported issues [5]. This multilayered approach includes promotion of a zero tolerance culture, establishing empowerment for training residents to report discriminatory behaviors, as well as extensive training of all training faculty, staff, and trainees to recognize and respond to discrimination, which becomes essential to improve DEIB within the workplace [5]. In 2020, the American Academy of Orthopaedic Surgeons (AAOS) conducted a study on harassment, bullying, and discrimination (DBSH) in the workplace within orthopaedic surgery residencies [16]. Of the 16.4% members who responded to the survey, 66% of respondents reported experiencing DBSH behavior with specific exposures to DBSH [16]. Women had an increased likelihood of experiencing these behaviors, with exposures of 85% and 35%, respectively, when compared to their male counterparts [16]. Fifty-eight percent of respondents reported that their workplaces were adequately suited to dismantle DBSH behaviors. [16]

Other studies worked to evaluate the Provider Awareness and Cultural Dexterity Toolkit for Surgeons (PACTS) curriculum focusing across eight US academic general surgery training programs mostly concentrated in the northeast [17]. PACTS is an innovative curriculum focused on improving patient outcomes by increasing surgical residents’ overall knowledge, skills, and attitude when caring for diverse patient populations [17]. Using this to evaluate an everyday discrimination score (EDS), the study found that resident race, non-English fluency, and median household income were significantly associated with increased EDS scores in 22% of surgical residents training at academic centers [17]. Black surgical residents were also 4 times more likely to have high levels of perceived discrimination compared to their White counterparts [17].

Threats to Retention in Surgical Residency

Attempts to increase recruitment and retention of women and minorities, specifically within surgery, raise a few foundational questions. Should approaches to improve DEIB be separated in relation to different worn and unworn identities of trainees? Should all underrepresented and historically marginalized groups be considered a monolith when trying to combat issues of DEIB or should they be separated based on diversifying identifiers such as race, ethnicity, gender/sexual orientation, and identity as well as disability? We then must question, how do people with intersectional identities fit into these strategies? For example, a noticeable shortage of medically underrepresented women in surgical subspecialties exists, and this is exemplified at every level as surgeons progress from interested medical students, to residents and attendings, and finally to leadership positions [6]. A total decrease in representation of Black women can be seen at each increase in professional rank as assistant professor rank consisted of 2.8%, associate professors 1.6%, and full professor 0.7% [6]. While the numbers of Black males within surgical subspecialties has declined, the percentage of Black men in leadership positions has remained stable with assistant, associate, and full professor percentages at 2.1%, 2.4%, and 2.1%, respectively [6]. A 2021, meta-analysis and systematic review on factors related to attrition, such as personal, workplace, program, and educational/academic factors, showed that women had a significantly higher pooled attrition in general surgery residency than men (24% vs 16%, p < 0.001) [18].

In addition to the lack of minority women in surgery, recent studies have also reported that Hispanic residents have a higher attrition rate than non-Hispanic residents. However, there was no increased risk of attrition with age, marital, or parental status [18]. Factors reported to influence performance were non-white ethnicity and faculty assessment of clinical performance, while childrearing was not associated with performance [18]. Ultimately, female sex was associated with higher attrition; however, this study did not further categorize cis-gendered, trans-gendered, or other non-binary persons [18].

Due to these findings, it is important for academic surgery programs to implement or create intentional—rather than passive—approaches to overcome these barriers in equity in academic surgery. Efforts to remove institutional barriers to acquire diverse faculty and strategies to fortify environment, recruitment, professional development, and leadership must be prioritized [19].

Initiatives to Improve Retention in Surgical Residency

Strategies to increase retention of diverse residents are multifactorial. Previous studies suggest restructuring of academic career paths at a national level to increase flexibility during the onset of residency in order to increase retention and advancement for all physicians and trainees. Increased flexibility during these periods would be vital to decreasing attrition as physicians would have more opportunity to learn how to balance competing personal and familial demands on the physician’s time [20]. Furthermore, institutional or national development programs for specific underrepresented groups, for example, the Women in Medicine and Science chapters, the Executive Leadership in Academic Medicine program, or the University of California, San Diego Hispanic Center of Excellence, play a vital role in supporting trainees wholistically, which allows for earlier, relevant conversations and actions that provide a unique template for underrepresented trainees in order to directly improve retention while setting a foundation as these residents advance in their careers [20]. Other medical trainee, resident, and junior-faculty focused mentorship programs, such as Surgeons as Leaders offered by the American College of Surgeons, work to instill confidence and the expertise necessary for academic success, subsequently leading to increased retention and decreased recruitment costs [20]. Ultimately, the retention and promotion of non-white and female faculty require a critical look at the environmental factors imposed on the diverse surgical trainee.

The recognition of those in leadership positions to address disparities is also crucial. Men are more likely to reach tenured positions when compared to women who account for only 9.8% of full professors in academic surgery [19]. These positions were also likely to be service-oriented, as opposed to executive administrative clinical or research positions held by their male counterparts. URiM faculty promotions to the associate professor level were also found to be delayed up to 3 to 7 years later compared to white faculty. Chopra et al., which evaluated demographic qualities in shoulder and elbow fellowship directors, showed that directors were 97% male and 73% white [21]. The near complete lack of female fellowship directors in this field parallels that of spine, arthroplasty, and sports medicine, of which orthopaedic surgery has the lowest number of female residents compared to other surgical specialties [21]. In Levy et al., which reviewed demographic data from the American Orthopaedic Association’s Orthopaedic Residency Network database, it was revealed that a mean of 13.55% attendings were female and 14.14% were URiM. The study also showed that residency programs with more female and/or diverse attendings were more likely to match and retain female and URiM residents and faculty [22]. Expanding diversity in authority positions is also crucial to ensuring that physicians in related specialties can properly serve diverse communities, as well as resemble the incoming trainees they will be responsible for mentoring. However, efforts such as the creation of the American Shoulder and Elbow Surgery (ASES) Committee on Diversity, Equity, and Inclusion in 2020 are now working toward promoting diversity in leadership within the shoulder and elbow surgery community as well as creating ways to increase female and URiM orthopaedic residents and surgeons [21].

In cardiothoracic surgery, the Society of Thoracic Surgeons (STS) Workforce on Diversity and Inclusion presented a framework (adopted from a model developed by the National Institute on Minority Health and Health Disparities) based on four circles of importance in cardiothoracic surgery with associated improvements and applications [23]. This framework focuses on the role of cardiothoracic surgery on a macro- and micro-level (i.e., globally, nationally, institutionally, and individually) in order to increase diversity and retention. Such interventions include Women in Thoracic Surgery (WTS) developing financial initiatives to attract female medical students/residents, and mentorship opportunities at an institutional, national, and international level. The creation of the Workforce for Diversity and Inclusion in 2019 was also dedicated to creating grants and inclusion efforts for their annual meeting, which included lactation rooms and prayer/mediation rooms [23]. At the attending level, practicing cardiothoracic surgeons in both the academic and community setting should consider mentoring across all backgrounds while continuing to monitor their own indirect biases, while also cultivating cultural understanding in order to create a welcoming environment among medical trainees and healthcare members. This may include helping to seek mentors from similar backgrounds for mentees, as well as speaking up in the setting of explicit biases in the professional and personal setting [23].

The concept of feeding the pipeline (i.e., recruitment initiatives at the medical school and pre-residency level) is prevalent in the conversation of increasing diversity and inclusion in surgical subspecialties. However, it is important to distinguish between recruitment and retention, as getting the diverse applicant through the door is only a short-term solution if the house—the institution—needs remodeling. Due to the inherently demanding and hierarchical nature of surgical training, there are notable biases that arise at a systemic level. This can be as simple and commonplace as URiM surgical residents being mistaken for non-physician staff members both in and out of the operating room, which can have debilitating consequences in the quality of training and overall sense of inclusion within the field [24]. Thus, in order to make a more diverse workforce, systemic changes that include nurturing young surgeons are necessary. The roles of department leadership should include consistently evaluating factors that are important for resident success, such as the quality and involvement of such leadership, the hospital system, and the relevant surgical societies. Holistic screening, and identifying distinctive skill sets, personal qualities, and persistence while increasing transparency in the recruitment process across an entire faculty in lieu of a constrained number of senior faculty, will allow more feedback from both diverse and junior faculty [25]. Proactive, focused mentorship programs that cultivate success while acknowledging the increased burden of underrepresentation with regard to receiving professional acknowledgement and respect and participating in committee work, education, and training is crucial [25]. It is important for surgical departments to consistently strive to remove institutional and interpersonal biases, as this often plays a large role in unfairly influencing promotion meetings, faculty ambiguity, and apathy toward diversity and equity. Finally, these departments should work toward promoting substantive rather than cosmetic inclusion [25].

Conclusion

Ultimately, increasing diversity in the healthcare setting is crucial to improving patient health outcomes and reducing health disparities in traditionally medically underserved groups. However, this diversity is not reflected currently in surgical residency training, which continues to lead to deficits across all levels. Decreasing attrition among diverse residents requires a multifaceted approach and a greater focus on retention efforts in order to ensure success in residency and beyond.

Declarations

Conflict of Interest

Ucheze Ononuju declares that she has no conflict of interest. Jakara Morgan declares that she has no conflict of interest. Gabriella Ode declares that she has no conflict of interest.