Trends in Racial, Ethnic and Sex Disparities in U.S. Surgical Residency Programs

A recent study of residency programs from the Association of American Medical Colleges analyzed trends in racial disparities, ethnic disparities, and sex disparities among the field of surgery over 18 years. Published in JAMA Surgery, the analysis included 407,461 program-reported resident years from 112,205 surgical residents.

Researchers confirmed a continued need for more diversity in surgical training programs despite recent gains in some specialties. Significant disparities remain among female and other underrepresented surgical residents despite equivalent pass rates on the General Surgery Qualifying or Certifying Exams.

Some noted trends:

• Women’s representation across surgical specialties increased over the study period. The most significant gains were in urology, integrated vascular surgery, otolaryngology and thoracic surgery.
• However, gains for women were offset by higher attrition in female trainees compared to their male counterparts (relative risk 1.16). Female unintended attrition was also higher (relative risk 1.17), with unintended attrition defined as all withdrawals, dismissals and transfers other than a career change.
• Overall, women represented 40 percent of surgical residents, with the lowest rates in neurosurgery (15%) and orthopedic surgery (13%) and the highest rates in OB-GYN (80%) and ophthalmology (40%).

The story was similar for people of color, where representation decreased by two percent over the study period, finally accounting for about 15 percent of all surgical residents.

• The most significant gains were in otolaryngology, where residencies held by people of color increased by 33 percent, and in vascular surgery and urology, with increases of 26 percent and 23 percent, respectively.
• Disproportionate attrition risk was again a factor. White trainees had the lowest overall attrition rates (6.2%) and unintended attrition (1.8%).
• In contrast, attrition rates were disproportionately higher for people of color. Black trainees had the highest rates of attrition (10.6%), followed by American Indian and Alaska Native residents (9.6%), multiracial and multiethnic residents (7.8%), Asian and Native Hawaiian and Pacific Islander residents (7.5% for each), and Hispanic residents (7%). Unintended attrition was also high, ranging from 2.1 percent in Hispanic residents to 5.2 percent in Black residents.

What accounts for the ongoing diversity and attrition gaps in U.S. surgical specialties?

There are no definitive answers on why the attrition gap is disproportionately large, or the diversity gap is so resistant to change; however, public policy and research on clinician wellness and burnout offer some insight.

For instance, among the 87 medical schools ranked in US News & World Report in 2020, only 15 percent offered physician faculty three months of fully paid leave for birth parents. Less than 13 percent offered three-month paid leave for nonbirth parents, and about half offered no paid leave for birth parents, nonbirth parents, adoptive parents, or foster parents. Nearly one-third required physician faculty to use unpaid leave under the Federal Medical and Family Leave Act (FMLA) or other benefits such as vacation, sick leave, or short-term disability.

Though medical schools in some states are mandated to pay salaries to supplement FMLA, which provides job protections for people in certain medical situations (such as the birth of a child, adoption, foster care, or care for the self or a spouse, parent, or child with a serious health condition), salaries are discretionary and often limited.

Other factors likely to contribute to disparities in surgical specialties are prevalent more broadly, including occupational segregation that leads to the overrepresentation of some groups over others in particular professions, attitudes about the types of work best suited for specific gender or racial categories and the social contexts in which people live and work.

While it is true, for example, that women’s representation in OB-GYN has been historically high compared to other surgical specialties, the focus on women’s health and greater flexibility about parental leave likely play a role. Unfortunately, so do stereotypes.

Assumptions about the traits needed to thrive in certain specialties can encourage or dissuade entry. The negative stigma surrounding parental leave, childcare, and other leave can also be a barrier to career development, particularly if it is assumed that such responsibilities will impede the intensive time commitments needed for training. The JAMA Surgery study pointed out that medical programs with high attrition rates used redirectional (to another field) interventions more often than programs with low attrition rates, suggesting a correlation between disparities in attrition and attitudes about who best belongs where.

Likewise, promotional disparities persist, contributing to the underrepresentation of women and people of color in leadership positions. Inconsistent criteria for promotion and a lack of standard review processes contribute to unequal recognition and differences in the timing of advancement. Women and other underrepresented groups do a more significant share of lower-prestige teaching and service work, with less frequent publishing and fewer citations. People of color are more likely to serve underserved communities, having to do more with fewer resources.

Lack of diversity in surgical specialties means a lack of peers, mentors and role models, making it even more difficult to challenge stereotypes and encourage psychological safety, inspiration and a sense of belonging in the workplace. Research shows that exposure to racist and sexist microaggressions may be independently associated with burnout among underrepresented groups. Among female surgeons, such microaggressions include derogatory terms or images about women, sexual objectification, and feeling pressure to overcompensate, hide emotions, or intentionally appear less feminine. Among those in underrepresented racial and ethnic groups, these include having fewer role models, authority figures, and coworkers of the same race or ethnicity, feeling targeted for not fitting in, and being singled out or perceived as different.

Underrepresentation and lack of equity have consequences for individuals and organizations. The salary, promotion, opportunities, resources, and job satisfaction gap influence personal decisions to seek out or remain in a particular specialty. At a system level, reducing disparities in the healthcare workforce is vital in broadly addressing inequities in health and health care. As Alexander Ortega and Dylan Roby argue in JAMA, multilevel approaches are needed to “expand the diversity and inclusion of health care clinicians so that they reflect the demographics of the communities being served.” Understanding factors contributing to disparities in medical specialties is crucial for creating an equitable, diverse, and inclusive medical workforce and healthcare equity.