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The Training Needs and Priorities of Male and Female Surgeons and Their Trainees
The Training Needs and Priorities of Male and Female Surgeons and Their Trainees Alison R Saalwachter, MD, Julie A Freischlag, MD, FACS, Robert G Sawyer, MD, FACS, Hilary A Sanfey, MB, BCH, FACS Over the past decade, interest in general surgery careers has declined and the number of female medical school graduates has increased. This study was performed to identify the needs of both male and female surgical trainees and to guide design of training programs because attracting medical students to, and maintaining residents in, general surgery training programs can be difficult without a clear understanding of the training needs and priorities of both men and women. We hypothesized that men and women would express similar training priorities, yet have subjectively different experiences. STUDY DESIGN: Medical students, surgical residents, fellows, and fully trained surgeons affiliated with at least one of four major surgical societies were asked to complete a level-specific survey located on the American College of Surgeons Web site. RESULTS: There were 4,308 respondents (76% men). Men and women selected similar reasons for choosing a surgical career and residency program and criteria critical to a successful residency program, with women placing greater emphasis on clerkship experience and faculty diversity. There were no statistically significant differences between the men and women’s perceptions of their own training. Although, when asked to evaluate whether certain aspects of training were comparable for male and female residents, women were statistically less likely to agree that their experiences were comparable with those of their male colleagues. CONCLUSIONS: Male and female surgical residents, fellows, and trained surgeons identified almost identical training needs and priorities yet women perceived disparate treatment. (J Am Coll Surg 2005; 201:199–205. © 2005 by the American College of Surgeons) BACKGROUND:
surgical subspecialties over general surgery4-6 and, often for the same reasons, increased interest in fields with controllable lifestyles.7-11 From 1996 to 2002, the percentage of US medical school seniors entering anesthesia rose from 1.1% to 6.4%, entering dermatology rose from 0.2% to 2.3%, and entering radiology rose from 3.3% to 6.1%. Over the same time period, students selecting general surgery careers decreased from 10.4% to 7.6%.12 The ability to fill general surgery residency positions might suffer as more women enter and graduate from medical schools. From 1982 to 2002, medical school enrollment for women rose from 29.3% to 46.9%.13 The percentage of women in general surgery training programs has not kept pace with this rapid rise. Only 23% of the 1995 general surgery residency graduates were women14 and there has been only a negligible increase, with 25% of the 2002 general surgery residency enrollment comprising women.15 The discrepancy could be because women have historically been less attracted to
Although recent National Residency Matching Program results might suggest improving medical student interest in pursuing surgical careers,1 vacant residency positions continue to cause concern. Additionally, attrition from surgery residency programs is substantial, with reported rates exceeding 20%.2 In a survey of surgery program directors, Morris and colleagues3 noted that over half of the respondents’ programs were affected by attrition and that 34% of those programs lost more than one resident, most often attributable to lifestyle concerns. Surgical residency programs have suffered from decreased medical student interest, due in part to increased interest in Competing Interests Declared: None. Received January 7, 2005; Revised March 17, 2005; Accepted March 21, 2005. From the Departments of Surgery (Saalwachter, Sawyer, Sanfey) and Health Evaulation Sciences (Sawyer), The University of Virginia Health System, Charlottesville, VA and the Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD (Freischlag). Correspondence address: Hilary A Sanfey, MB, BCh, FACS, University of Virginia Health System, Box 800709, Charlottesville, VA 22908.
© 2005 by the American College of Surgeons Published by Elsevier Inc.
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the field.7,16 With about half of medical school enrollment composed of women, it is imperative that more women become attracted to general surgery to continue to fill residency positions with the most qualified candidates.17 Residency programs must continue to appeal to both male and female trainees to minimize attrition. This study was designed to identify both the training needs of the current generation of surgery residents and potential changes to improve recruitment and retention of male and female surgery residents. My colleagues and I hypothesized that men and women would have similar training needs and priorities but have subjectively different training experiences. METHODS Study design and participants
The Council of the Association of Women Surgeons initiated development of a questionnaire, which was supported by the American College of Surgeons (ACS), the American Surgical Association, and the Association of Program Directors in Surgery. The University of Virginia Institutional Review Board for the Social and Behavioral Sciences approved the study and consent was presumed with completion of the survey. No identifying information was collected. After a pilot study, a Web-based questionnaire was distributed electronically to members of the ACS, Association of Women Surgeons, American Surgical Association, and Association of Program Directors in Surgery, and to surgical residents by program directors. The invitation to participate included a request of the recipient to forward the questionnaire to other surgeons, surgical residents and fellows, and medical students. The questionnaire was available on the ACS Web site for 90 days from October 2003 through January 2004. Data were housed on the ACS server. Respondents completed one of four questionnaires: medical student, resident, fellow, and fully trained surgeon. Each contained both core and level-specific questions. Demographic information was solicited and opinions about training priorities, experiences, and career choices. Most questions were asked using a five-point Likert scale (1 ⫽ strongly disagree, 3 ⫽ don’t know, 5 ⫽ strongly agree). A copy of the trained surgeon questionnaire is available from the authors.
J Am Coll Surg
Statistical analysis
Categorical data were analyzed using chi-square test and Fisher’s exact test. Continuous data, found to have a nonnormal distribution, were analyzed using the MannWhitney U test. All variables were two-tailed and p values ⬍ 0.05 were considered significant. For questions asking respondents to select the top three of available choices, total number of responses was divided by three and, if necessary, rounded to the nearest whole number to calculate percentages and p values. RESULTS A total of 4,308 surgeons and surgical trainees responded to the survey: 482 medical students, 789 surgical residents, 179 surgical fellows, and 2,858 trained surgeons. The number of potential responders is not available, as there was potential for overlap in invitation to complete the questionnaire and dependence on recipients to forward the invitation to residents and medical students. Basic demographic information is available in Table 1. When asked to select reasons for choosing a career in surgery, men and women from all levels most frequently cited “hands on specialty,” “immediate results,” and “wanted a challenge.” Considerably more female than male residents, fellows, and trained surgeons selected “positive clerkship experience” (58% to 60% versus 41% to 45%; residents and trained surgeons, p ⬍ 0.001; fellows, p ⫽ 0.05). Considerably more men cited “financial gain” (7% to 14% versus 2% to 4%; all sections, p ⱕ 0.04) and “family tradition” (4% to 9% versus 2% to 3%; residents and trained surgeons, p ⱕ 0.01) as reasons for choosing surgery. Men and women in all nonstudent sections endorsed the same criteria for choosing residency programs: most frequently selecting “quality of training,” “location,” “program reputation,” and “resident satisfaction noted during interview.” Female residents and female trained surgeons were more likely than men to cite “resident satisfaction noted during interview” (46 versus 40% and 29 versus 22%, respectively, p ⱕ 0.02). Male residents were more likely than female residents to select “family friendly” as an important criterion (9 versus 4%, p ⫽ 0.01) even when analyzing respondents with and without children separately. Men and women in all nonstudent sections endorsed similar requirements for a successful residency program, most frequently citing “operative case load/mix,” “re-
⬍ 0.001 ⬍ 0.001 0.001 ⬍ 0.001 24 69 8 54 118 338 37 262 4 92 4 89 90 2,180 91 2,096 0.002 0.002 NS ⬍ 0.001 38 53 9 26 22 31 5 15
3
19 94 8 77 28 71 2 35 140 360 12 180 NS NS 0.02 0.04 58 40 2 9 15
55 46
146 123 0 41
125 85 5 19
5
142 130 6 41
50 ⬍ 0.001 41 ⬍ 0.001 2 NS 14 ⬍ 0.001
16 78 7 64
NS NS NS 0.01 NS NS — 415 84 16 3 43 9 10 2 1 ⬍1 9 2 43 1,986 84 43 2 158 7 107 5 2 ⬍1 59 3 48 NS NS NS NS NS NS — 71 9 12 5
42 5 7 3 0 2 35 69 3 15 8 1 3 84 4 18 10 1 4 35 NS 0.01 NS NS NS NS — 69 6 14 4 1 6 196 17 41 10 2 16 31 68 2 18 7
345 11 89 34 0 26 31 0.007 0.007 NS NS NS NS — 61 12 15 7 1 3 131 26 32 15 3 8 27 73 5 11 6 1 4 194 13 30 16 2 11 27
p Value
— 17 495 83 2,363 — 32 58 68 121
p Value p Value
— 36 284 64 505 — 45 215 55
p Value Demographics
201
267
Attendings Female n % Male n % Fellows Female n % Male n % Residents Female n % Male n % Students Female n % Male n %
cord of resident placement after training,” “resident success in passing boards,” and “faculty diversity.” Female respondents were more likely than their male counterparts to cite “faculty diversity” (43% to 62% versus 33% to 50%; residents and fellows, p ⱕ 0.03; trained surgeons, p ⫽ 0.06) and “child care on-site” (6% versus 1%; residents and trained surgeons, p ⱕ 0.003). Male residents and male trained surgeons were more likely than females to list “mandatory full time research” (5% versus 2%, p ⱕ 0.01). For those respondents who were planning to apply for a specialty fellowship (residents) were enrolled in a fellowship (fellows), or who selected the most applicable description of their practice (trained surgeons), some distinct differences between male and female respondents were demonstrated. Women were more likely to pursue breast surgery (all sections) and surgical oncology (residents) and men were more likely to pursue cardiothoracic (residents and trained surgeons), vascular (fellows and trained surgeons), and transplant surgery (residents and trained surgeons) (Table 2). No differences were demonstrated between male and female nonstudent responses to questions about whether certain aspects of their residency training are or were level appropriate. Over 80% of respondents agreed or strongly agreed that the case mix, level of responsibility, and degree of supervision are or were level appropriate. Female respondents were notably less likely than their male counterparts to agree with statements that asked respondents whether they agreed or disagreed (based on a five-point Likert scale) that certain experience in their residency programs are or were comparable for male and female residents. These data, shown in Table 3, depict the number of each gender who agreed or strongly agreed with the statements, followed by the percentage from that same gender who agreed or strongly agreed. These questions were simply phrased “comparable for both male and female residents” without indication of how the experiences might not be comparable. When asked, “In my residency program female residents are/ were treated in an inferior manner compared with male residents,” female residents and female trained surgeons were markedly more likely than their male counterparts to agree. A substantial minority of both male and female resident and fellow respondents (30% to 44%, p ⫽ NS) agreed or strongly agreed that residents in their training programs could be verbally abused and humiliated in
Needs and Priorities of Surgeons and Trainees
Gender Race/ethnicity Caucasian African American Asian Hispanic Native American None of the above Average age (y) Relationship status Single Married/in relationship Divorced/separated Have children
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Table 1. Demographic Details of Questionnaire Respondents
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Table 2. Specialty Choice for Male Compared with Female Residents Planning to Apply for a Fellowship, and Fellows Currently Enrolled in a Fellowship Residents
Surgical specialties
General Breast Cardiothoracic Colorectal Critical care Hepatobiliary Laparoscopic Pediatrics Plastic Oncology Transplant Trauma Vascular Other
Male (n ⴝ 421) n %
2 74 30 13 10 35 77 34 19 22 37 68
— ⬍1 18 7 3 2 — 8 18 8 5 5 9 16
Female (n ⴝ 221) n %
— 11 19 23 10 5
5 9 10 5 2 —
28 31 38 3 11 11 31
13 14 17 1 5 5 14
Fellows
p Value
— ⬍ 0.0001 0.003 NS NS NS — NS NS 0.001 0.03 NS NS NS
Male (n ⴝ 108) n %
Female (n ⴝ 55) n %
—
—
0 22 4 11 3 15 4
20 4 10 3 14 4
9 6 1 5 1 5 3
7 5 7 15 12
10 5 2 2 6
— 8 5 7 16 13
16 11 2 9 2 9 6 —
front of colleagues. Trained female surgeons were markedly more likely than men to agree to this mistreatment (51% versus 39%, p ⬍ 0.00001). Between 33% to 39% of female nonstudent respondents agreed that, in their residency programs, residents might be or might have been subject to sexually inappropriate comments or behavior, compared with 10% to 19% of male respondents (p ⬍ 0.00001 for residents and trained surgeons, p ⫽ 0.06 for fellows). Between 63% and 75% of all nonstudent responders agreed that they would encourage medical students to consider a career in surgery (p ⫽ NS). And over 76% of both male and female residents agreed that if they had to choose again they would definitely do surgery (p ⫽ NS), considerably more male fellows and male trained surgeons agreed to this (80% versus 61% and 76% versus 72%, respectively, p ⱕ 0.04). DISCUSSION Male and female general surgery residents, fellows, and trained surgeons expressed many similar training needs and perceptions of what is important in training programs, primarily related to high quality and broad depth of training. Male and female medical students expressed similar reasons for choosing a career in surgery, as also seen in a earlier study of graduating medical students.18 Of nonstudent responders, both men and women tended to agree that they were treated in a level-appropriate
18 9 4 4 11
Attendings
p Value
— ⬍ 0.0001 NS NS NS NS NS NS — NS NS NS 0.02 NS
Male (n ⴝ 2,006) n %
713 26 171 63 21 23 78 103
Female (n ⴝ 467) n %
36 1 9 3 1 1 4 5
176 64 19 19 6 4 10 27
5 2 7 10 16
21 5 29 22 65
— 103 43 140 205 317
38 14 4 4 1 1 2 6 — 50 1 6 5 14
p Value
NS ⬍ 0.0001 0.002 NS NS NS NS NS — NS NS NS 0.0003 NS
manner during residency. When asked if men and women were treated comparably in many different aspects of training, women were notably less likely than men to agree. Both male and female respondents cited family and childbearing concerns related to training in general surgery. Earlier studies confirm this common interest in maternity and paternity polices.7,19 Our data also showed that female residents, trained female surgeons, and male fellows consider on-site childcare to be an important component of a successful training program, although male residents and female fellows are considerably more likely than their opposite gender colleagues to look for training programs that are considered “family friendly.” Implementation of systems to support bearing and raising children will make programs more appealing to all applicants. Because female respondents frequently cited a positive clerkship experience as a reason for selecting a career in general surgery, emphasis should be placed on designing clerkships that do not alienate women. Enthusiastic teaching, availability of female role models, and increased involvement in the operating room have been recognized as important factors.16,20-22 Additionally, once the decision has been made to seek a career in general surgery, women place greater emphasis on faculty diversity in residency programs. Current literature fails to demonstrate this desired diversity. In a separate ACS
⬍ 0.0001 28 136 5 104 NS 14 8 7 9 ⬍ 0.00001 16 47 4 21
154 264 208 244 193 176 67 95 91 90 81 71 335 473 448 446 407 353
70 46 228
193 82
Quality of training Overall residency experience Impact of surgical residency on personal life Availability of mentorship opportunities Equal assignment of rotations Operative experience Research opportunities Evaluated by similar criteria Feedback provided in timely manner In my residency program female residents are treated in an inferior manner compared with male residents
— 411
n % n Experiences for male and female residents
n, Number of responders who agreed or strongly agreed that the experiences were comparable; %, the percentage of the total number of the same sex respondents who answered each question.
0.003 NS ⬍ 0.0001 NS ⬍ 0.0001 0.0003 43 89 72 78 55 57 138 430 350 383 267 279 53 85 83 81 76 66 806 1,980 1,937 1,896 1,762 1,538 NS NS NS NS NS 0.05 52 88 81 82 72 60 29 50 46 47 41 34 65 89 89 88 74 75 75 106 104 107 89 91 0.001 NS ⬍ 0.00001 NS ⬍ 0.00001 0.03 55 92 75 86 68 63
⬍ 0.0001 41 200 55 1,293 0.005 37 21 61 73 ⬍ 0.00001
203
—
25
67
p Value %
75 60 365 296 84 78 1,959 1,816 0.05 NS (0.06) 73 63 41 36 87 78 105 94
n p Value % n % n %
p Value
— ⬍ 0.00001
Female n %
Attendings
Male Female
Fellows
Male Residents
Female Male
survey, 89% of academic surgeons described themselves as white23 and women constitute less than one-third of US medical school full-time faculty.13 Female and minority representation could help to attract more medical students to the field. Medical schools with faculty comprised of 40% women send notably more female graduates to surgical residency programs than schools with ⬍15% of female surgical faculty.24 Although the majority of surgical subspecialties attracted similar percentages of men and women, certain specialties were more likely to appeal to either men or women. Breast surgery is likely more appealing to women both for personal reasons and patient demand. Few clear reasons exist to explain the male dominance in cardiothoracic and vascular surgery. Male cardiothoracic surgeons are less likely than their female counterparts to encourage women to pursue careers in the field.25 Perhaps women are less compelled to enter these specialties because of a lack of female role models or concern over an “old boys club” atmosphere. Female cardiothoracic surgeons do believe that discrimination negatively affected their career development.25 Although thoracic surgery has historically had the lowest percentage of women residents at just 5%,26 our data suggest a possible trend toward increased female interest in the field. Although only 4% of female trained surgeons described their practice as cardiothoracic, about 10% of female residents and fellows indicated an interest in the field. Although male and female respondents tended to report similar training needs and priorities, there were considerable discrepancies between the genders when asked if certain aspects of their training were comparable for male and female residents, with women being less likely to agree that experiences were comparable, a phenomenon also demonstrated with surgery attendings in a separate study.27 Although those questions were not phrased to imply that one gender received preferential treatment over the other, women residents and trained surgeons were considerably more likely to agree with a statement that read “female residents are treated in an inferior manner compared with male residents.” Clearly this is a major problem for surgeons in practice and in training. Dissimilar treatment could prevent female surgeons from achieving their ultimate potential, dissuade female medical students from pursuing a career in the field, affect morale, or contribute to attrition and poor productivity. Also concerning was the minority of respondents who
⬍ 0.0001 ⬍ 0.0001
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Table 3. Male and Female Residents’ Responses to Statements About Experiences During Residency (Basled on a Five-Point Likert Scale)
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agreed that, in their residency programs, residents might be verbally abused or humiliated in front of colleagues or subject to sexually inappropriate comments and behavior. Apparently maltreatment continues to exist in surgical training programs and could contribute to medical student disinterest in the field16,21,22,28 and, perhaps, resident, fellow, or trained surgeon attrition. Despite this perceived maltreatment, more than half of male and female respondents agreed that they would definitely do surgery again and encourage medical students to consider careers in surgery. Perhaps female residents, fellows, and trained surgeons have grown to accept a different standard of treatment or simply put up with it in exchange for training in their field of interest. Although the majority of respondents appear content with their choice to enter into a surgical career, a notable minority disagreed that they would make the same career choice or encourage others to do so. Changing some aspects of surgery training programs might help attract the best candidates and minimize attrition. Disparities in treatment of male and female residents need to be better clarified and addressed, and resident mistreatment must cease. Future studies should be designed to identify particular scenarios in which female surgery trainees feel alienated so that measures can be taken to educate those involved about particular behaviors that could possibly be changed. General surgery residency training is a long process, which has the potential to be more enjoyable and less stressful than it appears to be at this time. This study was carried out during implementation of the 80-hour workweek regulations and any effects that the regulations might have on respondent perceptions are not accounted for in these results. Although we are reporting data provided by over 4,000 surgeons and their trainees, there are some weaknesses to this study. These results, as with all questionnaire-based studies, are subject to responder bias. Such bias is minimized by the large number of respondents, the wide variety of groups approached to distribute the questionnaire, and the complete anonymity of the responses. Finally, this study is weakened by the inability to determine the potential number of respondents. Despite the large number of respondents, we are unable to calculate a response rate, which could either strengthen or weaken our conclusions. We believe that these data reflect as accurately as possible the opinions of current medical students, residents, fellows, and attendings and indicate certain spe-
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cific areas of training that could be changed to recruit more women and stronger applicants to the field of general surgery. Author Contributions
Study conception and design: Freischlag, Sanfey Acquisition of data: Freischlag, Sanfey Analysis and interpretation of data: Saalwachter, Sawyer, Sanfey Drafting of manuscript: Saalwachter Critical revision: Freischlag, Sawyer, Sanfey Statistical expertise: Sawyer Supervision: Sanfey Acknowledgment: We would like to acknowledge the support of the Council of the Association of Women Surgeons, Mr Jim Losby at the American College of Surgeons, the Association of Program Directors in Surgery, and the American Surgical Association Blue Ribbon Committee.
REFERENCES 1. National Resident Match Program 2004. Available at: www. nrmp.org. 2. Kwakwa F, Jonasson O. Attrition in graduate surgical education: an analysis of the 1993 entering cohort of surgical residents. J Am Coll Surg 1999;189:602–610. 3. Morris JB, Leibrandt TJ, Rhodes RS. Voluntary changes in surgery career paths: a survey of the program directors in surgery. J Am Coll Surg 2003;196:611–616. 4. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties. Arch Surg 2002;137:259–267. 5. Callcut R, Snow M, Lewis B, Chen H. Do the best students go into general surgery? J Surg Res 2003;115:69–73. 6. Wendel TM, Godellas CV, Prinz RA. Are there gender differences in choosing a surgical career? Surgery 2003;134:591–598. 7. Baxter N, Cohen R, McLeod R. The impact of gender on the choice of surgery as a career. Am J Surg 1996;172:373–376. 8. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173–1178. 9. Gelfand DV, Podnos YD, Wilson SE, et al. Choosing general surgery: insights into career choices of current medical students. Arch Surg 2002;137:941–947. 10. Lind DS, Cendan JC. Two decades of student career choice at the University of Florida: increasingly a lifestyle decision. Am Surg 2003;69:53–55. 11. Schwartz RW, Jarecky RK, Strodel WE, et al. Controllable lifestyle: a new factor in career choice by medical students. Acad Med 1989;64:606–609. 12. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173–1178. 13. Barzansky B, Etzel SI. Educational programs in US medical schools, 2002–2003. JAMA 2003;290:1190–1196.
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14. Kwakwa F, Jonasson O. The longitudinal study of surgical residents, 1994–1996. J Am Coll Surg 1999;188:575–585. 15. Graduate medical educations (Appendix II). JAMA 2003;290: 1234–1248. 16. Richardson HC, Redfern N. Why do women reject surgical careers? Ann R Coll Surg Engl 2000;82[Suppl]:290–293. 17. Debas HT. Medical education and practice: end of century reflections. Arch Surg 2000;135:1096–1100. 18. Wendel TM, Godellas CV, Prinz RA. Are there gender differences in choosing a surgical career? Surgery 2003;134:591–598. 19. Mayer KL, Ho HS, Goodnight JE Jr. Childbearing and child care in surgery. Arch Surg 2001;136:649–655. 20. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Why do students choose careers in surgery? J Surg Res 2004;119:124–129. 21. Cochran A, Paukert JL, Neumayer LA. Does a general surgery clerkship influence student perceptions of surgeons and surgical careers? Surgery 2003;134:153–157.
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22. Williams C, Cantillon P. A surgical career? The views of junior women doctors. Med Educ 2000;34:602–607. 23. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med 2004;79:310–318. 24. Neumayer L, Kaiser S, Anderson K, et al. Perception of women medical students and their influence on career choice. Am J Surg 2002;183:146–150. 25. Dresler CM, Padgett DL, MacKinnon SE, Patterson GA. Experiences of women in cardiothoracic surgery. A gender comparison. Arch Surg 1996;131:1128–1134. 26. Burrow GN, Burgess NL. The evolution of women as physicians and surgeons. Ann Thorac Surg 2001;71:S27–S29. 27. Colletti LM, Mulholland MW, Sonnad SS. Perceived obstacles to career success for women in academic surgery. Arch Surg 2000;135:972–977. 28. Kozar RA, Anderson KD, Escobar-Chaves SL, et al. Preclinical students: who are surgeons? J Surg Res 2004;119:113–116.
surgical subspecialties over general surgery4-6 and, often for the same reasons, increased interest in fields with controllable lifestyles.7-11 From 1996 to 2002, the percentage of US medical school seniors entering anesthesia rose from 1.1% to 6.4%, entering dermatology rose from 0.2% to 2.3%, and entering radiology rose from 3.3% to 6.1%. Over the same time period, students selecting general surgery careers decreased from 10.4% to 7.6%.12 The ability to fill general surgery residency positions might suffer as more women enter and graduate from medical schools. From 1982 to 2002, medical school enrollment for women rose from 29.3% to 46.9%.13 The percentage of women in general surgery training programs has not kept pace with this rapid rise. Only 23% of the 1995 general surgery residency graduates were women14 and there has been only a negligible increase, with 25% of the 2002 general surgery residency enrollment comprising women.15 The discrepancy could be because women have historically been less attracted to
Although recent National Residency Matching Program results might suggest improving medical student interest in pursuing surgical careers,1 vacant residency positions continue to cause concern. Additionally, attrition from surgery residency programs is substantial, with reported rates exceeding 20%.2 In a survey of surgery program directors, Morris and colleagues3 noted that over half of the respondents’ programs were affected by attrition and that 34% of those programs lost more than one resident, most often attributable to lifestyle concerns. Surgical residency programs have suffered from decreased medical student interest, due in part to increased interest in Competing Interests Declared: None. Received January 7, 2005; Revised March 17, 2005; Accepted March 21, 2005. From the Departments of Surgery (Saalwachter, Sawyer, Sanfey) and Health Evaulation Sciences (Sawyer), The University of Virginia Health System, Charlottesville, VA and the Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD (Freischlag). Correspondence address: Hilary A Sanfey, MB, BCh, FACS, University of Virginia Health System, Box 800709, Charlottesville, VA 22908.
© 2005 by the American College of Surgeons Published by Elsevier Inc.
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the field.7,16 With about half of medical school enrollment composed of women, it is imperative that more women become attracted to general surgery to continue to fill residency positions with the most qualified candidates.17 Residency programs must continue to appeal to both male and female trainees to minimize attrition. This study was designed to identify both the training needs of the current generation of surgery residents and potential changes to improve recruitment and retention of male and female surgery residents. My colleagues and I hypothesized that men and women would have similar training needs and priorities but have subjectively different training experiences. METHODS Study design and participants
The Council of the Association of Women Surgeons initiated development of a questionnaire, which was supported by the American College of Surgeons (ACS), the American Surgical Association, and the Association of Program Directors in Surgery. The University of Virginia Institutional Review Board for the Social and Behavioral Sciences approved the study and consent was presumed with completion of the survey. No identifying information was collected. After a pilot study, a Web-based questionnaire was distributed electronically to members of the ACS, Association of Women Surgeons, American Surgical Association, and Association of Program Directors in Surgery, and to surgical residents by program directors. The invitation to participate included a request of the recipient to forward the questionnaire to other surgeons, surgical residents and fellows, and medical students. The questionnaire was available on the ACS Web site for 90 days from October 2003 through January 2004. Data were housed on the ACS server. Respondents completed one of four questionnaires: medical student, resident, fellow, and fully trained surgeon. Each contained both core and level-specific questions. Demographic information was solicited and opinions about training priorities, experiences, and career choices. Most questions were asked using a five-point Likert scale (1 ⫽ strongly disagree, 3 ⫽ don’t know, 5 ⫽ strongly agree). A copy of the trained surgeon questionnaire is available from the authors.
J Am Coll Surg
Statistical analysis
Categorical data were analyzed using chi-square test and Fisher’s exact test. Continuous data, found to have a nonnormal distribution, were analyzed using the MannWhitney U test. All variables were two-tailed and p values ⬍ 0.05 were considered significant. For questions asking respondents to select the top three of available choices, total number of responses was divided by three and, if necessary, rounded to the nearest whole number to calculate percentages and p values. RESULTS A total of 4,308 surgeons and surgical trainees responded to the survey: 482 medical students, 789 surgical residents, 179 surgical fellows, and 2,858 trained surgeons. The number of potential responders is not available, as there was potential for overlap in invitation to complete the questionnaire and dependence on recipients to forward the invitation to residents and medical students. Basic demographic information is available in Table 1. When asked to select reasons for choosing a career in surgery, men and women from all levels most frequently cited “hands on specialty,” “immediate results,” and “wanted a challenge.” Considerably more female than male residents, fellows, and trained surgeons selected “positive clerkship experience” (58% to 60% versus 41% to 45%; residents and trained surgeons, p ⬍ 0.001; fellows, p ⫽ 0.05). Considerably more men cited “financial gain” (7% to 14% versus 2% to 4%; all sections, p ⱕ 0.04) and “family tradition” (4% to 9% versus 2% to 3%; residents and trained surgeons, p ⱕ 0.01) as reasons for choosing surgery. Men and women in all nonstudent sections endorsed the same criteria for choosing residency programs: most frequently selecting “quality of training,” “location,” “program reputation,” and “resident satisfaction noted during interview.” Female residents and female trained surgeons were more likely than men to cite “resident satisfaction noted during interview” (46 versus 40% and 29 versus 22%, respectively, p ⱕ 0.02). Male residents were more likely than female residents to select “family friendly” as an important criterion (9 versus 4%, p ⫽ 0.01) even when analyzing respondents with and without children separately. Men and women in all nonstudent sections endorsed similar requirements for a successful residency program, most frequently citing “operative case load/mix,” “re-
⬍ 0.001 ⬍ 0.001 0.001 ⬍ 0.001 24 69 8 54 118 338 37 262 4 92 4 89 90 2,180 91 2,096 0.002 0.002 NS ⬍ 0.001 38 53 9 26 22 31 5 15
3
19 94 8 77 28 71 2 35 140 360 12 180 NS NS 0.02 0.04 58 40 2 9 15
55 46
146 123 0 41
125 85 5 19
5
142 130 6 41
50 ⬍ 0.001 41 ⬍ 0.001 2 NS 14 ⬍ 0.001
16 78 7 64
NS NS NS 0.01 NS NS — 415 84 16 3 43 9 10 2 1 ⬍1 9 2 43 1,986 84 43 2 158 7 107 5 2 ⬍1 59 3 48 NS NS NS NS NS NS — 71 9 12 5
42 5 7 3 0 2 35 69 3 15 8 1 3 84 4 18 10 1 4 35 NS 0.01 NS NS NS NS — 69 6 14 4 1 6 196 17 41 10 2 16 31 68 2 18 7
345 11 89 34 0 26 31 0.007 0.007 NS NS NS NS — 61 12 15 7 1 3 131 26 32 15 3 8 27 73 5 11 6 1 4 194 13 30 16 2 11 27
p Value
— 17 495 83 2,363 — 32 58 68 121
p Value p Value
— 36 284 64 505 — 45 215 55
p Value Demographics
201
267
Attendings Female n % Male n % Fellows Female n % Male n % Residents Female n % Male n % Students Female n % Male n %
cord of resident placement after training,” “resident success in passing boards,” and “faculty diversity.” Female respondents were more likely than their male counterparts to cite “faculty diversity” (43% to 62% versus 33% to 50%; residents and fellows, p ⱕ 0.03; trained surgeons, p ⫽ 0.06) and “child care on-site” (6% versus 1%; residents and trained surgeons, p ⱕ 0.003). Male residents and male trained surgeons were more likely than females to list “mandatory full time research” (5% versus 2%, p ⱕ 0.01). For those respondents who were planning to apply for a specialty fellowship (residents) were enrolled in a fellowship (fellows), or who selected the most applicable description of their practice (trained surgeons), some distinct differences between male and female respondents were demonstrated. Women were more likely to pursue breast surgery (all sections) and surgical oncology (residents) and men were more likely to pursue cardiothoracic (residents and trained surgeons), vascular (fellows and trained surgeons), and transplant surgery (residents and trained surgeons) (Table 2). No differences were demonstrated between male and female nonstudent responses to questions about whether certain aspects of their residency training are or were level appropriate. Over 80% of respondents agreed or strongly agreed that the case mix, level of responsibility, and degree of supervision are or were level appropriate. Female respondents were notably less likely than their male counterparts to agree with statements that asked respondents whether they agreed or disagreed (based on a five-point Likert scale) that certain experience in their residency programs are or were comparable for male and female residents. These data, shown in Table 3, depict the number of each gender who agreed or strongly agreed with the statements, followed by the percentage from that same gender who agreed or strongly agreed. These questions were simply phrased “comparable for both male and female residents” without indication of how the experiences might not be comparable. When asked, “In my residency program female residents are/ were treated in an inferior manner compared with male residents,” female residents and female trained surgeons were markedly more likely than their male counterparts to agree. A substantial minority of both male and female resident and fellow respondents (30% to 44%, p ⫽ NS) agreed or strongly agreed that residents in their training programs could be verbally abused and humiliated in
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Gender Race/ethnicity Caucasian African American Asian Hispanic Native American None of the above Average age (y) Relationship status Single Married/in relationship Divorced/separated Have children
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Table 1. Demographic Details of Questionnaire Respondents
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Table 2. Specialty Choice for Male Compared with Female Residents Planning to Apply for a Fellowship, and Fellows Currently Enrolled in a Fellowship Residents
Surgical specialties
General Breast Cardiothoracic Colorectal Critical care Hepatobiliary Laparoscopic Pediatrics Plastic Oncology Transplant Trauma Vascular Other
Male (n ⴝ 421) n %
2 74 30 13 10 35 77 34 19 22 37 68
— ⬍1 18 7 3 2 — 8 18 8 5 5 9 16
Female (n ⴝ 221) n %
— 11 19 23 10 5
5 9 10 5 2 —
28 31 38 3 11 11 31
13 14 17 1 5 5 14
Fellows
p Value
— ⬍ 0.0001 0.003 NS NS NS — NS NS 0.001 0.03 NS NS NS
Male (n ⴝ 108) n %
Female (n ⴝ 55) n %
—
—
0 22 4 11 3 15 4
20 4 10 3 14 4
9 6 1 5 1 5 3
7 5 7 15 12
10 5 2 2 6
— 8 5 7 16 13
16 11 2 9 2 9 6 —
front of colleagues. Trained female surgeons were markedly more likely than men to agree to this mistreatment (51% versus 39%, p ⬍ 0.00001). Between 33% to 39% of female nonstudent respondents agreed that, in their residency programs, residents might be or might have been subject to sexually inappropriate comments or behavior, compared with 10% to 19% of male respondents (p ⬍ 0.00001 for residents and trained surgeons, p ⫽ 0.06 for fellows). Between 63% and 75% of all nonstudent responders agreed that they would encourage medical students to consider a career in surgery (p ⫽ NS). And over 76% of both male and female residents agreed that if they had to choose again they would definitely do surgery (p ⫽ NS), considerably more male fellows and male trained surgeons agreed to this (80% versus 61% and 76% versus 72%, respectively, p ⱕ 0.04). DISCUSSION Male and female general surgery residents, fellows, and trained surgeons expressed many similar training needs and perceptions of what is important in training programs, primarily related to high quality and broad depth of training. Male and female medical students expressed similar reasons for choosing a career in surgery, as also seen in a earlier study of graduating medical students.18 Of nonstudent responders, both men and women tended to agree that they were treated in a level-appropriate
18 9 4 4 11
Attendings
p Value
— ⬍ 0.0001 NS NS NS NS NS NS — NS NS NS 0.02 NS
Male (n ⴝ 2,006) n %
713 26 171 63 21 23 78 103
Female (n ⴝ 467) n %
36 1 9 3 1 1 4 5
176 64 19 19 6 4 10 27
5 2 7 10 16
21 5 29 22 65
— 103 43 140 205 317
38 14 4 4 1 1 2 6 — 50 1 6 5 14
p Value
NS ⬍ 0.0001 0.002 NS NS NS NS NS — NS NS NS 0.0003 NS
manner during residency. When asked if men and women were treated comparably in many different aspects of training, women were notably less likely than men to agree. Both male and female respondents cited family and childbearing concerns related to training in general surgery. Earlier studies confirm this common interest in maternity and paternity polices.7,19 Our data also showed that female residents, trained female surgeons, and male fellows consider on-site childcare to be an important component of a successful training program, although male residents and female fellows are considerably more likely than their opposite gender colleagues to look for training programs that are considered “family friendly.” Implementation of systems to support bearing and raising children will make programs more appealing to all applicants. Because female respondents frequently cited a positive clerkship experience as a reason for selecting a career in general surgery, emphasis should be placed on designing clerkships that do not alienate women. Enthusiastic teaching, availability of female role models, and increased involvement in the operating room have been recognized as important factors.16,20-22 Additionally, once the decision has been made to seek a career in general surgery, women place greater emphasis on faculty diversity in residency programs. Current literature fails to demonstrate this desired diversity. In a separate ACS
⬍ 0.0001 28 136 5 104 NS 14 8 7 9 ⬍ 0.00001 16 47 4 21
154 264 208 244 193 176 67 95 91 90 81 71 335 473 448 446 407 353
70 46 228
193 82
Quality of training Overall residency experience Impact of surgical residency on personal life Availability of mentorship opportunities Equal assignment of rotations Operative experience Research opportunities Evaluated by similar criteria Feedback provided in timely manner In my residency program female residents are treated in an inferior manner compared with male residents
— 411
n % n Experiences for male and female residents
n, Number of responders who agreed or strongly agreed that the experiences were comparable; %, the percentage of the total number of the same sex respondents who answered each question.
0.003 NS ⬍ 0.0001 NS ⬍ 0.0001 0.0003 43 89 72 78 55 57 138 430 350 383 267 279 53 85 83 81 76 66 806 1,980 1,937 1,896 1,762 1,538 NS NS NS NS NS 0.05 52 88 81 82 72 60 29 50 46 47 41 34 65 89 89 88 74 75 75 106 104 107 89 91 0.001 NS ⬍ 0.00001 NS ⬍ 0.00001 0.03 55 92 75 86 68 63
⬍ 0.0001 41 200 55 1,293 0.005 37 21 61 73 ⬍ 0.00001
203
—
25
67
p Value %
75 60 365 296 84 78 1,959 1,816 0.05 NS (0.06) 73 63 41 36 87 78 105 94
n p Value % n % n %
p Value
— ⬍ 0.00001
Female n %
Attendings
Male Female
Fellows
Male Residents
Female Male
survey, 89% of academic surgeons described themselves as white23 and women constitute less than one-third of US medical school full-time faculty.13 Female and minority representation could help to attract more medical students to the field. Medical schools with faculty comprised of 40% women send notably more female graduates to surgical residency programs than schools with ⬍15% of female surgical faculty.24 Although the majority of surgical subspecialties attracted similar percentages of men and women, certain specialties were more likely to appeal to either men or women. Breast surgery is likely more appealing to women both for personal reasons and patient demand. Few clear reasons exist to explain the male dominance in cardiothoracic and vascular surgery. Male cardiothoracic surgeons are less likely than their female counterparts to encourage women to pursue careers in the field.25 Perhaps women are less compelled to enter these specialties because of a lack of female role models or concern over an “old boys club” atmosphere. Female cardiothoracic surgeons do believe that discrimination negatively affected their career development.25 Although thoracic surgery has historically had the lowest percentage of women residents at just 5%,26 our data suggest a possible trend toward increased female interest in the field. Although only 4% of female trained surgeons described their practice as cardiothoracic, about 10% of female residents and fellows indicated an interest in the field. Although male and female respondents tended to report similar training needs and priorities, there were considerable discrepancies between the genders when asked if certain aspects of their training were comparable for male and female residents, with women being less likely to agree that experiences were comparable, a phenomenon also demonstrated with surgery attendings in a separate study.27 Although those questions were not phrased to imply that one gender received preferential treatment over the other, women residents and trained surgeons were considerably more likely to agree with a statement that read “female residents are treated in an inferior manner compared with male residents.” Clearly this is a major problem for surgeons in practice and in training. Dissimilar treatment could prevent female surgeons from achieving their ultimate potential, dissuade female medical students from pursuing a career in the field, affect morale, or contribute to attrition and poor productivity. Also concerning was the minority of respondents who
⬍ 0.0001 ⬍ 0.0001
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Table 3. Male and Female Residents’ Responses to Statements About Experiences During Residency (Basled on a Five-Point Likert Scale)
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agreed that, in their residency programs, residents might be verbally abused or humiliated in front of colleagues or subject to sexually inappropriate comments and behavior. Apparently maltreatment continues to exist in surgical training programs and could contribute to medical student disinterest in the field16,21,22,28 and, perhaps, resident, fellow, or trained surgeon attrition. Despite this perceived maltreatment, more than half of male and female respondents agreed that they would definitely do surgery again and encourage medical students to consider careers in surgery. Perhaps female residents, fellows, and trained surgeons have grown to accept a different standard of treatment or simply put up with it in exchange for training in their field of interest. Although the majority of respondents appear content with their choice to enter into a surgical career, a notable minority disagreed that they would make the same career choice or encourage others to do so. Changing some aspects of surgery training programs might help attract the best candidates and minimize attrition. Disparities in treatment of male and female residents need to be better clarified and addressed, and resident mistreatment must cease. Future studies should be designed to identify particular scenarios in which female surgery trainees feel alienated so that measures can be taken to educate those involved about particular behaviors that could possibly be changed. General surgery residency training is a long process, which has the potential to be more enjoyable and less stressful than it appears to be at this time. This study was carried out during implementation of the 80-hour workweek regulations and any effects that the regulations might have on respondent perceptions are not accounted for in these results. Although we are reporting data provided by over 4,000 surgeons and their trainees, there are some weaknesses to this study. These results, as with all questionnaire-based studies, are subject to responder bias. Such bias is minimized by the large number of respondents, the wide variety of groups approached to distribute the questionnaire, and the complete anonymity of the responses. Finally, this study is weakened by the inability to determine the potential number of respondents. Despite the large number of respondents, we are unable to calculate a response rate, which could either strengthen or weaken our conclusions. We believe that these data reflect as accurately as possible the opinions of current medical students, residents, fellows, and attendings and indicate certain spe-
J Am Coll Surg
cific areas of training that could be changed to recruit more women and stronger applicants to the field of general surgery. Author Contributions
Study conception and design: Freischlag, Sanfey Acquisition of data: Freischlag, Sanfey Analysis and interpretation of data: Saalwachter, Sawyer, Sanfey Drafting of manuscript: Saalwachter Critical revision: Freischlag, Sawyer, Sanfey Statistical expertise: Sawyer Supervision: Sanfey Acknowledgment: We would like to acknowledge the support of the Council of the Association of Women Surgeons, Mr Jim Losby at the American College of Surgeons, the Association of Program Directors in Surgery, and the American Surgical Association Blue Ribbon Committee.
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