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Original Investigation
May 20, 2020

Effects of Gender Bias and Stereotypes in Surgical Training: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2Department of Surgery, University of Washington, Seattle
  • 3Department of Surgery, University of North Carolina at Chapel Hill School of Medicine
  • 4Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 5Fred Hutchinson Cancer Research Center, Seattle, Washington
JAMA Surg. Published online May 20, 2020. doi:10.1001/jamasurg.2020.1127
Key Points

Question  Do the associations between pro-male bias and career engagement, as well as stereotype threat and skill performance, differ by gender?

Findings  In this multicenter randomized clinical trial that included 86 general surgery trainees interested in pursuing academic careers, pro-male gender bias was significantly associated with higher career engagement among men; no significant association was observed in women. Women with higher susceptibility to stereotype threat scored lower on Fundamentals of Laparoscopic Surgery assessment after receiving a stereotype threat trigger.

Meaning  Pro-male gender bias may increase career engagement among men, and stereotype threat may negatively influence women surgical trainees’ skill performance in a way that can be detrimental to professional development.


Importance  Factors contributing to underrepresentation of women in surgery are incompletely understood. Pro-male bias and stereotype threat appear to contribute to gender imbalance in surgery.

Objectives  To evaluate the association between pro-male gender bias and career engagement and the effect of stereotype threat on skill performance among trainees in academic surgery.

Design, Setting, and Participants  A 2-phase study with a double-blind, randomized clinical trial component was conducted in 3 academic general surgery training programs. Residents were recruited between August 1 and August 15, 2018, and the study was completed at the end of that academic year. In phase 1, surveys administered 5 to 6 months apart investigated the association of gender bias with career engagement. In phase 2, residents were randomized 1:1 using permuted-block design stratified by site, training level, and gender to receive either a trigger of or protection against stereotype threat. Immediately after the interventions, residents completed the Fundamentals of Laparoscopic Surgery (FLS) assessment followed by a final survey. A total of 131 general surgery residents were recruited; of these 96 individuals with academic career interests met eligibility criteria; 86 residents completed phase 1. Eighty-five residents were randomized in phase 2, and 4 residents in each arm were lost to follow-up.

Intervention  Residents read abstracts that either reported that women had worse laparoscopic skill performance than men (trigger of stereotype threat [A]) or had no difference in performance (protection against stereotype threat [B]).

Main Outcomes and Measures  Association between perception of pro-male gender bias and career engagement survey scores (phase 1) and stereotype threat intervention and FLS scores (phase 2) were the outcomes. Intention-to-treat analysis was conducted.

Results  Seventy-seven residents (38 women [49.4%]) completed both phases of the study. The association between pro-male gender bias and career engagement differed by gender (interaction coefficient, −1.19; 95% CI, −1.90 to −0.49; P = .02); higher perception of bias was associated with higher engagement among men (coefficient, 1.02; 95% CI, 0.19-2.24; P = .04), but no significant association was observed among women (coefficient, −0.25; 95% CI, −1.59 to 1.08; P = .50). There was no evidence of a difference in FLS score between interventions (mean [SD], A: 395 [150] vs B: 367 [157]; P = .51). The response to stereotype threat activation was similar in men and women (interaction coefficient, 15.1; 95% CI, −124.5 to 154.7; P = .39). The association between stereotype threat activation and FLS score differed by gender across levels of susceptibility to stereotype threat (interaction coefficient, −35.3; 95% CI, −47.0 to −23.6; P = .006). Higher susceptibility to stereotype threat was associated with lower FLS scores among women who received a stereotype threat trigger (coefficient, −43.4; 95% CI, −48.0 to −38.9; P = .001).

Conclusions and Relevance  Perception of pro-male bias and gender stereotypes may influence career engagement and skill performance, respectively, among surgical trainees.

Trial Registration  ClinicalTrials.gov Identifier: NCT03623009

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