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Original Investigation
August 26, 2020

Assessment of Autonomy in Operative Procedures Among Female and Male New Zealand General Surgery Trainees

Author Affiliations
  • 1Department of Surgery, The University of Auckland, Auckland, New Zealand
  • 2Department of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
  • 3Department of Surgery, Auckland District Health Board, Auckland, New Zealand
  • 4Department of Surgery, Waikato District Health Board, Hamilton, New Zealand
  • 5Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
  • 6Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
  • 7Department of Surgery, Royal Melbourne Hospital, Victoria, Australia
JAMA Surg. 2020;155(11):1019-1026. doi:10.1001/jamasurg.2020.3021
Key Points

Question  Does trainee sex play a role in assessing the level of procedural autonomy a trainee receives during the New Zealand general surgery training program?

Findings  In this 5-year cohort study that included 119 380 general surgery procedures performed by 120 trainees, female trainees performed fewer endoscopic, major, and minor procedures autonomously than their male counterparts.

Meaning  Results of this study suggest that female trainees are more likely to receive less procedural autonomy throughout their general surgery training program in New Zealand.


Importance  The need for trainee sex equality within surgical training has resulted in an appraisal of the training experience in the New Zealand general surgery training program.

Objective  To investigate the association between trainee sex and surgical autonomy in the operating room in the New Zealand general surgery training program.

Design, Setting, and Participants  Retrospective cohort study conducted from December 10, 2012, to December 10, 2017, examining all endoscopic, major, and minor procedures performed by all New Zealand general surgery trainees in every training hospital in New Zealand.

Main Outcomes and Measures  The primary outcome was the level of meaningful autonomy by each New Zealand general surgery trainee (ie, trainee as primary operator without the surgeon mentor scrubbed for the case). Outcomes were compared using multivariable analysis.

Results  This study included 120 New Zealand general surgery trainees (42 women [35%] and 78 men [65%]) who were analyzed over 279.5 trainee-years (88.5 trainee-years for women and 191.0 trainee-years for men). Included were 119 380 general surgery procedures (17 465 endoscopic, 56 964 major, and 44 951 minor) in 18 hospitals. By the end of the 5-year training program, female trainees had a lower cumulative mean autonomous caseload than male trainees for endoscopic (284.0 [95% CI, 207.0-361.0] vs 352.2 [95% CI, 282.9-421.6], P = .03), major (139.9 [95% CI, 76.7-203.2] vs 198.1 [95% CI, 142.3-254.0], P = .02), and minor (456.3 [95% CI, 394.8-517.9] vs 519.9 [95% CI, 465.6-574.2], P = .007) procedures.

Conclusions and Relevance  After accounting for differences among trainees, hospital type, number of female and male surgeon mentors at each hospital, and trainee seniority, female trainees performed fewer cases with meaningful autonomy compared with male trainees. These findings support the need for pragmatic solutions to address this bias and further investigations on mechanisms contributing to discrepancies.

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