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Comment & Response
March 18, 2020

Meeting the Educational Needs of an Increasingly Diverse Surgical Workforce

Author Affiliations
  • 1Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston
  • 2Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
  • 3Department of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
JAMA Surg. Published online March 18, 2020. doi:10.1001/jamasurg.2020.0097

To the Editor As an organization devoted to advancing women in cardiothoracic surgery, we read with great interest the study by Yeo et al1 identifying demographic factors associated with pass rates on the American Board of Surgery examinations, and we congratulate the authors. On behalf of the Women in Thoracic Surgery, we would like to echo the authors’ call to action, share our understanding of the findings, and caution against misinterpretation of the results.

Yeo et al1 demonstrated that single women were more likely to pass the certifying examination on the first try (90% vs 75% partnered/married without children and 56% married with children). Moreover, these findings did not hold true for men, among whom partnership and parenting status were irrelevant.

While this study represents a valuable contribution, it has several limitations, many of which are acknowledged by the authors. First, marital and parental status often change between internship and boards (mean, 6 years), and survey responses may inaccurately reflect status at examination time. Additionally, the low number of mothers during internship (n = 9) renders the analysis inadequately powered and at substantial risk for type II error. Further, there are likely insufficient degrees of freedom to perform the multivariable analysis, thereby further violating constraints of the model. Despite these issues, the article serves as a foundation to characterize a potential problem and call for change.

Many factors may contribute to differential pass rates: quantity and quality of study time, confidence, mentoring or coaching on examsmanship, and conflicts on the day of the examination. We firmly uphold that there are no inherent gender-related differences in ability, and we feel strongly that demographic markers do not reflect lesser knowledge, skill, or ability to provide safe surgical care.

We fully support the authors’ challenge to increase diversity among examiners and educate all regarding implicit bias.1 We also add further areas for improvement:

  • Enhanced support for work-life balance for all trainees, recognizing that work-home conflicts are a major contributor to surgeon burnout and are more common among women surgeons.2

  • Concrete commitments to mitigate “imposter syndrome,” which disproportionately affects female trainees.3

  • Eliminating sex-related distribution of administrative responsibilities within training programs.4

  • Sponsorship and mentorship of all trainees.

Recognizing the limitations of this study, it is still critical that we use these findings as an impetus for change and not to dissuade women interested in surgical specialties, not to dissuade program directors from recruiting women into their programs, and, perhaps most importantly, not to perpetuate conscious and unconscious biases regarding the ability of women to be successful in surgical careers.

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Article Information

Corresponding Author: Mara B. Antonoff, MD, Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1489, Houston, TX 77030 (mbantonoff@mdanderson.org).

Published Online: March 18, 2020. doi:10.1001/jamasurg.2020.0097

Conflict of Interest Disclosures: None reported.

Additional Contributions: We recognize the following individuals who contributed substantially to this submission: Amy Fiedler, MD, Erin A. Gillaspie, MD, Kimberly Holst, MD, Lauren C. Kane, MD, Tara Karamlou, MD, MSc, Helen-Mari Merritt Genore, DO, Daniela Molena, MD, and Stephanie G. Worrell, MD. This letter was written by members of the Women in Thoracic Surgery (WTS) on behalf of the organization.

Yeo  HL, Dolan  PT, Mao  J, Sosa  JA.  Association of demographic and program factors with American Board of Surgery qualifying and certifying examinations pass rates.  JAMA Surg. 2019;155(1):22-30. doi:10.1001/jamasurg.2019.4081PubMedGoogle Scholar
Dyrbye  LN, Shanafelt  TD, Balch  CM, Satele  D, Sloan  J, Freischlag  J.  Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex.  Arch Surg. 2011;146(2):211-217. doi:10.1001/archsurg.2010.310PubMedGoogle ScholarCrossref
Mullangi  S, Jagsi  R.  Imposter syndrome: treat the cause, not the symptom.  JAMA. 2019;322(5):403-404. doi:10.1001/jama.2019.9788PubMedGoogle ScholarCrossref
Greenberg  CC.  Association for Academic Surgery presidential address: sticky floors and glass ceilings.  J Surg Res. 2017;219:ix-xviii. doi:10.1016/j.jss.2017.09.006PubMedGoogle ScholarCrossref
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