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

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

Medicine trails other fields in gender diversity.^1,2 Gender disparity is particularly pronounced within academic surgery; women represent less than 10% of full professors and only 22 department chairs in the US and Canada.³ Evidence indicates that pro-male bias and negative stereotypes depress women's performance⁴ in male-dominated professions.^5,6 If and how this bias differentially affects health care professionals remains to be characterized. Lack of information is a substantial impediment to developing valid interventions that address challenges to the promotion and retention of female surgeons.⁷ We studied how technical skill performance and engagement—2 crucial components of career advancement—are influenced by pro-male bias and negative stereotypes against women during residency, which is a phase of profound personal and professional development.

Psychosocial constructs, ie, attitudes or behaviors that arise from interactions between an individual and their environment,⁸ forecast and reinforce professional success. These constructs have been investigated in models of educational achievement, making them especially relevant to residency, which is a period of intensive training. Previous investigations have emphasized learner engagement as integral to professional advancement.⁹ Engagement is defined as involvement with social or academic activities and is associated with affective aspects, such as sense of belonging¹⁰; cognitive components, such as resilience and self-regulation¹¹; and ability to relate to one’s profession (ie, domain identification).¹² Negative stereotypes have been shown to undermine engagement and associated behaviors among members of stigmatized social groups.¹³Quiz Ref ID The risk of confirming negative stereotypes, known as stereotype threat, is especially germane to women employed in medicine, as they are frequently reminded of gender stereotypes in their environments.⁵ Stereotype threat contributes to measurable differences in technical skill performance¹⁴ by depleting executive function and siphoning attention away from the task at hand.¹⁵

Quiz Ref IDThis multicenter study, conducted in 2 phases, first sought to evaluate the association between gender bias and research-related career engagement among trainees, Quiz Ref IDand second, to investigate the interaction between gender and stereotype threat on laparoscopic skill performance. Our hypothesis for phase 1 was that the association between perceiving pro-male bias in the training environment and career engagement would differ by gender. For phase 2, we hypothesized that stereotype threat activation would affect technical skill performance and that this association would differ between men and women.

We conducted a 2-phase study of general surgery residents at 3 diverse academic campuses: University of North Carolina–Chapel Hill; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and University of Washington, Seattle (Figure 1). The study included a survey-based investigation into gender bias and career engagement and a multicenter randomized clinical trial exploring the effect of stereotype threat activation on technical skill performance. Institutional review board approval was obtained at each institution. The trial protocol appears in Supplement 1. Participants provided written informed consent (eAppendix 3 in Supplement 2). We assigned each resident a unique alphanumeric code for deidentification of serially collected data, the purpose of which was to blind the individuals conducting the study. No compensation was provided for study participation. This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline for randomized clinical trials.

General surgery residents at University of Pittsburgh Medical Center, the University of North Carolina–Chapel Hill, and the University of Washington were recruited (eAppendix 1 in Supplement 2) and completed an electronic pre-enrollment survey to determine eligibility (eAppendix 2 in Supplement 2). Residents who completed undergraduate medical education in the US and were interested in pursuing teaching or research as a principal component of their career (ie, academic surgery)¹⁶ were eligible for inclusion. Those who were in noncategorical positions and/or not interested in pursuing a career in academic surgery, did not identify as their biologic sex, or had entered general surgery training after completing any training in another specialty were excluded. Residents were asked to participate in a 2-part study over an academic year exploring how training experiences influenced psychosocial determinants of success.

During phase 1, 2 identical surveys (eAppendix 4 in Supplement 2) evaluating psychosocial constructs germane to professional achievement were sequentially administered (eFigure 1 in Supplement 2). Existing studies on burnout have suggested that trainees’ experiences can alter motivation, job satisfaction, and quality of life over time.¹⁷ Based on feasibility and previous studies investigating the association between behavioral interventions and resident attitudes and perceptions,^18,19 we chose the predetermined time frame of 5 to 6 months between survey administrations. Rationale for psychosocial constructs assessed and associated scales or subscales is provided in eAppendix 5 in Supplement 2.

Residents had 2 weeks to complete each survey after it was delivered via a software-generated link (Qualtrics). The survey instrument comprised 55 questions derived from validated scales assessing equity and fairness in the work environment, susceptibility to stereotype threat, sense of belonging, resilience, career engagement, and identification with the domain of surgery, and 5 questions that assessed demographic data. Eight items adapted from the Employee Environment Diagnostic Survey (EEDS)²⁰ were used to measure residents’ perceptions of pro-male gender bias in their environment. Nine items from the Social Identity and Attitudes Scale (SIAS)²¹ assessed susceptibility to stereotype threat based on the degree to which an individual identifies with their gender (ie, gender identity) and their level of gender stigma consciousness. Nine items adapted from the Career Engagement Scale (CES)²² were used to assess engagement, which has been suggested to be important for achieving professional success.⁹ The CES was modified to interrogate research-related engagement as scholarly pursuits are a distinguishing feature of academic vs nonacademic surgeons.¹⁶ Engagement is a complex concept influenced both by environmental cues and characteristics intrinsic to the individual.⁹ These characteristics and the tools used in their evaluation include sense of belonging (7-item Sense of Belonging Index-Psychological State subscale),²³ identification with one’s professional domain (7-item Domain Identification Measure),²⁴ and resilience (10-item Connor-Davidson Resilience Scale).²⁵ Subscale items were each graded on a 5-point Likert scale.

In phase 2, residents who completed phase 1 were randomized 1:1 to receive either a stereotype threat trigger (A) or protection against stereotype threat (B) in a permuted-block design stratified by site, postgraduate year, and gender. In an effort to enhance validity and promote spontaneous behavior, detailed information regarding the study’s purpose of investigating the effect of stereotype threat on skills performance was not proffered²⁶; instead, residents were told that they would be randomly assigned to receive an intervention meant to direct their focus to or away from a surgery-related subject. After the investigation was complete, participants were debriefed with regard to study intent, procedures, and results via email communication and open-forum presentation. We adapted a validated and previously used method of activating or protecting against stereotype threat.²⁷ Intervention A triggered stereotype threat by asking participants to read the abstracts of 2 articles that reported women performed worse with regard to laparoscopic skills than men. Intervention B was intended to protect against stereotype threat by asking participants to read 2 abstracts that reported no gender-based differences in laparoscopic skills performance. According to the randomization assignment, articles were placed in a sealed envelope labeled with the participant’s study code and provided to each participant just prior to administration of the Fundamentals of Laparoscopic Surgery (FLS) assessment (task portion). Immediately after the interventions, participants completed the FLS, a standardized, validated simulation-based assessment of laparoscopic ability,^28-31 followed by a third iteration of the survey, which included additional questions evaluating residents’ perception of their performance. The FLS exams were administered by 2 proctors certified by the Society of American Gastrointestinal and Endoscopic Surgeons, who were blinded to the participants’ intervention arm. Exams were sent to the Society of American Gastrointestinal and Endoscopic Surgeons for blind scoring under deidentified participant code. Residents understood that their score could not be used for formal FLS certification. Proctors and Society of American Gastrointestinal and Endoscopic Surgeons were compensated for exam administration and scoring.

Survey subscale items were assigned a score based on the 5-point Likert scale and then summated to yield a total subscale score. Internal consistency of each subscale was assessed using Cronbach α, with values between 0.7 and 0.9 considered acceptable.³² The α values from unmodified original subscales were as follows: EEDS, 0.96; CES, 0.87; Social Identity and Attitudes Scale gender identity, 0.81, Social Identity and Attitudes Scale gender stigma consciousness, 0.87; Sense of Belonging Index-Psychological State subscale, 0.93; Domain Identification Measure, 0.75; and Connor-Davidson Resilience Scale, 0.85.^20-25

Our primary hypothesis in phase 1 was that the association between perception of pro-male bias as measured by EEDS score and career engagement as measured by CES score differed by gender. To avoid sampling bias and accurately reflect resident population demographics, we used a poststratification weighting adjustment³³ for survey data based on the participant’s gender and race using national data.³⁴ Wilcoxon Mann-Whitney tests evaluated gender-based differences in subscale scores. Wilcoxon matched-pairs signed rank tests assessed differences between survey 1 and 2 scores. Since survey 1 was administered early in the academic year, first-year postgraduate residents may not have acclimated to their training environment; analyses for phase 1 were performed using survey 2 responses. Before regression analyses, nonnormally distributed data were logarithmically transformed. All statistical tests were clustered by site, as data within an institution may not be independent. We modeled the association between survey 2 EEDS and CES scores using linear regression incorporating an interaction term for gender. In phase 1 secondary analyses, we adjusted for the remaining 4 psychosocial constructs to determine whether these results modified the association between EEDS and CES.

The second part of this study explored the effects of stereotype threat, a concept related to but separate from gender bias, on technical skill performance. Differences in performance may manifest independent of bias within the work environment owing to gender stereotypes from a pervasive cultural context. We hypothesized that the FLS scores in the intervention arms would differ and that gender-based differences in performance would vary by whether stereotype threat was activated or protected against.

A minimum sample size of 84 residents was calculated to detect a 20-point difference in FLS score at 80% power and α = .05, and accounting for 10% attrition.^35,36 Analyses were based on intention-to-treat. Gender-based differences in survey 3 responses were assessed using the Wilcoxon Mann-Whitney test. Wilcoxon matched-pairs signed rank tests were used to compare survey 2 and 3 subscale responses. Differences in FLS scores between intervention arms and by gender were evaluated using 2-tailed, unpaired t tests. Post hoc analysis assessed whether susceptibility to stereotype threat modified the effect of intervention across genders on FLS scores. Stata, version 15 (StataCorp), was used for all analyses. A P value ≤.05 was considered significant.

General surgery residents at University of North Carolina–Chapel Hill, University of Washington, and University of Pittsburgh Medical Center were recruited between August 1 and August 15, 2018. A total of 131 residents were assessed for eligibility. Of 96 eligible residents (Figure 1), 86 individuals (90%) completed phase 1 and were enrolled in phase 2. One resident withdrew before randomization. Of 85 residents randomized (Table 1), 42 were assigned to intervention A and 43 were assigned to intervention B. Four residents in each arm dropped out; 77 residents (91%) completed the study.

Quiz Ref IDThe association between perception of pro-male gender bias in the environment and career engagement differed significantly by gender (interaction coefficient, −1.19; 95% CI, −1.90 to −0.49; P = .02); men who had a higher perception of pro-male bias had higher career engagement scores (coefficient, 1.02; 95% CI, 0.19-2.24; P = .04) (Figure 2). Although the direction of the data was opposite compared with that of men, no significant association was noted between perception of pro-male bias and career engagement scores among women (coefficient, −0.25; 95% CI, −1.59 to 1.08; P = .50). After adjusting for the other psychosocial constructs, the moderating effect of gender on the association between perception of pro-male bias and career engagement scores persisted (interaction coefficient, −1.15; 95% CI, −1.72 to 0.58; P = .01).

Men had significantly higher susceptibility to stereotype threat scores than women on survey 1 (median, 21.0; interquartile range [IQR], 17.5-26.5 vs 17.5; IQR, 15.0-21.0; P < .001) and survey 2 (median, 20.0; IQR, 16.5-24.0 vs 17.5; IQR, 16.0-20.0; P = .005) (Table 2; eTable 1, eFigure 3 and eFigure 4 in Supplement 2). Women had higher resilience scores than men on survey 1 (median, 17.0; IQR, 14.0-20.5 vs 16; IQR, 12-20; P = .009) and survey 2 (median, 19.0; IQR, 14.0-21.5 vs 15.0; IQR, 12.0-20.0; P = .02). Women had higher resilience scores on survey 2 compared with survey 1 (P = .004).

There was little difference among men and women in FLS score between interventions (mean [SD], A: 395 [150] vs B: 367 [157]; P = .51). Although the mean (SD) FLS score was lower for women compared with men in both intervention A (367 [152] vs 423 [148]; P = .12) and intervention B (328 [168] vs 400 [142]; P = .08), these differences were not statistically significant. 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). However, 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). Quiz Ref IDAmong women with higher susceptibility to stereotype threat, a trigger of stereotype threat was associated with lower FLS scores (coefficient, −43.4; 95% CI, −48.0 to −38.9; P = .001), but protection against stereotype threat was associated with higher FLS scores (coefficient, 12.0; 95% CI, 2.0-21.9; P = .04) (Figure 3). Among men with a higher SIAS score, evoking negative stereotypes about women trended toward a nonsignificant increase in FLS score (coefficient, 5.2; 95% CI, −7.6 to 18.0; P = .22), but those exposed to protection against stereotype threat did (coefficient, −8.2; 95% CI, −15.3 to −1.03; P = .04).

Significant differences in subscale responses were noted on survey 3 (eTable 2 in Supplement 2). Among participants who received intervention A, women had higher perception of pro-male bias scores than men (median, 16.0; IQR, 13.0-19.0 vs 13.5; IQR, 11.0-17.5; P = .04). In both study arms, women had higher resilience scores than men (A: median, 18.0; IQR, 14.0-20.0 vs 14.0; IQR, 10.0-19.0; P = .05; B: median, 19.0; IQR, 16.0-22.0 vs 13.5; IQR, 11.0-18.0; P = .03). When compared with intervention B, intervention A was associated with higher career engagement (median, 23.0; IQR, 17.0-30.0 vs median 17.5; IQR, 13.5-25.5; P = .02), susceptibility to stereotype threat (median, 20.0; IQR, 15.0-22.0 vs 17.0; IQR, 14.5-23.5; P = .05), and sense of belonging (median, 18.0; IQR, 15.0-21.0 vs 16.0; IQR, 15.0-20.0; P = .03) scores among men, but lower sense of belonging scores among women (median, 18.0; IQR, 14.0-22.0 vs 20.0; IQR, 16.0-25.0; P = .03) on survey 3. No adverse outcomes were reported.

Factors associated with the underrepresentation of women in academic surgery^1,2 are complex. This study explores how affective interactions between an individual and their residency environment are associated with engagement and technical skill performance, which are key factors in professional success (eFigure 2 in Supplement 2).⁹ The association of pro-male bias with engagement differed across genders. Although the association between intervention arm and FLS score did not differ by gender, higher susceptibility to stereotype threat among women who received a trigger of stereotype threat was associated with lower FLS scores. These findings suggest that negative stereotypes might be detrimental to the operative performance of stigmatized individuals.

Gender bias may influence women’s underrepresentation in surgery practice.³ We found that experiencing pro-male bias is associated with increased career engagement among men. Although the data had an opposite direction among women, no significant association was observed. Others have proposed that reduced engagement may contribute to reduced academic performance,⁹ burnout, and attrition among women in academic medicine.³⁷ While further investigations are necessary to establish the mechanisms by which bias challenges professional efficacy and engagement, one possibility is that bias may result in reduced motivation among stigmatized individuals.³⁸ Engagement appears to be malleable and therefore exists as a potential for targeted interventions aimed at cultivating professional development.³⁹ Gender-based differences in the affective constructs associated with engagement suggest that individual factors, such as resilience,^40,41 also may be candidates for intervention.⁴²

Prior research indicates that gender stereotypes depress the professional performance of women.^43,44 In male-dominated professions, role congruity theory posits that pro-male bias can seem to be more pronounced^5,6; being female and a surgeon is perceived as incompatible with the gendered stereotype of the surgeon as male. While previous studies have illustrated the consequences of gender stereotypes on promotion^45-48 and opportunities (eg, operative autonomy),^49,50 a causal link between bias and stereotype threat activation has not been established. Herein, we showed that after a trigger of stereotype threat, women had a higher perception of pro-male bias. However, differences in performance may manifest independent of whether bias exists in the work environment owing to the valences of gender stereotypes from a pervasive cultural context. For surgeons, a dominant metric of professional performance is technical ability, and this has become an important factor by which surgeon competence and achievement are judged.^51-53 The American Board of Surgery³¹ requires that surgeons achieve a passing score on the FLS examination. Although previous studies have been unable to identify gender-based differences in FLS scores⁵⁴ or other laparoscopic skills metrics,⁵⁵ we now show that reminding women who exhibit higher susceptibility to stereotype threat of negative gender stereotypes reduces their performance on the FLS examination. This result corresponds with data previously published indicating that individuals with underrepresented demographics express increased anxiety about their abilities^56,57 in a manner that may reduce performance. Among men with higher susceptibility to stereotype threat, there was a nonsignificant positive (ie, upward) directionality in FLS scores when presented with negative stereotypes about women. This phenomenon, referred to as stereotype lift,⁵⁸ theoretically occurs if men perceive an advantage when women are negatively labeled.⁵⁹ Given that technical skill performance is requisite to ascertaining surgical competence, efforts to reduce the effect of negative gender stereotypes are needed for the retention of women in academic surgery.

This study was conceptualized within a social cognitive theory framework⁶⁰; behaviors that facilitate or impede learning are dynamic and develop as a result of the interaction between a person and their surroundings. Psychosocial determinants of success may fluctuate in response to environmental triggers (eg, stereotypes or bias). In particular, we found that triggering stereotype threat was associated with a lower sense of belonging among women. Belonging is important for intentions to persist in academic endeavors.⁴³ Strategies such as values affirmation, ie, affirming the importance of a task for achieving goals, can ameliorate the consequences of reduced belonging⁶¹ and may be incorporated into surgical curricula as interventions to promote self-worth and motivation.

This study has limitations. It was underpowered to study effect modification or the intersectional effects associated with membership in multiple underrepresented groups (ie, intersectionality).⁶² The sample size restricted our ability to perform factor analyses that would confirm the validity of the modified survey and its subscales. Contamination⁶³ that resulted from residents recognizing the purpose of activating stereotype threat (ie, failure of planned deception) and developing a reactive, rather than vulnerability, response⁶⁴ may have biased our results toward the null. As there are no metrics with which to evaluate the degree to which training environments perpetuate negative stereotypes about women, we could not account for how ambient cues and organizational policies may have influenced intervention effect.⁶⁵

Negative stereotypes about women and pro-male gender bias affect career engagement and technical performance among individuals pursuing careers in academic surgery. Mitigating the effect of negative stereotypes is requisite for the professional development of surgeons-in-training, particularly women. Cultivating inclusivity is needed to protect our investment in future generations of surgeons and to advance medicine.

Accepted for Publication: February 22, 2020.

Corresponding Author: Sara P. Myers, MD, PhD, Department of Surgery, University of Pittsburgh School of Medicine, 200 Lothrop St, Pittsburgh, PA 15213 (myerssp@upmc.edu).

Published Online: May 20, 2020. doi:10.1001/jamasurg.2020.1127

Author Contributions: Drs Myers and Rosengart had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Myers, Lumpkin, Neal, Lee, Rosengart.

Acquisition, analysis, or interpretation of data: Myers, Dasari, Brown, Lumpkin, Abebe, Chaumont, Downs-Canner, Flanagan, Lee, Rosengart.

Drafting of the manuscript: Myers, Rosengart.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Myers, Brown, Lumpkin, Abebe, Rosengart.

Obtained funding: Myers.

Administrative, technical, or material support: Myers, Dasari, Neal, Chaumont, Downs-Canner.

Supervision: Myers, Neal, Chaumont, Downs-Canner, Lee, Rosengart.

Conflict of Interest Disclosures: Dr Lumpkin reported receiving grants from the Agency of Healthcare Quality and Research during the conduct of the study. Dr Neal reported receiving grants and personal fees from Janssen Pharmaceuticals, personal fees and nonfinancial support from Haemonetics, grants from Instrument Laboratories, financial support from Haima Therapeutics, grants from Noveome, and personal fees from CSL Behring outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Myers was supported in part by National Center for Advancing Translational Sciences training grant 5TL1TR001858-02.

Role of the Funder/Sponsor: The National Center for Advancing Translational Sciences contributed to the conduct of the study by supporting administration of the Fundamentals of Laparoscopic Surgery examinations at participating sites and reimbursement to the Society of American Gastrointestinal and Endoscopic Surgeons for scoring of these examinations. The funding did not include a role in study design, analysis or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We acknowledge the contribution of the residents who participated in this study as well as the faculty and staff of the University of North Carolina–Chapel Hill, UPMC, and University of Washington departments of general surgery. Melina R. Kibbe, MD, Michael O. Meyers, MD (both University of North Carolina–Chapel Hill), and Karen D. Horvath, MD (University of Washington), provided encouragement and support; Kathie Patterson (University of North Carolina–Chapel Hill), Maggie Mrozinski, BS (UPMC), and Inga Brissman (Society of American Gastrointestinal and Endoscopic Surgeons) assisted in the coordination and administration of Fundamentals of Laparoscopic Surgery examinations; and Scott D. Rothenberger, PhD (University of Pittsburgh), assisted with statistical analysis. In addition, we recognize the faculty and staff of the University of Pittsburgh’s Clinical and Translational Science Institute and the Pittsburgh Surgical Outcomes Research Center for their support of this study. No financial compensation outside of salary was provided.