Each blue dot represents a general surgery program. The orange line represents the Pearson correlation line of best fit.
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Schlick CJR, Ellis RJ, Etkin CD, et al. Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US. JAMA Surg. 2021;156(10):942–952. doi:10.1001/jamasurg.2021.3195
What are the experiences of residents in general surgery programs with regard to gender discrimination and sexual harassment?
In this survey study of 6764 residents enrolled in 301 general surgery programs across the US, 80% of women and 17% of men reported experiencing gender discrimination, and 43% of women and 22% of men reported experiencing sexual harassment. The types and sources of discrimination and harassment and their associated factors varied.
This study’s findings suggest that gender discrimination and sexual harassment are common experiences among residents in general surgery programs; these phenomena warrant multifaceted context-specific strategies for improvement.
Mistreatment is a common experience among surgical residents and is associated with burnout. Women have been found to experience mistreatment at higher rates than men. Further characterization of surgical residents’ experiences with gender discrimination and sexual harassment may inform solutions.
To describe the types, sources, and factors associated with (1) discrimination based on gender, gender identity, or sexual orientation and (2) sexual harassment experienced by residents in general surgery programs across the US.
Design, Setting, and Participants
This cross-sectional national survey study was conducted after the 2019 American Board of Surgery In-Training Examination (ABSITE). The survey asked respondents about their experiences with gender discrimination and sexual harassment during the academic year starting July 1, 2018, through the testing date in January 2019. All clinical residents enrolled in general surgery programs accredited by the Accreditation Council for Graduate Medical Education were eligible.
Specific types, sources, and factors associated with gender-based discrimination and sexual harassment.
Main Outcomes and Measures
Primary outcome was the prevalence of gender discrimination and sexual harassment. Secondary outcomes included sources of discrimination and harassment and associated individual- and program-level factors using gender-stratified multivariable logistic regression models.
The survey was administered to 8129 eligible residents; 6956 responded (85.6% response rate)from 301 general surgery programs. Of those, 6764 residents had gender data available (3968 [58.7%] were male and 2796 [41.3%] were female individuals). In total, 1878 of 2352 female residents (79.8%) vs 562 of 3288 male residents (17.1%) reported experiencing gender discrimination (P < .001), and 1026 of 2415 female residents (42.5%) vs 721 of 3360 male residents (21.5%) reported experiencing sexual harassment (P < .001). The most common type of gender discrimination was being mistaken for a nonphysician (1943 of 5640 residents [34.5%] overall; 1813 of 2352 female residents [77.1%]; 130 of 3288 male residents [4.0%]), with patients and/or families as the most frequent source. The most common form of sexual harassment was crude, demeaning, or explicit comments (1557 of 5775 residents [27.0%] overall; 901 of 2415 female residents [37.3%]; 656 of 3360 male residents [19.5%]); among female residents, the most common source of this harassment was patients and/or families, and among male residents, the most common source was coresidents and/or fellows. Among female residents, gender discrimination was associated with pregnancy (odds ratio [OR], 1.93; 95% CI, 1.03-3.62) and higher ABSITE scores (highest vs lowest quartile: OR, 1.67; 95% CI, 1.14-2.43); among male residents, gender discrimination was associated with parenthood (OR, 1.72; 95% CI, 1.31-2.27) and lower ABSITE scores (highest vs lowest quartile: OR, 0.57; 95% CI, 0.43-0.76). Senior residents were more likely to report experiencing sexual harassment than interns (postgraduate years 4 and 5 vs postgraduate year 1: OR, 1.77 [95% CI, 1.40-2.24] among female residents; 1.31 [95% CI, 1.01-1.70] among male residents).
Conclusions and Relevance
In this study, gender discrimination and sexual harassment were common experiences among surgical residents and were frequently reported by women. These phenomena warrant multifaceted context-specific strategies for improvement.
Gender discrimination, defined as unequal treatment that individuals experience based on their gender,1 is prevalent in academia, particularly in fields, such as surgery, with a predominance of men, hierarchical relationships, and substantial one-on-one time between trainees and supervisors.2-4 Although experts consider gender discrimination to be a type of sexual harassment,2,5 many people colloquially consider sexual harassment to be inappropriate conduct that is strictly sexual in nature.6 Among physicians, gender discrimination and sexual harassment have been associated with career dissatisfaction,3,4 decreased self-confidence,7 depression, and suicidal ideation.4 Discrimination and harassment likely have a role in the relative underrepresentation of women in full professorships8 and leadership positions in health care9,10 despite gender parity in medical school acceptances,11 which may further exacerbate the cycle of gender bias leading to discrimination.9,12,13
Because trainees are subject to a power differential, they are at increased risk of discrimination and harassment.2,4,6 A pooled meta-analysis revealed that 66.6% of residents reported experiencing gender discrimination, and 36.2% reported experiencing sexual harassment.14 In a previous study, 65.1% of female surgical residents reported experiencing gender discrimination, and 19.9% reported experiencing sexual harassment.15 No definitions of discrimination and harassment were provided,15 which may have contributed to lower mistreatment rates than previously reported,2,14,16 although those studies were limited by sample size and response rate.17-19 In addition to underestimating prevalence, a lack of granular detail limited the interpretation and actionability of the previous studies’ findings.
A better understanding of the nature of these experiences and the associated individual- and/or program-level factors is needed to successfully intervene. Thus, we sought to fully characterize the gender discrimination and sexual harassment experienced by residents in general surgery programs across the US by (1) querying specific behavior types, (2) identifying the sources of these specific behaviors, and (3) evaluating associated resident and program-level factors.
A confidential, optional closed-ended survey was offered to all 8907 residents in US general surgery programs accredited by the Accreditation Council for Graduate Medical Education who took the 2019 American Board of Surgery In-Training Examination (ABSITE).20 The survey was administered in January 2019 and queried respondents about the academic year starting on July 1, 2018. The American Board of Surgery deidentified survey responses before transferring the data for analysis.15,21 Residents who were not in a clinically active year of training or who did not have gender data available through the American Board of Surgery were excluded. This study was deemed exempt from review by the Northwestern University Institutional Review Board because of the use of deidentified data. The survey was prefaced by a statement explaining that its purpose was research and that responses would be deidentified. The delivery software was constructed so that participants could exit the survey at any time.
The survey evaluated aspects of the learning environment and respondents’ well-being. Because no single comprehensive instrument was available to evaluate gender discrimination and sexual harassment, items were developed and adapted based on a comprehensive review of the literature. Previously validated instruments22-24 were used when applicable. Survey items were evaluated for clarity and cohesion using a sample of research residents in general surgery programs across the US and iteratively revised until coherence consensus was achieved.20,21
Information regarding residents’ gender (obtained from the field labeled “gender” on the examination registration form, with response options of male or female) and postgraduate year (PGY-1, PGY-2/3, or PGY-4/5) were provided by the American Board of Surgery. Residents were queried regarding their relationship status (married, not married but in a relationship, not married and not in a relationship [single], divorced/separated, or widowed), number of children younger than 18 years (0, 1, 2, 3, 4, or ≥5, aggregated into any children vs no children), and whether they or their partner were pregnant, expecting a child, or adopting a child during the academic year (July 2018-January 2019). Respondents’ 2019 ABSITE scores were reported in quartiles.
Gender data were aggregated at the program level, and the proportion of each residency program that was female was reported in quartiles (with quartile 1 indicating <34.4%, quartile 2 indicating 34.4%-42.3%, quartile 3 indicating 42.5%-49.1%, and quartile 4 indicating ≥50.0%). Data on program size (based on the total number of residents in general surgery programs and reported by quartiles, with quartile 1 indicating <26, quartile 2 indicating 26-36, quartile 3 indicating 37-50, and quartile 5 indicating ≥51), program type (university, independent, or military), and program location (Northeast, Southeast, Midwest, Southwest, and West) were provided by the American Board of Surgery.
The Accreditation Council for Graduate Medical Education provided information about each program’s department chair and program director, and their genders were ascertained through a review of publicly available biographies. The Association of American Medical Colleges provided counts of active surgical faculty by gender for medical schools that participated in their faculty roster. The proportion of faculty that identified as female was calculated for each program and reported by quartiles (with quartile 1 indicating <19.5%, quartile 2 indicating 19.5%-23.6%, quartile 3 indicating 23.7%-26.9%, and quartile 4 indicating ≥27.0%). Programs with more than 1 medical school affiliation were assigned to the listed primary affiliate.
Specified types of discrimination based on gender, gender identity, and/or sexual orientation included (1) experiencing different standards of evaluation (eg, lowered expectations, need to work harder to achieve the same success as others, unfair punishment, or less respect of my opinions),18,25 (2) being denied opportunities (eg, allocation of cases, attendance at conferences, career options, opportunities for advancement, or mentorship),3,18,25,26 (3) being mistaken for a nonphysician,27 (4) being subject to slurs and/or hurtful, humiliating, negative, or uncomfortable comments, even when purported as jokes,18,24 (5) feeling socially isolated (eg, excluded from social events or malicious gossip),18 (6) being advised against having children during residency,28 and (7) feeling like my/my partner’s pregnancy or childcare needs led to negative reactions from coworkers and/or the program.28,29 If residents reported experiencing any of these feelings or behaviors within the academic year (July 2018-January 2019) before survey administration, they were considered to have experienced gender discrimination. Analyses of gender discrimination based on pregnancy and childcare needs were restricted to residents who indicated that they were pregnant, expecting a child, adopting a child, and/or had a minor child.
Specified types of sexual harassment included (1) being subject to crude, sexually demeaning, or explicit remarks, stories, or jokes18,24,26,30,31; (2) having unwanted sexual imagery or materials sent or shown to you24,30; (3) receiving unwanted verbal sexual attention (eg, comments, flirtations, or sexual advances)18,24,26,30; (4) offensive body language (eg, leering or standing too close)25,26,30; (5) receiving unwanted physical sexual attention (eg, inappropriate or uncomfortable touching or attempts to touch, fondle, or kiss)18,24-26,30; and (6) sexual coercion (eg, bribed or threatened to engage in sexual behavior or suggestion of better treatment if sexually cooperative).7,24,26,30 If residents reported experiencing any of these behaviors within the academic year (July 2018-January 2019) before survey administration, they were considered to have experienced sexual harassment.
For each reported behavior, residents were queried regarding the frequency (never, a few times per year, once per month or less, a few times per month, once per week, a few times per week, or every day) and source (patients and/or families [patients/families], attending physicians, administrators, coresidents and/or fellows [coresidents/fellows], or nurses and/or support staff [nurses/staff]). Frequency analyses were restricted to residents who reported experiencing any type of gender discrimination or sexual harassment. Respondents who reported experiencing a particular behavior but did not answer the source question were classified as having an unidentified source for that behavior.
χ2 tests adjusted for program-level clustering were used to compare male and female residents regarding (1) resident and program characteristics, (2) proportion of residents reporting each type of discrimination or harassment, (3) proportion of residents reporting any behavior consistent with either discrimination or harassment, and (4) frequency of discrimination or harassment. The most common source of each behavior was reported by gender. Respondents with missing data were excluded from the analyses.
Gender-stratified multivariable logistic regression analyses with robust SEs adjusted for program-level clustering were used to estimate the association of individual- and program-level factors with gender discrimination and sexual harassment. The proportion of residents within each program who reported experiencing discrimination or harassment was calculated. Pearson correlation analysis was used to assess program-level correlations between the rates of discrimination or harassment and the proportion of female residents. All statistical analyses were 2-sided with a predetermined significance threshold of P < .05. Analyses were performed using Stata software, version 14.2 (StataCorp LLC).
Among 8907 total residents in general surgery programs across the US, 778 residents were excluded because they were not clinically active. The remaining 8129 residents were eligible for inclusion, of whom 6956 responded (85.6% response rate). A total of 192 residents were excluded based on the absence of gender data, resulting in a final sample of 6764 residents from 301 general surgery programs. Of those, 3968 residents (58.7%) were male and 2796 (41.3%) were female. The proportion of female residents was higher in junior years (709 of 1687 residents [42.0%] in PGY-1 vs 1160 of 2689 residents [43.1%] in PGY-2/3 vs 927 of 2388 residents [38.8%] in PGY-4/5; P = .006). Compared with their male colleagues, female residents were less frequently married (1950 of 3920 men [49.7%] vs 886 of 2761 women [32.1%]; P < .001), had a minor child (946 of 3914 men [24.2%] vs 286 of 2758 women [10.4%]; P < .001), or were pregnant or expecting a child (568 of 3908 men [14.5%] vs 170 of 2757 women [6.2%]; P < .001). Large programs had a higher proportion of female residents (eg, largest vs smallest quartile: 717 of 1587 residents [45.2%] vs 635 of 1771 residents [35.9%]; P < .001), as did university programs (eg, 1691 of 3869 residents [43.7%] vs 1039 of 2708 residents [38.4%] in independent programs; P < .001) and programs with higher proportions of female faculty (eg, highest vs lowest quartile: 638 of 1452 residents [43.9%] vs 599 of 1529 residents [39.2%]; P = .04) (Table 1).
Of the 5640 residents (3288 men and 2352 women) who responded to questions regarding gender discrimination, 2440 residents (43.3%) reported experiencing at least 1 of the listed discriminatory behaviors. The most common type of gender discrimination was being mistaken for a nonphysician (1943 residents [34.5%]). Compared with male residents, female residents were more likely to experience discrimination overall (562 men [17.1%] vs 1878 women [79.8%]; P < .001), including every discrimination subtype (eg, being mistaken for a nonphysician: 130 men [4.0%] vs 1813 women [77.1%]; P < .001; different standards of evaluation: 307 men [9.3%] vs 1014 women [43.1%]; P < .001). Among residents who reported experiencing gender discrimination, women had more frequent experiences (eg, weekly or greater: 1241 of 1878 women [66.1%] vs 86 of 562 men [15.3%]; P < .001) (Table 2). The most common type of discrimination among male residents was a negative reaction to pregnancy and childcare needs (104 of 1000 men [10.4%]); however, this type of discrimination was more common among female residents (131 of 328 women [39.9%]; P < .001), with coresidents/fellows reported as the most frequent source. Among female residents who reported being advised not to have children or experiencing different standards of evaluation or denial of opportunities, the most common source was attending physicians; among those who reported being mistaken for a nonphysician, the most common source was patients/families. Among women who reported feeling socially isolated or experiencing negative reactions to pregnancy and childcare needs, the most common source was coresidents/fellows (Table 3).
Among 5775 residents (3360 men and 2415 women) who answered questions regarding sexual harassment, 1747 residents (30.3%) reported experiencing at least 1 listed behavior. The most common type of sexual harassment was crude, demeaning, or explicit comments (1557 residents [27.0%]). More female residents reported experiencing harassment overall (1026 women [42.5%] vs 721 men [21.5%]; P < .001), including most of the harassment subtypes (eg, crude, demeaning, or explicit comments: 901 women [37.3%] vs 656 men [19.5%]; P < .001; unwanted verbal sexual attention: 531 women [22.0%] vs 213 men [6.3%]; P < .001; offensive body language: 420 women [17.4%] vs 188 men [5.6%]; P < .001), with the exception of sexual coercion, for which there was no statistically significant difference (22 women [0.9%] vs 47 men [1.4%]; P = .14). Among residents who reported experiencing sexual harassment, men had more frequent experiences (eg, weekly or greater: 124 of 721 men [17.2%] vs 122 of 1026 women [11.9%]; P = .009) (Table 2). Sources of harassment varied by gender and behavior (Table 3). Among female residents who reported experiencing unwanted verbal sexual attention, offensive body language, and crude, demeaning, or explicit comments, the most common source was patients/families; among those who experienced unwanted sexual imagery, the most common source was coresidents/fellows. Among male residents who reported experiencing crude, demeaning, or explicit comments, the most common source was coresidents/fellows; among those who experienced unwanted verbal sexual attention, the most common source was nurses/staff.
After adjusting for individual- and program-level factors, women were more likely to report experiencing gender discrimination if they were pregnant or expecting a child (89.9% vs 80.1% among those not pregnant or expecting a child; odds ratio [OR], 1.93; 95% CI, 1.03-3.62) or had higher ABSITE scores (eg, highest vs lowest quartile: 84.6% vs 77.3%; OR, 1.67; 95% CI, 1.14-2.43). Men were more likely to report experiencing gender discrimination if they had lower ABSITE scores (eg, highest vs lowest quartile: 14.0% vs 21.8%; OR, 0.57; 95% CI, 0.43-0.76), had a minor child (23.9% vs 15.5% among those without a minor child; OR, 1.72; 95% CI, 1.31-2.27), or were training in the Northeast (eg, 19.7% vs 15.6% among those training in the Southeast; OR, 1.37; 95% CI, 1.00-1.88). No other factors, including gender of leadership and gender distribution of residents or faculty, were associated with discrimination (Table 4).
Sexual harassment experiences were more likely to be reported by women in PGY-2/3 (43.2%) vs PGY-1 (35.8%; OR, 1.42; 95% CI, 1.11-1.82) or PGY-4/5 (48.8%; OR, 1.77; 95% CI, 1.40-2.24), women with higher ABSITE scores (eg, highest vs lowest quartile: 49.2% vs 41.6%; OR, 1.40; 95% CI, 1.07-1.83), women in military programs (eg, 55.6% vs 44.0% among those in university programs; OR, 1.89; 95% CI, 1.02-3.48), and women in programs with higher proportions of female faculty (eg, highest vs lowest quartile: 45.7% vs 39.7%; OR, 1.33; 95% CI, 1.01-1.75). Among male residents, sexual harassment was associated with seniority (eg, PGY-4/5 vs PGY-1: 24.4% vs 18.8%; OR, 1.31; 95% CI, 1.01-1.70). No other individual or programmatic factors, including the gender of leadership and gender distribution of residency programs, were associated with harassment (Table 4).
Program-level rates ranged from 0% to 88.9% for gender discrimination (median, 42.9%; interquartile range [IQR], 33.3%-52.1%) and 0% to 80.0% for sexual harassment (median, 29.8%; IQR, 20.0%-38.2%). The gender composition of residency programs was highly correlated with program-level rates of gender discrimination (r = 0.64; 95% CI, 0.56-0.70) but minimally correlated with program-level rates of sexual harassment (r = 0.17; 95% CI, 0.06-0.28) (Figure).
To our knowledge, this survey study of gender discrimination and sexual harassment experiences among a large sample of residents in general surgery programs with a high response rate represents the most comprehensive analysis of gender discrimination and sexual harassment in any field of medicine. A total of 80.0% of female residents reported experiencing gender discrimination and 42.5% reported experiencing sexual harassment, with lower but substantial reporting of discrimination and harassment by male residents and wide program-level variability. Sources of gender discrimination and sexual harassment varied by behavior and residents’ gender. These data may provide insight to individuals working toward gender equity in the medical field.
The gender discrimination and sexual harassment rates identified by querying specific behaviors were higher than those calculated by pooled estimates in a meta-analysis14 and those of a previous survey study wherein respondents self-defined the terms.15 Because gender biases in the medical field are often insidious,32-35 the provision of defined terms and types of bias in the present survey may have allowed more accurate recollection. In addition to increasing the accuracy of prevalence estimates, the enumeration of specific behaviors provided a more comprehensive characterization of the experience of discrimination and harassment. The most common form of gender discrimination reported by female residents was being mistaken for a nonphysician. Consistent with findings from previous studies,36-38 the most common source of this microaggression was patients/families. Although less egregious than other forms of mistreatment (eg, inappropriate touching), microaggressions can negatively impact cognition39 and have substantial cumulative consequences for clinicians.32,34 Attending physicians were the most common source of gender discrimination based on opportunities and evaluation; this finding is consistent with previous studies reporting decreased opportunities for operative autonomy for female residents40 as well as more rapid progression through the Accreditation Council for Graduate Medical Education milestones41 and a greater number of awards given to male residents.42 Such gender discrimination has important potential consequences for clinical competence and career advancement.
Male residents also experience gender discrimination and sexual harassment, albeit less frequently than women.7,15 The most common harassment behavior reported by men was crude, sexually demeaning, or explicit remarks, stories, or jokes, and the most common source of this behavior was coresidents/fellows. These findings suggest that sexual humor among health care professionals, particularly among peers, is ubiquitous.38,43 Unwanted verbal sexual attention was the second most prevalent type of harassment reported by men, with nurses/staff identified as the most common source. Men may not label these behaviors as harassment, particularly given the difference in context (eg, the lack of a power differential), compared with that of their female colleagues.43 This factor may contribute to the underreporting observed in a previous study,15 in which behavioral prompts were not provided. Although some may question the utility of investigating events in which the person reporting the behavior does not feel harassed, such behaviors are clearly unprofessional.
Gender discrimination experiences were more likely to be reported by pregnant women and men with a minor child. Negative reactions to pregnancy or childcare needs were reported by 39.9% of women and were the most common type of gender discrimination reported by men. Bias against parenthood in the field of surgery, particularly toward women, has previously been reported28,29,44; however, these studies were limited by small sample sizes, incalculable response rates, and the requirement for surgeons to recall experiences over the course of their careers rather than a single academic year. Women in the field of surgery have reported being explicitly and implicitly discouraged from becoming pregnant during training; 15% of surgical program directors admit to advising against pregnancy during training, and 61% believe that parenthood negatively impacts women’s work (compared with 34% for men).28 Such discrimination may contribute to unequal personal sacrifices, which women may feel are necessary to train as physicians.45,46 Consistent with previous work,47-49 the present study found that female residents were less likely to be married, have a minor child, or be expecting a child compared with their male counterparts. Eliminating discrimination against parents of both genders is important because discrimination may create incentives for male physicians to take less active parenting roles44,50 and may exacerbate gender stereotyping at work.
Female residents with the highest ABSITE scores were more likely to report experiencing gender discrimination and sexual harassment, whereas male residents with low ABSITE scores were more likely to report experiencing gender discrimination. These differences may be associated with gender stereotypes. Confidence and assertiveness, which one might expect in high-performing surgical residents, are often perceived positively in men but negatively in women.51 In addition, male surgical residents may be more susceptible to stereotype threat, which is the risk of confirming negative stereotypes52; in a multi-institutional randomized study of surgical residents,52 evoking pro-male stereotypes was reported to improve engagement among men, whereas exposing men to data supporting gender neutrality was reported to worsen their technical performance. The loss of gender advantage may therefore adversely impact male performance on examinations or, alternatively, men with lower examination scores may perceive a loss of dominance as discrimination.53,54 Regardless of gender, senior residents were more likely to report experiencing sexual harassment, potentially associated with increased familiarity that blurs professional boundaries and/or increased one-on-one interactions.
At the program level, gender distribution was correlated with rates of gender discrimination. The capacity to recognize behaviors as discriminatory may improve with increasing numbers of women in the workplace. However, the correlation between the proportion of female residents and sexual harassment was minimal. Characteristics of local context (eg, organizational policies or the societal norms of the surrounding community) that were not reflected in the evaluated program variables may, at least in part, explain this finding. Nonetheless, considerable program-level variation in rates of gender discrimination and sexual harassment suggests that improvement is possible.
The Surgical Education Culture Optimization Through Targeted Interventions Based on National Comparative Data (SECOND) clinical trial,55 a cluster-randomized study of 215 general surgical residency programs across the US, was recently initiated. In this trial, residency programs in the intervention arm receive aggregated reports of their residents’ perceptions of various aspects of the learning environment (in which mistreatment is a prominent feature) compared with other programs in the country. In addition, these programs receive access to a toolkit of ready-to-implement interventions (eg, programmatic and institutional practices, policies, and infrastructure) to improve the learning environment. These data will inform protocols on recognizing, coping, and responding to gender discrimination and sexual harassment. In the interim, Sexual Harassment of Women, published by the National Academies of Sciences, Engineering, and Medicine in 2018,2 includes several chapters with action items.
This study has several limitations. First, the data originate from surgical residents and therefore may not be generalizable to residents who are training in other specialties. Second, the survey was administered after the ABSITE examination, which may have subjected respondents to recall biases associated with either postexamination anxiety or elation. Third, despite assurances of survey confidentiality, residents may have been reluctant to report sensitive exposures, producing underestimations of prevalence. Fourth, respondents selected only 1 source for each behavior, which simplified analyses but likely underestimated the pervasiveness of mistreatment. Fifth, we inquired about discrimination based on gender, gender identity, or sexual orientation because these concepts are intricately associated56; as a consequence, it was not possible to distinguish, for example, discrimination experienced by straight cisgendered women from that experienced by lesbian cisgendered women or by individuals who identify as nonbinary.
This study’s results suggest that gender discrimination and sexual harassment are common among surgical residents, originate from variable sources, and are associated with different individual- and program-level factors. These data may be used to inform interventions to mitigate gender discrimination and sexual harassment, which is a necessary step toward gender equity in health care.
Accepted for Publication: April 26, 2021.
Published Online: July 28, 2021. doi:10.1001/jamasurg.2021.3195
Corresponding Author: Yue-Yung Hu, MD, MPH, Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20-038, Chicago, IL 60611 (email@example.com).
Author Contributions: Drs Schlick and Hu 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: Schlick, Ellis, Etkin, C. C. Greenberg, Turner, Hoyt, Bilimoria, Hu.
Acquisition, analysis, or interpretation of data: Schlick, C. Greenberg, J. A. Greenberg, Buyske, Nasca, Bilimoria, Hu.
Drafting of the manuscript: Schlick, Etkin, J. A. Greenberg, Buyske, Hoyt, Nasca, Bilimoria, Hu.
Critical revision of the manuscript for important intellectual content: Schlick, Ellis, C. C. Greenberg, J. A. Greenberg, Turner, Nasca, Bilimoria, Hu.
Statistical analysis: Schlick, Ellis, Bilimoria, Hu.
Administrative, technical, or material support: Etkin, Hoyt, Nasca, Hu.
Supervision: Etkin, J. A. Greenberg, Turner, Buyske, Bilimoria, Hu.
Conflict of Interest Disclosures: Dr C. Greenberg reported receiving consulting fees from Johnson & Johnson, which were directed toward the nonprofit Academy for Surgical Coaching, outside the submitted work. Dr J. Greenberg reported receiving grants from BD Interventional and Medtronic outside the submitted work. No other disclosures were reported.
Funding/Support: This study was funded by grants 5T32HS000078 (Dr Ellis), R01HS025989 (Dr Greenberg), and R01HS024516 (Dr Billimoria) from the Agency for Healthcare Research and Quality; a grant R01HL076180 from the National Heart, Lung, and Blood Institute (Dr Hoyt); grants from the Accreditation Council for Graduate Medical Education (Drs Billimoria and Hu) and the American College of Surgeons (Drs Billimoria and Hu); and in-kind support from the American Board of Surgery.
Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Dr Hoyt, who is employed by the American College of Surgeons, and Dr Nasca, who is employed by the Accreditation Council for Graduate Medical Education, were involved in the conduct of the study, interpretation of the data, and review of the manuscript.
Disclaimer: The views expressed in this article represent those of the authors only.