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

Abstract

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.

Conflict of interest statement

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.

Figures

Figure 1.. Trial Profile

Diagram of participants in phases 1 and 2. Of the 85 participants randomized, 17 were from the University of North Carolina–Chapel Hill, 30 from University of Washington, and 38 from UPMC. FLS indicates Fundamentals of Laparoscopic Surgery; UPMC, University of Pittsburgh Medical Center.

Figure 2.. Association Between Perception of Gender Bias and Career Engagement Across Genders

The association between Employee Environment Diagnostic Survey score and Career Engagement Scale score is plotted for men and women participants.

Figure 3.. Gender-Based Differences in the Association Between Stereotype Threat and Susceptibility to Stereotype Threat and Fundamentals of Laparoscopic Surgery (FLS) Skills Assessment Score

The association between susceptibility to stereotype threat score and FLS score is depicted by participant gender and intervention arm.