Diversity,Equity,and Inclusion: A Current Analysis of General Surgery Residency Programs

Introduction

Diversity, equity, and inclusion (DEI) have historically presented challenges to equal opportunities for entry and promotion in medicine and have created barriers to patient care—all which remain to this day. Many studies have demonstrated that DEI efforts in medicine enhance the ability to care for patients, introduces diverse perspectives for rich information exchange while respecting differences, and eliminates barriers to equal representation and opportunities. The field of surgery, in particular, is lacking in diversity compared to other medical specialties. ¹

In the last decade, there have been many local, regional, and national initiatives to improve DEI in the field of surgery. Such initiatives include mentorship programs for female and underrepresented in medicine medical students, residents, and attending physicians, trainings in implicit bias, task force initiatives to identify barriers and motivate change, and DEI champions or offices within institutions, among many others. In 2016, the Association of Program Directors in Surgery started a diversity and inclusion task force, which later became a permanent committee. This committee published a Diversity and Inclusion Toolkit in 2020, which provides general information about the value of diversity and inclusion, in addition to specific guidelines for how to improve diversity and inclusivity in residency program recruitment, interview strategies, and retention. ² In 2018, the American Surgical Association Task Force on Equity, Diversity, and Inclusion published a handbook outlining some of the barriers to creating a more diverse surgical workforce in addition to establishing potential solutions and benchmarks of progress to help aid in this goal. ³ Other professional organizations such as the American College of Surgeons, Association for Surgical Education, and the Southeastern Surgical Congress established task forces to focus on improving DEI in the surgical workforce.

Previous evaluation of trends in resident diversity from the late 1990s to early 2000s showed increasing proportions of female residents and African American residents. ⁴ However, another study showed decreasing proportions of underrepresented groups such as black and Asian residents in the latter part of the decade. ⁵ Our study aims to evaluate current changes in diversity in general surgery residency programs. We hypothesize that resident diversity has remained stable both nationally and in distinct geographic areas when evaluating the trend in a 5-year period.

Materials and Methods

This study was approved by the Stanford University Institutional Review Board. A national survey following the 2020 American Board of Surgery In-Training Examination was completed by general surgery residents. Self-reported demographics were collected including sex (male, female), race (American Indian or Alaska Native, Asian, black or African American, Native Hawaiian or other Pacific Islander, white, and other), and ethnicity (Hispanic or Latinx and not Hispanic or Latinx). Residents were then grouped into 8 geographic regions based on the location of their surgery residency program: Northeast, Mid-Atlantic, Southeast, Midwest, Southwest, Northwest, West, and U.S. Territories (Puerto Rico).

Analyses of trends in diversity were completed using descriptive statistics, Kruskal-Wallis test, and chi-square analyses. Self-reported demographics for graduating, postgraduate year (PGY) 5 residents were compared to PGY 1 residents. In addition, trends between each PGY level (PGY 1-5) were evaluated. Two-sided P-values were calculated, and P < .05 was used to determine statistical significance. Analyses were completed using IBM SPSS Statistics for Mac (version 27.0, IBM Corp., Armonk, NY, USA).

Results

Residents (n = 9276) from 325 General surgery residency programs responded to the survey: 25.3% PGY 1, 24.1% PGY 2, 20.5% PGY 3, 15.4% PGY 4, and 14.7% PGY 5. Demographic analysis of all resident responses revealed that 43.6% (n = 4041) of residents were female and 56.4% (n = 5232) were male (Figure 1); .6% (n = 50) American Indian or Alaska Native, 18.6% (n = 1477) Asian, 4.7% (n = 376) black or African American, .2% (n = 13) Native Hawaiian or other Pacific Islander, 63.4% (n = 5024) white, and 7.6% (n = 606) other. Additionally, 8.4% (n = 663) of residents reported Hispanic or Latinx ethnicity (Figure 2).

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Figure 1.

Sex breakdown of all residents by geographic location.

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Figure 2.

Proportion of race and ethnicity of all residents based on geographic location.

Sex

Nationally, a significant increase in female residents from 38.0% to 46.0% was observed. Analysis of geographic regions revealed that the Northwest (51.9% to 58.3%, P = .039), Midwest (36.9% to 43.3%, P = .006), and Southwest (35.8% to 47.5%, P = .027) showed a similar trend (Table 1).

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Table 1.

Trends in Diversity Over 5-Year Period, 2020-2025.

	Sex		Race/Ethnicity
Region	Male, % (n)	Female, % (n)	American Indian or Alaska Native, % (n)	Asian, % (n)	Black or African American, % (n)	Native Hawaiian or Other Pacific Islander, % (n)	White, % (n)	Other, % (n)	Hispanic or Latinx, % (n)
Northeast	−12.9 (15)	12.9 (42)	−1.1 (1)	3.2 (14)	1.2 (3)	—	−12.9 (15)	5.2 (9)	2.4 (6)
Mid-Atlantic	−5.8 (136)	5.8 (146)	−.3 (0)	1.4 (57)	.2 (16)	—	−10.0 (86)*	2.7 (38)	−.1 (18)
Southeast	−9.5 (91)	9.5 (120)	.3 (3)	−1.4 (20)	.9 (15)	−.4 (1)	−5.5 (96)*	1.7 (20)	2.3 (30)*
Midwest	−6.5 (80)	6.5 (99)*	−.4 (1)	1.5 (29)	−.5 (4)	0 (0)	−4.5 (85)	−.2 (10)	2.2 (21)
Northwest	−3.4 (4)	3.4 (7)*	−3.7 (1)	13.6 (6)	15.8 (6)*	−3.7 (1)	−14.0 (2)	−3.7 (1)	−2.2 (0)
Southwest	−11.7 (49)	11.7 (78)*	1.4 (4)	4.6 (28)	−.8 (2)	.4 (1)	−15.9 (40)*	−.1 (9)	−2.0 (7)
West	−.6 (52)	.6 (46)	.5 (1)	1.2 (28)	.2 (2)	.5 (1)	−7.8 (28)	1.4 (8)	3.2 (11)
Puerto Rico	−19.3 (3)	19.3 (7)	—	—	—	—	−11.7 (0)	−19.3 (3)	−30.4 (2)
All regions	−7.4 (430)	7.4 (545)*	−.1 (5)	1.6 (142)	.4 (36)	−.1 (0)	−8.9 (352)*	1.3 (52)*	1.0 (41)*

%, change in diversity.

n, number of residents contributing to trend.

*P < .05.

Discussion

Nationally, there was a significant change in diversity when comparing those graduating in June 2020 to those beginning their intern year in July 2019. Similar to findings by Keshinro et al, our study found a decreasing trend in white residents, although they continue to represent the majority of general surgery residents, with markedly lower proportions of underrepresented and minority groups. ⁶ Our findings suggest that diversity initiatives may be exhibiting some success; however there is still a need for increased efforts, as racial and ethnic diversity is not showing the same tendencies as diversities in residents’ sex.

Many program-led and professional organization-led initiatives exist to increase DEI in surgical residencies. Several studies have described strategies that increase not only diversity in surgery residency but also equity and inclusion, including altering the screening tools to be more inclusive, implementing a holistic review process with an inclusive interview team, and conducting structured interviews.^7,8 In some instances, programs have been implemented at the undergraduate medical education level to foster a diverse and inclusive environment, to recognize implicit bias and microaggressions, and ultimately to aid in recruitment.^9,10 Programs have also showcased their DEI efforts on their website such as photographs and biographies of residents and faculty, resources available to residents, and diversity and inclusion messages.

When looking at diversity within the field of surgery, it is important to consider the surgical pipeline and to evaluate trends among graduating medical students, surgery residents, surgical faculty, and surgical leadership roles. A 2020 study on trends in applicants to surgical residencies from 2008-2018 showed an increase in female applicants to surgical residency programs. Among graduating US medical students, there was an increase in Asian and Hispanic graduates with a corresponding decrease in black and in white graduates without a significant change in Hispanic or black applicants applying into surgical specialties. ¹¹ Another study assessed general surgery and vascular programs for resident diversity from 2011 to 2020, and showed a positive trend for female trainees, but proportionally decreased black and Asian trainees. ⁵ These studies would suggest that despite a more focused effort on DEI within surgery, significant changes within surgical residency programs have not yet been observed.

While DEI initiatives remain critical and necessary, recruitment in isolation is inadequate and strategies for retention and promotion of residents are vital. Lack of representation on a faculty level, scarcity of mentorship and sponsorship, and inadequate safeguards and support networks also pose significant issues and can be counterproductive to DEI strategies. A study conducted by Khoushhal et al in 2017 showed that the estimated general surgery resident attrition rate was 18%, with females experiencing higher rates of attrition. ¹² However, it was shown that having a female full-time faculty member resulted in a 4% decrease in the odds of reaching the top quartile of attrition rates. ¹³ While this study demonstrates the importance of having diverse faculty, Jarman et al revealed that simply having diverse faculty does not equate to increases in diverse candidate recruitment during the selection process. ¹⁴

We recognize that our study faces several limitations. Our analysis of resident responses is limited to a cross-sectional representation of diversity and may therefore require further evaluation to detail-specific factors affecting diversity. We did not run a correlative analysis between resident diversity and DEI initiatives and therefore have assumed that the reported trends may be directly and indirectly correlated with these initiatives. We are also unable to account for changes in resident diversity due to external factors such as attrition. Furthermore, there are a larger proportion of PGY 1 and PGY 2 residents due to opportunities for preliminary residency positions which may reflect a wider range of diversity at the junior level.

Several trends in DEI exist with diversity in residents’ sex showing the most significant changes. Recruitment alone, as it stands now, is inadequate without proper measures to ensure underrepresented and minority populations are supported and equipped to overcome the rigors of surgical residency within the burdens of these social constructs.