Abstract
Introduction
Despite the increasing number of female surgeons in general surgery programs, women are still inadequately represented in leadership positions. This study aims to investigate the magnitude of gender bias in university-based trauma surgery fellowship programs and leadership positions in the United States of America.
Material and Methods
FRIEDA was used to identify trauma surgery programs. A thorough website review of each program obtained further information on faculty members, including their name, age, gender, and faculty rank. Trauma surgeons with an MD or DO qualification and a faculty rank of Professor, Associate Professor, or Assistant Professor were selected for inclusion in this study. SCOPUS was used to assess the H-index and the number of publications and citations of surgeons.
Results
The total number of programs included was 136, consisting of 715 faculty members. Less than a quarter (n = 166; 23.2%) comprised females and less than one-fifth (n = 30; 19%) of female surgeons were Professors. The difference in the research productivity of male and female trauma surgeons was statistically significant (P < .05), with the average H-index being 10 vs 7.5, respectively, amongst the top 50 surgeons of both genders. Based on a multiple regression analysis, academic rank was significantly associated (P < .05), and gender was not significantly associated (P > .05) with H-index.
Conclusion
Gender disparity exists in the field of trauma surgery, as noted in senior faculty ranks and leadership positions. Female-inclusive state policies, appropriate mentorship, and supportive institutions can help to bridge this gap.
Keywords
Background
Diversity, equity, and inclusion (DEI) in surgery is a work in progress. The female surgical workforce in general surgery residency programs has increased over the last decade. 1 However, the ratio of women to men in academic surgery is still unbalanced. Women currently hold less than 20% of the full professor, tenured faculty, and head of department positions. Women are also less likely to be promoted to associate or full professor, and they make up a tiny percentage of medical school deans and department chairs. 2 Based on predictions of current trends, female surgeons will not make up an equal distribution of full professors for at least another 121 years. 3 Appointments and promotions in academic surgery combine many factors driven by personal accomplishments and hierarchical regulations. 4 Often, there has been an association of the advancement of females with the “glass ceiling” phenomenon, which explains how, despite the increased number of women entering male-dominated specialties, their progress to the upper tiers of leadership is stagnant.5-7
Women are also documented to have fewer publications and citations than men, especially in surgery. 8 The H-index is a numerical indicator of the research productivity of an author. 9 It is used to assess gender disparity in specialties of surgery, 8 professional surgical societies, 10 and editorial boards of journals. 11 Professional organizations frequently use such indicators to decide on employment, retention, and promotion, and therefore, it is vital to understand their effects and how they vary based on gender.
The underrepresentation of female surgeons in trauma surgery is well documented. Until 2018, the American Board of Surgery comprised only 28% of women trained in acute care surgery.
12
However, Abelson et al. reported that there has been an increase (1.4%/year) in female trainees pursuing surgical critical care. Based on these statistics, it is imperative to study the distribution of leadership in trauma surgery based on gender. More females in leadership positions may attract other aspiring female trauma surgeons to the field. Thus, our study aims to fulfill the following objective: i. To determine the extent of gender disparity in university-based trauma surgery fellowship programs in the United States by numerical representation ii. We also sought to evaluate whether research productivity is correlated with gender-based differences in academic and leadership positions in trauma surgery.
Methods
The STROCSS 13 and STROBE 14 guidelines were employed to report this retrospective cross-sectional study. Institutional Review Board approval was waived, as all data collected in our research was publicly available. Our research methodology is similar to previous studies to identify faculty, their academic and leadership rank, and determine research productivity.4,8,15-22 A database of all faculty members associated with the division(s) of trauma surgery within the surgery department was created. The period of data collection was from January 2022 to June 2022. The terms “trauma surgery,” “acute care surgery,” and “surgical critical care” were used interchangeably during our literature search. All trauma surgery programs nationwide were identified using the American Medical Association’s Fellowship and Residency Electronic Interactive Database (FREIDA). Two independent investigators (SAF) and (ES) collected the data, and disagreements were resolved through mutual discussion with a third investigator (FK). The FREIDA system contains information on all surgery departments that offer general surgery residency and associated fellowship training programs and is annually updated. Academic programs that did not disclose their faculty information publicly or the information was incomplete were excluded from our study. All programs were divided into geographical regions characterized by the USA Census Bureau: Midwest, Northeast, South, and West. 20
Further information on faculty members, including their name, gender, and faculty rank, was provided through the website review of each program. Adjunct, retired, visiting, and emeritus faculty were excluded from our study. Trauma surgeons with an MD or DO qualification and a faculty rank of Professor, Associate Professor, or Assistant Professor were selected for inclusion in this study. “Leadership positions” were defined as any title of the following: Co-Director, Director, Associate Program Director, Program Director, Section Chief, Vice-Chair, Chair, Associate Dean, or Dean. In further analysis of the top 50 highly productive surgeons’, we consolidated these leadership positions into three main categories: Program Director (Program Director + Associate Program Director), Section Chiefs and Directors (Section Chief + Co-Director + Director), and Departmental Chairs and Deans (Chair + Vice-Chair + Dean +Associate Deans). “Multiple leadership positions” were defined as individuals who held two or more two leadership positions. The “additional degree” included a Master in Public Health (M.P.H.) and a Doctor of Philosophy (Ph.D.). Publicly accessible resources such as institutional websites, Doximity, Google, LinkedIn, ResearchGate, Twitter, and curriculum vitae were utilized to collect the data mentioned above and ascertain the gender identity (“man” or “woman”) of the study participants.
Previously, research has shown a significant correlation between the H-index calculated by Scopus and that calculated by other research databases. 21 Therefore, we utilized Elsevier’s Scopus database (https://www.scopus.com/) to record an individual’s H-index, number of publications, citations, and years of active research. Years of active research were calculated by subtracting the upper and lower limits of each individual’s “Publications Range,” as stated on Scopus. Based on the H-index, authors were arranged in descending order, with the most productive authors having the highest H-index. A subgroup analysis of the top 50 productive surgeons assessed the gender disparity against variables such as H-index (median), yearly citations, the median number of publications, leadership position, and geographical preference as mentioned in Table 3. This was done as per the study conducted by Battaglia F et al. 8
SPSS Statistics version 20.0 (International Business Machines Corporation, Armonk, NY, USA) was used to perform the statistical analyses. A chi-squared test was used to assess the statistical association between categorical variables. The Kruskal-Wallis test and Mann-Whitney U test were used to compare the number of publications, the number of citations, H-indices, years of active research, the average number of publications per year, and the average number of citations per year with variables such as gender, faculty ranks, and leadership ranks. Multiple linear regression was used to assess the association of variables with the H-index, which was set as the primary outcome. Independent variables included gender, academic rank, leadership rank, total citations, average publications per year, and total publications. A P-value of less than .05 was deemed significant.
Results
Study Characteristics
Demographic and Academic Characteristics of Trauma Surgeons.
H-index, no. of publications, and citations were statistically significant (P < .05) across faculty ranks, with research productivity increasing with increasing faculty ranks. Further gender-based subgroup analysis of the H-index across the faculty ranks was not significant and demonstrated minor differences at the level of Assistant (females = 4 vs males = 5) and Associate Professor (female = 9 vs male=10). At the rank of professor, female trauma surgeons had accumulated a higher H-index (26.5) in comparison to their male trauma surgeons (22), as shown in Figure 1. Cross-tabulation of faculty ranks with leadership positions was significantly and positively correlated (P < .05; Effect Size = .3) as three out of every three professors (59%) in our study held a leadership position, as shown in Figure 2. Multiple leadership positions also showed a significant upward trend with increasing academic rank (P < .05; effect size = .1). Possession of additional degrees across faculty ranks was non-significant (P > .05). Relationship between faculty rank and H-index according to gender stratification. Relationship between faculty rank and number of leadership positions.
Statistical Analysis of Leadership Positions
Analysis of Leadership Positions with Research Output.
Relationship between leadership roles and H-index according to gender stratification.
Statistical Analysis of Highly Productive Surgeons
Analysis of Research Productivity in 50 Highly Productive Trauma Surgeons as Stratified by Gender.
Statistical Analysis Based on a Multiple Regression Model
Upon multiple regression analysis, gender, leadership rank, academic rank, and the number of citations were significant predictors of the H-index (P < .05). Academic rank was significantly associated with H-index when controlled for gender, leadership rank, and citations (P < .05). Gender was not statistically associated with H-index when controlled for academic rank, leadership rank, citations, number of publications, and average publications per year (P > .05).
Discussion
The increase in female medical school graduates has led to a concomitant rise in female surgeons, with two out of every five surgical residents being female. 1 Despite these numbers, gender disparity in surgery has remained a vital concern. Historically, this disparity has been noticeable in leadership roles, where women are grossly underrepresented. 22 Our research shows that trauma surgery faculty comprises 77% males and 23% females. After a thorough literature search, our study is the first to estimate the breakdown of academic trauma surgeons based on gender. The American Board of Surgery states that 34% of women have certification in surgical critical care, which is second only to the number of females certified in Surgical Oncology, 39%. 12 Our number is similar to full-time general surgery faculty, that is, 21% published by Battaglia et al. 8 In plain sight, these numbers may not represent an accurate ground situation as evidenced by the fact that trauma surgery was found to have the highest rate of growth of female surgeons in contrast to other surgical subspecialties. Trauma surgery is also estimated to reach gender parity the quickest (6 years) amongst other surgical sub-divisions. 23
Geographically, the representation of female trauma surgeons in the United States is relatively equal. However, most of the top 50 female trauma surgeons, that is, 30%, resided in the West Region of the United States, in contrast to a similar analysis done by Battaglia et al 8 where the majority of the top 50 female general surgeons were affiliated with academic programs of the Northeast. California, the largest and the most populous state of the West employs more female surgeons than the national average of 25%. 24 This data may support the idea that female surgeons have a high recruitment rate in the Western United States and a better foothold in academic programs.
Our study data shows that most female trauma surgeons held lower academic ranks and only 19% of women held the position of a Professor. This statistic is comparatively better than that of other surgical subspecialties, where a lower proportion of female surgeons achieve the rank of professor.13,25-27 In contrast to our number of female full professors in trauma surgery (19%∼2 out of 10), Wilson et al. 28 report women trauma fellows to be approximately 4 out of 10 (43%) in proportion to males. Prospectively, we can envision more women entering academic programs in trauma surgery and subsequently achieving higher positions on the academic ladder. Although work is in progress to equal representation of women surgeons in full professor ranks, it appears difficult to achieve this milestone until 2132. 1
Women trauma surgeons hold 40% of leadership positions in trauma surgery. Though this appears to point toward an unequal representation of female trauma surgeons in leadership positions, a closer analysis of our results indicates that the proportion of female leaders in trauma surgery is equitable to the proportion of male trauma surgeons who held a leadership position in our study, that is, 43%. In comparison, the estimation of leadership positions in other fields of surgery provided was lower. Examples include general surgery 8 (19%), otolaryngology 26 (19%), and neurosurgery 27 (7%). Interestingly, Foster et al 22 showed a representation of 24% of female trauma surgeons in leadership positions in trauma surgery societies of the United States. This disparity of female trauma surgeons in leadership numbers in academic programs to that of trauma surgery societies highlights the networking gap that can hopefully be reduced as more women trauma surgeons climb the leadership ladder in their respective societies.
In our study, female trauma surgeons in leadership positions may have acquired “critical mass.” The critical concept hypothesizes that women in academia achieve a threshold of 30%-35% female faculty members to make the desired impact in policy and decision-making processes. 29 However, a closer analysis of leadership positions reveals the alarming lack of female leadership in positions of command and decision-making, as only 1 female Departmental Chair and 7 female Vice-Chairs were part of our study population. Unfortunately, this is true for general surgery, where more women serve in lower rungs of the hierarchal ladder, such as Associate/Co-Director and Chiefs, rather than Program Directors and Departmental Chairs.5,8 Lower numbers of female trauma surgeons at the apex of the leadership pyramid were noted, as only 4 out of the analyzed 50 surgeons possessed the rank of a Dean or a Departmental Chair. This may disregard an association between research productivity and leadership position, as stated by Analiz 30 and further discussed below.
A secondary aim of our study was to evaluate whether a correlation exists between gender disparity and research productivity in trauma surgery and if this could serve as a valuable predictor for those who ascend the leadership ladder. The average H-index of males was 10 compared to 7.5 for females. Though this difference is not as pronounced compared to other surgical subspecialties, 8 the differences in H-index are far larger when an analysis of the top 50 trauma surgeons was done based on research productivity. However, in the same analysis, when adjusted for active years in research, women publish similar, if not statistically equal, number of publications. Furthermore, based on the conclusions of our regression analysis model, the relationship between gender and H-index may be affected by several confounders such as academic rank and leadership rank. This can also be explained through the notion that as more men occupy positions of departmental chairs, they may be privileged to “honorary authorships” as senior authors, which inadvertently leads to the multiplication of their H-index.
The etiology of gender imbalance in surgery is multifactorial and complex. Workplace discrimination and bias, lack of mentorship, and poor work-life balance are some of the salient contributory determinants. 7 Sangji et al 31 highlighted that women trauma surgeons are more likely to be subjected to gender-based discrimination in verbal abuse, disrespect, and sexual harassment. However, subspecialties like trauma surgery and colorectal surgery are generally appreciated to have an accommodating work-life balance equilibrium, making it easier to explain the increasing number of women in these fields. Salles et al 32 shed light on ingrained stereotypes that may help implicit bias find roots in our system and describe how both men and women associate the terms “career” and “surgery” with males and “family” and “family medicine” with females. These professional stereotypes demand attention, and their dissipation requires the support of the entire surgical community.6,16
The process of removing these hurdles must be pre-emptive, and much collaboration is needed. Examples include improvements in the recruitment process and selection committees. These committees should adopt gender-neutral and impartial criteria that improve equity in appointments. Furthermore, a more diversified approach should assess candidates for leadership positions such as department chair, program director, and associate program director. This approach is necessary because many women are often more invested in clinical service or educational responsibilities, leaving less time to work on research projects, stagnating their research output.2,17 This makes it necessary to focus not only on a candidate’s research productivity when making leadership appointments, but also on other aspects of their professional profile, such as their public relations skills, previous possession of a leadership/administrative rank, and additional qualifications that they may have achieved in the form of an additional degree or certifications.
A vital factor in helping women climb the professional ladder is mentorship. The visibility of female and male mentors continuously nurturing female talent is paramount. Multiple studies discuss the importance of having a mentor who appreciates the difficulties faced by women in academia.18,19 In this age of networking and socializing, the role of trauma surgery societies may be more robust and influential than ever before. 22 Dr. Andrew Bernard of the Eastern Association for the Surgery of Trauma (EAST) discussed gender disparity, diversity, and inclusion in surgery in his speech. The EAST equity, quality, and inclusion task force was created, and the hashtag #EAST4ALL was introduced under his presidency. 23 Such encouragement is why there a surge in female speakers in trauma surgery professional societies. 22 Spotlighting these female trauma surgeons will help attract the brightest minds in trauma surgery and further strengthen the cause to achieve parity in the profession.
Limitations
Our study is not without limitations. The quantitative data obtained from SCOPUS might not be accurate as the data available on the platform is limited and does not store metrics for older publications. Furthermore, the discrepancy in the researcher’s last name could possibly limit our search for their respective research productivity variables on SCOPUS. To reduce inaccuracies, we cross-checked full names using Google Search before acquiring lists of publications by a particular researcher.
Our study’s inclusion and exclusion criteria may have resulted in a selection bias as we did not include non-academic or community programs that could’ve potentially influenced the results of our study. We also excluded programs with incomplete information regarding their faculty, which may have resulted in highly productive trauma surgeons of either sex being left out of data analysis. Leadership ranks included in our study were purely academic and did not include administrative leadership ranks which may have also contributed to this bias.
Research productivity variables such as the H-index of an individual and an individual's faculty and leadership rank(s) are likely to change over time. However, since these changes could be equally applicable to both genders, this effect on our analysis gets alleviated. Our study’s data and research productivity variables are current as of June 2022.
Furthermore, as no evidence of individual choices was available, our study presumes that every individual aspires to reach an academic or professional leadership position or obtain higher research productivity metrics such as H-index. This presumption could be incorrect as there is no way of knowing whether a surgeon purposely chose not to strive for leadership positions and be less involved in research work to achieve a better family life.
The authors suggest qualitative studies to get a personalized and in-depth perspective of the gender-based barricades women face in the field. The age or number of years served in professional ranks was unavailable. Therefore, trauma surgeons who are younger or have spent fewer years in trauma surgery may have decreased research productivity compared to older male surgeons with more experience. “Gender” is a paradigm that incorporates all sex-based identities, including and between “man” and “woman.” However, to improve our manuscript’s textual flow and understanding, gender assessment in our study was conventional and binary.
Conclusion
This quantitative study was conducted to provide insight into the current state of gender equilibrium in trauma surgery. In summary, our research shows female surgeons to be underrepresented in the field of trauma surgery, and this diminished representation has further translated to faculty ranks and leadership positions. However, new research highlights that the gender-based disparity in trauma surgery is narrowing. The cracks can be further sealed by increased institutionalized support, closely-knit mentorship associations, and the adoption of female-inclusive policies at the state and national levels. Future studies should be conducted to interview residents, faculty members, and policymakers to obtain more qualitative and personalized data on the lingering factors that contribute to gender disparity in surgery in general and trauma surgery in particular.
Footnotes
Author Contributions
Syed Ali Farhan: conduct a literature search, manuscript preparation, manuscript editing and manuscript review, final approval, and agreeing to the accuracy of the work. Nimra Hasnain: data acquisition, statistical analysis, manuscript writing, manuscript editing, final approval, and agreeing to the accuracy of the work. Manpreet Moorpani: conduct a literature search, manuscript preparation, manuscript editing and manuscript review, final approval, and agreeing to the accuracy of the work. Emad-ud-din Sajid: conduct, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, final approval, and agreeing to the accuracy of the work. Izza Shahid: planning, conduct, data acquisition, data analysis, statistical analysis, manuscript review, final approval, and agreeing to the accuracy of the work. Tanya Anand: planning, conduct, data acquisition, data analysis, statistical analysis, manuscript editing, manuscript review, final approval, and agreeing to the accuracy of the work. Faisal Khosa (Guarantor): planning, conduct, manuscript preparation, manuscript editing and manuscript review, final approval, and agreeing to the accuracy of the work.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.