Disparities in Diversity,Equity,and Inclusion in Surgical Residency Education: A Systematic Review

Abstract

Background

Increasing minority representation in surgical training is an important step toward eliminating health care disparities and access to care for vulnerable patient populations. Underrepresented minorities (URMs) face unique barriers to becoming board-certified surgeons, affecting their recruitment, retention, and overall success. This systematic review aims to consolidate existing literature on these disparities by examining trends affecting URMs across the surgical training continuum.

Methods

A systematic literature search was conducted using PubMed/Ovid, Google Scholar, and Elsevier Library. Search terms included “diversity, surgical education, and underrepresented minorities.” Articles were screened based on selection criteria focusing on US general surgery residency training, URM recruitment, retention, and performance. Final selection of articles for review were assessed for quality and summarized according to thematic trends.

Results

Of 180 articles reviewed, 42 met the criteria for inclusion. Underrepresented minorities face barriers in educational pathways including lower retention rates and institutional climates that disproportionately impact their experiences and wellbeing. Both URMs and women were less likely to apply, match, and succeed in surgical residency, often due to challenges related to academic performance, lack of mentorship, and institutional support. Additionally, significant gaps were identified in surgical mentorship, leadership, and faculty diversity among these groups.

Conclusions

Underrepresented minority surgical trainees encounter significant barriers along the medical education continuum for successful completion of surgical training and subsequent surgical careers. Our study underscores the need to create a diverse and inclusive workforce that promotes health equity and access to care.

Keywords

surgical education diversity disparities equity access of care

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References

Jensen

Jones

. The Chance That Two People Chosen at Random Are of Different Race or Ethnicity Groups Has Increased Since 2010. Census.gov. 2021; Available from: https://www.census.gov/library/stories/2021/08/2020-united-states-population-more-racially-ethnically-diverse-than-2010.html

Kim

Kassam

McElroy

, et al. The current status of the diversity pipeline in surgical training. Am J Surg. 2022;224(1):250-256.

Goode

Landefeld

. The lack of diversity in healthcare. Journal of Best Practices in Health Professions Diversity. 2018;11(2):73-95.

Lett

Murdock

Orji

Aysola

Sebro

. Trends in racial/ethnic representation among US medical students. JAMA Netw Open. 2019;2(9):e1910490.

Elkbuli

Rhodes

Breeding

, et al. Analysis of racial and gender distribution of US MD graduates entering into general surgery and surgical subspecialties residencies: the need for effective & sustainable diversity, equity, and inclusion strategies. J Surg Res. 2023;289:141-151.

Pérez-Stable

El-Toukhy

. Communicating with diverse patients: how patient and clinician factors affect disparities. Patient Education and Counseling. 2018;101(12):2186-2194.

Lee

JKH

McGuire

Raîche

Domecq

Tudorache

Gawad

. Underrepresented in medicine (URiM) residents: a scoping review on prevalence trends & improving recruitment. Am J Surg. 2024;237:115924.

Ouzzani

Hammady

Fedorowicz

Elmagarmid

. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.

Iwai

AYL

Thomas

, et al. At the intersection of intersectionality: race and gender diversity among surgical faculty and trainees. Ann Surg. 2024;279(1):77-87.

10.

Haruno

Chen

Metzger

, et al. Racial and sex disparities in resident attrition among surgical subspecialties. JAMA Surg. 2023;158(4):368-376.

11.

Yeo

Abelson

Symer

, et al. Association of time to attrition in surgical residency with individual resident and programmatic factors. JAMA Surg. 2018;153(6):511-517.

12.

Greenberg

Cevallos

Ojute

Davis

Greene

Lebares

. The General Surgery Residency Experience: a multicenter study of differences in wellbeing by race/ethnicity. Ann Surg Open. 2022;3(3):e187.

13.

Janczewski

Eng

, et al. Pregnancy and Parenthood Among US Surgical Residents. JAMA Surg. 2024;159(10):1127-1137.

14.

Nguyen

Mason

HRC

Russell

, et al. Leave of absence and medical student placement into graduate medical education by race and ethnicity. JAMA. 2024;331(18):1588-1590.

15.

Bruce

Battista

Plankey

Johnson

Marshall

. Perceptions of gender-based discrimination during surgical training and practice. Med Educ Online. 2015;20(1):25923.

16.

Yuce

Turner

Glass

, et al. National evaluation of racial/ethnic discrimination in US surgical residency programs. JAMA Surg. 2020;155(6):526-528.

17.

Riner

Herremans

Neal

, et al. Diversification of academic surgery, its leadership, and the importance of intersectionality. JAMA Surg. 2021;156(8):748-756.

18.

Mohan

Banuelos

Cespedes-Gomez

, et al. Diversity matters: a 21-year review of trends in resident recruitment into surgical specialties. Ann Surg Open. 2021;2(4):e100.

19.

Santosa

Priest

Oliver

, et al. Influence of faculty diversity on resident diversity across surgical subspecialties. Am J Surg. 2022;224(1):273-281.

20.

Morris-Wiseman

Dent

Nfonsam

Arora

. Leadership diversity in the association of program directors in surgery: a report of progress. J Surg Educ. 2022;79(6):e109-e115.

21.

Turner

Artz

Darling

, et al. Diversity in national society leadership and podium speakers in cardiothoracic surgery. Ann Thorac Surg. 2022;114(2):561-566.

22.

Aggarwal

Rosen

Nehemiah

, et al. Is there color or sex behind the mask and sterile blue? Examining sex and racial demographics within academic surgery. Ann Surg. 2021;273(1):21-27.

23.

Abelson

Wong

Symer

Eckenrode

Watkins

Yeo

. Racial and ethnic disparities in promotion and retention of academic surgeons. Am J Surg. 2018;216(4):678-682.

24.

Morris-Wiseman

Cañez

Romero Arenas

Hsu

Nfonsam

. Race, gender, and international medical graduates: leadership trends in academic surgical societies. J Surg Res. 2022;270:430-436.

25.

Choinski

Lipsitz

Indes

, et al. Trends in sex and racial/ethnic diversity in applicants to surgery residency and fellowship programs. JAMA Surg. 2020;155(8):778-781.

26.

Sutherland

Sanchez

Baroutjian

Ali

McKenney

Elkbuli

. Gender, race, age, allopathic degree, board score, and research experience among applicants matching to general and orthopedic surgery residencies, 2015-2019. Am Surg. 2022;88(6):1207-1216.

27.

Woodyard

Lee

Ferguson

, et al. Surgical fellowships demonstrate variable improvement in gender representation despite greater female enrollment in general surgery residencies. J Surg Educ. 2023;80(8):1104-1112.

28.

Keshinro

Butler

Fayanju

, et al. Examination of intersectionality and the pipeline for black academic surgeons. JAMA Surg. 2022;157(4):327-334.

29.

Butler

Longaker

Britt

. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg. 2008;248(5):704-709.

30.

Berry

Khabele

Johnson-Mann

, et al.

A call to action: Black/African American women surgeon scientists, where are they?

Ann Surg. 2020;272(1):24-29.

31.

Keshinro

Frangos

Berman

, et al. Underrepresented minorities in surgical residencies: where are they? A call to action to increase the pipeline. Ann Surg. 2020;272(3):512-520.

32.

Carter

Badejo

Ogola

Waddimba

Fleshman

JWJ

Harrington

MAJ

. National trends in distribution of underrepresented minorities within United States general surgery residency programs: A longitudinal panel study. Am J Surg. 2023;225(6):1000-1008. doi:10.1016/j.amjsurg.2023.01.011

33.

Eruchalu

Etheridge

Hammaker

, et al. Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium. Ann Surg. 2024;279(1):172-179. doi:10.1097/SLA.0000000000005848

34.

Nieblas-Bedolla

Williams

Christophers

Kweon

Williams

Jimenez

. Trends in Race/Ethnicity Among Applicants and Matriculants to US Surgical Specialties, 2010-2018. JAMA Netw Open. 2020;3(11):e2023509. doi:10.1001/jamanetworkopen.2020.23509

35.

Didier

Creeden

Pannell

Sutton

. Trends in Racial and Gender Diversity Among Complex General Surgical Oncology Fellowship Trainees. Ann Surg Oncol. 2023;30(11):6824-6834. doi:10.1245/s10434-023-13743-6.

36.

AYL

Iwai

Thomas

Beasley

Sudan

Fayanju

. Trends in Racial, Ethnic, and Sex Representation Among Surgical Faculty Members and Medical Students in the US, 2011-2020. JAMA Surg. 2021;156(12):1177-1179. doi:10.1001/jamasurg.2021.4904

37.

Aguwa

Onor

, et al. Racial and ethnic diversity within U.S. Residencies: trends from 2011 to 2019. J Surg Educ. 2022;79(3):587-594.

38.

Cazorla-Morales

Chan

Mikhail

, et al.

The Accreditation Council for Graduate Medical Education 20-Year Trends in Diversity, Equity, and Inclusion in the United States: How Does Neurological Surgery Compare?

World Neurosurg. 2024;185:e969-e975. doi:10.1016/j.wneu.2024.03.007

39.

Eruchalu

Etheridge

, et al. Gender Racial/Ethnic Disparities in Operative Volumes of Graduating General Surgery Residents. J Surg Res. 2022;279:104-112. doi:10.1016/j.jss.2022.05.020

40.

Bowe

Wang

Whipple

Bly

. Evidence of Specialty-Specific Gender Disparities in Resident Recruitment and Selection. J Grad Med Educ. 2021;13(6):841-847. doi:10.4300/JGME-D-21-00337.1

41.

Kuo

Lyu

Jarman

, et al. Gender Disparity in Awards in General Surgery Residency Programs. JAMA Surg. 2020;156(1):60-66. doi:10.1001/jamasurg.2020.3518

42.

Kim

Pendleton

Boitano

, et al. The Changing Demographics of Surgical Trainees in General and Vascular Surgery: National Trends over the Past Decade. J Surg Educ. 2021;78(6):2117-2126. doi:10.1016/j.jsurg.2021.05.002

43.

Stephens

Heisler

Temkin

Miller

. The Current Status of Women in Surgery: How to Affect the Future. JAMA Surg. 2020;155(9):876-885. doi:10.1001/jamasurg.2020.0312

44.

Bennett

Baker

Rangel

Marsh

. The gender gap in surgical residencies. JAMA Surg. 2020;155(9):893-894.

45.

Arya

Franco-Mesa

Erben

. An analysis of gender disparities amongst United States medical students, general surgery residents, vascular surgery trainees, and the vascular surgery workforce. J Vasc Surg. 2022;75(1):5-9.

46.

Gelhard

O’Brien

Vincenti

, et al.

Disparities in Gender and Diversity Representation Among Surgical Subspecialties: Are we Losing Momentum?

J Surg Res. 2024;293:413-419.

47.

Matriculants to U.S . MD-granting medical schools by race/ethnicity (alone) and state of legal. Association of American Medical Colleges (AAMC): https://www.aamc.org/media/6041/download. Accessed October 30, 2024.

48.

Greenwood

Hardeman

Huang

Sojourner

. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci USA. 2020;117(35):21194-21200. doi:10.1073/pnas.1913405117

49.

Alsan

Garrick

Graziani

. Does diversity matter for health: experimental evidence from Oakland. Am Econ Rev. 2019;109(12):4071-4111.

50.

Evans

Rosenbaum

Malina

Morrissey

Rubin

. Diagnosing and Treating Systemic Racism. N Engl J Med. 2020;383(3):274-276. doi:10.1056/NEJMe2021693

51.

Greenwood

Carnahan

Huang

. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci. 2018;115(34):8569-8574. doi:10.1073/pnas.1800097115

52.

Moy

Bartman

. Physician race and care of minority and medically indigent patients. JAMA. 1995;273(19):1515-1520.

53.

Marrast

Zallman

Woolhandler

Bor

McCormick

. Minority physicians' role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med. 2014;174(2):289-291.

54.

Clarke

. Disparities in Creating a Diverse Surgical Oncology Physician Workforce: Just a Leaky Pipeline? Surg Oncol Clin N Am. 2022;31(1):21-27. doi:10.1016/j.soc.2021.07.004

55.

King

Turner

Stewart

. Current state and need for more black surgeons in academic surgery. Am J Surg. 2022;224(1):299-301. doi:10.1016/j.amjsurg.2022.02.040