Clin Colon Rectal Surg 2023; 36(05): 315-320
DOI: 10.1055/s-0043-1763519
Review Article

Surgical Education: Disparities in Education May Impact the Quality and Likelihood of Completion of Training

Asya Ofshteyn
1   Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
Emily Steinhagen
2   Division of Colorectal, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
› Author Affiliations


Female surgical trainees experience bias that begins at the preclinical stages of medical school, extending into their surgery clerkships, and then into their residency training. There are important implications in terms of training opportunities and career advancement, mentorship, sponsorship, and ultimately burnout. Childbearing and lactation also impact the experiences and perceptions of female trainees who have children. There are limited interventions that have improved the experience of women in surgical training. Mentorship appears to play an important role in ameliorating some of the negative consequences of the training environment and improving outcomes for women surgeons.

Publication History

Article published online:
08 March 2023

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  • References

  • 1 2019 Fall Applicant, Matriculant, and Enrollment Data Tables. AAMC. Accessed September 15, 2022 at:
  • 2 Park J, Minor S, Taylor RA, Vikis E, Poenaru D. Why are women deterred from general surgery training?. Am J Surg 2005; 190 (01) 141-146
  • 3 McCord JH, McDonald R, Leverson G. et al. Motivation to pursue surgical subspecialty training: is there a gender difference?. J Am Coll Surg 2007; 205 (05) 698-703
  • 4 Peel JK, Schlachta CM, Alkhamesi NA. A systematic review of the factors affecting choice of surgery as a career. Can J Surg 2018; 61 (01) 58-67
  • 5 Williams C, Cantillon P. A surgical career? The views of junior women doctors. Med Educ 2000; 34 (08) 602-607
  • 6 Gofin Y, Afek A, Derazne E, Toker A, Shamiss A. A model for assessing the gap between physician residency demand and present status. Isr Med Assoc J 2012; 14 (05) 275-280
  • 7 O'Connor MI. Medical school experiences shape women students' interest in orthopaedic surgery. Clin Orthop Relat Res 2016; 474 (09) 1967-1972
  • 8 Cook MR, Yoon M, Hunter J, Kwong K, Kiraly L. A nonmetropolitan surgery clerkship increases interest in a surgical career. Am J Surg 2015; 209 (01) 21-25
  • 9 ACGME Residents and Fellows by Sex and Specialty, 2019. AAMC. Accessed on September 15, 2022 at:
  • 10 Wolbrom DH, Brunt LM, Lidor A, Jeyarajah DR, Mattar SG, Pryor A. Gender disparities in gastrointestinal surgery fellowship programs. Surg Endosc 2022; 36 (06) 3805-3810
  • 11 Arora TK, Dent D, Morris-Wiseman L, Nfonsam V. Diversity in the last decade of the association of program directors in surgery: a descriptive analysis of leadership and future directions. J Surg Educ 2019; 76 (06) e125-e131
  • 12 Barnes KL, McGuire L, Dunivan G, Sussman AL, McKee R. Gender bias experiences of female surgical trainees. J Surg Educ 2019; 76 (06) e1-e14
  • 13 Lim WH, Wong C, Jain SR. et al. The unspoken reality of gender bias in surgery: a qualitative systematic review. PLoS One 2021; 16 (02) e0246420
  • 14 Hu Y-Y, Ellis RJ, Hewitt DB. et al. Discrimination, abuse, harassment, and burnout in surgical residency training. N Engl J Med 2019; 381 (18) 1741-1752
  • 15 Dahlke AR, Johnson JK, Greenberg CC. et al. Gender differences in utilization of duty-hour regulations, aspects of burnout, and psychological well-being among general surgery residents in the United States. Ann Surg 2018; 268 (02) 204-211
  • 16 Bernardi K, Shah P, Lyons NB. et al. Perceptions on gender disparity in surgery and surgical leadership: a multicenter mixed methods study. Surgery 2020; 167 (04) 743-750
  • 17 Rudman LA, Glick P. Feminized management and backlash toward agentic women: the hidden costs to women of a kinder, gentler image of middle managers. J Pers Soc Psychol 1999; 77 (05) 1004-1010
  • 18 Myers SP, Hill KA, Nicholson KJ. et al. A qualitative study of gender differences in the experiences of general surgery trainees. J Surg Res 2018; 228: 127-134
  • 19 Liang R, Dornan T, Nestel D. Why do women leave surgical training? A qualitative and feminist study. Lancet 2019; 393 10171 541-549
  • 20 Webster F, Rice K, Christian J. et al. The erasure of gender in academic surgery: a qualitative study. Am J Surg 2016; 212 (04) 559-565
  • 21 Williams J, Phillips KW, Hall EV. . Double Jeopardy? Gender Bias Against Women of Color in Science. Berkeley, CA: Hastings College of the Law, Center for WorkLife Law; 2014
  • 22 Hutchison K. Four types of gender bias affecting women surgeons and their cumulative impact. J Med Ethics 2020; 46 (04) 236-241
  • 23 Elmore LC, Jeffe DB, Jin L, Awad MM, Turnbull IR. National survey of burnout among US general surgery residents. J Am Coll Surg 2016; 223 (03) 440-451
  • 24 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
  • 25 Hinze SW. ‘Am I being over-sensitive?’ Women's experience of sexual harassment during medical training. Health 2004; 8 (01) 101-127
  • 26 Kinslow K, Sutherland M, McKenney M, Elkbuli A. Reported burnout among U.S. general surgery residents: a survey of the association of program directors in surgery members. Ann Med Surg (Lond) 2020; 60: 14-19
  • 27 Rotenstein LS, Torre M, Ramos MA. et al. Prevalence of burnout among physicians: a systematic review. JAMA 2018; 320 (11) 1131-1150
  • 28 Meyerson SL, Odell DD, Zwischenberger JB. et al; Procedural Learning and Safety Collaborative. The effect of gender on operative autonomy in general surgery residents. Surgery 2019; 166 (05) 738-743
  • 29 Meyerson SL, Sternbach JM, Zwischenberger JB, Bender EM. The effect of gender on resident autonomy in the operating room. J Surg Educ 2017; 74 (06) e111-e118
  • 30 Chen JX, Chang EH, Deng F. et al. Autonomy in the operating room: a multicenter study of gender disparities during surgical training. J Grad Med Educ 2021; 13 (05) 666-672
  • 31 Hoops H, Heston A, Dewey E, Spight D, Brasel K, Kiraly L. Resident autonomy in the operating room: does gender matter?. Am J Surg 2019; 217 (02) 301-305
  • 32 Cookenmaster C, Shebrain S, Vos D, Munene G, Miller L, Sawyer R. Gender perception bias of operative autonomy evaluations among residents and faculty in general surgery training. Am J Surg 2021; 221 (03) 515-520
  • 33 Lane SM, Young KA, Hayek SA. et al. Meaningful autonomy in general surgery training: Exploring for gender bias. Am J Surg 2020; 219 (02) 240-244
  • 34 Thompson-Burdine J, Sutzko DC, Nikolian VC. et al. Impact of a resident's sex on intraoperative entrustment of surgery trainees. Surgery 2018; 164 (03) 583-588
  • 35 Lind D, Rekkas S, Bui V. et al. Competency-based student self-assessment on a surgery rotation. J Surg Res 2002; 105 (01) 31-34
  • 36 Minter RM, Gruppen LD, Napolitano KS, Gauger PG. Gender differences in the self-assessment of surgical residents. Am J Surg 2005; 189 (06) 647-650
  • 37 Anderson JE, Zern NK, Calhoun KE, Wood DE, Smith CA. Assessment of potential gender bias in general surgery resident milestone evaluations. JAMA Surg 2022; 157 (12) 1164-1166
  • 38 Kwasny L, Shebrain S, Munene G, Sawyer R. Is there a gender bias in milestones evaluations in general surgery residency training?. Am J Surg 2021; 221 (03) 505-508
  • 39 Axelson RD, Solow CM, Ferguson KJ, Cohen MB. Assessing implicit gender bias in medical student performance evaluations. Eval Health Prof 2010; 33 (03) 365-385
  • 40 Gerull KM, Loe M, Seiler K, McAllister J, Salles A. Assessing gender bias in qualitative evaluations of surgical residents. Am J Surg 2019; 217 (02) 306-313
  • 41 Turrentine FE, Dreisbach CN, St Ivany AR, Hanks JB, Schroen AT. Influence of gender on surgical residency applicants' recommendation letters. J Am Coll Surg 2019; 228 (04) 356-365.e3
  • 42 Jodeh D, Miller-Ocuin J, Ginesi M, Steinhagen E, Abelson J, Saraidaridis J. The effect of gender on narrative letters of recommendation for colorectal residency. Dis Colon Rectum 2022; 65 (05) e383-e656
  • 43 French JC, Zolin SJ, Lampert E. et al. Gender and letters of recommendation: a linguistic comparison of the impact of gender on general surgery residency applicants. J Surg Educ 2019; 76 (04) 899-905
  • 44 Khan S, Kirubarajan A, Shamsheri T, Clayton A, Mehta G. Gender bias in reference letters for residency and academic medicine: a systematic review. Postgrad Med J 2021; (e-pub ahead of print). DOI: 10.1136/postgradmedj-2021-140045.
  • 45 Klein R, Julian KA, Snyder ED. et al; From the Gender Equity in Medicine (GEM) workgroup. Gender bias in resident assessment in graduate medical education: review of the literature. J Gen Intern Med 2019; 34 (05) 712-719
  • 46 Ofshteyn A, Steinhagen E, Stein SL. Despite a match communication code of conduct, applicants continue to be asked inappropriate questions. Dis Colon Rectum 2021; 64 (05) 508-510
  • 47 Hern Jr HG, Trivedi T, Alter HJ, Wills CP. How prevalent are potentially illegal questions during residency interviews? A follow-up study of applicants to all specialties in the national resident matching program. Acad Med 2016; 91 (11) 1546-1553
  • 48 Ong TQ, Kopp JP, Jones AT, Malangoni MA. Is there gender bias on the American Board of Surgery General Surgery certifying examination?. J Surg Res 2019; 237: 131-135
  • 49 Nguyen J, Liu A, McKenney M, Elkbuli A. Predictive factors of first time pass rate on the American Board of Surgery Certification in general surgery exams: a systematic review. J Surg Educ 2021; 78 (05) 1676-1691
  • 50 Yeo HL, Dolan PT, Mao J, Sosa JA. Association of demographic and program factors with american board of surgery qualifying and certifying examinations pass rates. JAMA Surg 2020; 155 (01) 22-30
  • 51 Lyu HG, Davids JS, Scully RE, Melnitchouk N. Association of domestic responsibilities with career satisfaction for physician mothers in procedural vs nonprocedural fields. JAMA Surg 2019; 154 (08) 689-695
  • 52 Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg 2016; 212 (04) 566-572.e1
  • 53 Bingmer K, Ofshteyn A, Bliggenstorfer JT, Steinhagen E, Stein SL. Where is the leak in the surgeon pipeline?. Am J Surg 2020; 220 (05) 1174-1178
  • 54 Gerull KM, Wahba BM, Goldin LM. et al. Representation of women in speaking roles at surgical conferences. Am J Surg 2020; 220 (01) 20-26
  • 55 Mahendran GN, Walker ER, Bennett M, Chen AY. Suturing the gender gap through sponsorship: the role of sponsorship in female entry and advancement through their surgical careers. Am J Surg 2022; 224 (1 Pt B): 266-270
  • 56 Bettis J, Thrush CR, Slotcavage RL, Stephenson K, Petersen E, Kimbrough MK. What makes them different? An exploration of mentoring for female faculty, residents, and medical students pursuing a career in surgery. Am J Surg 2019; 218 (04) 767-771
  • 57 Yeo HL, Abelson JS, Mao J. et al. Who makes it to the end?: A novel predictive model for identifying surgical residents at risk for attrition. Ann Surg 2017; 266 (03) 499-507
  • 58 Ying Y, Dupre J, Bhanji F. Female surgical trainee recruitment and attrition - a 10-year national retrospective review. Am J Surg 2022; (e-pub ahead of print) DOI: 10.1016/J.AMJSURG.2022.07.020.
  • 59 British Fertility Society. Accessed September 10, 2022 at:
  • 60 Stack SW, Jagsi R, Biermann JS. et al. Childbearing decisions in residency: a multicenter survey of female residents. Acad Med 2020; 95 (10) 1550-1557
  • 61 Rangel EL, Lyu H, Haider AH, Castillo-Angeles M, Doherty GM, Smink DS. Factors associated with residency and career dissatisfaction in childbearing surgical residents. JAMA Surg 2018; 153 (11) 1004-1011
  • 62 Altieri MS, Salles A, Bevilacqua LA. et al. Perceptions of surgery residents about parental leave during training. JAMA Surg 2019; 154 (10) 952-958
  • 63 Leave Policy – General Surgery. American Board of Surgery. Accessed September 15, 2022 at:
  • 64 Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and parenthood among surgery residents: results of the first nationwide survey of general surgery residency program directors. J Am Coll Surg 2016; 222 (06) 1090-1096
  • 65 Rich A, Viney R, Needleman S, Griffin A, Woolf K. ‘You can’t be a person and a doctor': the work-life balance of doctors in training-a qualitative study. BMJ Open 2016; 6 (12) e013897