AATS/WTS DEI: Bridging the Gap in CT Surgery | In Collaboration with AATS and WTS

Objective: Systemic gender bias remains prominent in cardiothoracic surgery, including inequities in the number of women in the field, compensation, mentorship, and leadership opportunities. Entry into cardiothoracic surgery, application for residency, and letters of recommendation are potential mechanisms for gender disparity. Our goal was to investigate if gender influences letters of recommendation for cardiothoracic fellowship.

Methods: From applications to an accredited cardiothoracic surgery fellowship program between 2016 and 2021, applicant and author characteristics were examined with descriptive statistics, analysis of variance, and Pearson-Chi square tests. Letters of recommendation were assessed using linguistic analysis software for differences in communication with respect to author and applicant gender, with higher-level analysis through a Generalized Estimating Equations model of linguistic differences among author-applicant gender pairs.

Results: 739 recommendation letters extracted from 196 applications of individuals were analyzed; 90% (n=665) of authors were male and 55.8% (n=412) of authors were cardiothoracic surgeons. Compared to female authors, male authors wrote more informal (p=0.03) and authentic (p=0.01) recommendation letters. When writing for female applicants, male-authored letters were more likely to display their own leadership and status (p=0.03) and discuss female applicants' social affiliations (p=0.01), like occupation of applicant's father or husband. In contrast, male authors emphasized male applicants' technical abilities (p=0.01). Female authors wrote longer letters (p=0.03) and discussed applicants' work (p=0.01) more often than male authors. They also mentioned leisure activities (p=0.03) more often when writing for female applicants.

Conclusions: Our work identifies gender-specific differences in letters of recommendation. Female applicants are potentially disadvantaged because their recommendation letters are significantly more likely to focus on their social ties, leisure activities, and the status of the letter-writer, while recommendation letters of male colleagues focus on technical skill. Our study identifies an opportunity for individual authors of recommendation letters, applicant review committees, and our professional societies to mitigate gender bias in the selection of candidates to cardiothoracic surgery. 

Objective
Underrepresented minorities (URM) account for less than 6 percent of physicians and 2 percent of cardiothoracic surgeons. Many structural inequities account for this low representation, including lack of exposure to healthcare opportunities and a paucity of minority role models among URM students. Our goal was to determine the impact of participation in a cardiothoracic surgery-guided mentorship program on perceptions of medicine and surgery by URM students.
Methods
From 2016 to 2022, an academic division of cardiothoracic surgery conducted an annual mentorship program across eight high schools for URM students. In Phase 1, a minority physician visited the participating high schools, discussed life as a cardiothoracic surgeon and obstacles faced during training. In Phase 2, students were invited to the surgical simulation center or microanatomy lab to perform various imaging (ultrasound) and surgical procedures on cadaveric specimens that engaged them in "hands-on" practice. In Phase 3, selected applicants were awarded a summer internship and given a stipend. During the two-month internship, they attended weekly simulation sessions organized by the division of cardiothoracic surgery.
Results
Over the study period, the number of applicants for the summer internship increased from 11 in 2017 to 438 in 2022. Students involved in Phase 2 had a statistically significant increase in post-participation survey scores when asked about interest in becoming a surgeon, choosing a college major and having the manual dexterity necessary to become a surgeon (Table 1). All students involved in Phase 3 described the program as favorable, including comments such as "taught me to set my goals ridiculously high" and "it was important to see people that look like me doing the job that I wanted to do."
Conclusions
Cardiothoracic surgery divisions can positively influence URM students with a structured mentorship program that includes surgical simulation and exposure to minority physicians. Students who participate develop increased self-confidence in their ability to become a physician. Over time, an increased number of URM students may thus express interest and pursue careers in cardiothoracic surgery. Ongoing exposure of URM students to URM surgeons will decrease the "leaky pipeline" and reduce disparities in medicine and surgery. 

Objectives: The purpose of our study was to examine changes in the demographic makeup of I6 residency and thoracic fellowship programs from 2012- 2022 compared to vascular surgery, general surgery (GS), and orthopedic surgery (OS) residency programs. Additionally, we sought to better understand where leaks in the training pathway to thoracic surgery exist for women, Black, and Hispanic medical students.

Methods: Data from U.S. Graduate Medical Education reports from 2012-2022 and medical student enrollment data from the Association of American Medical Colleges were obtained. Average percentages of women and underrepresented minorities were then calculated in two 5-year intervals: 2013-2017 and 2018-2022. Average percentages of women, Black, and Hispanic medical students were calculated for the 2019-22 period. Simple statistics using Pearson Chi-Squared tests were conducted to determine significant differences in proportions of women, Black/African-American, and Hispanic trainees across time. Significance levels were set at α = 0.05.

Results: Thoracic surgery fellowship and I6 residency programs saw a significant increase in women trainees across the two time periods (19.9% [210/1055] to 24.6% [87/1169], p<0.01 and 24.1% [143/592] to 28.9% [330/1142], p<0.05). A similarly significant increase in women trainees was seen in GS and OS. The percentage of Black GS residents decreased significantly across this period (6% [2430/40531] to 5.6% [2626/47033], p<0.01), while the percentage of Hispanics increased in OS and GS residents increased significantly (5.2% [936/17935] to 6.2% [1296/20845], p<0.01 and 8.3% [3373/40531] to 9.3% [4390/47033], p<0.01). There was no significant change in Black and Hispanic residents in thoracic fellowships or I6 programs. In comparison to medical school representation, Hispanic trainees were the only group whose proportion of thoracic fellows and GS residents significantly increased (p<0.05 and p<0.01). However, women and Black trainees had significantly lower proportions of thoracic fellows and I6 residents than their proportions in medical school (p<0.01).

Conclusions: The field of cardiothoracic surgery has not significantly increased the number of Black and Hispanic residents in the past decade. The lower proportion of Blacks and women in thoracic residency and fellowship compared to their proportion in medical school is an area of concern and an opportunity for intervention by institutions and national societies. 

Objective: Diversity in the physician workforce improves patient care, physician well-being and innovation in a rapidly changing healthcare environment. Attaining workforce diversity is influenced by fair compensation that is unbiased by race or ethnicity. We examined the relationship between the race/ethnicity of academic cardiothoracic surgeons and salary compensation.

Methods: We performed a cross-sectional analysis of data collected by Association of American Medical Colleges (AAMC) Faculty Data for U.S. Medical School Faculty 2021 which reports specialty as Thoracic and Cardiac Surgeons, academic rank, race/ethnicity, and mean and median compensation. Salary data were not available if an academic rank and race/ethnicity had fewer than 5 cardiothoracic surgeons. We used descriptive analysis of the number of faculty and median and mean salaries according to academic rank and compared them using a paired t-test.

Results: Of 786 cardiothoracic surgeons in academic medicine, 65.6% were White, 25.2% were Asian, 4.0% were Hispanic/Latino, 3.3% were Black/African American, 1.5% were multiple/other race and 0.4% were American Indian/Alaskan Indian. Cardiothoracic surgeons at the academic rank of professor were 78% White, 15% Asian, 3% Hispanic/Latino and 2% Black/African American. Asian cardiothoracic surgeons earned 71-102%, Hispanic/Latino cardiothoracic surgeons earned 86-130%, and Black/African American cardiothoracic surgeons earned 76-85% of the mean and median salary earned by White cardiothoracic surgeons. Black/African American cardiothoracic surgeons were consistently and significantly (p=0.002) earning lower median salaries compared to their White colleagues at every academic rank.

Conclusion: The academic cardiothoracic surgery workforce lacks diversity, especially at the highest academic rank of professor. Salary equity among races/ethnicities is complex, requiring additional study. However, Black/African American cardiothoracic surgeons experience low representation and salary disparity at every academic rank. This data informs principal parties who negotiate salary compensation of potential unconscious biases and establishes a need for assessment and mitigation of inequity based on race/ethnicity. 

Objective: Recent data suggests that female patients may have better outcomes from cardiothoracic (CT) surgical intervention when under the care of female surgeons. An increasing number of women pursue medical training, but it is not clear if that is translating into an increased number and access to female cardiothoracic surgeons. Our purpose was to assess recent trends in access by geographical region.

Methods: We accessed the Medicare Provider Utilization and Payment Database from 2013 to 2019 and generated a list of cardiothoracic surgeons submitting to that database. Data was extracted for 88 CPT codes for major aortic, valve, and revascularization procedures. These data were used to compare cases by gender of the surgeon across the United States.

Results: 2435 CT surgeons were identified in the database. From 2013 to 2019, the percentage of female surgeons reporting in all categories rose from 64/2076 (3.08%) to 122/2435 (5.01%). Cochran-Armitage Trend test showed a statistically significant increase in the proportion of female surgeons over time (p < 0.0001). Volumes in non-CABG operations by female surgeons were minimal. In 2019, there were 107 female surgeons who performed CABGs in the database. The ten states with the greatest number of female surgeons performing CABG were California (12 surgeons), Massachusetts, New York, Pennsylvania (all 7), Michigan, Illinois, and Ohio (all 5) and Georgia, Missouri, and Texas (all 4). 14 states (28%) did not have a reported female CT surgeon in the Medicare database. Figure 1 is a representation of the number of female cardiac surgeons by state.

Conclusions: Review of Medicare Provider Utilization Database indicates that female CT surgeons are still a significant minority of the total available providers in cardiothoracic care. This suggests a potential care gap for female patients considering recent data suggesting female patients have improved outcomes when under the care of female providers. Hearteningly, the data indicate slow but steady growth in the proportion of female cardiothoracic surgeons. There is pronounced regional variation in the availability of female providers favoring the Northeast and Western regions of the US. This may reflect differences in regional recruitment, reimbursement, or reporting that could be additional avenues of study to determine if there are modifiable factors that could improve access to female surgeons. There continues to be a large gender disparity in CT care 

Objective:Women continue to be underrepresented in academia. Society leadership plays a vital role in the academic career exerting considerable influence among the specialty. This study aimed to delineate gender representation in the lead role of presidents of cardiothoracic surgery societies worldwide.
Methods:A comprehensive search was performed to identify various cardiothoracic surgical societies worldwide and divided by regions of Northern America, Southern America, Europe, Asia, Africa, Australia and international societies. The society data obtained was further cross verified with the societies list available on CTSNet.org. Respective societies official webpage was searched to extract data on past and present presidents. If one individual was elected as a president in two different societies,it was considered as two presidencies; however, if one individual remained the president in one respective society for two consecutive terms, we considered this as single presidency. Gender was determined and verified via publicly available online profiles. The 95% confidence interval (CI) of proportion was calculated using Binomial exact calculation. All analyses were computed in R statistical software version 4.1.2.
Results: A total of 34 societies pertaining to cardiothoracic surgery were identified globally. Of these, 19 societies were from the Northern America, 1 from Southern America, 5 from Europe, 4 from Asia, 2 from Africa, 1 from Australia and 2 international societies. Of the 34 societies identified, only 16 societies provided complete information about their past and present presidents in the public domain. Among these 16 societies, a total of 535 past and current society presidents were identified. Women constituted only 11 [2.06%; 95% CI:1.03%; 3.65%] of the total 535 presidents. The absolute distribution of female presidents based on continent is delineated in Figure 1. The proportion of female past and current presidents in the North American continent was 2.31%; 95% CI:1.06%; 4.35%, whilst, in the Europe was 1.68%; 95% CI:0.20%; 5.94%. Furthermore, the first female president was appointed in the year 2007 across societies.
Conclusion: A stark lag exists in the gender distribution of presidential roles of the cardiothoracic societies globally with paucity of women. Although, there has been increasing inclusion of women in the last two decades, definitive measures are imperative to identify and mitigate the disparities to improve inclusion.