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Assessment of Autonomy in Operative Procedures Among Female and Male New Zealand General Surgery Trainees

Educational Objective
To identify the role of trainee sex in assessments of the level of procedural autonomy in New Zealand general surgery residents.
1 Credit CME
Key Points

Question  Does trainee sex play a role in assessing the level of procedural autonomy a trainee receives during the New Zealand general surgery training program?

Findings  In this 5-year cohort study that included 119 380 general surgery procedures performed by 120 trainees, female trainees performed fewer endoscopic, major, and minor procedures autonomously than their male counterparts.

Meaning  Results of this study suggest that female trainees are more likely to receive less procedural autonomy throughout their general surgery training program in New Zealand.


Importance  The need for trainee sex equality within surgical training has resulted in an appraisal of the training experience in the New Zealand general surgery training program.

Objective  To investigate the association between trainee sex and surgical autonomy in the operating room in the New Zealand general surgery training program.

Design, Setting, and Participants  Retrospective cohort study conducted from December 10, 2012, to December 10, 2017, examining all endoscopic, major, and minor procedures performed by all New Zealand general surgery trainees in every training hospital in New Zealand.

Main Outcomes and Measures  The primary outcome was the level of meaningful autonomy by each New Zealand general surgery trainee (ie, trainee as primary operator without the surgeon mentor scrubbed for the case). Outcomes were compared using multivariable analysis.

Results  This study included 120 New Zealand general surgery trainees (42 women [35%] and 78 men [65%]) who were analyzed over 279.5 trainee-years (88.5 trainee-years for women and 191.0 trainee-years for men). Included were 119 380 general surgery procedures (17 465 endoscopic, 56 964 major, and 44 951 minor) in 18 hospitals. By the end of the 5-year training program, female trainees had a lower cumulative mean autonomous caseload than male trainees for endoscopic (284.0 [95% CI, 207.0-361.0] vs 352.2 [95% CI, 282.9-421.6], P = .03), major (139.9 [95% CI, 76.7-203.2] vs 198.1 [95% CI, 142.3-254.0], P = .02), and minor (456.3 [95% CI, 394.8-517.9] vs 519.9 [95% CI, 465.6-574.2], P = .007) procedures.

Conclusions and Relevance  After accounting for differences among trainees, hospital type, number of female and male surgeon mentors at each hospital, and trainee seniority, female trainees performed fewer cases with meaningful autonomy compared with male trainees. These findings support the need for pragmatic solutions to address this bias and further investigations on mechanisms contributing to discrepancies.

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Article Information

Accepted for Publication: May 4, 2020.

Corresponding Author: Benjamin P. T. Loveday, MBChB, PhD, Department of Surgery, The University of Auckland, Auckland, New Zealand 1023 (b.loveday@auckland.ac.nz).

Published Online: August 26, 2020. doi:10.1001/jamasurg.2020.3021

Author Contributions: Dr Loveday had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Watson, Loveday.

Acquisition, analysis, or interpretation of data: Joh, van der Werf, French, Bann, Dennett, Loveday.

Drafting of the manuscript: Joh, van der Werf, Dennett, Loveday.

Critical revision of the manuscript for important intellectual content: van der Werf, Watson, French, Bann, Dennett, Loveday.

Statistical analysis: van der Werf, Loveday.

Administrative, technical, or material support: Dennett, Loveday.

Supervision: Bann, Loveday.

Conflict of Interest Disclosures: None reported.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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