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Medical Education and Training

Experiences of LGBTQ+ Residents in US General Surgery Training Programs

Educational Objective To determine the national prevalence of mistreatment and poor well-being for lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) surgery residents compared with their non-LGBTQ+ peers.

1 Credit CME

JAMA Surgery

Published Online: October 20, 2021

Original Investigation

Article Information and Disclosures

Evan A. Heiderscheit, BS¹;

Cary Jo R. Schlick, MD, MS¹;

Ryan J. Ellis, MD, MS¹;

Elaine O. Cheung, PhD²;

Dre Irizarry, MD³;

Daniela Amortegui, MA¹;

Joshua Eng, PhD¹;

Julie Ann Sosa, MD, MA⁴;

David B. Hoyt, MD⁵;

Jo Buyske, MD⁶;

Thomas J. Nasca, MD⁷;

Karl Y. Bilimoria, MD, MS¹;

Yue-Yung Hu, MD, MPH^1,8

Author Affiliations

¹Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
²Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
³Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford University, Palo Alto, California
⁴Department of Surgery, University of California, San Francisco
⁵American College of Surgeons, Chicago, Illinois
⁶American Board of Surgery, Philadelphia, Pennsylvania
⁷Accreditation Council for Graduate Medical Education, Chicago, Illinois
⁸Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois

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Key Points

Question How do rates of self-reported mistreatment and sources of mistreatment vary between lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) general surgery residents and their non-LGBTQ+ peers?

Findings In this survey study of 6381 surgical residents, LGBTQ+ general surgery residents reported higher rates of discrimination, harassment, and bullying than their non-LGBTQ+ peers, with attending surgeons as the most common source. Despite reporting similar career satisfaction, LGBTQ+ residents were twice as likely to consider leaving their program and/or have thoughts of suicide.

Meaning Mistreatment is a common experience for LGBTQ+ general surgery residents, and multifaceted interventions are necessary to develop safer and more inclusive learning environments.

Abstract

Importance Previous studies have shown high rates of mistreatment among US general surgery residents, leading to poor well-being. Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) residents represent a high-risk group for mistreatment; however, their experience in general surgery programs is largely unexplored.

Objective To determine the national prevalence of mistreatment and poor well-being for LGBTQ+ surgery residents compared with their non-LGBTQ+ peers.

Design, Setting, and Participants A voluntary, anonymous survey adapting validated survey instruments was administered to all clinically active general surgery residents training in Accreditation Council for Graduate Medical Education–accredited general surgery programs following the 2019 American Board of Surgery In-Training Examination.

Main Outcomes and Measures Self-reported mistreatment, sources of mistreatment, perceptions of learning environment, career satisfaction, burnout, thoughts of attrition, and suicidality. The associations between LGBTQ+ status and (1) mistreatment, (2) burnout, (3) thoughts of attrition, and (4) suicidality were examined using multivariable regression models, accounting for interactions between gender and LGBTQ+ identity.

Results A total of 6956 clinically active residents completed the survey (85.6% response rate). Of 6381 respondents included in this analysis, 305 respondents (4.8%) identified as LGBTQ+ and 6076 (95.2%) as non-LGBTQ+. Discrimination was reported among 161 LGBTQ+ respondents (59.2%) vs 2187 non-LGBTQ+ respondents (42.3%; P < .001); sexual harassment, 131 (47.5%) vs 1551 (29.3%; P < .001); and bullying, 220 (74.8%) vs 3730 (66.9%; P = .005); attending surgeons were the most common overall source. Compared with non-LGBTQ+ men, LGBTQ+ residents were more likely to report discrimination (men: odds ratio [OR], 2.57; 95% CI, 1.78-3.72; women: OR, 25.30; 95% CI, 16.51-38.79), sexual harassment (men: OR, 2.04; 95% CI, 1.39-2.99; women: OR, 5.72; 95% CI, 4.09-8.01), and bullying (men: OR, 1.51; 95% CI, 1.07-2.12; women: OR, 2.00; 95% CI, 1.37-2.91). LGBTQ+ residents reported similar perceptions of the learning environment, career satisfaction, and burnout (OR, 1.22; 95% CI, 0.97-1.52) but had more frequent considerations of leaving their program (OR, 2.04; 95% CI, 1.52-2.74) and suicide (OR, 1.95; 95% CI, 1.26-3.04). This increased risk of suicidality was eliminated after adjusting for mistreatment (OR, 1.47; 95% CI, 0.90-2.39).

Conclusions and Relevance Mistreatment is a common experience for LGBTQ+ surgery residents, with attending surgeons being the most common overall source. Increased suicidality among LGBTQ+ surgery residents is associated with this mistreatment. Multifaceted interventions are necessary to develop safer and more inclusive learning environments.

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Article Information

Accepted for Publication: August 10, 2021.

Published Online: October 20, 2021. doi:10.1001/jamasurg.2021.5246

Corresponding Author: Yue-Yung Hu, MD, MPH, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL 60611 (yue-yung.hu@northwestern.edu).

Author Contributions: Dr Hu 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. Mr Heiderscheit and Dr Schlick contributed equally to this work.

Study concept and design: Heiderscheit, Ellis, Irizarry, Eng, Hoyt, Bilimoria, Hu.

Acquisition, analysis, or interpretation of data: Heiderscheit, Schlick, Ellis, Cheung, Amortegui, Eng, Sosa, Hoyt, Buyske, Nasca, Bilimoria, Hu.

Drafting of the manuscript: Heiderscheit, Hoyt, Hu.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Heiderscheit, Schlick, Eng, Bilimoria, Hu.

Obtained funding: Nasca, Bilimoria, Hu.

Administrative, technical, or material support: Ellis, Amortegui, Hoyt, Buyske, Nasca, Hu.

Study supervision: Ellis, Cheung, Sosa, Hoyt, Bilimoria, Hu.

Conflict of Interest Disclosures: Dr Sosa has received institutional research funding from Exelixis and Eli Lilly and is a member of the data monitoring committee of the Medullary Thyroid Cancer Consortium Registry, which is supported by GlaxoSmithKline, NovoNordisk, AstraZeneca, and Eli Lilly. Drs Bilimoria and Hu have received grants for serving as co–principal investigators of the SECOND trial from the American College of Surgeons and the Accreditation Council for Graduate Medical Education as well as nonfinancial support from the American Board of Surgery. No other disclosures were reported.

Funding/Support: Funding for this work was provided by the Accreditation Council for Graduate Medical Education and American College of Surgeons. The American Board of Surgery provided in-kind support. Dr Ellis was supported by a postdoctoral research fellowship from the Agency for Healthcare Research and Quality (grant 5T32HS000078).

Role of the Funder/Sponsor: The funding agencies had no role in the design and conduct of the study; analysis of data; preparation or review of the manuscript; and decision to submit the manuscript for publication. Authors affiliated with funding agencies were involved in the collection and interpretation of the data and review and approval of the manuscript.

Disclaimer: The views expressed in this work represent those of the authors only.

Meeting Information: This paper was presented at the Academic Surgical Congress; February 4 and 6, 2020; Orlando, Florida.

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 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.