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General Orthopaedics

The correlation between trainee gender and operative autonomy during trauma and orthopaedic training in Ireland and the UK

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Abstract

Aims

The aim of this study was to explore differences in operative autonomy by trainee gender during orthopaedic training in Ireland and the UK, and to explore differences in operative autonomy by trainee gender with regard to training year, case complexity, index procedures, and speciality area.

Methods

This retrospective cohort study examined all operations recorded by orthopaedic trainees in Ireland and the UK between July 2012 and July 2022. The primary outcome was operative autonomy, which was defined as the trainee performing the case without the supervising trainer scrubbed.

Results

A total of 3,533,223 operations were included for analysis. Overall, male trainees performed 5% more operations with autonomy than female trainees (30.5% vs 25.5%; 95% CI 4.85 to 5.09). Female trainees assisted for 3% more operations (35% vs 32%; 95% CI 2.91 to 3.17) and performed 2% more operations with a supervising trainer scrubbed (39% vs 37%; 95% CI 1.79 to 2.06). Male trainees performed more operations with autonomy than female trainees in every year of training, in each category of case complexity, for each orthopaedic speciality area, and for every index procedure except nerve decompression. When adjusting for year, training level, case complexity, speciality area, and urgency, male trainees had 145% (95% CI 2.18 to 2.76) increased odds of performing an operation with autonomy and 35% (95% CI 1.25 to 1.45) increased odds of performing an operation under trainer supervision, than assisting, compared to female trainees.

Conclusion

Male trainees perform more operations with autonomy during orthopaedic training than female trainees. Female orthopaedic trainees assist for a greater proportion of cases than their male counterparts. A comprehensive review of trauma and orthopaedic training is needed to identify any additional differences in training opportunities between female and male trainees, particularly with regard to progression through training.

Cite this article: Bone Jt Open 2025;6(1):62–73.

Take home message

This paper evaluates ten years of operative logbook data for all orthopaedic trainees in Ireland and the UK for differences in operative training opportunities by trainee gender.

Female trainees perform 5% fewer operations with autonomy than male trainees during orthopaedic training in Ireland and the UK.

There is a greater difference in assisting rates in the earlier years of training, with female trainees assisting for 3% more operations in speciality training (ST) years 3, ST4, and ST5; however, by ST8 there is no difference in assisting rates.

Introduction

Operative competency is the fundamental objective of surgical training and is a progression metric for trauma and orthopaedic (T&O) trainees in Ireland and the UK. Trainees must log a minimum of 1,800 operations over six years, of which 1,260 must be performed as primary operator.1 There are 13 defined index surgical procedures that a trainee must be skilled in to allow independent practice. Trainees must achieve competency in these procedures by performing indicative numbers of each in order to be eligible for certification of completion of training.

Training programmes should ensure that training opportunities are equitable among trainees. There are numerous variables that will determine the number of cases an orthopaedic trainee performs during training and the degree of autonomy given to them. A previous study of UK T&O trainees reported no difference in autonomy between female and male trainees, but reported that male trainees perform 3% more cases as lead operator during training.2 This study was estimated to include 21% of UK orthopaedic trainees and was not powered to detect a difference in trainees in the later stages of training (speciality training (ST) years ST6 to ST8). To our knowledge, logbooks from the entire trainee cohort in Ireland and the UK have not been evaluated for differences in operative autonomy by trainee gender.

Orthopaedic surgery has the lowest number of women across all surgical and non-surgical specialities.3 Women in surgical training have higher attrition rates and are more likely to have their progression delayed during training than men.4-6 Women who do pursue a career in orthopaedics are more likely to practise in hand and paediatric orthopaedics, with smaller proportions of women practising in spine, hip, and knee subspecialities.7,8 Disparities between men and women in income, industry sponsorship, and leadership roles have been documented in orthopaedic surgery.9-11

Studies in the orthopaedic literature have shown that female orthopaedic surgeons have equivalent surgical outcomes to male orthopaedic surgeons.12,13 Furthermore, it has been shown more generally that patient outcomes are positively impacted in hospitals with higher proportions of female surgeons and anaesthetists.14-16 There is also evidence to suggest that patient-surgeon gender concordance influences patient outcomes, and it is likely that orthopaedic patients would benefit if the gender balance improved among orthopaedic consultant surgeons.17

The aim of this study was to explore potential differences in operative autonomy by trainee gender during orthopaedic training in Ireland and the UK. We hypothesized that there would be a difference in operative autonomy by trainee gender. The secondary aims of this study were to explore potential differences in operative autonomy by trainee gender with regard to training year, case complexity, index procedures, and speciality area.

Methods

Anonymized logbook data for all orthopaedic trainees with a national training number in Ireland and the UK between July 2012 and July 2022 were obtained from the Joint Committee on Surgical Training (JCST) and the Royal College of Surgeons in Ireland (RCSI). ST years ST3 to ST8 were included. Cases logged in ST1 and ST2 do not count towards certification and were therefore excluded. Gender was recorded as that reported by the trainee at the time of registration. Cases recorded as assisting (A), supervised trainer scrubbed (STS), supervised trainer unscrubbed (STU), performed (P), and training a junior colleague (T) were included. Cases recorded as observed (O) were excluded as the trainee is not scrubbed for the procedure. Autonomy was defined as the trainee performing the case without a supervising trainer scrubbed, i.e. STU, P, and T. Cases are categorized as complex major operation (CMO), major (MAJ), intermediate (INT), minor (MIN), and sub-minor (SUB) by the RCSI. Cases recorded as SUB were excluded as they do not contribute towards trainee progression or eligibility for certification. Procedures were classified by speciality area by two authors (RMC, DD) into eight categories; foot & ankle, hand & wrist, hip & femur, knee & lower leg, paediatrics, pelvis & acetabulum, shoulder & elbow, and spine.

Statistical analysis

Descriptive statistics (percentages) were used to summarize the data. Chi-squared and proportions tests were used to explore differences between autonomy and gender, complexity level, and year of training. The threshold for statistical significance was set at p = 0.05. Unadjusted and adjusted multivariable logistic regression models were used to explore potential associations between trainee gender and operative autonomy. Models were adjusted for year, training level, case complexity, index procedure, speciality area, and urgency, and results reported as odds ratios (ORs) and 95% CI. Statistical analysis was performed using Stata v. 18 (StataCorp, USA).

Results

A total of 3,666,809 T&O procedures were recorded during the study period. After excluding 9,310 cases recorded as O and 123,276 cases recorded as SUB, 3,533,223 cases were included for analysis. Female trainees recorded a total of 653,935 cases (18.5%) and male trainees recorded a total of 2,879,288 cases (81.5%).

Overall, female trainees performed 5% (95% CI -5.09 to -4.85) fewer operations with autonomy than male trainees (25.5% (n = 166,915) vs 30.5% (n = 878,315); p < 0.001). Female trainees assisted for 3% (95% CI 2.91 to 3.17) more cases (35% (n = 231,273) vs 32% (n = 930,661); p < 0.001) and performed 2% (95% CI 1.79 to 2.06) more cases with a supervising trainer scrubbed than their male counterparts (39% (n = 255,711) vs 37% (n = 1,070,312); p < 0.001). Male trainees had 40% increased odds of performing an operation with autonomy than assisting, and 5% increased odds of performing an operation under supervision than assisting, compared to female trainees in the unadjusted multivariable analysis (crude odds ratio (cOR) 1.4; 95% CI 1.38 to 1.43; p < 0.001; and cOR 1.05; 95% CI 1.03 to 1.06; p < 0.001). When controlling for the confounding factors of year, training level, case complexity, speciality area, and urgency, male trainees had 145% increased odds of performing an operation with autonomy than assisting, and 35% increased odds of performing an operation under trainer supervision than assisting, compared to female trainees (adjusted odds ratio (aOR) 2.45; 95% CI 2.18 to 2.76; p < 0.001; and aOR 1.35; 95% CI 1.25 to 1.45; p < 0.001) (Table I and Table II).

Table I.

Unadjusted and adjusted multivariable logistic analysis exploring for associations between trainee autonomy and level, year, gender, complexity, and speciality area.

Variable cOR p-value* 95% CI aOR p-value* 95% CI
Training level
ST3 Ref Ref
ST4 1.34 < 0.001 1.31 to 1.37 1.65 < 0.001 1.6 to 1.69
ST5 1.71 < 0.001 1.67 to 1.75 2.37 < 0.001 2.31 to 2.44
ST6 2.14 < 0.001 2.09 to 2.19 3.07 < 0.001 2.98 to 3.16
ST7 2.68 < 0.001 2.61 to 2.74 4.36 < 0.001 4.24 to 4.49
ST8 3.62 < 0.001 3.53 to 3.70 6.65 < 0.001 6.45 to 6.85
Year
2012 Ref Ref
2013 0.99 0.823 0.98 to 1.01 1.00 0.54 0.98 to 1.02
2014 0.94 < 0.001 0.93 to 0.95 0.92 < 0.001 0.90 to 0.94
2015 0.89 < 0.001 0.88 to 0.91 0.84 < 0.001 0.82 to 0.85
2016 0.89 < 0.001 0.87 to 0.90 0.79 < 0.001 0.77 to 0.80
2017 0.88 < 0.001 0.87 to 0.90 0.74 < 0.001 0.72 to 0.75
2018 0.81 < 0.001 0.80 to 0.83 0.66 < 0.001 0.65 to 0.67
2019 0.85 < 0.001 0.84 to 0.87 0.69 < 0.001 0.68 to 0.71
2020 0.93 < 0.001 0.91 to 0.94 0.6 < 0.001 0.59 to 0.61
2021 0.85 < 0.001 0.83 to 0.86 0.56 < 0.001 0.55 to 0.57
2022 0.91 < 0.001 0.90 to 0.93 0.62 < 0.001 0.61 to 0.64
Gender
Female Ref Ref
Male 1.4 < 0.001 1.38 to 1.43 2.45 < 0.001 2.18 to 2.76
Complexity
Complex major Ref Ref
Major 9.05 < 0.001 8.92 to 9.19 4.35 < 0.001 4.07 to 4.65
Intermediate 19.56 < 0.001 19.26 to 19.86 38.05 < 0.001 35.53 to 40.74
Minor 36.42 < 0.001 35.80 to 37.04 51.53 < 0.001 48.12 to 55.18
Speciality area
Foot & ankle Ref
Hand & wrist 1.95 < 0.001 1.88 to 2.02
Hip & femur 1.13 < 0.001 1.08 to 1.19
Knee & lower leg 1.86 < 0.001 1.78 to 1.94
Paediatrics 1.04 0.103 0.99 to 1.09
Pelvis & acetabulum 0.05 < 0.001 0.03 to 0.08
Shoulder & elbow 0.84 < 0.001 0.80 to 0.88
Spine 2.06 < 0.001 1.94 to 2.18
Unspecified 2.08 < 0.001 2.01 to 2.15
  1. *

    Logistic regression.

  1. aOR, adjusted odds ratio; cOR, crude odds ratio; ST, speciality training.

Table II.

Unadjusted and adjusted multivariable logistics analysis exploring for associations between trainee supervised operating and level, year, gender, complexity, and speciality area.

Variable cOR p-value* 95% CI aOR p-value* 95% CI
Training level
ST3 Ref Ref
ST4 1.15 < 0.001 1.13 to 1.17 1.24 < 0.001 1.22 to 1.27
ST5 1.24 < 0.001 1.22 to 1.26 1.41 < 0.001 1.38 to 1.43
ST6 1.24 < 0.001 1.22 to 1.27 1.46 < 0.001 1.43 to 1.49
ST7 1.32 < 0.001 1.30 to 1.35 1.61 < 0.001 1.57 to 1.64
ST8 1.46 < 0.001 1.43 to 1.49 1.81 < 0.001 1.77 to 1.85
Year
2012 Ref Ref
2013 1.09 < 0.001 1.07 to 1.11 1.09 < 0.001 1.08 to 1.11
2014 1.18 < 0.001 1.16 to 1.19 1.16 < 0.001 1.15 to 1.18
2015 1.21 < 0.001 1.19 to 1.22 1.19 < 0.001 1.17 to 1.20
2016 1.27 < 0.001 1.25 to 1.29 1.23 < 0.001 1.22 to 1.25
2017 1.3 < 0.001 1.28 to 1.32 1.26 < 0.001 1.24 to 1.27
2018 1.37 <0.001 1.35 to 1.39 1.3 < 0.001 1.28 to 1.32
2019 1.49 < 0.001 1.47 to 1.52 1.4 < 0.001 1.38 to 1.42
2020 1.65 < 0.001 1.62 to 1.67 1.44 < 0.001 1.42 to 1.47
2021 1.67 < 0.001 1.65 to 1.70 1.49 < 0.001 1.46 to 1.51
2022 1.82 < 0.001 1.79 to 1.85 1.68 < 0.001 1.65 to 1.71
Gender
Female Ref Ref
Male 1.05 < 0.001 1.03 to 1.06 1.35 < 0.001 1.25 to 1.45
Complexity
Complex major Ref Ref
Major 1.92 < 0.001 1.90 to 1.93 1.73 < 0.001 1.68 to 1.78
Intermediate 2.67 < 0.001 2.65 to 2.69 4.31 < 0.001 4.17 to 4.45
Minor 2.6 < 0.001 2.57 to 2.63 4.89 < 0.001 4.71 to 5.08
Speciality
Foot & ankle Ref Ref
Hand & wrist 1.3 < 0.001 1.27 to 1.34
Hip & femur 0.71 < 0.001 0.69 to 0.74
Knee & lower leg 1.2 < 0.001 1.17 to 1.24
Paediatrics 0.91 < 0.001 0.88 to 0.95
Pelvis & acetabulum 0.33 < 0.001 0.29 to 0.36
Shoulder & elbow 0.86 < 0.001 0.84 to 0.89
Spine 0.7 < 0.001 0.66 to 0.73
Unspecified 1.21 < 0.001 1.18 to 1.24
  1. *

    Logistic regression.

  1. aOR, adjusted odds ratio; cOR, crude odds ratio; ST, speciality training.

Training year

Autonomy increased with training year from 22% in ST3 to 39% in ST8. Male trainees performed more operations with autonomy than female trainees in every year of training (ST3 to ST8) (Figure 1 and Table III). The greatest difference in autonomy between male and female trainees was observed in ST5, with male trainees performing 6% more operations with autonomy. The smallest difference was observed in ST8, with male trainees performing 3% more operations with autonomy. Female trainees assisted for a greater proportion of cases in every year of orthopaedic training except ST8. A greater difference was observed in the first three years of higher specialist training, with female trainees assisting for 3% more operations in ST3, ST4, and ST5.

Fig. 1 Comparison of female trainee supervision by training stage to male trainee supervision. ST, speciality training.

Fig. 1

Comparison of female trainee supervision by training stage to male trainee supervision. ST, speciality training.

Table III.

Supervision level by training year by trainee gender.

Level Supervision Female, n (%) Male, n (%) Difference, % 95% CI p-value*
ST3 Autonomy 24,741 (18) 112,776 (23) -5 -4.8 to -4.3 < 0.001
Supervised 53,217 (39) 86,497 (37) 1.5 1.1 to 1.7 < 0.001
Assisted 59,066 (43) 199,242 (40) 3 2.8 to 3.4 < 0.001
ST4 Autonomy 925,481 (21) 123,181 (25) -4.5 -4.7 to -4.2 < 0.001
Supervised 49,159 (40) 188,930 (39) 1.5 1.0 to 1.6 < 0.001
Assisted 47,076 (39) 171,679 (35) 3 2.8 to 3.4 < 0.001
ST5 Autonomy 27,543 (24) 147,965 (30) -6 -6.0 to -5.4 < 0.001
Supervised 46,380 (41) 188,152 (38) 2.5 2.2 to 2.9 < 0.001
Assisted 40,515 (35) 159,772 (32) 3 2.8 to 3.4 < 0.001
ST6 Autonomy 28,266 (28) 147,835 (32) -3.5 -3.7 to -3.1 < 0.001
Supervised 38,953 (39) 177,873 (38) 1 0.4 to 1.1 < 0.001
Assisted 33,383 (33) 143,526 (31) 2.5 2.2 to 2.9 < 0.001
ST7 Autonomy 27,174 (31) 156,527 (34) -3.5 -3.8 to -3.1 < 0.001
Supervised 33,710 (38) 165,698 (36) 2 1.5 to 2.2 < 0.001
Assisted 27,054 (31) 132,870 (29) 1.5 1.2 to 1.9 < 0.001
ST8 Autonomy 33,746 (37) 190,031 (40) -3 -3.6 to -2.9 < 0.001
Supervised 34,292 (37) 163,162 (34) 3 2.6 to 3.3 < 0.001
Assisted 24,179 (26) 123,572 (26) 0 -0.0 to 0.6 0.056
  1. *

    Two-sample test of proportions.

  1. ST, speciality training.

Complexity

Male trainees performed more operations with autonomy than female trainees in each category of case complexity (Figure 2 and Table IV). With regards to case complexity, the greatest difference in autonomy between female and male trainees was observed for MAJ operations. Female trainees performed 6% fewer MAJ operations with autonomy. The smallest difference in autonomy was observed for CMO, with female trainees performing 3% fewer CMO cases with autonomy. However, male trainees also performed a greater proportion of CMO cases with a trainer scrubbed (4%) and therefore female trainees assisted for 7% more CMO cases. The smallest difference in assisting rates was observed with INT cases, with female trainees assisting for 2.5% more INT cases.

Fig. 2 Comparison of female trainee supervision by case complexity to male trainee supervision.

Fig. 2

Comparison of female trainee supervision by case complexity to male trainee supervision.

Table IV.

Supervision level by case complexity by trainee gender.

Case complexity Supervision Female, n (%) Male, n (%) Difference, % 95% CI (of difference) p-value*
Minor Autonomy 33,519 (46) 63,008 (52) -5.5 -5.9 to -5.1 < 0.001
Supervised 22,625 (31) 89,728 (29) 2.5 2.3 to 3.0 < 0.001
Assisted 15,966 (22) 60,385 (19) 3 2.5 to 3.1 < 0.001
Intermediate Autonomy 83,381 (32) 415,076 (37) -5.5 -5.9 to -5.5 < 0.001
Supervised 107,655 (41) 418,391 (38) 3 2.9 to 3.3 < 0.001
Assisted 72,420 (27) 275,522 (25) 2.5 2.4 to 2.8 < 0.001
Major Autonomy 48,521 (19) 282,019) (25) -6 -6.3 to -5.9 < 0.001
Supervised 104,240 (41) 438,373 (39) 2 1.6 to 2.1 < 0.001
Assisted 99,256 (39) 390,468 (35) 4 4.0 to 4.4 < 0.001
Complex major Autonomy 1,530 (2) 18,212 (5) -3 -3.0 to -2.8 < 0.001
Supervised 21,191 (32) 123,820 (36) -4 -4.2 to -3.4 < 0.001
Assisted 43,631 (66) 204,286 (59) 7 6.3 to 7.1 < 0.001
  1. *

    Two-sample test of proportions.

Index procedure

Male trainees performed more operations with autonomy for every index procedure except nerve decompression (Figure 3 and Table V). The greatest difference in autonomy was observed with hip hemiarthroplasty and intramedullary nailing for fracture or arthrodesis, with male trainees performing 10.5% more of these procedures independently. Male trainees performed a greater proportion of cases with a trainer scrubbed, as well as autonomously, for osteotomy and major joint arthroplasty. Female trainees assisted for a greater proportion of all index procedures except nerve decompression and tension band wire for fracture or arthrodesis. The greatest difference was observed for children’s displaced supracondylar fracture, with female trainees assisting for 7.5% more of these cases.

Fig. 3 Comparison of female trainee autonomy by index procedure to male trainee autonomy.

Fig. 3

Comparison of female trainee autonomy by index procedure to male trainee autonomy.

Table V.

Supervision level by index procedure by trainee gender.

Index procedure Supervision Female, n (%) Male, n (%) Difference, % 95% CI (of difference) p-value*
Application of limb external fixator Autonomy 1,542 (19) 9,126 (25) -6 -7.0 to -5.1 < 0.001
Supervised 4,025 (49) 18,090 (50) 0 -1.3 to 1 0.749
Assisted 2,573 (32) 9,224 (25) 6 5.1 to 7.4 < 0.001
Arthroscopy Autonomy 7,731 (12) 66,892 (21) -8.5 -8.8 to -8.3 < 0.001
Supervised 26,247 (42) 124,815 (39) 2.8 2.4 to 3.2 < 0.001
Assisted 28,593 (46) 127,513 (40) 6 5.3 to 6.1 < 0.001
Children’s displaced supracondylar fracture Autonomy 928 (20) 5,171 (26) -6.5 -7.7 to -5 < 0.001
Supervised 2,393 (50) 10,218 (51) -1 -2.5 to 0.5 0.221
Assisted 1,422 (30) 4,474 (23) 7.5 6 to 8.8 < 0.001
Compression hip screw Autonomy 16,233 (64) 82,399 (74) -9 -9.7 to -8.4 < 0.001
Supervised 7,069 (28) 23,553 (21) 7 6.4 to 7.6 < 0.001
Assisted 1,905 (8) 6,107 (5) 2 1.7 to 2.4 < 0.001
Hip hemiarthroplasty Autonomy 10,975 (35) 62,397 (45) -10.5 -11.1 to -9.99 < 0.001
Supervised 15,897 (50) 58,627 (43) 8 7.1 to 8.3 < 0.001
Assisted 4,664 (15) 16,451 (12) 3 2.3 to 3.2 < 0.001
Intramedullary nailing for fracture or arthrodesis Autonomy 6,462 (23) 40,777 (34) -10.5 -11.0 to -9.9 < 0.001
Supervised 15,995 (57) 62,575 (51) 6 4.9 to 6.2 < 0.001
Assisted 5,601 (20) 18,348 (15) 5 4.3 to 5.3 < 0.001
Kirschner wire fixation Autonomy 6,681 (33) 35,120 (45) -9.5 -10.4 to -8.9 < 0.001
Supervised 9,115 (44) 32,334 (39) 6 4.7 to 6.2 < 0.001
Assisted 4,758 (23) 15,875 (19) 5 3.4 to 4.7 < 0.001
Major joint arthroplasty Autonomy 2,118 (2) 27,443 (6) -4.5 -3.8 to -3.5 < 0.001
Supervised 32,682 (37) 176,252 (39) -2 -2.6 to -1.9 < 0.001
Assisted 54,180 (61) 247,737 (55) 6 5.6 to 6.3 < 0.001
Nerve decompression Autonomy 12,150 (35) 47,913 (35) 0 -0.5 to 0.5 0.976
Supervised 12,926 (37) 48,775 (35) 2 1.0 to 2.1 < 0.001
Assisted 10,006 (29) 41,691 (30) -2 -2.1 to -1.0 < 0.001
Osteotomy Autonomy 1,269 (5) 99,638 (7) -2 -2.2 to -1.6 < 0.001
Supervised 11,329 (45) 47,552 (48) -2 -3.0 to -1.6 < 0.001
Assisted 12,365 (50) 45,089 (45) 4 3.5 to 4.9 < 0.001
Plate fixation for fracture or arthrodesis Autonomy 16,039 (18) 99,296 (26) -8 -8.3 to -7.7 < 0.001
Supervised 41,666 (46) 168,985 (44) 2 1.8 to 2.6 < 0.001
Assisted 32,300 (36) 115,371 (30) 6 5.4 to 6.1 < 0.001
Tendon repair for trauma Autonomy 3,179 (26) 16,425 (31) -5.5 -6.5 to -4.7 < 0.001
Supervised 5,631 (45) 22,440 (43) 3 1.6 to 3.6 < 0.001
Assisted 3,586 (29) 13,617 (26) 3 2.1 to 3.8 < 0.001
Tension band wire Autonomy 565 (25) 3,124 (33) -8 -9.9 to -5.8 < 0.001
Supervised 1,432 (64) 5,400 (57) 7 4.3 to 8.8 < 0.001
Assisted 248 (11) 916 (10) 1 -0.08 to 2.7 0.056
  1. *

    Two-sample test of proportions.

Speciality area

Male trainees performed more operations with autonomy in every speciality area of orthopaedics (Figure 4 and Table VI). The greatest difference in autonomy was observed in knee & lower leg, with male trainees performing 7% more cases independently. The smallest difference was observed in pelvis & acetabulum, with male trainees performing 2% more cases independently. The speciality areas that male trainees performed a greater proportion of cases with a trainer scrubbed, in addition to performing more cases independently, were pelvis & acetabulum (4%), spine (4%), and shoulder & elbow (1%). Female trainees assisted for a greater proportion of cases in every speciality area. The greatest difference in assisting was observed in spine, with female trainees assisting for 7% more spine operations, and the smallest difference was observed in hand & wrist, with female trainees assisting for 2.5% more hand & wrist procedures.

Fig. 4 Comparison of female trainee supervision by speciality area to male trainee supervision.

Fig. 4

Comparison of female trainee supervision by speciality area to male trainee supervision.

Table VI.

Supervision level by body part by trainee gender.

Speciality Supervision Female, n (%) Male, n (%) Difference 95% CI (of difference) p-value*
Foot & ankle Autonomy 15,058 (18) 82,347 (25) -6 -6.5 to -5.9 < 0.001
Supervised 37,866 (46) 147,407 (44) 2 1.8 to 2.6 < 0.001
Assisted 28,647 (35) 104,051 (31) 4 3.5 to 4.3 < 0.001
Hand & wrist Autonomy 35,292 (32) 160,000 (38) -6.5 -6.9 to -6.3 < 0.001
Supervised 46,026 (41) 155,572 (37) 4 3.6 to 4.3 < 0.001
Assisted 30,444 (27) 102,944 (25) 2.5 2.3 to 2.9 < 0.001
Hip & femur Autonomy 37,583 (29) 210,603 (35) -6 -6.3 to -5.8 < 0.001
Supervised 51,245 (39) 219,369 (36) 3 2.5 to 3.1 < 0.001
Knee & lower leg Autonomy 11,997 (12) 99,316 (19) -7 -7.3 to -6.9 < 0.001
Supervised 41,658 (42) 207,013 (40) 2 1.3 to 2.0 < 0.001
Assisted 46,436 (46) 212,295 (41) 5.5 5.1 to 5.7 < 0.001
Paediatrics Autonomy 7,720 (25) 35,925 (30) -5 -5.5 to -4.4 < 0.001
Supervised 12,536 (41) 46,370 (39) 2 1.3 to 2.5 < 0.001
Assisted 10,523 (34) 37,268 (31) 3 2.4 to 3.6 < 0.001
Pelvis & acetabulum Autonomy 29 (1) 377 (3) -2 -2.6 to -1.5 < 0.001
Supervised 483 (21) 2,793 (25) -4 -5.9 to -2.2 < 0.001
Assisted 1,814 (78) 8,050 (72) 6 4.3 to 8.1 < 0.001
Shoulder & elbow Autonomy 7,011 (12) 43,473 (16) -4 -4.2 to -3.6 < 0.001
Supervised 22,833 (38) 108,350 (39) -1 -1.3 to -0.05 < 0.001
Assisted 29,974 (50) 125,032 (45) 5 4.5 to 5.3 < 0.001
Spine Autonomy 5,611 (23) 35,464 (27) -3 -3.8 to -2.6 < 0.001
Supervised 5,339 (22) 34,982 (26) -4 -4.5 to -3.4 < 0.001
Assisted 13,045 (54) 62,868 (47) 7 6.5 to 7.8 < 0.001
  1. *

    Two-sample test of proportions.

Discussion

During orthopaedic training in Ireland and the UK, male trainees perform 5% more cases with autonomy than female trainees. Female trainees assist for 3% more cases than male trainees, and perform 2% more cases under trainer supervision. Male trainees perform more operations with autonomy during each year of training, for each category of case complexity, for each orthopaedic speciality area, and for every index procedure except nerve decompression. Male trainees also perform a greater proportion of more complex operations under trainer supervision than female trainees, and female trainees assist for a greater proportion of these cases than intermediate and minor operations. In a structured training programme, there should not be a difference in surgical autonomy or assisting rates by trainee gender. The difference in autonomy between the genders recorded by the JCST and reported in this paper needs to be addressed by the training bodies in Ireland and the UK.

The discrepancy in meaningful autonomy by trainee gender has been reported in various surgical specialities and in different geographical areas.18-22 The only other study examining the effect of gender on operative autonomy in orthopaedics in the UK reported no difference in autonomy between male and female trainees, but reported that female trainees performed 3% fewer cases as lead surgeon.5 This was a much smaller study of 285,915 operations which relied on voluntary submission of logbook data, thus introducing the risk of selection bias. Unlike our study, data from ST1 and ST2 trainees were included, as well as operations recorded as O and categorized as SUB, which do not count towards certification. The gender breakdown of the study was 33% female; however, only 19% of specialist registrars the UK are female.23 Similar to our results, Bond et al24 reported that female trainees performed 6% fewer cases with autonomy than male trainees during orthopaedic training in New Zealand. Equal operative autonomy by trainee gender has been reported in some surgical specialities. Parr et al25 reported equal autonomy in the New Zealand plastic surgery training programme. The authors attributed this to gender balance among the trainee cohort. Olumolade et al26 reported equal autonomy in a single USA urology training programme with a female residency programme director. Based on the findings of these studies, it is possible that increasing the gender balance among orthopaedic trainees and the proportion of women in leadership positions may be strategies to promote equitable opportunities for operative autonomy.

The level of autonomy is assigned by the trainee. It is possible that the difference in autonomy observed between female and male trainees is due to female trainees’ perception of lower autonomy. It has been shown that female surgical trainees rate themselves lower in autonomy than their male counterparts.27 This may be a reflection of treatment experienced by female trainees in the workplace. Female trainees and surgeons experience lower levels of trust from patients, staff, and trainers.28-30 Furthermore, it has been shown that surgical trainers rate female trainees lower in autonomy than male trainees, especially with increasing surgical complexity and in later stages of training.27,31 Trainer entrustment has been shown to be the main driver of trainee entrustability in the operating theatre.32

Based on a minimum of 1,800 cases at completion of T&O training, female trainees assist for 54 (3%) more cases than male trainees and perform a minimum of 90 (5%) fewer cases with autonomy, which equates to 2.16 to 3.6 months of training. In 2021, the surgical curriculum in Ireland and the UK was updated.33 Trainees may progress through training at a faster pace if supervising trainers deem that they have the necessary capabilities. One of the five key capabilities in practice essential for progression is managing an operating list. The reduced operative autonomy that female trainees record during training may result in prolonged training time for women compared to men. Furthermore, it has been shown that autonomy during surgical training reduces trainee burnout and thoughts of attrition.34 The reduced autonomy observed among the female trainee cohort in Ireland and the UK could have a negative impact on female orthopaedic trainee wellbeing, and contribute to a higher attrition rate among female surgical trainees.

Strengths and limitations

The strength of this study is that it is the largest quantitative examination of operative autonomy in orthopaedic trainees based on trainee gender. We examined data submitted by all orthopaedic specialist registrars in two countries over a ten-year period. We provide a breakdown by case complexity, body part, and index procedure. There are a number of limitations to this study. First, supervision level is recorded by trainees who might overestimate or underestimate their participation in a case. We used independent operating to define autonomy (i.e. STU, P, T) to mitigate against this. For recording purposes, there is greater ambiguity with regard to supervised operating and assisting (STS and A) than autonomous operating (STU, P, T) as the trainer is not scrubbed for autonomous cases. Second, our study did not evaluate the influence of deanery on operative autonomy by trainee gender. Third, although this study shows that there is a difference in training opportunities with regard to surgical autonomy between female and male orthopaedic trainees, it does not explain why this difference exists. Finally, we acknowledge that operative autonomy is only one aspect of surgical training, albeit an important one. There is much to be learned from assisting and supervised operating with experienced surgeons.

Female trainees perform fewer operations with autonomy during orthopaedic training in Ireland and the UK, and assist for a greater proportion of cases than their male counterparts. It is likely that the cause of the difference in autonomy between trainees is multifactorial. However, the training bodies and trainers must be cognisant of the difference in training opportunities between trainees by trainee gender, and create conditions that promote equity. A comprehensive review of orthopaedic training is needed to identify any additional differences in training opportunities, particularly with regard to progression through training, between men and women.

Correspondence should be sent to Rosie Mc Colgan. E-mail:

References

1. Bowditch M , Ryan W , Gregory R , Bussey M . Trauma & Orthopaedic Surgery Curriculum . The Intercollegiate Surgical Curriculum Programme . 2023 . https://www.iscp.ac.uk/media/1114/trauma-orthopaedic-surgery-curriculum-aug-2021-approved-oct-20.pdf ( date last accessed 30 December 2024 ). Google Scholar

2. Downie S , Cherry J , Dunn J , et al. The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (GOAST) . Bone Joint J . 2023 ; 105-B ( 7 ): 821 – 832 . Crossref PubMed Google Scholar

3. Scerpella TA , Spiker AM , Lee CA , Mulcahey MK , Carnes ML . Next steps: advocating for women in orthopaedic surgery . J Am Acad Orthop Surg . 2022 ; 30 ( 8 ): 377 – 386 . Crossref PubMed Google Scholar

4. Haruno LS , Chen X , Metzger M , et al. Racial and sex disparities in resident attrition in orthopaedic surgery . JB JS Open Access . 2023 ; 8 ( 2 ): e22.00148 . Crossref PubMed Google Scholar

5. Hope C , Humes D , Griffiths G , Lund J . Personal characteristics associated with progression in trauma and orthopaedic specialty training: a longitudinal cohort study . J Surg Educ . 2022 ; 79 ( 1 ): 253 – 259 . Crossref PubMed Google Scholar

6. Liang R , Dornan T , Nestel D . Why do women leave surgical training? A qualitative and feminist study . Lancet . 2019 ; 393 ( 10171 ): 541 – 549 . Crossref PubMed Google Scholar

7. Chapman TR , Zmistowski B , Purtill JJ , Chen AF . Profiles of practicing female orthopaedists caring for medicare patients in the United States . J Bone Joint Surg Am . 2018 ; 100-A ( 10 ): e69 . Crossref PubMed Google Scholar

8. Cannada LK . Women in orthopaedic fellowships: what is their match rate, and what specialties do they choose? Clin Orthop Relat Res . 2016 ; 474 ( 9 ): 1957 – 1961 . Crossref PubMed Google Scholar

9. Silvestre J , Tippabhatla A , Chopra A , Nelson CL , LaPorte DM . Sex disparities among fellowship program directors in orthopaedic surgery . J Bone Joint Surg Am . 2024 ; 106-A ( 3 ): 251 – 257 . Crossref PubMed Google Scholar

10. Beebe KS , Krell ES , Rynecki ND , Ippolito JA . The effect of sex on orthopaedic surgeon income . J Bone Joint Surg Am . 2019 ; 101-A ( 17 ): e87 . Crossref PubMed Google Scholar

11. Forrester LA , Seo LJ , Gonzalez LJ , Zhao C , Friedlander S , Chu A . Men receive three times more industry payments than women academic orthopaedic surgeons, even after controlling for confounding variables . Clin Orthop Relat Res . 2020 ; 478 ( 7 ): 1593 – 1599 . Crossref PubMed Google Scholar

12. Jolbäck P , Rogmark C , Bedeschi Rego De Mattos C , Chen AF , Nauclér E , Tsikandylakis G . The influence of surgeon sex on adverse events following primary total hip arthroplasty: a register-based study of 11,993 procedures and 200 surgeons in Swedish public hospitals . J Bone Joint Surg Am . 2022 ; 104-A ( 15 ): 1327 – 1333 . Crossref PubMed Google Scholar

13. Chapman TR , Zmistowski B , Votta K , Abdeen A , Purtill JJ , Chen AF . Patient complications after total joint arthroplasty: does surgeon gender matter? J Am Acad Orthop Surg . 2020 ; 28 ( 22 ): 937 – 944 . Crossref PubMed Google Scholar

14. Wallis CJD , Jerath A , Aminoltejari K , et al. Surgeon sex and long-term postoperative outcomes among patients undergoing common surgeries . JAMA Surg . 2023 ; 158 ( 11 ): 1185 – 1194 . Crossref PubMed Google Scholar

15. Wallis CJ , Ravi B , Coburn N , Nam RK , Detsky AS , Satkunasivam R . Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study . BMJ . 2017 ; 359 : j4366 . Crossref PubMed Google Scholar

16. Hallet J , Sutradhar R , Flexman A , et al. Association between anaesthesia-surgery team sex diversity and major morbidity . Br J Surg . 2024 ; 111 ( 5 ): znae097 . Crossref PubMed Google Scholar

17. Wallis CJD , Jerath A , Coburn N , et al. Association of surgeon-patient sex concordance with postoperative outcomes . JAMA Surg . 2022 ; 157 ( 2 ): 146 – 156 . Crossref PubMed Google Scholar

18. Gurgel RK , Cardon BR , Allen CM , et al. Evaluating gender parity in operative experience for otolaryngology residencies in the United States . Laryngoscope . 2020 ; 130 ( 7 ): 1651 – 1656 . Crossref PubMed Google Scholar

19. Gong D , Winn BJ , Beal CJ , et al. Gender differences in case volume among ophthalmology residents . JAMA Ophthalmol . 2019 ; 137 ( 9 ): 1015 . Crossref PubMed Google Scholar

20. Joh DB , van der Werf B , Watson BJ , et al. Assessment of autonomy in operative procedures among female and male New Zealand general surgery trainees . JAMA Surg . 2020 ; 155 ( 11 ): 1019 – 1026 . Crossref PubMed Google Scholar

21. Meyerson SL , Odell DD , Zwischenberger JB , et al. The effect of gender on operative autonomy in general surgery residents . Surgery . 2019 ; 166 ( 5 ): 738 – 743 . Crossref PubMed Google Scholar

22. Lenhart A , Chen F , Condon A , et al. Gender and other factors associated with endoscopy volume among U.S. gastroenterology fellows . Clin Gastroenterol Hepatol . 2022 ; 20 ( 12 ): 2911 – 2914 . Crossref PubMed Google Scholar

23. Kontoghiorghe C , Morgan C , Eastwood D , McNally S . UK pregnancy in orthopaedics (UK-POP): a cross-sectional study of UK female trauma and orthopaedic surgeons and their experiences of pregnancy . Bone Jt Open . 2023 ; 4 ( 12 ): 970 – 979 . Crossref PubMed Google Scholar

24. Bond EC , Whiting FH , Larsen PD , Chan G . A comparison of operative autonomy between men and women in orthopaedic surgical training in Aotearoa New Zealand . N Z Med J . 2023 ; 136 ( 1579 ): 36 – 48 . Crossref PubMed Google Scholar

25. Parr JM , van der Werf B , Locke M . Operative autonomy in a gender-balanced cohort of surgical trainees . Plast Reconstr Surg . 2023 ; 152 ( 6 ): 1367 – 1374 . Crossref PubMed Google Scholar

26. Olumolade OO , Rollins PD , Daignault-Newton S , George BC , Kraft KH . Closing the gap: evaluation of gender disparities in urology resident operative autonomy and performance . J Surg Educ . 2022 ; 79 ( 2 ): 524 – 530 . Crossref PubMed Google Scholar

27. 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 ( 5 ): 666 – 672 . Crossref PubMed Google Scholar

28. Brown A , Bonneville G , Nevertheless GS . They persisted: how women experience gender-based discrimination during postgraduate surgical training . J Surg Educ . 2021 ; 78 ( 1 ): 17 – 34 . Crossref PubMed Google Scholar

29. Hiemstra LA , Kerslake S , Clark M , Temple-Oberle C , Boynton E . Experiences of canadian female orthopaedic surgeons in the workplace: defining the barriers to gender equity . J Bone Joint Surg Am . 2022 ; 104-A ( 16 ): 1455 – 1461 . Crossref PubMed Google Scholar

30. Cardador MT , Hill PL , Salles A . Unpacking the status-leveling burden for women in male-dominated occupations . Adm Sci Q . 2022 ; 67 ( 1 ): 237 – 284 . Crossref Google Scholar

31. Chang AJ , Kwon CM , Shabahang MM , Factor M , Rapp M , Hoffman RL . Sex influences how attendings evaluate surgical residents in the operating room . Am J Surg . 2024 ; 227 : 127 – 131 . Crossref PubMed Google Scholar

32. Sandhu G , Thompson-Burdine J , Nikolian VC , et al. Association of faculty entrustment with resident autonomy in the operating room . JAMA Surg . 2018 ; 153 ( 6 ): 518 – 524 . Crossref PubMed Google Scholar

33. James HK , Gregory RJH . The dawn of a new competency-based training era . Bone Jt Open . 2021 ; 2 ( 3 ): 181 – 190 . Crossref PubMed Google Scholar

34. Abahuje E , Smith KS , Amortegui D , et al. See one, do one, improve one’s wellness: resident autonomy in US General Surgery programs: a mixed-methods study . Ann Surg . 2023 ; 278 ( 6 ): 1045 – 1052 . Crossref PubMed Google Scholar

Author contributions

R. Mc Colgan: Conceptualization, Data curation, Methodology, Project administration, Writing – original draft

F. Boland: Data curation, Formal analysis, Methodology, Writing – review & editing

G. A. Sheridan: Supervision, Writing – review & editing

G. Colgan: Supervision, Writing – review & editing

D. Bose: Supervision, Writing – review & editing

D. M. Eastwood: Supervision, Writing – review & editing

D. M. Dalton: Conceptualization, Data curation, Supervision, Writing – review & editing

Funding statement

The author(s) received no financial or material support for the research, authorship, and/or publication of this article.

ICMJE COI statement

D. Bose reports being a trustee of the British Orthopaedic Association, unrelated to this work. D. Eastwood declares book-related royalties from Oxford University Press, participation on the CRAFFT and SCIENCE projects, and being a council member for the Royal College of Surgeons of England, and vice president of the International Orthopaedic Diversity Alliance, all of which are unrelated. R. Mc Colgan discloses grants or contracts from AO UK & Ireland, which are also unrelated.

Data sharing

The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.

Ethical review statement

This retrospective longitudinal cohort study was approved by the RCSI ethics committee and the study was reported in line with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Open access funding

The authors report that the open access funding for this manuscript was self-funded.

© 2025 Mc Colgan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

Information

Journal

Bone & Joint Open

Volume

6 No.1 | Pages 62 - 73

Section

General Orthopaedics

Published

11 January 2025

DOI

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Specialist Registrar Trauma and Orthopaedics

Royal College of Surgeons in Ireland, Dublin, Ireland

mccolgar@tcd.ie

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Senior Lecturer in Biostatistics and Research Methods

Royal College of Surgeons in Ireland, Dublin, Ireland

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Consultant Trauma and Orthopaedic Surgeon

Galway University Hospital, Galway, Ireland

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Consultant Trauma and Orthopaedic Surgeon

Mater Misericordiae University Hospital, Dublin, Ireland

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Queen Elizabeth Hospital Birmingham, Birmingham, UK

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Great Ormond Street Hospital, London, UK

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Galway University Hospital, Galway, Ireland

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Figures

Fig. 1 Comparison of female trainee supervision by training stage to male trainee supervision. ST, speciality training.

Fig. 1

Comparison of female trainee supervision by training stage to male trainee supervision. ST, speciality training.
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Fig. 2 Comparison of female trainee supervision by case complexity to male trainee supervision.

Fig. 2

Comparison of female trainee supervision by case complexity to male trainee supervision.
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Fig. 3 Comparison of female trainee autonomy by index procedure to male trainee autonomy.

Fig. 3

Comparison of female trainee autonomy by index procedure to male trainee autonomy.
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Fig. 4 Comparison of female trainee supervision by speciality area to male trainee supervision.

Fig. 4

Comparison of female trainee supervision by speciality area to male trainee supervision.
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Metrics

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References

1. Find in article

Bowditch M , Ryan W , Gregory R , Bussey M . Trauma & Orthopaedic Surgery Curriculum . The Intercollegiate Surgical Curriculum Programme . 2023 . ( date last accessed 30 December 2024 ).

https://www.iscp.ac.uk/media/1114/trauma-orthopaedic-surgery-curriculum-aug-2021-approved-oct-20.pdf Google Scholar
2. Find in article

Downie S , Cherry J , Dunn J , et al. The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (GOAST) . Bone Joint J . 2023 ; 105-B ( 7 ): 821 – 832 .

Crossref PubMed Google Scholar
3. Find in article

Scerpella TA , Spiker AM , Lee CA , Mulcahey MK , Carnes ML . Next steps: advocating for women in orthopaedic surgery . J Am Acad Orthop Surg . 2022 ; 30 ( 8 ): 377 – 386 .

Crossref PubMed Google Scholar
4. Find in article

Haruno LS , Chen X , Metzger M , et al. Racial and sex disparities in resident attrition in orthopaedic surgery . JB JS Open Access . 2023 ; 8 ( 2 ): e22.00148 .

Crossref PubMed Google Scholar
5. Find in article

Hope C , Humes D , Griffiths G , Lund J . Personal characteristics associated with progression in trauma and orthopaedic specialty training: a longitudinal cohort study . J Surg Educ . 2022 ; 79 ( 1 ): 253 – 259 .

Crossref PubMed Google Scholar
6. Find in article

Liang R , Dornan T , Nestel D . Why do women leave surgical training? A qualitative and feminist study . Lancet . 2019 ; 393 ( 10171 ): 541 – 549 .

Crossref PubMed Google Scholar
7. Find in article

Chapman TR , Zmistowski B , Purtill JJ , Chen AF . Profiles of practicing female orthopaedists caring for medicare patients in the United States . J Bone Joint Surg Am . 2018 ; 100-A ( 10 ): e69 .

Crossref PubMed Google Scholar
8. Find in article

Cannada LK . Women in orthopaedic fellowships: what is their match rate, and what specialties do they choose? Clin Orthop Relat Res . 2016 ; 474 ( 9 ): 1957 – 1961 .

Crossref PubMed Google Scholar
9. Find in article

Silvestre J , Tippabhatla A , Chopra A , Nelson CL , LaPorte DM . Sex disparities among fellowship program directors in orthopaedic surgery . J Bone Joint Surg Am . 2024 ; 106-A ( 3 ): 251 – 257 .

Crossref PubMed Google Scholar
10. Find in article

Beebe KS , Krell ES , Rynecki ND , Ippolito JA . The effect of sex on orthopaedic surgeon income . J Bone Joint Surg Am . 2019 ; 101-A ( 17 ): e87 .

Crossref PubMed Google Scholar
11. Find in article

Forrester LA , Seo LJ , Gonzalez LJ , Zhao C , Friedlander S , Chu A . Men receive three times more industry payments than women academic orthopaedic surgeons, even after controlling for confounding variables . Clin Orthop Relat Res . 2020 ; 478 ( 7 ): 1593 – 1599 .

Crossref PubMed Google Scholar
12. Find in article

Jolbäck P , Rogmark C , Bedeschi Rego De Mattos C , Chen AF , Nauclér E , Tsikandylakis G . The influence of surgeon sex on adverse events following primary total hip arthroplasty: a register-based study of 11,993 procedures and 200 surgeons in Swedish public hospitals . J Bone Joint Surg Am . 2022 ; 104-A ( 15 ): 1327 – 1333 .

Crossref PubMed Google Scholar
13. Find in article

Chapman TR , Zmistowski B , Votta K , Abdeen A , Purtill JJ , Chen AF . Patient complications after total joint arthroplasty: does surgeon gender matter? J Am Acad Orthop Surg . 2020 ; 28 ( 22 ): 937 – 944 .

Crossref PubMed Google Scholar
14. Find in article

Wallis CJD , Jerath A , Aminoltejari K , et al. Surgeon sex and long-term postoperative outcomes among patients undergoing common surgeries . JAMA Surg . 2023 ; 158 ( 11 ): 1185 – 1194 .

Crossref PubMed Google Scholar
15. Find in article

Wallis CJ , Ravi B , Coburn N , Nam RK , Detsky AS , Satkunasivam R . Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study . BMJ . 2017 ; 359 : j4366 .

Crossref PubMed Google Scholar
16. Find in article

Hallet J , Sutradhar R , Flexman A , et al. Association between anaesthesia-surgery team sex diversity and major morbidity . Br J Surg . 2024 ; 111 ( 5 ): znae097 .

Crossref PubMed Google Scholar
17. Find in article

Wallis CJD , Jerath A , Coburn N , et al. Association of surgeon-patient sex concordance with postoperative outcomes . JAMA Surg . 2022 ; 157 ( 2 ): 146 – 156 .

Crossref PubMed Google Scholar
18. Find in article

Gurgel RK , Cardon BR , Allen CM , et al. Evaluating gender parity in operative experience for otolaryngology residencies in the United States . Laryngoscope . 2020 ; 130 ( 7 ): 1651 – 1656 .

Crossref PubMed Google Scholar
19. Find in article

Gong D , Winn BJ , Beal CJ , et al. Gender differences in case volume among ophthalmology residents . JAMA Ophthalmol . 2019 ; 137 ( 9 ): 1015 .

Crossref PubMed Google Scholar
20. Find in article

Joh DB , van der Werf B , Watson BJ , et al. Assessment of autonomy in operative procedures among female and male New Zealand general surgery trainees . JAMA Surg . 2020 ; 155 ( 11 ): 1019 – 1026 .

Crossref PubMed Google Scholar
21. Find in article

Meyerson SL , Odell DD , Zwischenberger JB , et al. The effect of gender on operative autonomy in general surgery residents . Surgery . 2019 ; 166 ( 5 ): 738 – 743 .

Crossref PubMed Google Scholar
22. Find in article

Lenhart A , Chen F , Condon A , et al. Gender and other factors associated with endoscopy volume among U.S. gastroenterology fellows . Clin Gastroenterol Hepatol . 2022 ; 20 ( 12 ): 2911 – 2914 .

Crossref PubMed Google Scholar
23. Find in article

Kontoghiorghe C , Morgan C , Eastwood D , McNally S . UK pregnancy in orthopaedics (UK-POP): a cross-sectional study of UK female trauma and orthopaedic surgeons and their experiences of pregnancy . Bone Jt Open . 2023 ; 4 ( 12 ): 970 – 979 .

Crossref PubMed Google Scholar
24. Find in article

Bond EC , Whiting FH , Larsen PD , Chan G . A comparison of operative autonomy between men and women in orthopaedic surgical training in Aotearoa New Zealand . N Z Med J . 2023 ; 136 ( 1579 ): 36 – 48 .

Crossref PubMed Google Scholar
25. Find in article

Parr JM , van der Werf B , Locke M . Operative autonomy in a gender-balanced cohort of surgical trainees . Plast Reconstr Surg . 2023 ; 152 ( 6 ): 1367 – 1374 .

Crossref PubMed Google Scholar
26. Find in article

Olumolade OO , Rollins PD , Daignault-Newton S , George BC , Kraft KH . Closing the gap: evaluation of gender disparities in urology resident operative autonomy and performance . J Surg Educ . 2022 ; 79 ( 2 ): 524 – 530 .

Crossref PubMed Google Scholar
27. Find in article

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 ( 5 ): 666 – 672 .

Crossref PubMed Google Scholar
28. Find in article

Brown A , Bonneville G , Nevertheless GS . They persisted: how women experience gender-based discrimination during postgraduate surgical training . J Surg Educ . 2021 ; 78 ( 1 ): 17 – 34 .

Crossref PubMed Google Scholar
29. Find in article

Hiemstra LA , Kerslake S , Clark M , Temple-Oberle C , Boynton E . Experiences of canadian female orthopaedic surgeons in the workplace: defining the barriers to gender equity . J Bone Joint Surg Am . 2022 ; 104-A ( 16 ): 1455 – 1461 .

Crossref PubMed Google Scholar
30. Find in article

Cardador MT , Hill PL , Salles A . Unpacking the status-leveling burden for women in male-dominated occupations . Adm Sci Q . 2022 ; 67 ( 1 ): 237 – 284 .

Crossref Google Scholar
31. Find in article

Chang AJ , Kwon CM , Shabahang MM , Factor M , Rapp M , Hoffman RL . Sex influences how attendings evaluate surgical residents in the operating room . Am J Surg . 2024 ; 227 : 127 – 131 .

Crossref PubMed Google Scholar
32. Find in article

Sandhu G , Thompson-Burdine J , Nikolian VC , et al. Association of faculty entrustment with resident autonomy in the operating room . JAMA Surg . 2018 ; 153 ( 6 ): 518 – 524 .

Crossref PubMed Google Scholar
33. Find in article

James HK , Gregory RJH . The dawn of a new competency-based training era . Bone Jt Open . 2021 ; 2 ( 3 ): 181 – 190 .

Crossref PubMed Google Scholar
34. Find in article

Abahuje E , Smith KS , Amortegui D , et al. See one, do one, improve one’s wellness: resident autonomy in US General Surgery programs: a mixed-methods study . Ann Surg . 2023 ; 278 ( 6 ): 1045 – 1052 .

Crossref PubMed Google Scholar
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