Diversity in Education: Vascular and Cardiothoracic Fellowship Representation by Gender, Background, and Training

Introduction: The pursuit of diversity, equity, and inclusion in medicine has been widely acknowledged as crucial for enhancing health outcomes. However, despite advancements in some surgical programs, females remain notably underrepresented in vascular and cardiothoracic surgery. This disparity suggests that other discrepancies may exist, emphasizing the need for further review and action towards achieving greater gender balance and inclusivity in these specialized surgical disciplines. This study observes the latest matriculation data for trainees to vascular and cardiothoracic surgery (CTS) fellowship to gain insight into trends and identify possible barriers to diversity. We hypothesized that females, osteopaths (DOs), and Non-US graduates would be underrepresented compared to male, allopath’s (MDs) and US graduate peers.

Methods: Data was obtained through FRIEDA™, the nationally recognized graduate medical education’s (GME) residency and fellowship database for the 2022-2023 matriculation year. We collected program information on male vs female gender, MD vs DO certification, and US vs Non-US graduate medical education. Lack of diversity was indicated by p<0.05.

Results: For vascular surgery female frequency was 40 (32%) (p<0.0001) (CI 24,41), DO frequency 21 (16.2%) (p<0.0001) (CI 11,23), and Non-US graduate frequency 12 (13.3%) (p<0.0001) (CI 8,22). There was statistical significance to suggest that females, DOs, and Non-US graduates remain underrepresented in vascular surgery. The same was true for CTS with female frequency 76 (36.2%) (p<0.0001) (CI 30,43), DO frequency 16 (7.6%) (p<0.0001) (CI 5,12), and Non-US graduate frequency 25 (12.2%) (p<0.0001) (CI 8,17).

Conclusion: We found that significant disparities remain for vascular and cardiothoracic surgery when gender, degree obtained during training, and US GME status are observed. We involve the latest FRIEDA™ data on accepted candidates to fellowship. Objective information in this regard adds knowledge to diversity conversations and may work toward improving representation. Further efforts should be made to decrease disparities, to improve the impact on patient outcomes, and to enhance trainee career opportunities.

Diversity in medicine has proven essential to improving health outcomes, however the level of representation by the providers who service patients has not matched the pace of a changing demographic in the United States (US) [1]. There is previous data on backgrounds such as gender, race, and ethnicity where trends are noted for medical trainees and practicing physicians. 

Medical schools have experienced a significant increase in female accepted candidates, increasing from 24.4% in 1978 over 40 years to 50.6% in 2019, attributed to a 12-fold increase in the matriculation of Asian women [2]. However surgical specialties have lagged in comparison. For general surgery (GS), which is the base to sub specialization, females comprised 31% of trainees in 2008 with a decade increase to 40% in 2018 [3]. Females still remain underrepresented (less than 50%) and this maintains true for further training into vascular (VS) and cardiothoracic surgery (CTS).3 The underrepresentation may suggest an issue with recruitment or retention [3-4]. 

Other-than-white races, where black/African American is the typical comparator, has not increased significantly for VS3,5. Additionally, CTS remains among the least diverse specialties for gender and race, where the most frequent sample are white males.6 In numbers, a 2017 review noted 7% of cardiothoracic surgeons to be female and only 5% of overall providers identified as black/African American [6-7]. 

Osteopathic (DO) candidates often encounter barriers despite equally competent and similar training with an additional holistic component of care. Starting at surgery residency, 54% of programs had no current DO representation, and 35% had never had a DO in their program.8 As noted with other trends, this percentage decreases into further sub specialization.

For Non-US graduated medical students, including Caribbean, non-continental US options, as well as other foreign graduates, acceptance into programs is much decreased compared to their US graduated counterparts. There are sites that list international medical graduate (IMG) friendly programs such as The Match Guy, but note that this list is limited and some sites state that IMG matching into surgical programs is “difficult but not impossible” [10]. 

We wished to observe data toward current positive or negative trends in diversity for VS and CTS fellowship regarding male vs female gender, allopathic Medical Doctor (MD) vs osteopathic Doctor of Osteopathy (DO), and US graduate vs Non-US graduate. These three backgrounds are rarely observed together among cardiology-related fields and may further elucidate areas toward improvement. We hypothesized that VS and CTS trainees would be predominantly male MDs from US medical schools and females and that DOs and Non-US graduates would be underrepresented.

Accredited program data was obtained through the Fellowship and Residency Electronic Database Access system (FRIEDA™) [11]. Our search focused on VS and CTS with male vs female demographic, MD vs DO doctorate, and US vs Non-US graduate status. Fellow information was obtained from public program websites, where available, for the 2022-2023 academic year. Demographic information collected were gender, doctorate degree, and US graduate medical education (GME) status. We did not include newly accredited programs which contain limited information and were not able to include programs where otherwise information was unavailable. If p less than 0.05 then females, DOs, and Non-US graduates were underrepresented for their respective categories. Statistical analyses were performed using SAS Studio 3.8, version 9.4 (SAS Institute, Inc., Cary, NC) and confidence intervals were calculated via the Wilson score interval procedure (Wilson) [12]. 

For VS, female frequency was 40 (32%) (p less than 0.0001) (CI 24,31), DO frequency 21 (16.2%) (p less than 0.0001) (CI 11,23), and Non-US graduate frequency 12 (13.3%) (p less than 0.0001) (CI 8,22), indicating disparity for all fields. 

For CTS, female frequency was 76 (36.2%) (p less than 0.0001) (CI 30, 43), DO frequency 16 (7.6%) (p less than 0.0001) (CI 5,12), and Non-US graduate frequency 25 (12.2%) (p less than 0.0001) (CI 8,17). There were disparities again across all fields. Our data is shown in the Table.

Table: Diversity in vascular and cardiothoracic surgery fellowships.

Definitions: CI, confidence interval. DO, doctor of osteopathy. US, United States.

Healthcare-wide diversity efforts can be appreciated from a historic perspective.  The 1960s Civil Rights Movement epitomized a changing atmosphere after centuries of racial mistreatment and led to positive policy changes. Over decades and centuries, leaders within businesses, local communities, and educational institutions have promoted anti-discriminatory legislation and social justice philosophy [13]. Originally the focus was to address racial injustice but grew to include gender, sexual preference, age, ethnicity, religion, disability, and gender identity [13]. Despite many years of attempts to advance equity in healthcare, disparities persist and, in some cases, have worsened [14]. A critical view argues that diversity and excellence compete. When diversity is over-favored, there is an increased risk of worse performance [15] In favor, diverse groups are more likely to come to holistic solutions [15]. 

Our study specific to recent 2022-2023 match data demonstrates that disparities in VS and CTS persist. Finding female disparity in VS and CTS supports previous data and shows that minimal change has occurred in the past five years [4]. Female practice in medicine impacts patient outcomes, and patient-doctor gender concordance has a role in decreasing mortality for patients presenting with acute health crises [16]. Higher numbers of female surgeons, including those who continue training to subspecialize in VS and CTS, may enhance outcomes and bridge gaps in care, especially for female patients. Future studies should aim to identify causes of lagging representation within surgical fellowships, including intrinsic bias and misogyny. It may be useful to observe recent program implementations and critically assess their utility, as female representation has continued its sluggish course. 

Earlier career female presence may be advantageous in affecting representation. Surgery interest groups and women-in-surgery groups have proven impactful for female representation in GS. An increase in integrated VS and CTS residency positions provides the opportunity for further attempts at recruitment. Anonymously surveying these trainees on perspectives helps fellowships to inform policy decisions [17]. 

There are also opportunities to improve representation within leadership. The percentage of females in program director (PD) positions for integrated VS residency and fellowship programs is 14% and 12%, respectively [18]. Only 8.6% of editorial board members on the three highest impact VS journals are female for Journal of Vascular Surgery, Journal of Vascular and Endovascular Surgery, and Annals of Vascular Surgery [19]. For CTS also, only 4.2% of department chairs or division chiefs and 10.4% of PD were female [20]. Considering to increase female presence in research leadership will ultimately coincide with improvements in women’s health. We hope to see changes to research community and leadership structure within VS and CTS training [21-22].

Our study was also consistent with the literature regarding DO disparity and MD preference. VS and CTS fellowship positions are disproportionately filled by MD candidates, suggesting partiality [23]. Step 2 CK score, research productivity, honor status on clerkships, and number of away rotations have been significant predictors of successfully matching into preliminary GS residency [24]. These opportunities may be more readily available to MD than DO students,[25] either from the perspective of medical school offerings, seeking out opportunities, or attendings or journals favoring a MD option.

Transition of USMLE Step 1/COMLEX Level 1 to Pass/Fail may have an impact on DO match into GS as well as integrated VS and CTS programs. One way of increasing representation within fellowships may be the use of vascular and cardiothoracic integrated GS residencies. Another would be attending and researcher awareness to more readily include their equally competent DO trainees in research projects.

Our data was also consistent with US-favored trainees over Non-US counterparts for VS and CTS. Immigration barriers, extra costs, timing of belabored certification from the Education Commission for Foreign Medical Graduates (ECGMG), and state-specific rules for licensing are all factors that affect Non-US medical graduates seeking residency within the US [26-27]. 

Non-US graduates are often equally competent. Interestingly, foreign-born IMGs (3.9%) produce significantly more scholarly works than US graduates (1.7%) [28]. Objective assessments between the two groups (US vs IMG graduate) are similar within a large GS program, suggesting no measurable difference in surgical skills [29]. Considering these findings, it is unclear regarding why the relative lack of representation of Non-US graduates within VS fellowship. 

Several limitations occur in our study. First, program information was obtained by various students. Any discrepancies were attempted to be reduced by oversight of the corresponding author and attending physician. Second, data on Non-US graduates does not differentiate between US and Non-US born trainees, even though the distinction affects the individual. Lastly, we did not include integrated VS or CTS residencies in our assessment as nonaccredited programs, which may affect representation outcomes. We were not able to find sufficient information on new candidate program makeup for these. 

Despite attention to inequities of representation in medicine, our study shows that disparities within VS and CTS training persist for females, DOs, and Non-US graduates. This may carry implications on patient outcomes and career opportunities. Further research is needed to address continued barriers for VS and CTS in order to provide high-quality care and foster an inclusive environment for competitive individuals interested in the field.