Research

JAMA Surgery | Original Investigation

Effects of Gender Bias and Stereotypes in Surgical Training

A Randomized Clinical Trial
Sara P. Myers, MD, PhD; Mohini Dasari, MD, MS; Joshua B. Brown, MD, MSc; Stephanie T. Lumpkin, MD;
Matthew D. Neal, MD; Kaleab Z. Abebe, PhD; Nicole Chaumont, MD; Stephanie M. Downs-Canner, MD;
Meghan R. Flanagan, MD; Kenneth K. Lee, MD; Matthew R. Rosengart, MD, MPH

Invited Commentary
IMPORTANCE Factors contributing to underrepresentation of women in surgery are page 560
incompletely understood. Pro-male bias and stereotype threat appear to contribute to Author Audio Interview
gender imbalance in surgery.
Supplemental content
OBJECTIVES To evaluate the association between pro-male gender bias and career
CME Quiz at
engagement and the effect of stereotype threat on skill performance among trainees in jamacmelookup.com and CME
academic surgery. Questions page 674
DESIGN, SETTING, AND PARTICIPANTS A 2-phase study with a double-blind, randomized clinical
trial component was conducted in 3 academic general surgery training programs. Residents
were recruited between August 1 and August 15, 2018, and the study was completed at the
end of that academic year. In phase 1, surveys administered 5 to 6 months apart investigated
the association of gender bias with career engagement. In phase 2, residents were
randomized 1:1 using permuted-block design stratified by site, training level, and gender to
receive either a trigger of or protection against stereotype threat. Immediately after the
interventions, residents completed the Fundamentals of Laparoscopic Surgery (FLS)
assessment followed by a final survey. A total of 131 general surgery residents were recruited;
of these 96 individuals with academic career interests met eligibility criteria; 86 residents
completed phase 1. Eighty-five residents were randomized in phase 2, and 4 residents in each
arm were lost to follow-up.

INTERVENTION Residents read abstracts that either reported that women had worse
laparoscopic skill performance than men (trigger of stereotype threat [A]) or had no
difference in performance (protection against stereotype threat [B]).

MAIN OUTCOMES AND MEASURES Association between perception of pro-male gender bias
and career engagement survey scores (phase 1) and stereotype threat intervention and FLS
scores (phase 2) were the outcomes. Intention-to-treat analysis was conducted.

RESULTS Seventy-seven residents (38 women [49.4%]) completed both phases of the study.
The association between pro-male gender bias and career engagement differed by gender
(interaction coefficient, −1.19; 95% CI, −1.90 to −0.49; P = .02); higher perception of bias was
associated with higher engagement among men (coefficient, 1.02; 95% CI, 0.19-2.24;
P = .04), but no significant association was observed among women (coefficient, −0.25; 95% Author Affiliations: Department of
CI, −1.59 to 1.08; P = .50). There was no evidence of a difference in FLS score between Surgery, University of Pittsburgh
School of Medicine, Pittsburgh,
interventions (mean [SD], A: 395 [150] vs B: 367 [157]; P = .51). The response to stereotype Pennsylvania (Myers, Brown, Neal,
threat activation was similar in men and women (interaction coefficient, 15.1; 95% CI, −124.5 Lee, Rosengart); Department of
to 154.7; P = .39). The association between stereotype threat activation and FLS score Surgery, University of Washington,
Seattle (Dasari, Flanagan);
differed by gender across levels of susceptibility to stereotype threat (interaction coefficient,
Department of Surgery, University of
−35.3; 95% CI, −47.0 to −23.6; P = .006). Higher susceptibility to stereotype threat was North Carolina at Chapel Hill School
associated with lower FLS scores among women who received a stereotype threat trigger of Medicine (Lumpkin, Chaumont,
(coefficient, −43.4; 95% CI, −48.0 to −38.9; P = .001). Downs-Canner); Division of General
Internal Medicine, University of
CONCLUSIONS AND RELEVANCE Perception of pro-male bias and gender stereotypes may Pittsburgh, Pittsburgh, Pennsylvania
(Abebe); Fred Hutchinson Cancer
influence career engagement and skill performance, respectively, among surgical trainees.
Research Center, Seattle, Washington
TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03623009 (Flanagan).
Corresponding Author: Sara P.
Myers, MD, PhD, Department of
Surgery, University of Pittsburgh
School of Medicine, 200 Lothrop St,
JAMA Surg. 2020;155(7):552-560. doi:10.1001/jamasurg.2020.1127 Pittsburgh, PA 15213
Published online May 20, 2020. (myerssp@upmc.edu).

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 Effects of Gender Bias and Stereotypes in Surgical Training
M
edicine trails other fields in gender diversity.1,2 Gen-
der disparity is particularly pronounced within aca-
demic surgery; women represent less than 10% of full
professors and only 22 department chairs in the US and
Canada.3 Evidence indicates that pro-male bias and negative
stereotypes depress women's performance 4 in male-
dominated professions.5,6 If and how this bias differentially af-
fects health care professionals remains to be characterized.
Lack of information is a substantial impediment to develop-
ing valid interventions that address challenges to the promo-
tion and retention of female surgeons.7 We studied how tech-
nical skill performance and engagement—2 crucial components
of career advancement—are influenced by pro-male bias and
negative stereotypes against women during residency, which
is a phase of profound personal and professional develop-
ment.
Psychosocial constructs, ie, attitudes or behaviors that
arise from interactions between an individual and their
environment,8 forecast and reinforce professional success.
These constructs have been investigated in models of educa-
tional achievement, making them especially relevant to resi-
dency, which is a period of intensive training. Previous inves-
tigations have emphasized learner engagement as integral to
professional advancement.9 Engagement is defined as involve-
ment with social or academic activities and is associated with
affective aspects, such as sense of belonging10; cognitive com-
ponents, such as resilience and self-regulation11; and ability to
relate to one’s profession (ie, domain identification).12 Nega-
tive stereotypes have been shown to undermine engagement
and associated behaviors among members of stigmatized so-
cial groups.13 The risk of confirming negative stereotypes,
known as stereotype threat, is especially germane to women
employed in medicine, as they are frequently reminded of gen-
der stereotypes in their environments.5 Stereotype threat
contributes to measurable differences in technical skill
performance14 by depleting executive function and siphon-
ing attention away from the task at hand.15
This multicenter study, conducted in 2 phases, first sought
to evaluate the association between gender bias and research-
related career engagement among trainees, and second, to in-
vestigate the interaction between gender and stereotype threat
on laparoscopic skill performance. Our hypothesis for phase 1
was that the association between perceiving pro-male bias in
the training environment and career engagement would dif-
fer by gender. For phase 2, we hypothesized that stereotype
threat activation would affect technical skill performance and
that this association would differ between men and women.
Methods
Study Setting and Design
We conducted a 2-phase study of general surgery residents at
3 diverse academic campuses: University of North Carolina–
Chapel Hill; University of Pittsburgh Medical Center, Pitts-
burgh, Pennsylvania; and University of Washington, Seattle
(Figure 1). The study included a survey-based investigation into
gender bias and career engagement and a multicenter ran-
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Original Investigation Research
Key Points
Question Do the associations between pro-male bias and career
engagement, as well as stereotype threat and skill performance,
differ by gender?
Findings In this multicenter randomized clinical trial that included
86 general surgery trainees interested in pursuing academic
careers, pro-male gender bias was significantly associated with
higher career engagement among men; no significant association
was observed in women. Women with higher susceptibility to
stereotype threat scored lower on Fundamentals of Laparoscopic
Surgery assessment after receiving a stereotype threat trigger.
Meaning Pro-male gender bias may increase career engagement
among men, and stereotype threat may negatively influence
women surgical trainees’ skill performance in a way that can be
detrimental to professional development.
domized clinical trial exploring the effect of stereotype threat
activation on technical skill performance. Institutional re-
view board approval was obtained at each institution. The trial
protocol appears in Supplement 1. Participants provided writ-
ten informed consent (eAppendix 3 in Supplement 2). We as-
signed each resident a unique alphanumeric code for deiden-
tification of serially collected data, the purpose of which was
to blind the individuals conducting the study. No compensa-
tion was provided for study participation. This study fol-
lowed the Consolidated Standards of Reporting Trials
(CONSORT) reporting guideline for randomized clinical trials.
Participants
General surgery residents at University of Pittsburgh Medical
Center, the University of North Carolina–Chapel Hill, and the
University of Washington were recruited (eAppendix 1 in
Supplement 2) and completed an electronic pre-enrollment
survey to determine eligibility (eAppendix 2 in Supple-
ment 2). Residents who completed undergraduate medical
education in the US and were interested in pursuing teaching
or research as a principal component of their career (ie, aca-
demic surgery)16 were eligible for inclusion. Those who were
in noncategorical positions and/or not interested in pursuing
a career in academic surgery, did not identify as their biologic
sex, or had entered general surgery training after completing
any training in another specialty were excluded. Residents were
asked to participate in a 2-part study over an academic year
exploring how training experiences influenced psychosocial
determinants of success.
Study Instruments and Interventions
During phase 1, 2 identical surveys (eAppendix 4 in Supple-
ment 2) evaluating psychosocial constructs germane to pro-
fessional achievement were sequentially administered (eFig-
ure 1 in Supplement 2). Existing studies on burnout have
suggested that trainees’ experiences can alter motivation, job
satisfaction, and quality of life over time.17 Based on feasibil-
ity and previous studies investigating the association be-
tween behavioral interventions and resident attitudes and
perceptions,18,19 we chose the predetermined time frame of
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 Research Original Investigation Effects of Gender Bias and Stereotypes in Surgical Training

Figure 1. Trial Profile

147 Recruitment emails sent

45 University of North Carolina-Chapel Hill
52 University of Washington
50 UPMC

16 Excluded
16 Did not respond

131 Expressed interest; request sent for further

eligibility information

35 Excluded
22 Noncategorical
13 Categorical; not interested in pursuing
academic career

10 Excluded
10 Did not complete surveys 1 and 2

86 Completed surveys 1 and 2

1 Excluded
1 Withdrew before randomization

85 Randomized
17 University of
North Carolina-Chapel Hill
30 University of Washington
38 UPMC

42 Assigned to receive stereotype 43 Assigned to receive protection Diagram of participants in phases 1

threat trigger against stereotype threat and 2. Of the 85 participants
randomized, 17 were from the
4 Excluded 4 Excluded
University of North Carolina–Chapel
4 Did not complete FLS task 4 Did not complete FLS task Hill, 30 from University of
Washington, and 38 from UPMC.
FLS indicates Fundamentals of
38 Completed the study (20 men, 39 Completed the study (19 men, Laparoscopic Surgery;
18 women) 20 women)
UPMC, University of Pittsburgh
Medical Center.

5 to 6 months between survey administrations. Rationale for
psychosocial constructs assessed and associated scales or sub-
scales is provided in eAppendix 5 in Supplement 2.
Residents had 2 weeks to complete each survey after it was
delivered via a software-generated link (Qualtrics). The sur-
vey instrument comprised 55 questions derived from vali-
dated scales assessing equity and fairness in the work envi-
ronment, susceptibility to stereotype threat, sense of belonging,
resilience, career engagement, and identification with the do-
main of surgery, and 5 questions that assessed demographic
data. Eight items adapted from the Employee Environment
Diagnostic Survey (EEDS)20 were used to measure residents’
perceptions of pro-male gender bias in their environment. Nine
items from the Social Identity and Attitudes Scale (SIAS)21 as-
sessed susceptibility to stereotype threat based on the degree
to which an individual identifies with their gender (ie, gen-
der identity) and their level of gender stigma consciousness.
Nine items adapted from the Career Engagement Scale (CES)22
were used to assess engagement, which has been suggested
to be important for achieving professional success.9 The CES
was modified to interrogate research-related engagement as
scholarly pursuits are a distinguishing feature of academic vs
nonacademic surgeons.16 Engagement is a complex concept
influenced both by environmental cues and characteristics in-
trinsic to the individual.9 These characteristics and the tools
used in their evaluation include sense of belonging (7-item
Sense of Belonging Index-Psychological State subscale),23 iden-
tification with one’s professional domain (7-item Domain
Identification Measure),24 and resilience (10-item Connor-
Davidson Resilience Scale).25 Subscale items were each graded
on a 5-point Likert scale.
In phase 2, residents who completed phase 1 were ran-
domized 1:1 to receive either a stereotype threat trigger (A) or
protection against stereotype threat (B) in a permuted-block
design stratified by site, postgraduate year, and gender. In an
effort to enhance validity and promote spontaneous behav-
ior, detailed information regarding the study’s purpose of
investigating the effect of stereotype threat on skills perfor-
mance was not proffered26; instead, residents were told that
they would be randomly assigned to receive an intervention

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 Effects of Gender Bias and Stereotypes in Surgical Training
meant to direct their focus to or away from a surgery-related
subject. After the investigation was complete, participants
were debriefed with regard to study intent, procedures, and
results via email communication and open-forum presenta-
tion. We adapted a validated and previously used method of
activating or protecting against stereotype threat.27 Inter-
vention A triggered stereotype threat by asking participants
to read the abstracts of 2 articles that reported women per-
formed worse with regard to laparoscopic skills than men.
Intervention B was intended to protect against stereotype
threat by asking participants to read 2 abstracts that reported
no gender-based differences in laparoscopic skills perfor-
mance. According to the randomization assignment, articles
were placed in a sealed envelope labeled with the partici-
pant’s study code and provided to each participant just prior
to administration of the Fundamentals of Laparoscopic Sur-
gery (FLS) assessment (task portion). Immediately after the
interventions, participants completed the FLS, a standard-
ized, validated simulation-based assessment of laparoscopic
ability,28-31 followed by a third iteration of the survey, which
included additional questions evaluating residents’ percep-
tion of their performance. The FLS exams were administered
by 2 proctors certified by the Society of American Gastro-
intestinal and Endoscopic Surgeons, who were blinded to
the participants’ intervention arm. Exams were sent to the
Society of American Gastrointestinal and Endoscopic Sur-
geons for blind scoring under deidentified participant code.
Residents understood that their score could not be used for
formal FLS certification. Proctors and Society of American
Gastrointestinal and Endoscopic Surgeons were compen-
sated for exam administration and scoring.
Statistical Analysis
Survey subscale items were assigned a score based on the
5-point Likert scale and then summated to yield a total sub-
scale score. Internal consistency of each subscale was as-
sessed using Cronbach α, with values between 0.7 and 0.9 con-
sidered acceptable.32 The α values from unmodified original
subscales were as follows: EEDS, 0.96; CES, 0.87; Social Iden-
tity and Attitudes Scale gender identity, 0.81, Social Identity
and Attitudes Scale gender stigma consciousness, 0.87; Sense
of Belonging Index-Psychological State subscale, 0.93;
Domain Identification Measure, 0.75; and Connor-Davidson
Resilience Scale, 0.85.20-25
Our primary hypothesis in phase 1 was that the associa-
tion between perception of pro-male bias as measured by EEDS
score and career engagement as measured by CES score dif-
fered by gender. To avoid sampling bias and accurately re-
flect resident population demographics, we used a poststrati-
fication weighting adjustment33 for survey data based on the
participant’s gender and race using national data.34 Wilcoxon
Mann-Whitney tests evaluated gender-based differences in
subscale scores. Wilcoxon matched-pairs signed rank tests as-
sessed differences between survey 1 and 2 scores. Since sur-
vey 1 was administered early in the academic year, first-year
postgraduate residents may not have acclimated to their train-
ing environment; analyses for phase 1 were performed using
survey 2 responses. Before regression analyses, nonnormally
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Original Investigation Research
distributed data were logarithmically transformed. All statis-
tical tests were clustered by site, as data within an institution
may not be independent. We modeled the association be-
tween survey 2 EEDS and CES scores using linear regression
incorporating an interaction term for gender. In phase 1 sec-
ondary analyses, we adjusted for the remaining 4 psychoso-
cial constructs to determine whether these results modified
the association between EEDS and CES.
The second part of this study explored the effects of ste-
reotype threat, a concept related to but separate from gender
bias, on technical skill performance. Differences in perfor-
mance may manifest independent of bias within the work en-
vironment owing to gender stereotypes from a pervasive cul-
tural context. We hypothesized that the FLS scores in the
intervention arms would differ and that gender-based differ-
ences in performance would vary by whether stereotype threat
was activated or protected against.
A minimum sample size of 84 residents was calculated to
detect a 20-point difference in FLS score at 80% power and
α = .05, and accounting for 10% attrition.35,36 Analyses were
based on intention-to-treat. Gender-based differences in sur-
vey 3 responses were assessed using the Wilcoxon Mann-
Whitney test. Wilcoxon matched-pairs signed rank tests were
used to compare survey 2 and 3 subscale responses. Differ-
ences in FLS scores between intervention arms and by gen-
der were evaluated using 2-tailed, unpaired t tests. Post hoc
analysis assessed whether susceptibility to stereotype threat
modified the effect of intervention across genders on FLS
scores. Stata, version 15 (StataCorp), was used for all analy-
ses. A P value ≤.05 was considered significant.
Results
General surgery residents at University of North Carolina–
Chapel Hill, University of Washington, and University of Pitts-
burgh Medical Center were recruited between August 1 and
August 15, 2018. A total of 131 residents were assessed for eli-
gibility. Of 96 eligible residents (Figure 1), 86 individuals (90%)
completed phase 1 and were enrolled in phase 2. One resident
withdrew before randomization. Of 85 residents randomized
(Table 1), 42 were assigned to intervention A and 43 were as-
signed to intervention B. Four residents in each arm dropped
out; 77 residents (91%) completed the study.
Phase 1
The association between perception of pro-male gender bias
in the environment and career engagement differed signifi-
cantly by gender (interaction coefficient, −1.19; 95% CI, −1.90
to −0.49; P = .02); men who had a higher perception of pro-
male bias had higher career engagement scores (coefficient,
1.02; 95% CI, 0.19-2.24; P = .04) (Figure 2). Although the di-
rection of the data was opposite compared with that of men,
no significant association was noted between perception of pro-
male bias and career engagement scores among women (co-
efficient, −0.25; 95% CI, −1.59 to 1.08; P = .50). After adjust-
ing for the other psychosocial constructs, the moderating effect
of gender on the association between perception of pro-male
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 Research Original Investigation Effects of Gender Bias and Stereotypes in Surgical Training

Table 1. Demographics of Participants Who Underwent Randomization

No. (%)
Trigger of Protection against
stereotype threat stereotype threat
Variable All participants (intervention A) (intervention B)
No. 85 42 43
Postgraduate training level, y
1 15 (17.6) 7 (16.7) 8 (18.6)
2 18 (21.2) 9 (21.4) 9 (20.9)
3 11 (12.9) 6 (14.3) 5 (11.6)
4 11 (12.9) 5 (11.9) 6 (14.0)
5 10 (11.8) 5 (11.9) 5 (11.6)
Lab 20 (23.5) 10 (23.8) 10 (23.3)
Sex
Male 43 (50.6) 21 (50.0) 22 (51.2)
Female 42 (49.4) 21 (50.0) 21 (48.8)
Racea
a
No participants identified as
White 57 (67.1) 28 (66.7) 29 (67.4)
American Indian or Alaska Native or
Black/African American 6 (7.1) 2 (4.8) 4 (9.3) as Native Hawaiian or Pacific
Asian 16 (18.8) 10 (23.8) 6 (14.0) Islander.
b
Other 6 (7.1) 2 (4.8) 4 (9.3) No participants identified as
widowed. Divorced and separated
Marital statusb
represented separate response
Married 40 (47.1) 23 (54.8) 17 (39.5) categories on the survey instrument
Divorced/separated 2 (2.4) 0 2 (4.7) but have been collapsed within
these data for presentation
Never married 43 (50.6) 19 (45.2) 24 (55.8)
purposes.

Figure 2. Association Between Perception of Gender Bias

Phase 2
and Career Engagement Across Genders There was little difference among men and women in FLS score
between interventions (mean [SD], A: 395 [150] vs B: 367 [157];
50 P = .51). Although the mean (SD) FLS score was lower for
women compared with men in both intervention A (367 [152]
40 vs 423 [148]; P = .12) and intervention B (328 [168] vs 400 [142];
Men
P = .08), these differences were not statistically significant. The
Career engagement

30 response to stereotype threat activation was similar in men and

20
Women
10
0
5 10 15 20 25
Perception of pro-male bias
The association between Employee Environment Diagnostic Survey score and
Career Engagement Scale score is plotted for men and women participants.
bias and career engagement scores persisted (interaction co-
efficient, −1.15; 95% CI, −1.72 to 0.58; P = .01).
Men had significantly higher susceptibility to stereotype
threat scores than women on survey 1 (median, 21.0; inter-
quartile range [IQR], 17.5-26.5 vs 17.5; IQR, 15.0-21.0; P < .001)
and survey 2 (median, 20.0; IQR, 16.5-24.0 vs 17.5; IQR, 16.0-
20.0; P = .005) (Table 2; eTable 1, eFigure 3 and eFigure 4 in
Supplement 2). Women had higher resilience scores than men
on survey 1 (median, 17.0; IQR, 14.0-20.5 vs 16; IQR, 12-20;
P = .009) and survey 2 (median, 19.0; IQR, 14.0-21.5 vs 15.0;
IQR, 12.0-20.0; P = .02). Women had higher resilience scores
on survey 2 compared with survey 1 (P = .004).
women (interaction coefficient, 15.1; 95% CI, −124.5 to 154.7;
P = .39). However, association between stereotype threat ac-
tivation and FLS score differed by gender across levels of sus-
ceptibility to stereotype threat (interaction coefficient, −35.3;
95% CI, −47.0 to −23.6; P = .006). Among women with higher
susceptibility to stereotype threat, a trigger of stereotype threat
30 was associated with lower FLS scores (coefficient, −43.4; 95%
CI, −48.0 to −38.9; P = .001), but protection against stereo-
type threat was associated with higher FLS scores (coeffi-
cient, 12.0; 95% CI, 2.0-21.9; P = .04) (Figure 3). Among men
with a higher SIAS score, evoking negative stereotypes about
women trended toward a nonsignificant increase in FLS score
(coefficient, 5.2; 95% CI, −7.6 to 18.0; P = .22), but those ex-
posed to protection against stereotype threat did (coeffi-
cient, −8.2; 95% CI, −15.3 to −1.03; P = .04).
Significant differences in subscale responses were noted
on survey 3 (eTable 2 in Supplement 2). Among participants
who received intervention A, women had higher perception
of pro-male bias scores than men (median, 16.0; IQR, 13.0-
19.0 vs 13.5; IQR, 11.0-17.5; P = .04). In both study arms, women
had higher resilience scores than men (A: median, 18.0; IQR,
14.0-20.0 vs 14.0; IQR, 10.0-19.0; P = .05; B: median, 19.0; IQR,
16.0-22.0 vs 13.5; IQR, 11.0-18.0; P = .03). When compared with

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 Effects of Gender Bias and Stereotypes in Surgical Training Original Investigation Research

Table 2. Survey 1 and 2 Responses

Median (IQR) P value for

between-gender
Subscale Women Men difference Cronbach α
Career Engagement Scale
Survey 1 23.5 (13.5-29.0) 21.5 (16.5-29.0) .46 0.87
Survey 2 22.5 (15.5-28.5) 21 (17.0-29.0) .97 0.85
P value for between-survey difference .15 .75
Employee Environment Diagnostic Survey
Survey 1 14 (12.0-17.5) 15 (13.0-17.5) .69 0.83
Survey 2 15 (11.0-19) 15 (13.0-18.0) .69 0.82
P value for between-survey difference .36 .40
Social Identity and Attitudes Scale
Survey 1 17.5 (15.0-21.0) 21.0 (17.5-26.5) <.001 0.85
Survey 2 17.5 (16.0-20.0) 20.0 (16.5-24.0) .005 0.86
P value for between-survey difference .32 .14
Sense of Belonging Index
Survey 1 19.5 (17.0-23.5) 20.5 (17.0-23.5) .91 0.87
Survey 2 20 (16.5-23.0) 21 (17.0-23.5) .52 0.85
P value for between-survey difference .57 .24
Domain Identification Measure
Survey 1 12 (9.0-14.0) 10 (9.0-15.5) .21 0.80
Survey 2 13 (10.0-14.5) 11 (9.0-14.5) .75 0.82
P value for between-survey difference .38 .99
Connor-Davidson resilience scale
Survey 1 17 (14.0-20.5) 16 (12.0-20.0) .009 0.86
Survey 2 19 (14.0-21.5) 15 (12.0-20.0) .02 0.86
Abbreviation: IQR, interquartile
P value for between-survey difference .004 .87
range.

intervention B, intervention A was associated with higher ca-
reer engagement (median, 23.0; IQR, 17.0-30.0 vs median 17.5;
IQR, 13.5-25.5; P = .02), susceptibility to stereotype threat (me-
dian, 20.0; IQR, 15.0-22.0 vs 17.0; IQR, 14.5-23.5; P = .05), and
sense of belonging (median, 18.0; IQR, 15.0-21.0 vs 16.0; IQR,
15.0-20.0; P = .03) scores among men, but lower sense of be-
longing scores among women (median, 18.0; IQR, 14.0-22.0 vs
20.0; IQR, 16.0-25.0; P = .03) on survey 3. No adverse out-
Figure 3. Gender-Based Differences in the Association Between
Stereotype Threat and Susceptibility to Stereotype Threat and
Fundamentals of Laparoscopic Surgery (FLS) Skills Assessment Score
1000
Men, protection against stereotype threat arm
Men, stereotype threat trigger arm
800
Women, protection against stereotype threat arm
Women, stereotype threat trigger arm

comes were reported. 600

FLS score

400

Discussion
200
Factors associated with the underrepresentation of women in
academic surgery1,2 are complex. This study explores how af-
0
fective interactions between an individual and their resi- 0 5 10 15 20 25 30

dency environment are associated with engagement and tech- Susceptibility to stereotype threat score

nical skill performance, which are key factors in professional

success (eFigure 2 in Supplement 2).9 The association of pro-
male bias with engagement differed across genders. Al-
though the association between intervention arm and FLS score
did not differ by gender, higher susceptibility to stereotype
threat among women who received a trigger of stereotype
threat was associated with lower FLS scores. These findings
suggest that negative stereotypes might be detrimental to the
operative performance of stigmatized individuals.
Gender bias may influence women’s underrepresenta-
tion in surgery practice.3 We found that experiencing pro-
The association between susceptibility to stereotype threat score and FLS score
is depicted by participant gender and intervention arm.
male bias is associated with increased career engagement
among men. Although the data had an opposite direction
among women, no significant association was observed. Oth-
ers have proposed that reduced engagement may contribute
to reduced academic performance,9 burnout, and attrition
among women in academic medicine.37 While further inves-
tigations are necessary to establish the mechanisms by which

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 Research Original Investigation Effects of Gender Bias and Stereotypes in Surgical Training

bias challenges professional efficacy and engagement, one pos-
sibility is that bias may result in reduced motivation among stig-
matized individuals.38 Engagement appears to be malleable and
therefore exists as a potential for targeted interventions aimed
at cultivating professional development.39 Gender-based dif-
ferences in the affective constructs associated with engage-
ment suggest that individual factors, such as resilience,40,41
also may be candidates for intervention.42
Prior research indicates that gender stereotypes depress
the professional performance of women. 43,44 In male-
dominated professions, role congruity theory posits that pro-
male bias can seem to be more pronounced5,6; being female
and a surgeon is perceived as incompatible with the gen-
dered stereotype of the surgeon as male. While previous stud-
ies have illustrated the consequences of gender stereotypes
on promotion 4 5 - 4 8 and opportunities (eg, operative
autonomy),49,50 a causal link between bias and stereotype
threat activation has not been established. Herein, we showed
that after a trigger of stereotype threat, women had a higher
perception of pro-male bias. However, differences in perfor-
mance may manifest independent of whether bias exists in the
work environment owing to the valences of gender stereo-
types from a pervasive cultural context. For surgeons, a domi-
nant metric of professional performance is technical ability, and
this has become an important factor by which surgeon com-
petence and achievement are judged.51-53 The American Board
of Surgery31 requires that surgeons achieve a passing score on
the FLS examination. Although previous studies have been
unable to identify gender-based differences in FLS scores54 or
other laparoscopic skills metrics,55 we now show that remind-
ing women who exhibit higher susceptibility to stereotype
threat of negative gender stereotypes reduces their perfor-
mance on the FLS examination. This result corresponds with
data previously published indicating that individuals with un-
derrepresented demographics express increased anxiety about
their abilities56,57 in a manner that may reduce performance.
Among men with higher susceptibility to stereotype threat,
there was a nonsignificant positive (ie, upward) directional-
ity in FLS scores when presented with negative stereotypes
about women. This phenomenon, referred to as stereotype
lift,58 theoretically occurs if men perceive an advantage when
women are negatively labeled.59 Given that technical skill per-
formance is requisite to ascertaining surgical competence,
efforts to reduce the effect of negative gender stereotypes are
needed for the retention of women in academic surgery.
This study was conceptualized within a social cognitive
theory framework60; behaviors that facilitate or impede learn-
ing are dynamic and develop as a result of the interaction be-
tween a person and their surroundings. Psychosocial deter-
minants of success may fluctuate in response to environmental
triggers (eg, stereotypes or bias). In particular, we found that
triggering stereotype threat was associated with a lower sense
of belonging among women. Belonging is important for inten-
tions to persist in academic endeavors.43 Strategies such as val-
ues affirmation, ie, affirming the importance of a task for
achieving goals, can ameliorate the consequences of reduced
belonging61 and may be incorporated into surgical curricula as
interventions to promote self-worth and motivation.
Limitations
This study has limitations. It was underpowered to study ef-
fect modification or the intersectional effects associated with
membership in multiple underrepresented groups (ie,
intersectionality).62 The sample size restricted our ability to
perform factor analyses that would confirm the validity of the
modified survey and its subscales. Contamination63 that re-
sulted from residents recognizing the purpose of activating ste-
reotype threat (ie, failure of planned deception) and develop-
ing a reactive, rather than vulnerability, response64 may have
biased our results toward the null. As there are no metrics with
which to evaluate the degree to which training environments
perpetuate negative stereotypes about women, we could not
account for how ambient cues and organizational policies may
have influenced intervention effect.65
Conclusions
Negative stereotypes about women and pro-male gender bias
affect career engagement and technical performance among
individuals pursuing careers in academic surgery. Mitigating
the effect of negative stereotypes is requisite for the profes-
sional development of surgeons-in-training, particularly
women. Cultivating inclusivity is needed to protect our in-
vestment in future generations of surgeons and to advance
medicine.

ARTICLE INFORMATION
Accepted for Publication: February 22, 2020.
Published Online: May 20, 2020.
doi:10.1001/jamasurg.2020.1127
Author Contributions: Drs Myers and Rosengart
had full access to all of the data in the study and
take responsibility for the integrity of the data and
the accuracy of the data analysis.
Concept and design: Myers, Lumpkin, Neal, Lee,
Rosengart.
Acquisition, analysis, or interpretation of data:
Myers, Dasari, Brown, Lumpkin, Abebe, Chaumont,
Downs-Canner, Flanagan, Lee, Rosengart.
Drafting of the manuscript: Myers, Rosengart.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Myers, Brown, Lumpkin, Abebe,
Rosengart.
Obtained funding: Myers.
Administrative, technical, or material support:
Myers, Dasari, Neal, Chaumont, Downs-Canner.
Supervision: Myers, Neal, Chaumont,
Downs-Canner, Lee, Rosengart.
Conflict of Interest Disclosures: Dr Lumpkin
reported receiving grants from the Agency of
Healthcare Quality and Research during the
conduct of the study. Dr Neal reported receiving
grants and personal fees from Janssen
Pharmaceuticals, personal fees and nonfinancial
support from Haemonetics, grants from Instrument
Laboratories, financial support from Haima
Therapeutics, grants from Noveome, and personal
fees from CSL Behring outside the submitted work.
No other disclosures were reported.
Funding/Support: Dr Myers was supported in part
by National Center for Advancing Translational
Sciences training grant 5TL1TR001858-02.
Role of the Funder/Sponsor: The National Center
for Advancing Translational Sciences contributed to
the conduct of the study by supporting
administration of the Fundamentals of
Laparoscopic Surgery examinations at participating
sites and reimbursement to the Society of American
Gastrointestinal and Endoscopic Surgeons for
scoring of these examinations. The funding did not
include a role in study design, analysis or
interpretation of the data; preparation, review, or

558 JAMA Surgery July 2020 Volume 155, Number 7 (Reprinted) jamasurgery.com

© 2020 American Medical Association. All rights reserved.

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 Effects of Gender Bias and Stereotypes in Surgical Training
approval of the manuscript; or decision to submit
the manuscript for publication.
Data Sharing Statement: See Supplement 3.
Additional Contributions: We acknowledge the
contribution of the residents who participated in
this study as well as the faculty and staff of the
University of North Carolina–Chapel Hill, UPMC, and
University of Washington departments of general
surgery. Melina R. Kibbe, MD, Michael O. Meyers,
MD (both University of North Carolina–Chapel Hill),
and Karen D. Horvath, MD (University of
Washington), provided encouragement and
support; Kathie Patterson (University of North
Carolina–Chapel Hill), Maggie Mrozinski, BS (UPMC)
, and Inga Brissman (Society of American
Gastrointestinal and Endoscopic Surgeons) assisted
in the coordination and administration of
Fundamentals of Laparoscopic Surgery
examinations; and Scott D. Rothenberger, PhD
(University of Pittsburgh), assisted with statistical
analysis. In addition, we recognize the faculty and
staff of the University of Pittsburgh’s Clinical and
Translational Science Institute and the Pittsburgh
Surgical Outcomes Research Center for their
support of this study. No financial compensation
outside of salary was provided.
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032414-111322

Invited Commentary

Gender Bias and Stereotypes in Surgical Training

Is It Really Women Residents We Need to Worry About?
Caprice C. Greenberg, MD, MPH; Jacob A. Greenberg, MD, EdM

It is uncomfortable to acknowledge that our interpersonal in-
teractions and experiences in the workplace are affected by
gender. Traditional mantra tells us that gender (or skin color
or religion or any other char-
acteristic) should not influ-
Related article page 552 ence our expectations, our as-
sessment, or our treatment of
any individual as a surgeon. This one-size-fits-all approach has
existed, especially in surgical training, for a very long time. The
problem with this, of course, is that the one size is not agnos-
tic but rather reflects the traditional majority, and the rest of
us have been expected to conform. To think otherwise re-
quires an acknowledgement that interpersonal interactions and
experiences vary by gender and as a result may require differ-
ent approaches to training.1
In this issue of JAMA Surgery, Myers et al 2 present a
thought-provoking study investigating gender bias and ste-
reotypes in surgical training. The study explores how affec-
tive interactions between an individual and the residency en-
vironment affect engagement and technical skill performance
(Fundamentals of Laparoscopic Surgery [FLS] score) as mea-
sures of professional success. This study is richly nuanced and
packed with insightful observations about this important is-
sue. There are many conclusions that can be drawn from this
well-designed study, and we are not convinced the authors fo-
cus on the most salient ones. The authors’ main conclusions
are: (1) negative stereotypes about women and pro-male gen-
der bias affect career engagement and technical perfor-
mance; and (2) mitigating the effect of negative stereotypes
is requisite for the professional development of trainees, par-
ticularly women.
The study included a randomized clinical trial, with the
primary finding that triggering stereotype threat did not in-
fluence FLS score overall or when stratified by gender. This is
strongly encouraging and suggests that negative gender ste-
reotypes do not affect technical performance either for men
or women. While this may be an issue of power, it should be
considered a negative trial.
The second primary aim was to examine the effect of pro-
male gender bias on professional engagement. First and most

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