Who Gets to Hold the Knife? Gender and Autonomy in (Australian) Surgical Training

Who Gets to Hold the Knife? 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Gender and Autonomy in (Australian) Surgical Training Fiona S Reid, Curtis Lee, Debra Nestel, Ian W. Incoll This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7124948/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose Over the past decade there has been an increased focus on equality and diversity in surgical training globally. There is little doubt that increased diversity and representation leads to better healthcare outcomes; despite this, females account for only 12% of general surgeons in Australia. This study aimed to examine gender differences in autonomous operating of trainee general surgeons as a means of gaining insight to one aspect of the lived experience of female surgeons. Methods The study design was a retrospective cohort analysis of all general surgical trainees in Australia from 2013 to 2020. Data comprised self-reported, online logbook data (Morbidity Audit and Logbook Tool MALT) that is mandatory for all surgical trainees. Meaningful autonomy (MA) was defined as operating without a senior surgeon scrubbed. Operations were categorised as ‘minor operations’, ‘major operations’ and ‘endoscopy’ as defined by RACS and the online data recording tool MALT Results were analysed using SPSS for Windows with a paired t-test for all operations, major operations, minor operations and endoscopy. Due to the large data set and 2014 outlier data a Cohen’s d test of practical significance was also calculated. Results There were >1.3m logbook entries from 2,783 trainees (female=1,033; male=1,750) Procedures included ‘minor operations’, ‘major operations’ and ‘endoscopy’. Throughout their training, females had a significantly lower MA for procedures compared with their male peers (39.7% vs 42.2% t 7 =7.861 sig <.001). Cohen’s d analysis indicates a large effect size and practical significance (8.9). For major and minor operating combined (excluding endoscopy), the greatest difference in MA was in 2020 (10%) and the smallest in 2014 (2.1%). Conclusions This large dataset of general surgical trainees’ logbook entries shows that females have fewer opportunities for meaningful autonomy during training. This difference may contribute to lower recruitment, retention and confidence expressed by female surgeons in Australia. Autonomy Bias Gender General surgery Zwisch Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction In medicine and surgery diversity leads to improved health care outcomes, including a reduced risk of 30-day mortality, better communication, satisfaction and adherence to care protocols 1-4 . Given that most populations are 50% female, optimal health care outcomes are unlikely to be achieved without proportionate healthcare representation. With females comprising just 11.8% of Australia’s general surgeons, numerous communities are experiencing a lack of ideal surgical representation 1,2 In line with their commitment to achieving equitable representation, the Royal Australasian College of Surgeons (RACS) released a report in 2020 outlining the obstacles hindering women’s participation in all general and sub-specialty surgical training within Australia and New Zealand 5 Whilst not specific to general surgery, the report summarised 1,700 respondents’ views with the following list of perceived barriers to a career in surgery: poor culture (discrimination, bullying, sexism, and harassment), unsolicited gendered advice (‘boys club’, assumptions about ability, future children, and family life), lack of SET (Surgical Education and Training) transparency and flexibility, costs and inflexibility of part-time options once on the program, lack of quality mentors, and peers at university, tutors, lecturers, junior doctors, surgical trainees and surgeons/ consultants (both male and female) caused barriers for most women who were surveyed. It is tempting to conclude (as this report did) that “lifestyle choices” were the prevalent reason for females not pursuing surgery. However, this cannot be the whole picture as females are far more highly represented in paediatric surgery (29.4% of consultants), and obstetrics and gynaecology (44.6% of consultants), which have similar demanding training schedules and on-call commitments. 6 , 7 Given only 11.8% of general surgeons in Australia are female, lifestyle and family planning may not be the only, or even the largest, driver of this disparity. The paradigm of surgical training in Australia follows a structured progression characterised by escalating responsibilities, culminating in autonomous practice to prepare trainees for independent clinical work. Operative autonomy is considered equally important by consultants and trainees, with both ranking it as essential for effective learning. 8 Multiple studies have shown that this kind of participation and engagement has a significant impact on student’ and junior doctors’ feelings about surgery and surgical culture. 9-11 Being denied training opportunities and, in particular, intraoperative training opportunities comprises 31-38% of respondent’s complaints of gender-based bullying in Australia. 12 The journey of a surgical trainee’s progression from passive observer to independent practitioner is shaped by the co-created perspective of both trainee and trainer. Whilst many other factors may have an impact, evidence suggests the decision to bestow autonomy is influenced by: the estimated trustworthiness of the trainee; the estimated risk of the situation and the urgency or time pressure of the operation 13 ; complexity of case; personal knowledge of the trainee seniority and self-confidence 14-16 ; and even the congruence of trainee-trainer personality types. 17 Other influences include time pressure and subspecialisation, as well as an increase in community and institutional pressure for services to be “consultant-led” 18 . Teaching intra-operative technical skills also requires a great deal of effort, trust, and cognitive energy from both trainee and surgeon, and may paradoxically increase surgeon workloads. 19 Autonomy contributes to confidence and formation of professional identity which, in turn, play a role in reducing attrition from training. Female trainees have a 2.5 times greater rate of training attrition in Australia 20 . Amongst the reasons stated for withdrawal from training include; burnout, poor culture, insufficient operative experience and lack of technical confidence, lack of respect from seniors, 21 all of which are known to contribute to psychological distress and reduced coping. 12, 22-24 Three contemporary studies underpin our current knowledge of the influence of gender on autonomous operating. In laparoscopic general surgery, female trainees received much more intraoperative guidance than their matched male counterparts, with the rationale for this deemed to be a lower level of judgement of competence in the attending surgeon for female trainees. Male trainees were rated by their attendings as having significantly better operative technique and significantly higher operative knowledge; however, there were no technical differences found when supervising surgeons were blinded to the gender of the trainees. 25 Similar findings in cardiothoracic training in the USA and general surgical training in New Zealand conclude that these differences are likely to be harmful and that implicit bias in the trainer and behavioural gender norms in the trainee are the most likely explanation. 24-27 This study aims to determine if female general surgical trainees in Australia between 2013 and 2020 had a different level of surgical autonomy than male trainees during the same period. Methods This is a retrospective cohort study examining the logbook data of Australian general surgical trainees from January 2013 to August 2020. Deidentified data was made available through collaboration with the RACS and approved by General Surgeons Australia. RACS and GSA work together to administer a nation-wide, competitive entry, surgical training program. RACS sets and maintains surgical standards and GSA administers the training program. The data presented was grouped into SET years (from February to February) with the ‘year’ names for the calendar year in which the bulk of the training fell. For example, year 2010 runs from February 2010-February 2011. Trainees had terms (defined as either term 1: February to August or term 2: August to February) excluded if they did not have submitted data and/ or were on leave from clinical training. Trainees in this cohort self-identify their gender to RACS in a binary fashion at the point of entering training and this is recorded. As surgeons are all fellows of RACS their gender (as a binary construct) is also recorded. All trainees are mandated to record their operative experience and the surgeons who supervised them, and their level of autonomy according to the pre-determined RACS guidelines (based on the Zwisch scale). 28 Assisting surgeon mentor Surgeon mentor scrubbed (indicating active assistance and close coaching) Surgeon mentor in theatre (indicating verbal on-demand assistance) Surgeon mentor available (indicating mentor is available on-demand for non-standard, unpredictable, or unexpected events) RACS automatically also defines their year and term of training. The primary outcome was intraoperative autonomy by gender in surgical trainees. This was further classified into ‘meaningful autonomy’ (MA), defined as the trainee performing the operation with the surgeon mentor not scrubbed. Within each year the trainees were divided by gender and the total number of major operations documented in the logbook was calculated. The number of operations with MA was then calculated and the data is presented as the percentage of MA operations: (major operations with MA/ total number of major operations performed x 100). The data for operative experience (excluding endoscopy) was calculated per gender per year as follows: [(Major operations with MA + Minor operations with MA)/(total major operations + total minor operations)] x100. Results were analysed using SPSS for Windows with a paired t-test for all operations, major operations, minor operations and endoscopy. Due to the large data set and 2014 outlier data a Cohen’s d test of practical significance was also calculated. Ethical approval was obtained from the University of Melbourne Human Research Ethics Committee (2020-20405-13354-3) with a waiver of consent as all data is de-identified at the point of release. Results The data included 2,783 trainees’ (1,033=female; 1,750=male) logbook entries from 2013 to 2020. The representation of female trainees remained between 34.7%- 39.5% over the period of study. (Table 1) A total of 1,340,748 procedures were performed including 522,492 major, 410,043 minor and 235,167 endoscopies. Female trainees performed 485,333 (36%) and male trainees 855,415 (64%) of these operations. Meaningful Autonomy Throughout their training, females had MA in 39.7% of operations vs 42.2% of operations for their male peers for all operations. Results were analysed with a paired T test which showed a difference in MA between males and females for all operations (t 7 =7.861 sig <.001.), minor operations (0.002) endoscopy (0.011) but no difference for major operations across all 7 years (0.091). Cohen’s d was greater than 2 for MA overall (8.9) and each of major (7.3), minor (4.7) and endoscopy (8.3) indicating a large effect size (Table 2) Comparing MA by gender, the range of differences in combined major and minor operations was between 2.1% (in 2014) to 10% (in 2020) with males taking part in a higher percentage of MA operations. (Figure 1). The difference was also established in endoscopy (Figure 2): For major and minor operating separately, the trend was also established (Figures 3 and 4). In 2014, the normal trend was reversed (more MA for female trainees) for major operations but not for minor operations nor endoscopy. Discussion In Australia, female trainees constitute approximately 35–39% of the cohort within general surgical training. The data reveal that MA is notably lower among female trainees, culminating in a disparate training experience. Surgeons describe several factors as influencing their decision to award autonomy including: technical proficiency, complexity of procedure, amount of time spent in collaboration with the trainee, seniority of trainee and trainees self-confidence 19 , 29 . More subtle factors may also be at play with small studies showing that congruent personality types may be influential 17 and Joh et al 27 , Meyerson et al 24 , 26 and Hoops et al 25 have all postulated that gender may be an influence. Given that the perception of technical proficiency and trainee confidence are reported as factors that may influence the award of autonomy it becomes relevant to examine how these conclusions are reached and what influences them. Surgeon mentors describe trainee technical skill as a factor in determining the award of autonomy. However, females are often judged as less technically competent than their male peers even without objective evidence. This apparent bias is more prevalent in fields with a high level of male predominance. 15 , 30 In Australia, male surgeons, in particular, score female applicants lower on technical ability at interview despite having little to base this assessment on. 31 When objective metrics are used under controlled conditions (e.g. laparoscopic trainers), there is no difference in the learning curve between male and female trainees 32 and equal competency between genders. 25 , 33 Self-confidence has also been identified as a factor influencing autonomy, research consistently shows that female surgeons and female trainees have lower levels of confidence in their technical skills than their male counterparts. 34 35 ‘Lack of confidence’ is a common criticism given to female trainees during feedback; one study finding 56% of female residents reported this criticism vs 29% of male residents 34 , with female trainees even receiving conflicting confidence feedback (too much and too little) within the same rotation. 36 This has been explained by the Dunning-Kruger effect, which highlights that one’s ignorance can often be invisible to oneself 37 and has been postulated as influencing surgical trainees self-assessment of confidence. 38 Another explanation for this difference is variation in trainee self-reporting, there are currently no studies investigating whether there is a gender influence on self-reporting of level of involvement with surgery. It is not possible to know whether a reduction in MA alone impacts training. However, theories of professional learning emphasise the importance of MA in developing expertise and professional identity. The situated learning paradigm of Communities of Practice (COP) advocates for immersive and situated leaning within relevant professional communities; in this context the operating theatre, and a graduated increase from legitimate peripheral participation to independent practice concurrent with the development of professional identity 39 – 41 . According to the COP theoretical framework, not only is autonomy important to achieve mastery but lack of autonomy leads the more experienced learner to feel disempowered with a reduced sense of belonging and impaired professional identity. Therefore, the level of participation has inherent value, over and above the technical mastery, depending on the circumstances of the learner. 28 , 40 If females in the operating theatre remain ‘peripheral’ within their CoP they risk never fully ‘becoming’ surgeons within that community. Hamdorf and Hall’s model involves the necessity of autonomous practice to develop technical expertise. 42 . In this theory, trainees progress through cognition and integration steps to achieve automation. Once the skill becomes automated, deliberate practice is employed to develop expert practice 43 . These educational methodologies are ingrained within surgical training with trainees, at the time of this study, required to document the extent of intra-operative supervision and the proportion of ‘primary operating’ (operations whereby the trainee has completed a significant proportion of the case). These parameters are expected to incrementally rise thought the training period and are used to assess not only the trainee but also the training environment. 44 While it seems self-explanatory that a trainee must technically master an operation, becoming a surgeon also involves mastery of a myriad of other competencies including: Collaboration and teamwork, communication, cultural competence, health advocacy, judgement and clinical decision making, leadership and management, medical expertise, professionalism, scholarship and teaching. 45 41 46 Situated learning within this CoP also provides contextual learning of the cultural expectations and behaviours, and development of an identity that is being modelled intra-operatively. Research on female surgeons and trainees has revealed that identity is not felt securely. This is both an internal (“imposter phenomenon”) and externally inhibited (less likely to be correctly identified as a surgeon by peers/patients) phenomenon. 34 , 47 , 48 Burgos et al systematic review into gender differences in teaching and learning in surgery supports this view and extrapolated these effects onto professional identity formation of female surgeons, which they felt were impaired by implicit bias, poor access to autonomy, and harassment 33 They argued that feelings of guilt and resignation amongst female trainees who feel unable to address these factors would integrate harmfully into their long-term professional identity, continuing to undermine them in the long term. 33 Recently RACS and GSA changed the training requirements for SET trainees to a new competency-based curriculum. The fundamental difference is the attention to numbers of operations being ‘signed-off’ as performed independently. Procedure Based Activities (PBA) are operative skills which are assessed and completed when the trainee is: “Able to Perform Independently defined as the Trainee is able to complete the procedure with minimal supervision and guidance, and demonstrates knowledge of when to request appropriate assistance”. 49 There are now specific requirements for how many PBAs must be signed off as independent in order for the trainee to progress with training. 49 Given the weight RACS has now placed on independent operating as the benchmark for competency, the findings of this research may alter the training trajectory of male and female trainees. If a change in the bestowal of operative autonomy does not occur, it is possible that female trainees will take longer to achieve ‘competency’ as judged via PBAs. It is hoped that the formalisation of this style of training may be beneficial as it sets expectation and requirements for the trainee to ask for, and be given, a higher level of operative autonomy. It would behove RACS to conduct an early analysis on the gender-based experiences and consequences of this new training paradigm. Conclusion It is highly probable that diminished opportunities for autonomous operating impact a female trainee's technical proficiency, self-assurance, professional identity, and influence her perception of the surgical culture. The introduction of PBAs may exacerbate, rather than ameliorate, these disparities. To foster gender equality and ensure optimal outcomes for female trainees and fellows, it is imperative to confront and dismantle obstacles to equity. This includes critically evaluating the impact of PBAs on equitable access to training opportunities. Emphasis should be placed on cultivating a constructive workplace environment and prompting supervisors to critically evaluate their biases and practices in granting intra-operative autonomy. Declarations No scholarships or grants have been received in conjunction with this study. There are no conflicts of interest. Data Availability Statement: The data that support the findings of this study are not openly available due to reasons of confidentiality and are governed by a consent waiver. The data may be made available from the corresponding author upon reasonable request and consent waiver from a relevant Human Research Ethics Committee. Alternatively the original dataset can be requested with appropriate permissions from the Royal Australasian College of Surgeons. References Myers CG, Sutcliffe KM. How discrimination against female doctors hurts patients. Harv Bus Rev 2018. Wallis CJ, Jerath A, Coburn N, Klaassen Z, Luckenbaugh AN, Magee DE, Hird AE, Armstrong K, Ravi B, Esnaola NF. 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Cohen's d > 2 indicates practical significance Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 Aug, 2025 Reviewers invited by journal 13 Aug, 2025 Editor invited by journal 31 Jul, 2025 Editor assigned by journal 31 Jul, 2025 First submitted to journal 20 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7124948","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":499972812,"identity":"440526b2-e0dd-4baa-bf59-21e86cec0de0","order_by":0,"name":"Fiona S Reid","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYFACxgaJCgObBDA7oYBYLWcM0hIY2EBaDIi0R+IMw2GIFgZitJi3NzfeOFBwPo9fvjvxwwMDBnl+sQP4tcicOdhsccDgdrFkG+9mCaDDDGfOTiDgKInENukPBrcTNxzj3QDSkmBwm5AW+YdtEgcMzoG0bP5BnBYJRpCWAyAt24i0hScR5JfkxJltudssEgwkiPAL+/GHNw78sUvsZz67+eaPCht5fmkCWjCMIE35KBgFo2AUjALsAAAFNkS6w/Rq7QAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-6341-257X","institution":"University of Melbourne","correspondingAuthor":true,"prefix":"","firstName":"Fiona","middleName":"S","lastName":"Reid","suffix":""},{"id":499972813,"identity":"723022dc-27d0-4991-82fb-8cc63103195f","order_by":1,"name":"Curtis Lee","email":"","orcid":"","institution":"University of Newcastle","correspondingAuthor":false,"prefix":"","firstName":"Curtis","middleName":"","lastName":"Lee","suffix":""},{"id":499972814,"identity":"b6593789-d780-4690-8d49-1f2c6dd32a48","order_by":2,"name":"Debra Nestel","email":"","orcid":"","institution":"University of Melbourne","correspondingAuthor":false,"prefix":"","firstName":"Debra","middleName":"","lastName":"Nestel","suffix":""},{"id":499972815,"identity":"c3d46263-4149-4eca-a39d-321648a681d7","order_by":3,"name":"Ian W. Incoll","email":"","orcid":"","institution":"University of Newcastle","correspondingAuthor":false,"prefix":"","firstName":"Ian","middleName":"W.","lastName":"Incoll","suffix":""}],"badges":[],"createdAt":"2025-07-15 00:50:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7124948/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7124948/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89591789,"identity":"09fb92bb-7c40-4dd2-a9bf-2b86e9fb5fcc","added_by":"auto","created_at":"2025-08-21 16:09:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26251,"visible":true,"origin":"","legend":"\u003cp\u003epercentage MA major and minor cases (excluding endoscopy)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7124948/v1/ee8da9bd533f2873c06fa89f.png"},{"id":89591770,"identity":"7c128ce1-c180-4686-ac9c-8aa3e2d79dd0","added_by":"auto","created_at":"2025-08-21 16:08:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28142,"visible":true,"origin":"","legend":"\u003cp\u003epercentage MA endoscopy\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7124948/v1/a00354e984ba762a74fdc843.png"},{"id":89591794,"identity":"61a94061-1444-486b-8113-80a3b8fcd889","added_by":"auto","created_at":"2025-08-21 16:09:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29308,"visible":true,"origin":"","legend":"\u003cp\u003epercentage MA minor cases\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7124948/v1/7cb8f5f29c760d3d2b6d2308.png"},{"id":89591750,"identity":"d8108282-e633-44b1-9b24-bebc39acab3c","added_by":"auto","created_at":"2025-08-21 16:08:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":20018,"visible":true,"origin":"","legend":"\u003cp\u003epercentage MA major cases\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7124948/v1/a85a560b64a016f3a333b4a0.png"},{"id":89591887,"identity":"2f786775-4be7-4aaf-831d-c1186d59d510","added_by":"auto","created_at":"2025-08-21 16:09:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":504942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7124948/v1/15d8e68e-aecb-4a38-922f-71e1844992c1.pdf"}],"financialInterests":"","formattedTitle":"Who Gets to Hold the Knife? Gender and Autonomy in (Australian) Surgical Training","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn medicine and surgery diversity leads to improved health care outcomes, including a reduced risk of 30-day mortality, better communication, satisfaction and adherence to care protocols\u003csup\u003e1-4\u003c/sup\u003e. Given that most populations are 50% female, optimal health care outcomes are unlikely to be achieved without proportionate healthcare representation. With females comprising just 11.8% of Australia\u0026rsquo;s general surgeons, numerous communities are experiencing a lack of ideal surgical representation \u003csup\u003e1,2\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn line with their commitment to achieving equitable representation, the Royal Australasian College of Surgeons (RACS) released a report in 2020 outlining the obstacles hindering women\u0026rsquo;s participation in all general and sub-specialty surgical training within Australia and New Zealand \u003csup\u003e5\u003c/sup\u003e Whilst not specific to general surgery, the report summarised 1,700 respondents\u0026rsquo; views with the following list of perceived barriers to a career in surgery:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003epoor culture (discrimination, bullying, sexism, and harassment),\u003c/li\u003e\n \u003cli\u003eunsolicited gendered advice (\u0026lsquo;boys club\u0026rsquo;, assumptions about ability, future children, and family life),\u0026nbsp;\u003c/li\u003e\n \u003cli\u003elack of SET (Surgical Education and Training) transparency and flexibility, costs and inflexibility of part-time options once on the program,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003elack of quality mentors, and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003epeers at university, tutors, lecturers, junior doctors, surgical trainees and surgeons/ consultants (both male and female) caused barriers for most women who were surveyed.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIt is tempting to conclude (as this report did) that \u0026ldquo;lifestyle choices\u0026rdquo; were the prevalent reason for females not pursuing surgery. However, this cannot be the whole picture as females are far more highly represented in paediatric surgery (29.4% of consultants), and obstetrics and gynaecology (44.6% of consultants), which have similar demanding training schedules and \u0026nbsp;on-call commitments. \u003csup\u003e6\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e7\u003c/sup\u003e Given only 11.8% of general surgeons in Australia are female, lifestyle and family planning may not be the only, or even the largest, driver of this disparity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe paradigm of surgical training in Australia follows a structured progression characterised by escalating responsibilities, culminating in autonomous practice to prepare trainees for independent clinical work. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOperative autonomy is considered equally important by consultants \u0026nbsp;and trainees, with both ranking it as essential for effective learning. \u003csup\u003e8\u003c/sup\u003e Multiple studies have shown that this kind of participation and engagement has a significant impact on student\u0026rsquo; and junior doctors\u0026rsquo; feelings about surgery and surgical culture. \u003csup\u003e9-11\u003c/sup\u003e\u0026nbsp; Being denied training opportunities and, in particular, intraoperative training opportunities comprises 31-38% of respondent\u0026rsquo;s complaints of gender-based bullying in Australia. \u003csup\u003e12\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe journey of a surgical trainee\u0026rsquo;s progression from passive observer to independent practitioner is shaped by the co-created perspective of both trainee and trainer. Whilst many other factors may have an impact, evidence suggests the decision to bestow autonomy is influenced by: the estimated trustworthiness of the trainee; the estimated risk of the situation and the urgency or time pressure of the operation\u003csup\u003e13\u003c/sup\u003e ; complexity of case; personal knowledge of the trainee seniority and self-confidence \u003csup\u003e14-16\u003c/sup\u003e; and even the congruence of trainee-trainer personality types.\u003csup\u003e17\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther influences include time pressure and subspecialisation, as well as an increase in community and institutional pressure for services to be \u0026ldquo;consultant-led\u0026rdquo;\u003csup\u003e18\u003c/sup\u003e. Teaching intra-operative technical skills also requires a great deal of effort, trust, and cognitive energy from both trainee and surgeon, and may paradoxically increase surgeon workloads. \u003csup\u003e19\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAutonomy contributes to confidence and formation of professional identity which, in turn, play a role in reducing attrition from training. Female trainees have a 2.5 times greater rate of training attrition in Australia \u003csup\u003e20\u003c/sup\u003e. Amongst the reasons stated for withdrawal from training include; burnout, poor culture, insufficient operative experience and lack of technical confidence, lack of respect from seniors,\u003csup\u003e21\u003c/sup\u003e all of which are known to contribute to psychological distress and reduced coping.\u003csup\u003e12, 22-24\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree contemporary studies underpin our current knowledge of the influence of gender on autonomous operating. In laparoscopic general surgery, female trainees received much more intraoperative guidance than their matched male counterparts, with the rationale for this deemed to be a lower level of judgement of competence in the attending surgeon for female trainees. Male trainees were rated by their attendings as having significantly better operative technique and significantly higher operative knowledge; however, there were no technical differences found when supervising surgeons were blinded to the gender of the trainees. \u003csup\u003e25\u003c/sup\u003e Similar findings in cardiothoracic training in the USA and general surgical training in New Zealand conclude that these differences are likely to be harmful and that implicit bias in the trainer and behavioural gender norms in the trainee are the most likely explanation. \u003csup\u003e24-27\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study aims to determine if female general surgical trainees in Australia between 2013 and 2020 had a different level of surgical autonomy than male trainees during the same period.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a retrospective cohort study examining the logbook data of Australian general surgical trainees from January 2013 to August 2020. Deidentified data was made available through collaboration with the RACS and approved by General Surgeons Australia. RACS and GSA work together to administer a nation-wide, competitive entry, surgical training program. RACS sets and maintains surgical standards and GSA administers the training program. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data presented was grouped into SET years (from February to February) with the \u0026lsquo;year\u0026rsquo; names for the calendar year in which the bulk of the training fell. For example, year 2010 runs from February 2010-February 2011. Trainees had terms (defined as either term 1: February to August or term 2: August to February) excluded if they did not have submitted data and/ or were on leave from clinical training. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTrainees in this cohort self-identify their gender to RACS in a binary fashion at the point of entering training and this is recorded. As surgeons are all fellows of RACS their gender (as a binary construct) is also recorded. All trainees are mandated to record their operative experience and the surgeons who supervised them, and their level of autonomy according to the pre-determined RACS guidelines (based on the Zwisch scale).\u003csup\u003e28\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAssisting surgeon mentor\u003c/li\u003e\n \u003cli\u003eSurgeon mentor scrubbed (indicating active assistance and close coaching)\u003c/li\u003e\n \u003cli\u003eSurgeon mentor in theatre (indicating verbal on-demand assistance)\u003c/li\u003e\n \u003cli\u003eSurgeon mentor available (indicating mentor is available on-demand for non-standard, unpredictable, or unexpected events)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eRACS automatically also defines their year and term of training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe primary outcome was intraoperative autonomy by gender in surgical trainees. This was further classified into \u0026lsquo;meaningful autonomy\u0026rsquo; (MA), defined as the trainee performing the operation with the surgeon mentor not scrubbed. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWithin each year the trainees were divided by gender and the total number of major operations documented in the logbook was calculated. The number of operations with MA was then calculated and the data is presented as the percentage of MA operations: (major operations with MA/ total number of major operations performed x 100).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data for operative experience (excluding endoscopy) was calculated per gender per year as follows: [(Major operations with MA + Minor operations with MA)/(total major operations + total minor operations)] x100.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults were analysed using SPSS for Windows with a paired t-test for all operations, major operations, minor operations and endoscopy. Due to the large data set and 2014 outlier data a Cohen\u0026rsquo;s d test of practical significance was also calculated. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Melbourne Human Research Ethics Committee (2020-20405-13354-3) with a waiver of consent as all data is de-identified at the point of release.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe data included 2,783 trainees\u0026rsquo; (1,033=female; 1,750=male) logbook entries from 2013 to 2020. The representation of female trainees remained between 34.7%- 39.5% over the period of study. (Table 1)\u003c/p\u003e\n\u003cp\u003eA total of 1,340,748 procedures were performed including 522,492 major, 410,043 minor and 235,167 endoscopies. Female trainees performed 485,333 (36%) and male trainees 855,415 (64%) of these operations.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc104729088\"\u003eMeaningful Autonomy\u003c/h2\u003e\n\u003cp\u003eThroughout their training, females had MA in 39.7% of operations vs 42.2% of operations for their male peers for all operations. \u0026nbsp; Results were analysed with a paired T test which showed a difference in MA between males and females for all operations (t\u003csub\u003e7\u003c/sub\u003e=7.861 sig \u0026lt;.001.), minor operations (0.002) endoscopy (0.011) but no difference for major operations across all 7 years (0.091). Cohen\u0026rsquo;s d was greater than 2 for MA overall (8.9) and each of major (7.3), minor (4.7) and endoscopy (8.3) indicating a large effect size (Table 2)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComparing MA by gender, the range of differences in combined major and minor operations was between 2.1% (in 2014) to 10% (in 2020) with males taking part in a higher percentage of MA operations. (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe difference was also established in endoscopy (Figure 2):\u003c/p\u003e\n\u003cp\u003eFor major and minor operating separately, the trend was also established (Figures 3 and 4). In 2014, the normal trend was reversed (more MA for female trainees) for major operations but not for minor operations nor endoscopy.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn Australia, female trainees constitute approximately 35\u0026ndash;39% of the cohort within general surgical training. The data reveal that MA is notably lower among female trainees, culminating in a disparate training experience.\u003c/p\u003e\u003cp\u003eSurgeons describe several factors as influencing their decision to award autonomy including: technical proficiency, complexity of procedure, amount of time spent in collaboration with the trainee, seniority of trainee and trainees self-confidence \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. More subtle factors may also be at play with small studies showing that congruent personality types may be influential\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e and Joh et al\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, Meyerson et al\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e and Hoops et al\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e have all postulated that gender may be an influence.\u003c/p\u003e\u003cp\u003eGiven that the perception of technical proficiency and trainee confidence are reported as factors that may influence the award of autonomy it becomes relevant to examine how these conclusions are reached and what influences them.\u003c/p\u003e\u003cp\u003eSurgeon mentors describe trainee technical skill as a factor in determining the award of autonomy. However, females are often judged as less technically competent than their male peers even without objective evidence. This apparent bias is more prevalent in fields with a high level of male predominance. \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e In Australia, male surgeons, in particular, score female applicants lower on technical ability at interview despite having little to base this assessment on.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e When objective metrics are used under controlled conditions (e.g. laparoscopic trainers), there is no difference in the learning curve between male and female trainees \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e and equal competency between genders.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Self-confidence has also been identified as a factor influencing autonomy, research consistently shows that female surgeons and female trainees have lower levels of confidence in their technical skills than their male counterparts. \u003csup\u003e34 35\u003c/sup\u003e \u0026lsquo;Lack of confidence\u0026rsquo; is a common criticism given to female trainees during feedback; one study finding 56% of female residents reported this criticism vs 29% of male residents \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, with female trainees even receiving conflicting confidence feedback (too much and too little) within the same rotation. \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e This has been explained by the Dunning-Kruger effect, which highlights that one\u0026rsquo;s ignorance can often be invisible to oneself \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e and has been postulated as influencing surgical trainees self-assessment of confidence. \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAnother explanation for this difference is variation in trainee self-reporting, there are currently no studies investigating whether there is a gender influence on self-reporting of level of involvement with surgery.\u003c/p\u003e\u003cp\u003eIt is not possible to know whether a reduction in MA alone impacts training. However, theories of professional learning emphasise the importance of MA in developing expertise and professional identity. The situated learning paradigm of Communities of Practice (COP) advocates for immersive and situated leaning within relevant professional communities; in this context the operating theatre, and a graduated increase from legitimate peripheral participation to independent practice concurrent with the development of professional identity \u003csup\u003e\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. According to the COP theoretical framework, not only is autonomy important to achieve mastery but lack of autonomy leads the more experienced learner to feel disempowered with a reduced sense of belonging and impaired professional identity. Therefore, the level of participation has inherent value, over and above the technical mastery, depending on the circumstances of the learner. \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e If females in the operating theatre remain \u0026lsquo;peripheral\u0026rsquo; within their CoP they risk never fully \u0026lsquo;becoming\u0026rsquo; surgeons within that community.\u003c/p\u003e\u003cp\u003eHamdorf and Hall\u0026rsquo;s model involves the necessity of autonomous practice to develop technical expertise. \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. In this theory, trainees progress through cognition and integration steps to achieve automation. Once the skill becomes automated, deliberate practice is employed to develop expert practice \u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. These educational methodologies are ingrained within surgical training with trainees, at the time of this study, required to document the extent of intra-operative supervision and the proportion of \u0026lsquo;primary operating\u0026rsquo; (operations whereby the trainee has completed a significant proportion of the case). These parameters are expected to incrementally rise thought the training period and are used to assess not only the trainee but also the training environment. \u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWhile it seems self-explanatory that a trainee must technically master an operation, becoming a surgeon also involves mastery of a myriad of other competencies including: Collaboration and teamwork, communication, cultural competence, health advocacy, judgement and clinical decision making, leadership and management, medical expertise, professionalism, scholarship and teaching. \u003csup\u003e45 41 46\u003c/sup\u003e Situated learning within this CoP also provides contextual learning of the cultural expectations and behaviours, and development of an identity that is being modelled intra-operatively. Research on female surgeons and trainees has revealed that identity is not felt securely. This is both an internal (\u0026ldquo;imposter phenomenon\u0026rdquo;) and externally inhibited (less likely to be correctly identified as a surgeon by peers/patients) phenomenon.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eBurgos et al systematic review into gender differences in teaching and learning in surgery supports this view and extrapolated these effects onto professional identity formation of female surgeons, which they felt were impaired by implicit bias, poor access to autonomy, and harassment \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e They argued that feelings of guilt and resignation amongst female trainees who feel unable to address these factors would integrate harmfully into their long-term professional identity, continuing to undermine them in the long term. \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eRecently RACS and GSA changed the training requirements for SET trainees to a new competency-based curriculum. The fundamental difference is the attention to numbers of operations being \u0026lsquo;signed-off\u0026rsquo; as performed independently. Procedure Based Activities (PBA) are operative skills which are assessed and completed when the trainee is:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Able to Perform Independently defined as the Trainee is able to complete the procedure with minimal supervision and guidance, and demonstrates knowledge of when to request appropriate assistance\u0026rdquo;.\u003c/em\u003e \u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere are now specific requirements for how many PBAs must be signed off as independent in order for the trainee to progress with training. \u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e Given the weight RACS has now placed on independent operating as the benchmark for competency, the findings of this research may alter the training trajectory of male and female trainees. If a change in the bestowal of operative autonomy does not occur, it is possible that female trainees will take longer to achieve \u0026lsquo;competency\u0026rsquo; as judged via PBAs. It is hoped that the formalisation of this style of training may be beneficial as it sets expectation and requirements for the trainee to ask for, and be given, a higher level of operative autonomy. It would behove RACS to conduct an early analysis on the gender-based experiences and consequences of this new training paradigm.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIt is highly probable that diminished opportunities for autonomous operating impact a female trainee's technical proficiency, self-assurance, professional identity, and influence her perception of the surgical culture. The introduction of PBAs may exacerbate, rather than ameliorate, these disparities. To foster gender equality and ensure optimal outcomes for female trainees and fellows, it is imperative to confront and dismantle obstacles to equity. This includes critically evaluating the impact of PBAs on equitable access to training opportunities. Emphasis should be placed on cultivating a constructive workplace environment and prompting supervisors to critically evaluate their biases and practices in granting intra-operative autonomy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eNo scholarships or grants have been received in conjunction with this study. There are no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of confidentiality and are governed by a consent waiver. The data may be made available from the corresponding author upon reasonable request and consent waiver from a relevant Human Research Ethics Committee. Alternatively the original dataset can be requested with appropriate permissions from the Royal Australasian College of Surgeons.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMyers CG, Sutcliffe KM. How discrimination against female doctors hurts patients. Harv Bus Rev 2018.\u003c/li\u003e\n\u003cli\u003eWallis CJ, Jerath A, Coburn N, Klaassen Z, Luckenbaugh AN, Magee DE, Hird AE, Armstrong K, Ravi B, Esnaola NF. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA surgery 2022;157:146-56.\u003c/li\u003e\n\u003cli\u003eWallis 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. 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JAMA surgery 2017;152:265-72.\u003c/li\u003e\n\u003cli\u003eVan Boerum MS, Jarman AF, Veith J, Allen CM, Holoyda KA, Agarwal C, Crombie C, Cochran A. The confidence gap: Findings for women in plastic surgery. The American Journal of Surgery 2020.\u003c/li\u003e\n\u003cli\u003eLiang R, Anthony A, Leditschke IA. Five myths about unacceptable behaviour in surgical education. ANZ Journal of Surgery 2020.\u003c/li\u003e\n\u003cli\u003eMeyerson SL, Sternbach JM, Zwischenberger JB, Bender EM. The effect of gender on resident autonomy in the operating room. Journal of Surgical Education 2017;74:e111-e8.\u003c/li\u003e\n\u003cli\u003eHoops H, Heston A, Dewey E, Spight D, Brasel K, Kiraly L. Resident autonomy in the operating room: does gender matter? The American Journal of Surgery 2019;217:301-5.\u003c/li\u003e\n\u003cli\u003eMeyerson SL, Odell DD, Zwischenberger JB, Schuller M, Williams RG, Bohnen JD, Dunnington GL, Torbeck L, Mullen JT, Mandell SP. The effect of gender on operative autonomy in general surgery residents. Surgery 2019;166:738-43.\u003c/li\u003e\n\u003cli\u003eJoh DB, van der Werf B, Watson BJ, French R, Bann S, Dennet E, Loveday BP. Assessment of Autonomy in Operative Procedures Among Female and Male New Zealand General Surgery Trainees. JAMA surgery 2020.\u003c/li\u003e\n\u003cli\u003eGeorge BC, Teitelbaum EN, Meyerson SL, Schuller MC, DaRosa DA, Petrusa ER, Petito LC, Fryer JP. Reliability, validity, and feasibility of the Zwisch scale for the assessment of intraoperative performance. Journal of surgical education 2014;71:e90-e6.\u003c/li\u003e\n\u003cli\u003eMcKeon BA, Fryer K, Holmstrom S, Ricciotti H, Kenton K. Surgeon and Contextual Factors Influencing OB-GYN Resident Autonomy in the Operating Room. Obstetrics \u0026amp; Gynecology 2019;134:55S-6S.\u003c/li\u003e\n\u003cli\u003eBedi G, Van Dam NT, Munafo M. Gender inequality in awarded research grants. The Lancet 2012;380:474.\u003c/li\u003e\n\u003cli\u003eIncoll IW, Atkin J, Frank JR, Vrancic S, Khorshid O. Gender associations with selection into Australian Orthopaedic Surgical Training: 2007\u0026ndash;2019. ANZ Journal of Surgery 2021;91:2757-66.\u003c/li\u003e\n\u003cli\u003eMcKinney Jr EH, Davis KJ. Effects of deliberate practice on crisis decision performance. Human Factors 2003;45:436-44.\u003c/li\u003e\n\u003cli\u003eBurgos CM, Josephson A. Gender differences in the learning and teaching of surgery: a literature review. International journal of medical education 2014;5:110.\u003c/li\u003e\n\u003cli\u003eMyers SP, Hill KA, Nicholson KJ, Neal MD, Hamm ME, Switzer GE, Hausmann LR, Hamad GG, Rosengart MR, Littleton EB. A qualitative study of gender differences in the experiences of general surgery trainees. Journal of Surgical Research 2018;228:127-34.\u003c/li\u003e\n\u003cli\u003eFlyckt RL, White EE, Goodman LR, Mohr C, Dutta S, Zanotti KM. The use of laparoscopy simulation to explore gender differences in resident surgical confidence. Obstetrics and gynecology international 2017;2017.\u003c/li\u003e\n\u003cli\u003eMueller AS, Jenkins TM, Osborne M, Dayal A, O\u0026apos;Connor DM, Arora VM. Gender differences in attending physicians\u0026apos; feedback to residents: a qualitative analysis. Journal of Graduate Medical Education 2017;9:577-85.\u003c/li\u003e\n\u003cli\u003eDunning D, The Dunning\u0026ndash;Kruger effect: On being ignorant of one\u0026apos;s own ignorance Advances in experimental social psychology: Elsevier, 2011:247-96.\u003c/li\u003e\n\u003cli\u003eAhmed O, Walsh TN. Surgical trainee experience with open cholecystectomy and the Dunning-Kruger effect. Journal of Surgical Education 2020;77:1076-81.\u003c/li\u003e\n\u003cli\u003eLave J, Wenger E. Situated learning: Legitimate peripheral participation: Cambridge university press, 1991.\u003c/li\u003e\n\u003cli\u003eWenger E. Communities of practice: Learning, meaning, and identity: Cambridge university press, 1999.\u003c/li\u003e\n\u003cli\u003eNestel D, Burgess A. Surgical education and the theoretical concept of communities of practice. Journal of Health Specialties 2014;2:49.\u003c/li\u003e\n\u003cli\u003eHall JHJ. ArticleTitle Acquiring surgical skills. Br J Surg 2000;87:28-37.\u003c/li\u003e\n\u003cli\u003eEricsson KA. The influence of experience and deliberate practice on the development of superior expert performance. The Cambridge handbook of expertise and expert performance 2006;38:685-705.\u003c/li\u003e\n\u003cli\u003eSurgery BiG. Training Regulations: For the Surgical Education and Training Program in General Surgery. 2021.\u003c/li\u003e\n\u003cli\u003eSurgeons RACo. Surgical Competence and Performance. 2020.\u003c/li\u003e\n\u003cli\u003eGandamihardja TA. The role of communities of practice in surgical education. Journal of surgical education 2014;71:645-9.\u003c/li\u003e\n\u003cli\u003eDavids JS, Lyu HG, Hoang CM, Daniel VT, Scully RE, Xu TY, Phatak UR, Damle A, Melnitchouk N. Female representation and implicit gender bias at the 2017 American Society of Colon and Rectal Surgeons Annual Scientific and Tripartite Meeting. Diseases of the colon and rectum 2019;62:357.\u003c/li\u003e\n\u003cli\u003eFiles JA, Mayer AP, Ko MG, Friedrich P, Jenkins M, Bryan MJ, Vegunta S, Wittich CM, Lyle MA, Melikian R. Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias. Journal of women\u0026apos;s health 2017;26:413-9.\u003c/li\u003e\n\u003cli\u003eSurgery RACoSABiG. Training Regulations General Surgery Education and Training Program. 2022.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Trainee gender by calendar year\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"618\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2013\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2015\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2020\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003eFemale Trainees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003eMale Trainees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e269\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003eTotal Trainees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e426\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e431\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e399\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e% F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e39.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e37.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e38.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e34.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e37.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e37.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2: Cohen\u0026rsquo;s d analysis of practical significance\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"473\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003epoint estimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI lower\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI upper\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCohen\u0026apos;s d\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 131px;\"\u003e\n \u003cp\u003emajor f - major m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e7.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 131px;\"\u003e\n \u003cp\u003eminor f - minor m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e4.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 131px;\"\u003e\n \u003cp\u003eendo f - endo m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e8.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 131px;\"\u003e\n \u003cp\u003eall MA f - all MA m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-4.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e8.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99.7886%;\" colspan=\"5\"\u003eCohen\u0026apos;s d uses the sample standard deviation of the mean difference.\u003cbr\u003eCohen\u0026apos;s d \u0026gt; 2 indicates practical significance\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Autonomy, Bias, Gender, General surgery, Zwisch","lastPublishedDoi":"10.21203/rs.3.rs-7124948/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7124948/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver the past decade there has been an increased focus on equality and diversity in surgical training globally. There is little doubt that increased diversity and representation leads to better healthcare outcomes; despite this, females account for only 12% of general surgeons in Australia.\u0026nbsp; This study aimed to examine gender differences in autonomous operating of trainee general surgeons as a means of gaining insight to one aspect of the lived experience of female surgeons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study design was a retrospective cohort analysis of all general surgical trainees in Australia from 2013 to 2020. Data comprised self-reported, online logbook data (Morbidity Audit and Logbook Tool MALT) that is mandatory for all surgical trainees. Meaningful autonomy (MA) was defined as operating without a senior surgeon scrubbed. Operations were categorised as ‘minor operations’, ‘major operations’ and ‘endoscopy’ as defined by RACS and the online data recording tool MALT\u003c/p\u003e\n\u003cp\u003eResults were analysed using SPSS for Windows with a paired t-test for all operations, major operations, minor operations and endoscopy. Due to the large data set and 2014 outlier data a Cohen’s d test of practical significance was also calculated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were \u0026gt;1.3m logbook entries from 2,783 trainees (female=1,033; male=1,750) Procedures included ‘minor operations’, ‘major operations’ and ‘endoscopy’.\u0026nbsp; Throughout their training, females had a significantly lower MA for procedures compared with their male peers (39.7% vs 42.2% t\u003csub\u003e7\u003c/sub\u003e=7.861 sig \u0026lt;.001). Cohen’s d analysis indicates a large effect size and practical significance (8.9).\u0026nbsp; For major and minor operating combined (excluding endoscopy), the greatest difference in MA was in 2020 (10%) and the smallest in 2014 (2.1%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis large dataset of general surgical trainees’ logbook entries shows that females have fewer opportunities for meaningful autonomy during training. This difference may contribute to lower recruitment, retention and confidence expressed by female surgeons in Australia.\u003c/p\u003e","manuscriptTitle":"Who Gets to Hold the Knife? Gender and Autonomy in (Australian) Surgical Training","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 16:08:21","doi":"10.21203/rs.3.rs-7124948/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-08-18T15:36:51+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-13T12:49:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-07-31T14:52:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-31T14:18:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-07-21T02:36:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"da528a9d-2310-4298-af3f-5e1b7d3e2891","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-18T12:45:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 16:08:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7124948","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7124948","identity":"rs-7124948","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}