Patient Evaluation of White vs Non-White Surgical Senior and Intern Residents

Patient Evaluation of White vs Non-White Surgical Senior and Intern Residents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patient Evaluation of White vs Non-White Surgical Senior and Intern Residents Tiffany Bellomo, Shaghayegh Sabbaghan Kermani, Camila Marmolejo Muriel, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6960176/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 : Patient feedback may serve as a valuable source of information for surgical resident assessment. However, there is also recognition that systematic bias in any new forms of surgical resident evaluation could further disadvantage historically marginalized groups. This exploratory study investigated whether patient ratings of surgical resident care differ by resident race or underrepresented in medicine (URiM) status. Methods : Surgical inpatients who underwent elective gastrointestinal and oncologic surgery evaluated the quality of surgical resident care using a modified Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). The top-box method, which quantifies the frequency of the highest possible rating for each question, was used to analyze patient satisfaction with surgical resident care in a manner consistent with S-CAHPS reporting guidelines. Patient evaluations of senior and intern residents were stratified by resident race and underrepresented in medicine (URiM) status and compared both across and within gender. Results : A total of 324 patients completed 267 evaluations for senior residents and 256 evaluations for intern residents. There were no significant demographic differences between patients evaluating White vs non-White residents at either the senior or intern level (age, gender, or education level). Patient recognition rate of White vs non-White residents did not differ at either the senior (White 85.1% vs non-White 84.8%, p-value=1.0) or intern level (White 80.1% vs non-White 88.8%, p-value=0.085), even after accounting for gender. Top-box S-CAHPS scores across all 8 domains did not significantly differ between evaluations for White and non-White residents for both senior (p>0.10) and intern (p>0.36) residents, including when further stratified by gender. Similar results were observed when examining resident evaluation by URiM status, where patient recognition rate did not differ at either the senior (non-URiM 84.5% vs URiM 90.3%, p-value=0.545) or intern level (non-URiM 83.0% vs URiM 80.8%, p-value=0.982), even after accounting for gender. While there were no differences between the proportion of URiM compared to non-URiM senior evaluations that received top-box scores in 7 individual S-CAHPS items, a difference was observed in the item related to pain treatment. Specifically, 91.5% (214/229) of evaluations for non-URiM seniors had the top-box score whereas 71.4% (20/28) of evaluations for URiM seniors had the top-box score (p=0.004). However, patient-reported pain scores did not significantly differ between these groups, and this difference was not observed after further stratification by gender. Top-box S-CAHPS scores across all 8 domains did not significantly differ between non-URiM and URiM resident evaluations for intern (p>0.19) residents. Conclusions : Patient recognition rate and quality of care evaluations were overall similar regardless of surgical resident race or URiM status, including when further stratified by gender. These findings support the potential for patient feedback to serve as a valuable component of resident assessment. Further research is needed to explore how best to utilize patient evaluations to support all trainees as they prepare for independent practice. surgical resident evaluation patient evaluations multisource feedback underrepresented in medicine surgical resident assessment surgical resident feedback patient feedback Figures Figure 1 Figure 2 INTRODUCTION Patient satisfaction is an increasingly important component of healthcare evaluation, promoting quality improvement, influencing institutional ratings, and shaping public perceptions of care quality 1 , 2 . Public perception of an attending physician’s performance has become a critical metric with the rise of patient-reported outcome measures 3 . There is also growing interest in incorporating patient perspectives into the evaluation of surgical residents as part of multisource, competency-based assessment strategies mandated by the Accreditation Council for Graduate Medical Education (ACGME) 4 – 7 . Patients are in a unique position to evaluate surgical residents on communication, professionalism, and other skills not always observed by attending surgeons. Surgical residents receive focused feedback centered around operative technique and surgical decision-making from attending surgeons who provide direct supervision in the operating room 8 . While feedback after direct supervision is highly valued, most attending surgeons do not directly observe clinical care of patients in perioperative areas, the emergency department, or even in clinic 9 . Patients, however, directly experience these interactions and represent a valuable source of feedback on communication, empathy, professionalism, and patient-centered care. Patients themselves have identified qualities such as bedside manner, confidence, and team communication as critical to their care experience 7 . They have been shown to provide resident feedback when asked, and importantly, patient-derived feedback may differ significantly from that of attendings 7 . While there may be significant benefits to incorporating patient feedback into resident evaluations, there are legitimate concerns about potential biases in patient perception and satisfaction that may negatively impact trainees from historically underrepresented groups. Prior research in multiple specialties, including orthopedics and oncology, has demonstrated that provider demographic factors, such as race, ethnicity, and gender, can influence patient satisfaction scores independent of clinical performance 10 , 11 . Additionally, surgical residents have reported experiencing biased behavior from patients based on perceived identity traits, including race and gender, which can contribute to inequities in both workplace climate and performance evaluations 12 , 13 . However, few studies have systematically examined whether such biases are demonstrated in structured patient assessments of surgical residents 14 , 15 . Understanding whether patient evaluations differ based on resident race is critical as graduate medical education seeks to expand the use of patient-centered assessments. Without such insight, well-intentioned innovations in feedback processes may unintentionally reinforce disparities in training and advancement for residents from underrepresented backgrounds 16 – 18 . To address these concerns, we conducted an exploratory cross-sectional study of patient evaluations of residents, stratified by race and underrepresented in medicine (URiM) status. We also examined potential interactions between race and gender by further stratifying patient evaluations by resident gender. METHODS Study Design and Population This cross-sectional study utilized data collected from patients as previously described and approved by the Mass General Brigham Human Research Committee Institutional Review Board (IRB # 2017P000932) 19 . Briefly, general surgery patients admitted to the hospital after elective general or oncology surgery were recruited to participate. Inclusion criterion included inpatient admission for at least two nights post-operatively and being cared for by a consistent resident team of one senior resident (post-graduate year [PGY] 3, PGY4, or PGY5) and one intern (PGY1). Exclusion criteria included patients who underwent non-elective surgery, did not speak English as their primary language, had altered mental status, or were admitted to the intensive care unit. On postoperative day 2, 3, or 4, a student research assistant approached eligible patients to confirm that they were not currently undergoing clinical care and then described the study. After reviewing study materials and providing informed consent, patients were asked to identify who the senior resident and intern caring for them were based on a hospital profile photo. Patients who did not correctly identify the trainee did not provide ratings for that trainee. If the trainee was correctly identified, they completed an assessment of that resident. Survey Instrument for Patients The survey instrument included patient demographics, pain level, and attitudes towards surgical resident care 19 , 20 . Demographic questions included patient age, gender, ethnicity, race, perceived health status, and educational level. Patient pain level at the time of study participation was assessed using a 10-point scale, where 0 indicated no pain and 10 indicated the worst pain possible. Patient satisfaction with surgical resident care was assessed using a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS), created by the Agency for Healthcare Research and Quality (AHRQ) (Supplemental Methods) 21 . The S-CAHPS questions inquiring whether residents engaged in specific behaviors such as listening and ensuring physical comfort had three possible answer choices including “yes, definitely,” “yes, somewhat,” and “no.” Patients were asked whether they would recommend the resident to their family members with the options of “Definitely yes,” “Probably yes,” “Probably no,” and “Definitely no.” Patients were also asked to provide an overall rating of surgical resident care on a ten point scale, where 0 indicated the worst care and 10 indicated the best possible care. Resident Demographics No public announcement was made to residents regarding the patient satisfaction surveys to avoid influencing resident behavior. If a resident inquired about the study, the study purpose and procedures were freely shared, and any questions were answered by the research team. This occurred once during the study period. Resident demographic information, including PGY year, gender, race, and ethnicity were determined based on documentation from the general surgery residency office. Statistical Analysis To quantitatively analyze the S-CAHPS items, we used the method recommended by the AHRQ called top-box scoring 21 . To mitigate the known ceiling effect of patient ratings of physicians, the provider only received credit for an item if the highest possible option is selected. For behavior focused questions, the top-box selection was “Yes, definitely”. The top-box selection for whether a patient would recommend a resident to a family member was “Definitely yes.”. Lastly, the top-box selection for overall rating of surgical resident care on a ten-point scale was a 10. Descriptive statistics were used to calculate the distribution of demographic variables across both residents and patients stratified by resident race or URiM status. Differences were analyzed using Fisher exact test for categorical variables and the unpaired t-test for continuous variables. To address how the interaction of race and gender could influence evaluations, subgroup analyses were performed by splitting patient evaluations of residents by race and gender or URiM status and gender. Significance was defined as a p-value < 0.05 after Bonferroni correction for multiple testing. Figures indicate the p-values and statistical tests used, as noted in the figure legend. Statistical analysis was performed using R (version 4.4.1). RESULTS Resident demographic characteristics Ninety percent of recruited patients agreed to participate in this study (324/359). Patients correctly identified and provided satisfaction ratings for 119 residents (Table 1 ). Of the 46 senior residents, 66.0% (n = 31) were men, 78.3% (n = 36) were White, and 89.1% (n = 41) were non-Hispanic. Of the 73 intern residents, 64.4% (n = 47) were men, 63.0% (n = 46) were White, and 91.8% (n = 67) were non-Hispanic. Table 1 Characteristics of surgical residents who were evaluated by patients stratified by resident training level. Senior (n = 46) Intern (n = 73) Gender (%) Female 17 (37.8) 26 (37.1) Male 31 (66.0) 47 (64.4) Race (%) African American 2 (4.3) 5 (6.8) Asian 6 (13.0) 17 (23.3) Caucasian 36 (78.3) 46 (63.0) Hawaiian 0 (0.0) 1 (1.4) Middle Eastern 1 (2.2) 2 (2.7) Unknown 1 (2.2) 2 (2.7) Ethnicity (%) Hispanic 4 (8.7) 4 (5.5) Non-Hispanic 41 (89.1) 67 (91.8) Unknown 1 (2.2) 2 (2.7) PGY (%) 1 0 (0.0) 73 (100.0) 3 18 (40.0) 0 (0.0) 4 2 (4.4) 0 (0.0) 5 25 (55.6) 0 (0.0) Unknown 0 (0.0) 0 (0.0) Patient demographics in White vs non-White resident evaluations There were no differences in rates of patient recognition for residents when comparing White to non-White seniors (85.1% vs 84.8%, p = 1.00) or interns (80.1% vs 88.8%, p = 0.085). A total of 228 evaluations were collected for White senior residents and 39 evaluations were collected for non-White senior residents (Table 2 ). A total of 169 evaluations were collected for White intern residents and 87 evaluations were collected for non-White senior residents. Patients who completed evaluations for White vs non-White senior and intern residents were similar in age, race, ethnicity, education level, and health status. Patients also had an average of three prior operations and reported average pain scores of 3 to 4 out of 10 at the time of the survey, suggesting comparable postoperative experience and pain status. Table 2 Characteristics of patients who evaluated surgical residents stratified by resident training level and self-reported race. Patient Characteristic Senior Intern White (n = 228) Non-white (n = 39) p-value White (n = 169) Non-white (n = 87) p-value Age (years, mean (SD)) 61.88 (14.32) 62.05 (16.87) 0.947 62.09 (14.66) 61.23 (14.69) 0.655 Female Sex (%) 100 (45.9) 19 (50.0) 0.768 68 (41.7) 46 (55.4) 0.057 Race (%) 0.082 0.531 African American 10 (4.4) 0 (0.0) 5 (3.0) 2 (2.3) Asian 3 (1.3) 0 (0.0) 2 (1.2) 1 (1.1) Caucasian 109 (47.8) 11 (28.2) 75 (44.4) 33 (37.9) Native Islander 1 (0.4) 0 (0.0) 1 (0.6) 0 (0.0) Other 6 (2.6) 2 (5.1) 7 (4.1) 1 (1.1) Unknown 99 (43.4) 26 (66.7) 79 (46.7) 50 (57.5) Non-hispanic (%) 212 (96.8) 37 (97.4) 1.000 157 (96.9) 80 (95.2) 0.760 Education Level (%) 0.117 0.750 < 9th grade 3 (1.3) 0 (0.0) 2 (1.2) 2 (2.4) Some high school 1 (0.4) 2 (5.1) 4 (2.4) 1 (1.2) High school or GED 40 (17.7) 9 (23.1) 35 (20.8) 18 (21.2) Some college 52 (23.0) 6 (15.4) 32 (19.0) 22 (25.9) 4-year college 63 (27.9) 9 (23.1) 46 (27.4) 20 (23.5) >4-year college 67 (29.6) 13 (33.3) 49 (29.2) 22 (25.9) Overall Health Status (%) 0.330 0.177 Excellent 32 (14.2) 9 (23.1) 32 (19.2) 9 (10.6) Very good 66 (29.2) 12 (30.8) 43 (25.7) 31 (36.5) Good 83 (36.7) 11 (28.2) 56 (33.5) 29 (34.1) Fair 37 (16.4) 4 (10.3) 30 (18.0) 11 (12.9) Poor 8 (3.5) 3 (7.7) 6 (3.6) 5 (5.9) Mental Health Status (%) 0.617 0.362 Excellent 68 (30.1) 15 (38.5) 54 (32.5) 28 (32.9) Very good 66 (29.2) 13 (33.3) 43 (25.9) 31 (36.5) Good 71 (31.4) 9 (23.1) 51 (30.7) 18 (21.2) Fair 17 (7.5) 2 (5.1) 15 (9.0) 6 (7.1) Poor 4 (1.8) 0 (0.0) 3 (1.8) 2 (2.4) Operations (mean (SD)) 3.39 (1.24) 3.09 (1.35) 0.125 3.42 (1.24) 3.18 (1.28) 0.112 Pain Scale (mean (SD)) 3.36 (2.44) 3.04 (2.00) 0.409 3.26 (2.29) 3.43 (2.58) 0.550 Patient satisfaction with White vs non-White resident care There were no differences between the proportion of White compared to non-White senior resident evaluations that received top-box scores across all 8 S-CAHPS items (43.4% vs 41.0%, p = 0.917) (Fig. 1 A, Supplemental Table 1). There were also no differences in percent top-box scores for individual items between White and non-White senior resident evaluations. Similarly, there were no differences between the proportion of White compared to non-White intern evaluations that received top-box scores across all 8 S-CAHPS items (35.5% vs 39.1%, p = 0.670) and there were also no differences in the percent top-box scores for individual items (Fig. 1 B, Supplemental Table 1). Resident evaluations stratified by race and gender We evaluated the interaction between resident race and gender in patient evaluations. Patient recognition rate of White vs non-White residents did not differ by gender at either the senior or intern level. Patient demographics, when stratified by resident race and gender were overall similar (Supplemental Table 2). There were no differences between the proportion of White compared to non-White men senior resident evaluations that received top-box scores across all 8 S-CAHPS items (39.8% vs 30.0%, p = 0.552) (Supplemental Fig. 1, Supplemental Table 3). Similarly, there were no differences in top-box scores across all 8 S-CAHPS items for White compared to non-White women senior resident evaluations (48.0% vs 52.6%, p = 0.905), men intern evaluations (36.1% vs 42.3%, p = 0.553), and women intern evaluations (34.0% vs 31.2%, p = 0.986). There were no differences in the percent top-box scores for individual items for all groups of residents when stratified by race and gender. URiM vs non-URiM resident evaluations Patient recognition rate of URiM vs non-URiM residents did not differ at either the senior (non-URiM 84.5% vs URiM 90.3%, p-value = 0.545) or intern level (non-URiM 83.0% vs URiM 80.8%, p-value = 0.982). A total of 229 evaluations were collected for non-URiM senior residents, and 28 evaluations were collected for URiM senior residents (Supplemental Table 4). A total of 235 evaluations were collected for non-URiM intern residents and 21 evaluations were collected for URiM intern residents. Demographics of patients who completed evaluations for URIM vs non-URIM senior residents and interns is provided in Supplemental Table 4. Overall, there were few demographic differences in patients who evaluated URiM vs non-URIM residents at both the senior and intern level. Patient satisfaction with URiM vs non-URiM resident care There were no differences between the proportion of URiM compared to non-URiM senior evaluations that received top-box scores across all 8 S-CAHPS items (43.9% vs 35.7%, p = 0.529) (Fig. 2 , Supplemental Table 5). There were also no differences between the proportion of URiM compared to non-URiM senior evaluations that received top-box scores in 7 individual S-CAHPS items. However, when patients were asked if the senior doctor made sure they had enough pain relief, 91.5% (214/229) of evaluations reported non-URiM seniors had the top-box score whereas 71.4% (20/28) of evaluations reported URiM seniors had the top-box score (p = 0.004). Of note, patient reported pain levels were not significantly different between non-URiM (mean 3.25 out of 10, SD 2.42) and URiM (mean 3.07 out of 10, SD 0.710) senior resident evaluations. This difference was not observed for intern residents, where there were no differences in percent top-box scores for all 8 individual items between URiM and non-URiM intern residents. Resident evaluations stratified by URiM status and gender Further stratification of residents by URiM status and gender yielded very small sample sizes. Patient recognition rate of URiM vs non-URiM residents did not differ by gender at either the senior or intern level. Patient demographics stratified by these factors did not differ significantly (Supplemental Table 6). There were no differences in top-box scores across all 8 S-CAHPS items for non-URiM compared to URiM senior residents who were men (41.9% vs 15.8%, p = 0.054), senior residents who were women (46.4% vs 77.8%, p = 0.143), intern residents who were men (35.9% vs 60.0%, p = 0.119), and intern residents who were women (32.9% vs 33.0%, p = 1.00) (Supplemental Fig. 2, Supplemental Table 7). There were also no differences in the percent top-box scores for individual items for all groups of residents stratified by URiM and gender. DISCUSSION In this study of 267 senior resident evaluations and 256 intern resident evaluations stratified by race and gender, we found few substantial differences in how patients evaluated residents based on race or URiM status, even when further stratifying by resident gender. The rate of top-box scores, indicating the highest level of satisfaction, were comparable between White and non-White resident evaluations, both at the intern and senior levels, across all eight domains. When accounting for gender in addition to race, there were still no substantial differences in how patients evaluated senior or intern residents. While the number of evaluations of URiM residents was limited, their evaluation scores were overall similar to non-URIM residents across all domains. The only domain showing a statistically significant difference in top-box ratings was pain treatment by senior residents, but not by intern residents, suggesting that resident URiM status did not broadly influence patient perceptions of care. Notably, patients evaluating different groups of residents were demographically similar despite a lack of experimental randomization, suggesting favorable patient sampling and recruitment. Based on these data, we believe structured patient evaluations may serve as a valuable complementary source of resident assessment that would not overtly systematically disadvantage non-White or URIM trainees. Race and URiM resident status Although residents across various specialties have reported experiencing differential treatment from hospital staff based on race, there is limited literature examining how patient feedback may reflect these racial disparities. Implicit bias in medicine has been shown to negatively impacting trainees 22 . Surgical residents have reported experiencing race-based harassment 23 and being held to different standards of evaluation based on their race 24 . Some of this discriminatory behavior originates from patients. A qualitative analysis of interviews with minority general surgery resident interviews identified a recurring theme of “problems related to minority status”, including the use of “derogatory” language by patients 25 and instances in which patients have refused care from residents belonging to racial minority groups 26 . While one study found no differences in the qualitative content of attending evaluations of internal medicine residents based on race or ethnicity 27 , there remains a notable gap in the literature regarding potential bias in the content of patient feedback of surgical residents. Race and URiM resident status Our findings are consistent with existing research on attending and standardized patient evaluations, which have similarly shown no significant variation in assessments based on provider race. In our study, patients reported high satisfaction with both White and non-White surgical resident care both at the intern and senior levels, across all eight domains. These results are consistent with a prior analysis of internal medicine resident assessments by faculty, which found no differences in the characteristics, specificity, or positive/negative tone based on resident race or ethnicity 27 . Similarly, a study of over 300 internal medicine residents evaluated by standardized patients found no significant racial interactions with standardized patient communication ratings 28 . When our results were analyzed by resident URiM status, a difference emerged in the domain of pain treatment: patients reported higher satisfaction with pain management provided by senior non-URiM residents compared to their URiM counterparts. However, this difference was not observed among intern residents, and patient-reported pain ratings did not significantly differ by resident URiM status, suggesting that patients experienced similar levels of pain at the time of evaluation. Given the lack of corresponding differences in patient-reported pain scores and the small sample size, further investigation with a larger cohort is warranted to determine whether this discrepancy in the S-CAHPS pain treatment item reflects a consistent pattern and true potential bias. Future implementation of the modified S-CAHPS assessment tool may consider omission of this item if future work demonstrates a consistent discordance between patient evaluation and patient reported pain levels. Interaction between resident race and gender While prior evidence suggests that the intersection of race and gender can influence trainee evaluations 30 , 31 , our study did not find a significant interaction between gender and race or URiM status in patient feedback of residents. This result contrasts with a multi-institutional study of medical student assessment in which standardized patients found that female Black/African American, female White, and female Asian/Pacific Islander students scored significantly higher on empathy ratings compared to men counterparts 32 . The study also found male Black/African American medical students received the lowest empathy scores from standardized patients, regardless of the standardized patient race or ethnicity. Race, ethnicity, and gender concordance between patients and providers has been associated with improved care-seeking behaviors in real-world settings; for example, patients are more likely to seek care for new health concerns when their provider shares their Asian or Hispanic background 33 . Our study concerning resident evaluations as opposed to medical students or attendings show no significant differences in patient top-box ratings when residents are stratified by racial group and gender. While our prior work examining gender did uncover small differences in patient evaluations of intern surgical residents, this difference resolved by senior resident years 34 . Our findings offer a more nuanced understanding of how both resident gender and race influence patient evaluations, taking an important step toward addressing questions of intersectionality that have remained largely unexplored in prior analyses. Integration of patient feedback into resident assessment We show no substantial differences in how patients evaluated residents based on resident race or URiM status, which supports the thoughtful integration of patient feedback into resident assessment, as has been successfully implemented by other training programs around the world. For example, in a cohort of general surgery residents in China, a patient evaluation tool demonstrated strong concordance with assessments by residents themselves, peers, nurses, and office staff 35 . In the UK, a multisource feedback questionnaire was developed 36 and subsequently tested in a population of over 300 Swedish primary care residents, showing high internal consistency among residents 36 . Given the growing interest in incorporating patient feedback into resident assessment, researchers in Seattle designed a randomized controlled trial using crowdsourced laypeople to simulate patients and provide feedback on resident communication skills 37 . Although the communication skills of the family medicine residents studied significantly improved over time and the assessment showed high reliability, many residents either did not review their feedback or spent minimal time doing so. Notably, residents with lower performance were more likely to disengage and not complete the trial. A similar pattern was observed in a study evaluating a communication skills course specifically for surgical residents 38 , where general surgery residents showed improved communication ratings, but there was no clear evidence of increased resident insight. Future work may investigate the optimal way to deliver and incorporate patient evaluation into resident assessment, so that residents can be most effectively supported in their growth and development and gain the most benefit from patient feedback. In pediatrics, for example, trainees report that reviewing patient feedback with a trusted faculty member would increase its acceptability and impact 39 . Limitations The results of this single site study should be interpreted in the context of its limitations. First, the predominance of White non-Hispanic residents in this study limited the sample size of other demographic groups. As a result, the ability to detect differences in patient evaluations based on resident characteristics may have been constrained by the small number of non-White and URiM trainees, raising the possibility of a Type II error. Future studies should specifically include a broader representation of racial groups to allow for more granular analysis of potential patient biases in evaluations. Second, there was also a predominance of White, non-Hispanic, and highly educated patients. While a race concordance analysis could have added depth to the interpretation of patient evaluations, the limited diversity among patients prevented this analysis due to insufficient subgroup sample sizes. Third, this study was conducted at a single institution using a single instrument, which limits the generalizability of the findings to other institutions, specialties, and assessment tools. Fourth, the top-box method of analyzing the S-CAHPS data, while being the standard and accepted method of scoring, could potentially obscure subtle differences in patient satisfaction across residents. Finally, this study did not include narrative feedback to understand the rationale behind the ratings. Future studies should incorporate the perspectives of all stakeholders to help refine the patient feedback tool and develop a routine feedback system. Despite these limitations, our findings suggest that patient evaluations do not demonstrate consistent or overt racial bias and support continued efforts to integrate patient feedback into resident assessment systems as recommended by the ACGME. CONCLUSIONS Patient feedback may serve as a valuable supplementary source of information for resident assessment. However, existing evidence suggests that trainee evaluations can be influenced by trainee race and gender. In this cross-sectional study of 267 evaluations for senior residents and 256 evaluations for intern residents, we found few differences in patient evaluations of surgical residents based on resident race or URiM status. When further stratified by resident gender, there were no differences in top-box scores across all 8 S-CAHPS items, supporting the potential for patient feedback to serve as a valuable component of resident assessment that does not exacerbate known training disparities. While inequities in trainee experiences and evaluations have been reported elsewhere, structured patient feedback appears to offer a source of relatively equitable assessment. Given existing evidence from multiple international programs, patient evaluations have the potential to complement traditional assessments to inform and enhance resident development. Declarations This work was funded in part by an award from the Association for Academic Surgery (AAS/AASF Trainee Research Fellowship Award), which was awarded to Sophia K. McKinley, MD MEd. All other authors have no competing funding or disclosures to report. Acknowledgements The data and code to perform analyses in this manuscript are available from the authors upon request. We thank the patients for their participation in this study. References Kanouse DE, Schlesinger M, Shaller D, Martino SC, Rybowski L. How Patient Comments Affect Consumers’ Use of Physician Performance Measures. Med Care. 2016;54(1):24–31. doi: 10.1097/MLR.0000000000000443 Howell D, Rosberger Z, Mayer C, et al. Personalized symptom management: a quality improvement collaborative for implementation of patient reported outcomes (PROs) in ‘real-world’ oncology multisite practices. J Patient Rep Outcomes. 2020;4(1):47. doi: 10.1186/s41687-020-00212-x Piussi R, Senorski EH, Irrgang JJ. 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Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training. Patient Educ Couns. 2019;102(9):1738–1743. doi: 10.1016/j.pec.2019.04.023 McKinley SK, Wojcik BM, Witt EE, et al. Inpatient Satisfaction With Surgical Resident Care After Elective General and Oncologic Surgery. Ann Surg. 2023;277(6):e1380-e1386. doi: 10.1097/SLA.0000000000005598 McKinley SK, Wojcik BM, Kochis M, et al. A Pilot Study of Inpatient Satisfaction Rating of Surgical Resident Care. J Surg Educ. 2018;75(6):e192-e203. doi: 10.1016/j.jsurg.2018.08.007 Schmocker RK, Cherney Stafford LM, Siy AB, Leverson GE, Winslow ER. Understanding the determinants of patient satisfaction with surgical care using the Consumer Assessment of Healthcare Providers and Systems surgical care survey (S-CAHPS). Surgery. 2015;158(6):1724–1733. doi: 10.1016/j.surg.2015.06.018 Capers Q. How Clinicians and Educators Can Mitigate Implicit Bias in Patient Care and Candidate Selection in Medical Education. ATS Sch. 2020;1(3):211–217. doi: 10.34197/ats-scholar.2020-0024PS Foster N, Price M, Bettger JP, Goodwin CR, Erickson M. Objective Test Scores Throughout Orthopedic Surgery Residency Suggest Disparities in Training Experience. J Surg Educ. 2021;78(5):1400–1405. doi: 10.1016/j.jsurg.2021.01.003 Yuce TK, Turner PL, Glass C, et al. National Evaluation of Racial/Ethnic Discrimination in US Surgical Residency Programs. JAMA Surg. 2020;155(6):526. doi: 10.1001/jamasurg.2020.0260 Koech H, Albanese J, Saeks D, et al. Minority Resident Physicians’ Perspectives on the Role of Race/Ethnicity, Culture, and Gender in Their Surgical Training Experiences. J Surg Educ. 2023;80(6):833–845. doi: 10.1016/j.jsurg.2023.03.009 de Bourmont SS, Burra A, Nouri SS, et al. Resident Physician Experiences With and Responses to Biased Patients. JAMA Netw Open. 2020;3(11):e2021769. doi: 10.1001/jamanetworkopen.2020.21769 Klein R, Snyder ED, Koch J, et al. Analysis of narrative assessments of internal medicine resident performance: are there differences associated with gender or race and ethnicity? BMC Med Educ. 2024;24(1):72. doi: 10.1186/s12909-023-04970-2 Heath JK, Dine CJ, LaMarra D, Cardillo S. The Impact of Trainee and Standardized Patient Race and Gender on Internal Medicine Resident Communication Assessment Scores. J Grad Med Educ. 2021;13(5):643–649. doi: 10.4300/JGME-D-21-00106.1 Odonkor CA, Tucker-Bartley A, Leitner B, Chude C, Hirani S, Poree L. Closing the gap in representation of racial and ethnic minorities in pain medicine: A 2018–2019 status report. J Natl Med Assoc. 2022;113(6):612–615. doi: 10.1016/j.jnma.2021.05.010 Cooper-Patrick L. Race, Gender, and Partnership in the Patient-Physician Relationship. JAMA. 1999;282(6):583. doi: 10.1001/jama.282.6.583 Solnick RE, Peyton K, Kraft-Todd G, Safdar B. Effect of Physician Gender and Race on Simulated Patients’ Ratings and Confidence in Their Physicians. JAMA Netw Open. 2020;3(2):e1920511. doi: 10.1001/jamanetworkopen.2019.20511 Berg K, Blatt B, Lopreiato J, et al. Standardized Patient Assessment of Medical Student Empathy. Academic Medicine. 2015;90(1):105–111. doi: 10.1097/ACM.0000000000000529 Ma A, Sanchez A, Ma M. The Impact of Patient-Provider Race/Ethnicity Concordance on Provider Visits: Updated Evidence from the Medical Expenditure Panel Survey. J Racial Ethn Health Disparities. 2019;6(5):1011–1020. doi: 10.1007/s40615-019-00602-y Witt EE, Jogerst K, Wojcik BM, et al. Patient satisfaction with women vs men surgical interns and senior residents. The American Journal of Surgery. 2024;235:115813. doi: 10.1016/j.amjsurg.2024.115813 Zhao Y, Zhang X, Chang Q, Sun B. Psychometric Characteristics of the 360° Feedback Scales in Professionalism and Interpersonal and Communication Skills Assessment of Surgery Residents in China. J Surg Educ. 2013;70(5):628–635. doi: 10.1016/j.jsurg.2013.04.004 Wright C, Richards SH, Hill JJ, et al. Multisource Feedback in Evaluating the Performance of Doctors. Academic Medicine. 2012;87(12):1668–1678. doi: 10.1097/ACM.0b013e3182724cc0 White AA, King AM, D’Addario AE, et al. Crowdsourced Feedback to Improve Resident Physician Error Disclosure Skills. JAMA Netw Open. 2024;7(8):e2425923. doi: 10.1001/jamanetworkopen.2024.25923 Newcomb AB, Liu C, Trickey AW, Lita E, Dort J. Patient Perspectives of Surgical Residents’ Communication: Do Skills Improve Over Time With a Communication Curriculum? J Surg Educ. 2018;75(6):e142-e149. doi: 10.1016/j.jsurg.2018.06.015 Bogetz AL, Orlov N, Blankenburg R, Bhavaraju V, McQueen A, Rassbach C. How Residents Learn From Patient Feedback: A Multi-Institutional Qualitative Study of Pediatrics Residents’ Perspectives. J Grad Med Educ. 2018;10(2):176–184. doi: 10.4300/JGME-D-17-00447.1 , Supplementary Files Bellomoetal.URMResidentSupplementalData.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 11 Jul, 2025 Reviewers invited by journal 05 Jul, 2025 Editor invited by journal 04 Jul, 2025 Editor assigned by journal 01 Jul, 2025 First submitted to journal 25 Jun, 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-6960176","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":481184693,"identity":"fc8755f3-14ea-40df-ab40-bc168ef7bec5","order_by":0,"name":"Tiffany Bellomo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYDACCQbGAw+AND8DAxsDYwNMkIEZpw4eoOyBBCBDsoFkLQYHiNViL9184EBCxTY542vHrz1g3GGXb3D87MMbDBXWiQ24bJE5lnAg4cxtY7PbOeUGjGeSLTecSTe2YDiTjluLRI7BgcS224nbbuekSTC2MRtINqSxARmH8WjJ/wDWsnk2WEu9gWT/M6CWf/i05DCAtWyQTj8GMtyAXwJkSwMeLXeOGYD9InE7h00ise04UMszZouEY+nGuLSwz25++OBDxW05/tnpzyQ+tlUbsPGnMd74UGMti0sLsoUGDAkwdgJuZSgWPiBO3SgYBaNgFIw4AABKI1y7ckG1SAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-6884-3117","institution":"Massachusetts General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tiffany","middleName":"","lastName":"Bellomo","suffix":""},{"id":481184694,"identity":"e639520e-952a-4e36-875a-4e87677a6670","order_by":1,"name":"Shaghayegh Sabbaghan Kermani","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shaghayegh","middleName":"Sabbaghan","lastName":"Kermani","suffix":""},{"id":481184695,"identity":"175b4b95-0163-4a37-a621-dcbe01f0c5b7","order_by":2,"name":"Camila Marmolejo Muriel","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Camila","middleName":"Marmolejo","lastName":"Muriel","suffix":""},{"id":481184696,"identity":"4d505953-cbc9-4184-b4f0-4020a114ae84","order_by":3,"name":"Erick Herrera Castaneda","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Erick","middleName":"Herrera","lastName":"Castaneda","suffix":""},{"id":481184697,"identity":"d37197fa-4d36-4edf-96b7-64dc31d6041a","order_by":4,"name":"Arian Mansur","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Arian","middleName":"","lastName":"Mansur","suffix":""},{"id":481184698,"identity":"824e04b3-98b5-4a99-aac9-88019463a701","order_by":5,"name":"Claire C. Ferguson","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Claire","middleName":"C.","lastName":"Ferguson","suffix":""},{"id":481184699,"identity":"d69a0f97-c960-449b-b093-99a67854ab0e","order_by":6,"name":"Chase Marso","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chase","middleName":"","lastName":"Marso","suffix":""},{"id":481184700,"identity":"59996300-8693-47b3-9156-dd8ce49d6aa6","order_by":7,"name":"Roy Phitayakorn","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Roy","middleName":"","lastName":"Phitayakorn","suffix":""},{"id":481184701,"identity":"f7ca027c-af16-41ef-ba95-9a6e1a8b38d0","order_by":8,"name":"Sophia K McKinley","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sophia","middleName":"K","lastName":"McKinley","suffix":""}],"badges":[],"createdAt":"2025-06-24 00:00:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6960176/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6960176/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86625613,"identity":"39c9eb65-878c-48ae-a8ee-43bc8e11c00f","added_by":"auto","created_at":"2025-07-14 05:12:46","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":279194,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of A) senior and B) intern evaluations achieving the top-box score on the modified S-CAHPS assessment stratified by white vs non-White resident race. Fisher's exact test was used to compare white vs non-White evaluations within each S-CHAPS domain, and there were no significant differences in any domain.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6960176/v1/0a664c2d6c873ad8a75e9e39.jpeg"},{"id":86625609,"identity":"3ad214c3-9f1f-47dd-b55c-958053a28152","added_by":"auto","created_at":"2025-07-14 05:12:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":106736,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of A) Senior and B) Intern evaluations achieving the top-box score on the modified S-CAHPS assessment stratified by underrepresented in medicine (URiM) vs non-URiM residents. Fisher's exact test was used to compare white vs non-White evaluations within each S-CHAPS domain. * indicates a significant difference in the domain with Bonferroni corrected p-value\u0026lt;0.05.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6960176/v1/85be60a192ee181a28a32f0a.png"},{"id":86627476,"identity":"084fbd24-cf1f-4bd3-a712-c0e79fa9a810","added_by":"auto","created_at":"2025-07-14 05:37:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1435539,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6960176/v1/09d990ec-2398-4bc3-9c5d-6c7a95622e3c.pdf"},{"id":86625616,"identity":"dbc11c6c-38b9-4ee7-9c41-eb527063aa50","added_by":"auto","created_at":"2025-07-14 05:12:46","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":1049547,"visible":true,"origin":"","legend":"","description":"","filename":"Bellomoetal.URMResidentSupplementalData.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6960176/v1/179339375644c1d199487fe9.pdf"}],"financialInterests":"","formattedTitle":"Patient Evaluation of White vs Non-White Surgical Senior and Intern Residents","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePatient satisfaction is an increasingly important component of healthcare evaluation, promoting quality improvement, influencing institutional ratings, and shaping public perceptions of care quality\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Public perception of an attending physician\u0026rsquo;s performance has become a critical metric with the rise of patient-reported outcome measures\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. There is also growing interest in incorporating patient perspectives into the evaluation of surgical residents as part of multisource, competency-based assessment strategies mandated by the Accreditation Council for Graduate Medical Education (ACGME)\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePatients are in a unique position to evaluate surgical residents on communication, professionalism, and other skills not always observed by attending surgeons. Surgical residents receive focused feedback centered around operative technique and surgical decision-making from attending surgeons who provide direct supervision in the operating room\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. While feedback after direct supervision is highly valued, most attending surgeons do not directly observe clinical care of patients in perioperative areas, the emergency department, or even in clinic\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Patients, however, directly experience these interactions and represent a valuable source of feedback on communication, empathy, professionalism, and patient-centered care. Patients themselves have identified qualities such as bedside manner, confidence, and team communication as critical to their care experience\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. They have been shown to provide resident feedback when asked, and importantly, patient-derived feedback may differ significantly from that of attendings\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWhile there may be significant benefits to incorporating patient feedback into resident evaluations, there are legitimate concerns about potential biases in patient perception and satisfaction that may negatively impact trainees from historically underrepresented groups. Prior research in multiple specialties, including orthopedics and oncology, has demonstrated that provider demographic factors, such as race, ethnicity, and gender, can influence patient satisfaction scores independent of clinical performance \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Additionally, surgical residents have reported experiencing biased behavior from patients based on perceived identity traits, including race and gender, which can contribute to inequities in both workplace climate and performance evaluations \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. However, few studies have systematically examined whether such biases are demonstrated in structured patient assessments of surgical residents\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eUnderstanding whether patient evaluations differ based on resident race is critical as graduate medical education seeks to expand the use of patient-centered assessments. Without such insight, well-intentioned innovations in feedback processes may unintentionally reinforce disparities in training and advancement for residents from underrepresented backgrounds \u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. To address these concerns, we conducted an exploratory cross-sectional study of patient evaluations of residents, stratified by race and underrepresented in medicine (URiM) status. We also examined potential interactions between race and gender by further stratifying patient evaluations by resident gender.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Population\u003c/h2\u003e\u003cp\u003eThis cross-sectional study utilized data collected from patients as previously described and approved by the Mass General Brigham Human Research Committee Institutional Review Board (IRB # 2017P000932)\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Briefly, general surgery patients admitted to the hospital after elective general or oncology surgery were recruited to participate. Inclusion criterion included inpatient admission for at least two nights post-operatively and being cared for by a consistent resident team of one senior resident (post-graduate year [PGY] 3, PGY4, or PGY5) and one intern (PGY1). Exclusion criteria included patients who underwent non-elective surgery, did not speak English as their primary language, had altered mental status, or were admitted to the intensive care unit.\u003c/p\u003e\u003cp\u003eOn postoperative day 2, 3, or 4, a student research assistant approached eligible patients to confirm that they were not currently undergoing clinical care and then described the study. After reviewing study materials and providing informed consent, patients were asked to identify who the senior resident and intern caring for them were based on a hospital profile photo. Patients who did not correctly identify the trainee did not provide ratings for that trainee. If the trainee was correctly identified, they completed an assessment of that resident.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurvey Instrument for Patients\u003c/h3\u003e\n\u003cp\u003eThe survey instrument included patient demographics, pain level, and attitudes towards surgical resident care\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Demographic questions included patient age, gender, ethnicity, race, perceived health status, and educational level. Patient pain level at the time of study participation was assessed using a 10-point scale, where 0 indicated no pain and 10 indicated the worst pain possible. Patient satisfaction with surgical resident care was assessed using a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS), created by the Agency for Healthcare Research and Quality (AHRQ) (Supplemental Methods)\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. The S-CAHPS questions inquiring whether residents engaged in specific behaviors such as listening and ensuring physical comfort had three possible answer choices including \u0026ldquo;yes, definitely,\u0026rdquo; \u0026ldquo;yes, somewhat,\u0026rdquo; and \u0026ldquo;no.\u0026rdquo; Patients were asked whether they would recommend the resident to their family members with the options of \u0026ldquo;Definitely yes,\u0026rdquo; \u0026ldquo;Probably yes,\u0026rdquo; \u0026ldquo;Probably no,\u0026rdquo; and \u0026ldquo;Definitely no.\u0026rdquo; Patients were also asked to provide an overall rating of surgical resident care on a ten point scale, where 0 indicated the worst care and 10 indicated the best possible care.\u003c/p\u003e\n\u003ch3\u003eResident Demographics\u003c/h3\u003e\n\u003cp\u003eNo public announcement was made to residents regarding the patient satisfaction surveys to avoid influencing resident behavior. If a resident inquired about the study, the study purpose and procedures were freely shared, and any questions were answered by the research team. This occurred once during the study period. Resident demographic information, including PGY year, gender, race, and ethnicity were determined based on documentation from the general surgery residency office.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eTo quantitatively analyze the S-CAHPS items, we used the method recommended by the AHRQ called top-box scoring\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. To mitigate the known ceiling effect of patient ratings of physicians, the provider only received credit for an item if the highest possible option is selected. For behavior focused questions, the top-box selection was \u0026ldquo;Yes, definitely\u0026rdquo;. The top-box selection for whether a patient would recommend a resident to a family member was \u0026ldquo;Definitely yes.\u0026rdquo;. Lastly, the top-box selection for overall rating of surgical resident care on a ten-point scale was a 10.\u003c/p\u003e\u003cp\u003eDescriptive statistics were used to calculate the distribution of demographic variables across both residents and patients stratified by resident race or URiM status. Differences were analyzed using Fisher exact test for categorical variables and the unpaired t-test for continuous variables. To address how the interaction of race and gender could influence evaluations, subgroup analyses were performed by splitting patient evaluations of residents by race and gender or URiM status and gender. Significance was defined as a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 after Bonferroni correction for multiple testing. Figures indicate the p-values and statistical tests used, as noted in the figure legend. Statistical analysis was performed using R (version 4.4.1).\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eResident demographic characteristics\u003c/h2\u003e\u003cp\u003eNinety percent of recruited patients agreed to participate in this study (324/359). Patients correctly identified and provided satisfaction ratings for 119 residents (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the 46 senior residents, 66.0% (n\u0026thinsp;=\u0026thinsp;31) were men, 78.3% (n\u0026thinsp;=\u0026thinsp;36) were White, and 89.1% (n\u0026thinsp;=\u0026thinsp;41) were non-Hispanic. Of the 73 intern residents, 64.4% (n\u0026thinsp;=\u0026thinsp;47) were men, 63.0% (n\u0026thinsp;=\u0026thinsp;46) were White, and 91.8% (n\u0026thinsp;=\u0026thinsp;67) were non-Hispanic.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of surgical residents who were evaluated by patients stratified by resident training level.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntern\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (37.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26 (37.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31 (66.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47 (64.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfrican American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (6.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17 (23.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaucasian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36 (78.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46 (63.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHawaiian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (1.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle Eastern\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (2.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (2.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (5.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-Hispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41 (89.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67 (91.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (2.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePGY (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e73 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25 (55.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePatient demographics in White vs non-White resident evaluations\u003c/h3\u003e\n\u003cp\u003eThere were no differences in rates of patient recognition for residents when comparing White to non-White seniors (85.1% vs 84.8%, p\u0026thinsp;=\u0026thinsp;1.00) or interns (80.1% vs 88.8%, p\u0026thinsp;=\u0026thinsp;0.085). A total of 228 evaluations were collected for White senior residents and 39 evaluations were collected for non-White senior residents (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A total of 169 evaluations were collected for White intern residents and 87 evaluations were collected for non-White senior residents. Patients who completed evaluations for White vs non-White senior and intern residents were similar in age, race, ethnicity, education level, and health status. Patients also had an average of three prior operations and reported average pain scores of 3 to 4 out of 10 at the time of the survey, suggesting comparable postoperative experience and pain status.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of patients who evaluated surgical residents stratified by resident training level and self-reported race.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient Characteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eSenior\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eIntern\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhite (n\u0026thinsp;=\u0026thinsp;228)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNon-white (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWhite (n\u0026thinsp;=\u0026thinsp;169)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNon-white (n\u0026thinsp;=\u0026thinsp;87)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years, mean (SD))\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61.88 (14.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.05 (16.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.947\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e62.09 (14.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e61.23 (14.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.655\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFemale Sex (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100 (45.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.768\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e68 (41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e46 (55.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.057\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.082\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.531\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfrican American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2 (1.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaucasian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e109 (47.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11 (28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e75 (44.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e33 (37.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNative Islander\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1 (0.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e99 (43.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e79 (46.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e50 (57.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNon-hispanic (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e212 (96.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37 (97.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e157 (96.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e80 (95.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.760\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation Level (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.750\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; 9th grade\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2 (1.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSome high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1 (1.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school or GED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40 (17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e35 (20.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e18 (21.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSome college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52 (23.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6 (15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e32 (19.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22 (25.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4-year college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63 (27.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e46 (27.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e20 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;4-year college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67 (29.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e49 (29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22 (25.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOverall Health Status (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.330\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.177\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExcellent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32 (14.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e32 (19.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e9 (10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66 (29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12 (30.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e43 (25.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e31 (36.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e83 (36.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11 (28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e56 (33.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e29 (34.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37 (16.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e30 (18.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e11 (12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6 (3.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMental Health Status (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.617\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.362\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExcellent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68 (30.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15 (38.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e54 (32.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e28 (32.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66 (29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e43 (25.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e31 (36.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71 (31.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e51 (30.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e18 (21.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15 (9.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e6 (7.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOperations (mean (SD))\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.39 (1.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.09 (1.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.42 (1.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.18 (1.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePain Scale (mean (SD))\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.36 (2.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.04 (2.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.409\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.26 (2.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.43 (2.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.550\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003ePatient satisfaction with White vs non-White resident care\u003c/h3\u003e\n\u003cp\u003eThere were no differences between the proportion of White compared to non-White senior resident evaluations that received top-box scores across all 8 S-CAHPS items (43.4% vs 41.0%, p\u0026thinsp;=\u0026thinsp;0.917) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, Supplemental Table\u0026nbsp;1). There were also no differences in percent top-box scores for individual items between White and non-White senior resident evaluations. Similarly, there were no differences between the proportion of White compared to non-White intern evaluations that received top-box scores across all 8 S-CAHPS items (35.5% vs 39.1%, p\u0026thinsp;=\u0026thinsp;0.670) and there were also no differences in the percent top-box scores for individual items (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB, Supplemental Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eResident evaluations stratified by race and gender\u003c/h2\u003e\u003cp\u003eWe evaluated the interaction between resident race and gender in patient evaluations. Patient recognition rate of White vs non-White residents did not differ by gender at either the senior or intern level. Patient demographics, when stratified by resident race and gender were overall similar (Supplemental Table\u0026nbsp;2). There were no differences between the proportion of White compared to non-White men senior resident evaluations that received top-box scores across all 8 S-CAHPS items (39.8% vs 30.0%, p\u0026thinsp;=\u0026thinsp;0.552) (Supplemental Fig.\u0026nbsp;1, Supplemental Table\u0026nbsp;3). Similarly, there were no differences in top-box scores across all 8 S-CAHPS items for White compared to non-White women senior resident evaluations (48.0% vs 52.6%, p\u0026thinsp;=\u0026thinsp;0.905), men intern evaluations (36.1% vs 42.3%, p\u0026thinsp;=\u0026thinsp;0.553), and women intern evaluations (34.0% vs 31.2%, p\u0026thinsp;=\u0026thinsp;0.986). There were no differences in the percent top-box scores for individual items for all groups of residents when stratified by race and gender.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eURiM vs non-URiM resident evaluations\u003c/h2\u003e\u003cp\u003ePatient recognition rate of URiM vs non-URiM residents did not differ at either the senior (non-URiM 84.5% vs URiM 90.3%, p-value\u0026thinsp;=\u0026thinsp;0.545) or intern level (non-URiM 83.0% vs URiM 80.8%, p-value\u0026thinsp;=\u0026thinsp;0.982). A total of 229 evaluations were collected for non-URiM senior residents, and 28 evaluations were collected for URiM senior residents (Supplemental Table\u0026nbsp;4). A total of 235 evaluations were collected for non-URiM intern residents and 21 evaluations were collected for URiM intern residents. Demographics of patients who completed evaluations for URIM vs non-URIM senior residents and interns is provided in Supplemental Table\u0026nbsp;4. Overall, there were few demographic differences in patients who evaluated URiM vs non-URIM residents at both the senior and intern level.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePatient satisfaction with URiM vs non-URiM resident care\u003c/h2\u003e\u003cp\u003eThere were no differences between the proportion of URiM compared to non-URiM senior evaluations that received top-box scores across all 8 S-CAHPS items (43.9% vs 35.7%, p\u0026thinsp;=\u0026thinsp;0.529) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Supplemental Table\u0026nbsp;5). There were also no differences between the proportion of URiM compared to non-URiM senior evaluations that received top-box scores in 7 individual S-CAHPS items. However, when patients were asked if the senior doctor made sure they had enough pain relief, 91.5% (214/229) of evaluations reported non-URiM seniors had the top-box score whereas 71.4% (20/28) of evaluations reported URiM seniors had the top-box score (p\u0026thinsp;=\u0026thinsp;0.004). Of note, patient reported pain levels were not significantly different between non-URiM (mean 3.25 out of 10, SD 2.42) and URiM (mean 3.07 out of 10, SD 0.710) senior resident evaluations. This difference was not observed for intern residents, where there were no differences in percent top-box scores for all 8 individual items between URiM and non-URiM intern residents.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eResident evaluations stratified by URiM status and gender\u003c/h2\u003e\u003cp\u003eFurther stratification of residents by URiM status and gender yielded very small sample sizes. Patient recognition rate of URiM vs non-URiM residents did not differ by gender at either the senior or intern level. Patient demographics stratified by these factors did not differ significantly (Supplemental Table\u0026nbsp;6). There were no differences in top-box scores across all 8 S-CAHPS items for non-URiM compared to URiM senior residents who were men (41.9% vs 15.8%, p\u0026thinsp;=\u0026thinsp;0.054), senior residents who were women (46.4% vs 77.8%, p\u0026thinsp;=\u0026thinsp;0.143), intern residents who were men (35.9% vs 60.0%, p\u0026thinsp;=\u0026thinsp;0.119), and intern residents who were women (32.9% vs 33.0%, p\u0026thinsp;=\u0026thinsp;1.00) (Supplemental Fig.\u0026nbsp;2, Supplemental Table\u0026nbsp;7). There were also no differences in the percent top-box scores for individual items for all groups of residents stratified by URiM and gender.\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study of 267 senior resident evaluations and 256 intern resident evaluations stratified by race and gender, we found few substantial differences in how patients evaluated residents based on race or URiM status, even when further stratifying by resident gender. The rate of top-box scores, indicating the highest level of satisfaction, were comparable between White and non-White resident evaluations, both at the intern and senior levels, across all eight domains. When accounting for gender in addition to race, there were still no substantial differences in how patients evaluated senior or intern residents. While the number of evaluations of URiM residents was limited, their evaluation scores were overall similar to non-URIM residents across all domains. The only domain showing a statistically significant difference in top-box ratings was pain treatment by senior residents, but not by intern residents, suggesting that resident URiM status did not broadly influence patient perceptions of care. Notably, patients evaluating different groups of residents were demographically similar despite a lack of experimental randomization, suggesting favorable patient sampling and recruitment. Based on these data, we believe structured patient evaluations may serve as a valuable complementary source of resident assessment that would not overtly systematically disadvantage non-White or URIM trainees.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eRace and URiM resident status\u003c/h2\u003e\u003cp\u003eAlthough residents across various specialties have reported experiencing differential treatment from hospital staff based on race, there is limited literature examining how patient feedback may reflect these racial disparities. Implicit bias in medicine has been shown to negatively impacting trainees\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Surgical residents have reported experiencing race-based harassment\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and being held to different standards of evaluation based on their race\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Some of this discriminatory behavior originates from patients. A qualitative analysis of interviews with minority general surgery resident interviews identified a recurring theme of \u0026ldquo;problems related to minority status\u0026rdquo;, including the use of \u0026ldquo;derogatory\u0026rdquo; language by patients\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e and instances in which patients have refused care from residents belonging to racial minority groups\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. While one study found no differences in the qualitative content of attending evaluations of internal medicine residents based on race or ethnicity\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, there remains a notable gap in the literature regarding potential bias in the content of patient feedback of surgical residents.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eRace and URiM resident status\u003c/h2\u003e\u003cp\u003eOur findings are consistent with existing research on attending and standardized patient evaluations, which have similarly shown no significant variation in assessments based on provider race. In our study, patients reported high satisfaction with both White and non-White surgical resident care both at the intern and senior levels, across all eight domains. These results are consistent with a prior analysis of internal medicine resident assessments by faculty, which found no differences in the characteristics, specificity, or positive/negative tone based on resident race or ethnicity\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Similarly, a study of over 300 internal medicine residents evaluated by standardized patients found no significant racial interactions with standardized patient communication ratings\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. When our results were analyzed by resident URiM status, a difference emerged in the domain of pain treatment: patients reported higher satisfaction with pain management provided by senior non-URiM residents compared to their URiM counterparts. However, this difference was not observed among intern residents, and patient-reported pain ratings did not significantly differ by resident URiM status, suggesting that patients experienced similar levels of pain at the time of evaluation. Given the lack of corresponding differences in patient-reported pain scores and the small sample size, further investigation with a larger cohort is warranted to determine whether this discrepancy in the S-CAHPS pain treatment item reflects a consistent pattern and true potential bias. Future implementation of the modified S-CAHPS assessment tool may consider omission of this item if future work demonstrates a consistent discordance between patient evaluation and patient reported pain levels.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eInteraction between resident race and gender\u003c/h2\u003e\u003cp\u003eWhile prior evidence suggests that the intersection of race and gender can influence trainee evaluations\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e, our study did not find a significant interaction between gender and race or URiM status in patient feedback of residents. This result contrasts with a multi-institutional study of medical student assessment in which standardized patients found that female Black/African American, female White, and female Asian/Pacific Islander students scored significantly higher on empathy ratings compared to men counterparts\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. The study also found male Black/African American medical students received the lowest empathy scores from standardized patients, regardless of the standardized patient race or ethnicity. Race, ethnicity, and gender concordance between patients and providers has been associated with improved care-seeking behaviors in real-world settings; for example, patients are more likely to seek care for new health concerns when their provider shares their Asian or Hispanic background\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Our study concerning resident evaluations as opposed to medical students or attendings show no significant differences in patient top-box ratings when residents are stratified by racial group and gender. While our prior work examining gender did uncover small differences in patient evaluations of intern surgical residents, this difference resolved by senior resident years\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Our findings offer a more nuanced understanding of how both resident gender and race influence patient evaluations, taking an important step toward addressing questions of intersectionality that have remained largely unexplored in prior analyses.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eIntegration of patient feedback into resident assessment\u003c/h2\u003e\u003cp\u003eWe show no substantial differences in how patients evaluated residents based on resident race or URiM status, which supports the thoughtful integration of patient feedback into resident assessment, as has been successfully implemented by other training programs around the world. For example, in a cohort of general surgery residents in China, a patient evaluation tool demonstrated strong concordance with assessments by residents themselves, peers, nurses, and office staff\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. In the UK, a multisource feedback questionnaire was developed\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e and subsequently tested in a population of over 300 Swedish primary care residents, showing high internal consistency among residents\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Given the growing interest in incorporating patient feedback into resident assessment, researchers in Seattle designed a randomized controlled trial using crowdsourced laypeople to simulate patients and provide feedback on resident communication skills\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Although the communication skills of the family medicine residents studied significantly improved over time and the assessment showed high reliability, many residents either did not review their feedback or spent minimal time doing so. Notably, residents with lower performance were more likely to disengage and not complete the trial. A similar pattern was observed in a study evaluating a communication skills course specifically for surgical residents\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e, where general surgery residents showed improved communication ratings, but there was no clear evidence of increased resident insight. Future work may investigate the optimal way to deliver and incorporate patient evaluation into resident assessment, so that residents can be most effectively supported in their growth and development and gain the most benefit from patient feedback. In pediatrics, for example, trainees report that reviewing patient feedback with a trusted faculty member would increase its acceptability and impact\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThe results of this single site study should be interpreted in the context of its limitations. First, the predominance of White non-Hispanic residents in this study limited the sample size of other demographic groups. As a result, the ability to detect differences in patient evaluations based on resident characteristics may have been constrained by the small number of non-White and URiM trainees, raising the possibility of a Type II error. Future studies should specifically include a broader representation of racial groups to allow for more granular analysis of potential patient biases in evaluations. Second, there was also a predominance of White, non-Hispanic, and highly educated patients. While a race concordance analysis could have added depth to the interpretation of patient evaluations, the limited diversity among patients prevented this analysis due to insufficient subgroup sample sizes. Third, this study was conducted at a single institution using a single instrument, which limits the generalizability of the findings to other institutions, specialties, and assessment tools. Fourth, the top-box method of analyzing the S-CAHPS data, while being the standard and accepted method of scoring, could potentially obscure subtle differences in patient satisfaction across residents. Finally, this study did not include narrative feedback to understand the rationale behind the ratings. Future studies should incorporate the perspectives of all stakeholders to help refine the patient feedback tool and develop a routine feedback system. Despite these limitations, our findings suggest that patient evaluations do not demonstrate consistent or overt racial bias and support continued efforts to integrate patient feedback into resident assessment systems as recommended by the ACGME.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003ePatient feedback may serve as a valuable supplementary source of information for resident assessment. However, existing evidence suggests that trainee evaluations can be influenced by trainee race and gender. In this cross-sectional study of 267 evaluations for senior residents and 256 evaluations for intern residents, we found few differences in patient evaluations of surgical residents based on resident race or URiM status. When further stratified by resident gender, there were no differences in top-box scores across all 8 S-CAHPS items, supporting the potential for patient feedback to serve as a valuable component of resident assessment that does not exacerbate known training disparities. While inequities in trainee experiences and evaluations have been reported elsewhere, structured patient feedback appears to offer a source of relatively equitable assessment. Given existing evidence from multiple international programs, patient evaluations have the potential to complement traditional assessments to inform and enhance resident development.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis work was funded in part by an award from the Association for Academic Surgery (AAS/AASF Trainee Research Fellowship Award), which was awarded to Sophia K. McKinley, MD MEd. All other authors have no competing funding or disclosures to report.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eThe data and code to perform analyses in this manuscript are available from the authors upon request. We thank the patients for their participation in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKanouse DE, Schlesinger M, Shaller D, Martino SC, Rybowski L. How Patient Comments Affect Consumers\u0026rsquo; Use of Physician Performance Measures. Med Care. 2016;54(1):24\u0026ndash;31. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MLR.0000000000000443\u003c/span\u003e\u003cspan address=\"10.1097/MLR.0000000000000443\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHowell D, Rosberger Z, Mayer C, et al. 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JAMA Netw Open. 2024;7(8):e2425923. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2024.25923\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2024.25923\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNewcomb AB, Liu C, Trickey AW, Lita E, Dort J. Patient Perspectives of Surgical Residents\u0026rsquo; Communication: Do Skills Improve Over Time With a Communication Curriculum? J Surg Educ. 2018;75(6):e142-e149. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jsurg.2018.06.015\u003c/span\u003e\u003cspan address=\"10.1016/j.jsurg.2018.06.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBogetz AL, Orlov N, Blankenburg R, Bhavaraju V, McQueen A, Rassbach C. How Residents Learn From Patient Feedback: A Multi-Institutional Qualitative Study of Pediatrics Residents\u0026rsquo; Perspectives. J Grad Med Educ. 2018;10(2):176\u0026ndash;184. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4300/JGME-D-17-00447.1\u003c/span\u003e\u003cspan address=\"10.4300/JGME-D-17-00447.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e,\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":true,"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":"surgical resident evaluation, patient evaluations, multisource feedback, underrepresented in medicine, surgical resident assessment, surgical resident feedback, patient feedback","lastPublishedDoi":"10.21203/rs.3.rs-6960176/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6960176/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: Patient feedback may serve as a valuable source of information for surgical resident assessment. However, there is also recognition that systematic bias in any new forms of surgical resident evaluation could further disadvantage historically marginalized groups. This exploratory study investigated whether patient ratings of surgical resident care differ by resident race or underrepresented in medicine (URiM) status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Surgical inpatients who underwent elective gastrointestinal and oncologic surgery evaluated the quality of surgical resident care using a modified Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). The top-box method, which quantifies the frequency of the highest possible rating for each question, was used to analyze patient satisfaction with surgical resident care in a manner consistent with S-CAHPS reporting guidelines. Patient evaluations of senior and intern residents were stratified by resident race and underrepresented in medicine (URiM) status and compared both across and within gender.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 324 patients completed 267 evaluations for senior residents and 256 evaluations for intern residents. There were no significant demographic differences between patients evaluating White vs non-White residents at either the senior or intern level (age, gender, or education level). Patient recognition rate of White vs non-White residents did not differ at either the senior (White 85.1% vs non-White 84.8%, p-value=1.0) or intern level (White 80.1% vs non-White 88.8%, p-value=0.085), even after accounting for gender. Top-box S-CAHPS scores across all 8 domains did not significantly differ between evaluations for White and non-White residents for both senior (p\u0026gt;0.10) and intern (p\u0026gt;0.36) residents, including when further stratified by gender. Similar results were observed when examining resident evaluation by URiM status, where patient recognition rate did not differ at either the senior (non-URiM 84.5% vs URiM 90.3%, p-value=0.545) or intern level (non-URiM 83.0% vs URiM 80.8%, p-value=0.982), even after accounting for gender. While there were no differences between the proportion of URiM compared to non-URiM senior evaluations that received top-box scores in 7 individual S-CAHPS items, a difference was observed in the item related to pain treatment. Specifically, 91.5% (214/229) of evaluations for non-URiM seniors had the top-box score whereas 71.4% (20/28) of evaluations for URiM seniors had the top-box score (p=0.004). However, patient-reported pain scores did not significantly differ between these groups, and this difference was not observed after further stratification by gender. Top-box S-CAHPS scores across all 8 domains did not significantly differ between non-URiM and URiM resident evaluations for intern (p\u0026gt;0.19) residents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Patient recognition rate and quality of care evaluations were overall similar regardless of surgical resident race or URiM status, including when further stratified by gender. These findings support the potential for patient feedback to serve as a valuable component of resident assessment. Further research is needed to explore how best to utilize patient evaluations to support all trainees as they prepare for independent practice.\u003c/p\u003e","manuscriptTitle":"Patient Evaluation of White vs Non-White Surgical Senior and Intern Residents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 05:12:41","doi":"10.21203/rs.3.rs-6960176/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-07-11T19:55:02+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-06T03:59:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-07-04T23:32:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-01T05:50:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-06-25T21:23:14+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":"11fd57d5-7853-4856-b115-ecaaed6ada58","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-10T04:22:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 05:12:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6960176","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6960176","identity":"rs-6960176","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}