Gender Disparities in Critical Care Procedure Training of Internal Medicine Residents

Abstract

Background Procedural training is a required competency in internal medicine (IM) residency, yet limited data exist on residents’ experience of procedural training. Objectives We sought to understand how gender impacts access to procedural training among IM residents. Methods A mixed-methods, explanatory sequential study was performed. Procedure volume for IM residents between 2016 and 2020 was assessed at two large academic residencies (Program A and Program B: 399 residents and 4,020 procedures). Procedural rates and actual versus expected procedure volume by gender were compared, with separate analyses by clinical environment (intensive care unit [ICU] or structured procedural service). Semistructured gender-congruent focus groups were conducted. Topics included identity formation as a proceduralist and the resident procedural learning experience, including perceived gender bias in procedure allocation. Results Compared with men, women residents performed disproportionately fewer ICU procedures per month at Program A (1.4 vs. 2.7; P < 0.05) but not at Program B (0.36 vs. 0.54; P = 0.23). At Program A, women performed only 47% of ICU procedures, significantly fewer than the 54% they were expected to perform on the basis of their time on ICU rotations ( P < 0.001). For equal gender distribution of procedural volume at Program A, 11% of the procedures performed by men would have needed to have been performed by women instead. Gender was not associated with differences in the Program A structured procedural service (53% observed vs. 52% expected; P = 0.935), Program B structured procedural service (40% observed vs. 43% expected; P = 0.174), or in Program B ICUs (33% observed vs. 34% expected; P = 0.656). Focus group analysis identified that women from both residencies perceived that assertiveness was required for procedural training in unstructured learning environments. Residents felt that gender influenced access to procedural opportunities, ability to self-advocate for procedural experience, identity formation as a proceduralist, and confidence in acquiring procedural skills. Conclusion Gender disparities in access to procedural training during ICU rotations were seen at one institution but not another. There were ubiquitous perceptions that assertiveness was important to access procedural opportunities. We hypothesize that structured allocation of procedures would mitigate disparities by allowing all residents to access procedural training regardless of self-advocacy. Residency programs should adopt structured procedural training programs to counteract inequities.

Differences in emergency medicine resident procedural reporting by race and ethnicity

“…Prior literature has suggested that certain behaviors and personality characteristics such as procedural aggressiveness, assertiveness, and confidence can be influential factors in gaining access to procedures. 19 Persons who select EM as a specialty may possess these characteristics to a greater degree than the general graduate medical trainee population. 20 However, this notion is further complicated by the experiences reported by Black female physicians, for example, regarding the negative consequences surrounding perceptions of "anger" and "intimidation" when attempting to lead and assert themselves.…”

“…Resident self‐selection into the field of EM may also have dampened differences in our study population compared to a more broad graduate medical education population. Prior literature has suggested that certain behaviors and personality characteristics such as procedural aggressiveness, assertiveness, and confidence can be influential factors in gaining access to procedures 19 . Persons who select EM as a specialty may possess these characteristics to a greater degree than the general graduate medical trainee population 20 .…”

Beyond the Procedure Log: Using Individualized Learning Plans to Set Learner-Specific Milestones for Procedural Skills Acquisition

“…Because ILPs provide a structured way for interested residents to enroll in procedural rotation electives and to advocate for themselves to access experiences in the CLE, ILPs may partially mitigate inequities in procedural allocation. However, there are potential barriers to the effectiveness of ILPs in addressing inequities, such as residents who hold certain identities facing barriers to identifying themself as proceduralists 10 and supervisors not using ILPs to guide allocation of learning opportunities in the often hectic CLE. These barriers might be overcome by adequate coaching to assist residents with career exploration and goal setting, 44 robust faculty development, 23 and the creation of procedural services, 20–22 which help ensure access to procedural learning opportunities 10,21 …”

“…For example, recent data indicate that some IM trainees who identify as women are less likely to self-identify as future proceduralists. 10 Because ILPs rely on goals established by learners to guide educational activity planning, they will not in isolation address the forces that shape the goals trainees set for their training, including their likelihood to identify with an envisioned future self. 49 Specifically, ILPs will not address inadequate institutional support for identityconcordant mentorship programs, 50 failure of institutions to recruit and retain diverse faculty role models, 51,52 or identity-mediated differences in how learners are treated in the learning environment, [53][54][55][56][57] all of which may disrupt female trainees (or trainees with other minoritized identities) from imagining themselves as future proceduralists.…”

“…Second, ad hoc approaches to procedural training often require trainees to self-advocate for access to procedural practice, which contributes to gender inequities in procedural training. 10 Third, IM trainees pursue a wide range of future careers: some will need to perform moderate-to high-risk procedures daily, whereas others will never perform any invasive procedures after training is complete. Flexibility in procedural training plans may therefore result in misallocation of limited procedural learning opportunities and cause more patients to undergo procedures performed by novices, who may be aiming for exposure to procedures rather than mastery.…”