Gender Differences in Trainee Case Load in Surgical Training: A Systematic Review and Meta-Analysis
Olivia Elkington1, Omar Shadid2, Sidharth Rele3
1Division of Otolaryngology, Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.
Background:
Gender equity in surgical training is essential to delivering high-quality patient care and fostering a representative medical workforce. Despite increasing female representation in medical schools and in surgical training programs, studies suggest significant gender disparities persist in case load, procedural complexity and operative autonomy experiences. This systematic review aims to assess the extent of these disparities and evaluate their potential impact on surgical training outcomes and workforce equity.
Methods:
A systematic review was conducted following PRISMA guidelines, with literature sourced from PubMed, MEDLINE and EMBASE databases up to May 2024. Eligible studies reported gender-delineated surgical trainee case loads or autonomy, with ≥ 20 participants. A random-effects meta-analysis using restricted maximum likelihood estimation was performed to calculate pooled male-to-female case ratios, accounting for heterogeneity across studies in specialty and methodology.
Results:
From 2020 database records, 18 studies published between 2017 and 2024 met inclusion criteria, encompassing 4139 surgical trainees (2541 males; 1592 females) across diverse specialties and regions. A random-effects meta-analysis demonstrated a significant male advantage in overall case volumes, with a pooled M:F case ratio of 1.17 (95% CI: 1.11-1.25), indicating that male trainees performed approximately 17% more cases overall (p < 0.0001), with minimal heterogeneity (I2 = 1%). Eleven studies reporting basic procedures showed a pooled log M:F ratio of 0.49 (95% CI: 0.22-0.76; p = 0.0004), corresponding to ~63% higher volumes for male trainees. Nine studies reporting complex procedures revealed a pooled log M:F ratio of 0.48 (95% CI: 0.13-0.82; p = 0.0065), equating to ~61% higher volumes for male trainees, with substantial heterogeneity (I2 = 83.5%). Although individual studies varied, some approaching parity, the overall trend consistently indicated underrepresentation of female trainees in both basic and complex operative experience.
Conclusion:
Despite progress in certain specialties, persistent gender disparities in operative case load and autonomy remain across much of surgical training, reflecting broader issues of implicit bias and structural barriers. Addressing these inequities requires systemic interventions, including auditing training experiences, standardising competency frameworks, faculty education and enhanced support for trainees.
