The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (GOAST)

Listen to Andrew Duckworth, Sam Downie and Deborah Eastwood discuss the paper 'The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (GOAST)' published in the July 2023 issue of The Bone & Joint Journal.

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Transcript

[00:00:00] Welcome everyone to our BJJ podcast for the month of July. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone and Joint Journal. We hope you're all looking forward to some well-earned time off with family and friends during the summer period. As always, we'd like to start by thanking all of you for your continued comments and support for our podcasts as well as a big thanks to our many authors and colleagues who take part.

Our podcasts, continue to focus on papers published each month here at the BJJ, as well as accompanying our accompanying special edition podcasts throughout the year. So today I have the pleasure of firstly welcoming Sam Downie, who's an orthopaedic senior registrar based in D Dundee to discuss their paper entitled 'The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (the GOAST Collaborative): a national collaborative project', which has been published in this month's edition of the BJJ.

Welcome, Sam. It's great to have you join us today. Hello. Thanks very much for inviting me. Feel really privileged to be talking about GOAST here. On behalf of our steering committee and our 270 collaborative authors. That's, that's great Sam. It really is. It's an impre. Really impressive collaborative. It really is.

And so, joining Sam and I, we are delighted to welcome not only [00:01:00] a co-author of the study, but also the current president of the BOA Deborah Eastwood, Deborah. Thank you so much for taking time to join us today. I know how busy you are. It's really great to have you, have you with us. My pleasure. It's always good fun to chat about science and things like that.

Great. So both, I thought we'll get to the study cause I think there's lots to discuss and, and some really interesting sort of points that have come from this study. So your study highlights a really important area of the surgery and especially. Particularly given the global literature suggesting that female surgical trainees have lower rates of independent operating or operative autonomy than their male counterparts.

And given this as you highlight it is therefore important to recognize and understand the different training experience between the genders, why this might be, and what could potentially be done to try and improve the any disparities that exist. So, Sam, if I could maybe start with yourself as sort of a background to the study for our listeners.

Can you give us a brief overview of the state of the current data on this topic what we know already and what caused you to look at this question in particular? Yes. So this study was inspired by another study of general surgery trainees in New Zealand, which was published in 2020. [00:02:00] So they looked at national training data for 120,000 procedures and showed that female trainees had lower total cases as independent operator than males.

They didn't include, however, supervised cases, i.e. those with the trainer present and scrubbed in. So one of our other authors came to me with the idea of recreating this in UK orthopaedic trainees, and we both felt, however, that it was important to include not just autonomous operating, but supervised cases too.

We felt this could better reflect the trainees progression from learner to independent operator and reduce any adherent bias and trainees who may be the surgeon on a large number of cases, but with the boss scrubbed in. Yeah, absolutely. And I think like that, like you highlight that that surgical study was very interesting, but actually getting that the difference between the autonomy is really interesting.

And before we sort of go onto the design of the study, Deborah, if maybe come to you, you know, what, what are your own insights into this before maybe you were involved with the, the GOAST collaborative, about what? About what your thoughts are in this area and what your experiences were.

[00:03:00] Training is such an emotive subject at the moment and has been for quite some time and I, I think this collaborative has been a great starting point to help our understanding of how training a trainee sort of, if you like, delivers a surgeon ready for independent practice as bound to be confounding factors in what influences the trainer trainee relationship and.

You know the big question is really. Do we have to, or should we be individualizing the training programme and are we doing that enough to cater for the known differences? And probably the unknown differences in how we teach and how we learn. And that would feed into sort of different things like the neurodiversity agenda, the cultural agenda, you know, or an orthopaedic trainee is not just an orthopaedic trainee.

So we need to understand how they're going through the pathway at the moment. Absolutely. No, I I could agree more Deborah. And I think that's what we've, I think [00:04:00] that certainly we seem to have a better understanding of that now, but we still so much to learn, isn't there? I, I agree. And I think that's how, that's how we, it, it needs to evolve.

So, Sam if we move on to the study design, which I wasn't gonna spend too much time on, just cause I think there's a lot of other really interesting things to talk about with the study. But this was a retrospective ca case control study used electronic surgical log book data from 2009 to 2021 for 274 UK orthopaedic trainees.

So, Sam, I think maybe, but maybe before we talk about the study, can you give us a brief overview of, initially of the initial pilot study you performed and how this may be informed your study design and, and the data source that you used? Okay. Yeah. So so we did a pilot study in 2020 of all of our local trainees.

And we were lucky enough to get buy-in from all of our 15 current trainees and two recently qualified consultants who contributed the re-log book data. We saw that rates of supervised operating were the same between men and women, so around 38% in both, but found there's a small discrepancy in unsupervised cases favouring male trainees.[00:05:00] 

In particular, we saw this around ST-5 and ST-6. But as we noted that all four trainees who had had time out of programme were women, we hypothesized that this was due to a reduced percentage of autonomous operating after the time out of programme. Mm-hmm. Small numbers of female trainees in our deanery. We needed a bigger study to investigate this.

So we used the results of the pilot to generate a power calculation and sought to recruit 230 UK trainees to sort of explore this theory. Yeah, absolutely. And I think that it is just highlighting with any of these studies, like whether it's for a trial or whatever, having that pilot data so helpful to inform you to study design in a good way.

And, and so moving on from that, Sam, so what, what, what were the, in sort of inclusion, ex exclusion criteria if you were for the study, and what sort of outcomes did you look at? Okay, so we looked at all, so we potentially included all UK orthopaedic trainees with a national training number from ST-2 onwards.

We also included consultants who had CCTed within the previous five years. We [00:06:00] excluded trainees without a national training number as the goal was to assess the fairness of the specialty orthopaedic training programme. And we looked at percentage of cases by grade and chose the percentage of lead surgeon cases as the primary outcome measure.

Now, this was deliberately more inclusive than the New Zealand study. There is some evidence, and we knew this, that female trainees may be less likely to record cases as unsupervised, and we didn't want to miss these cases in our analysis. Mm, ab absolutely. And I think that's a really important point.

We'll maybe come on to in the discussion as well about that. I think it's really interesting. And, and Sam, before we move on to maybe the results I think I, I think this highlights an important point. Could you briefly describe the analysis you used and why that was? Cause there's some interesting findings in your study, but there's a subtle difference maybe between statistical and clinically relevant.

Maybe. Yeah, so I, I was really proud of this to be honest, that we had 274 respondents in a total of 285,000 cases. So massive numbers which of course dealt an unexpected difficulty in that any difference we found even [00:07:00] 1% between male and female trainees achieved statist statistical significance.

So to avoid overplaying these differences because we didn't want sensationalist headlines showing that, you know, male trainees or female trainees got more numbers. We focused on results that we deemed to be clinically significant. We did, however, include the statistics for completeness, but I was really proud of the way that, that this was analyzed and and discussed.

I, I couldn't agree more Sam, I think, you know, with the numbers, you know, it is, you know, it reminds me of like when we read an NJR paper or something like that. Like you get, get p-values everywhere, which significant, but actually interpreting them in a really sort of responsible way, I think is a, a really important thing to do.

I think that's, I think that's a great part of the study. And if you move on to what you found briefly, you know, the, like you say, there are 274 orthopaedic trainees or recently appointed consultants who completed the questionnaire and submitted their data. The mean age was just over 30 years and two thirds were male.

And like you said, there was a total of almost 286,000 surgical procedures logged over 1364 trainees years. I mean, amazing, amazing amount of data. [00:08:00] So Sam, maybe just as, as a precursor what was the general sort of makeup of the study group in terms of grade and overall operative exposure should we say?

Okay. Yeah. So from our 274 respondents 19 had full log books, so were consultants or post CCT fellows. And of the remaining 246, the main grade was ST-5. Similarly to the pilot, we found that as training grade increases, lead surgeon operating increases, and this plateaued at around 75% of all cases from ST-6 to ST-8, which is really a reflection of how fantastic the training is in UK orthopaedics.

We also found, which was very interesting, it was that independent operating so autonomously without the boss scrubbed in rose to around 40% at its peak in ST-8, and it didn't reach a plateau during training. Of those with complete log books, we found that the main number of cases was 2045. Hmm. Yeah, absolutely.

I agree with you Sam. So that was one thing for me, just looking at table three and the [00:09:00] autonomy by training grade, those numbers as you reach ST-6, 7, 8, I think they really are, like you say, a real, a real credit to our training system. I, I, I, you know, you'll, you are probably in the data better than I do, but I can't imagine there's many places around the world that you get that sort of numbers, really.

And I, I think it's fantastic. And so what, and so if we move on to the main finding, what did you find in terms of the relationship between gender and operative autonomy, which was one of the main things you wanted to look at. Yeah. So for our powered analysis we found that male trainees were lead surgeon on 3% more cases on average than women, which equates to, so 61% overall versus 58%.

Overall rates of autonomous operating were largely the same at 20, 22%, and there was a 1% difference. This was statistically significant, but we didn't deem this clinically significant. Absolutely. Yeah, absolutely. And then when you looked at, cause you looked at, I thought it was really interesting you looked at other sort of factors in relating to that.

So you looked at less than full-time training, those who took time out of programme and those were sort of no prior [00:10:00] orthopaedic experience. And how did that sort of influence things, if at all? I. Yeah, so some of it was quite surprising. So the less than full-time trainees, we had 20 of those we found in less than full-time trainees that lead surgeon operating was actually higher.

Mm-hmm. So an average 62% of cases versus 60%. But independent operating was lower by about the same margin of 2%. Those who took time out of programme, there were 75 of our individuals who did that. The commonest reason for that was researcher teaching posts. Yeah. So it was associated perhaps unsurprisingly with reduced rates of both lead surgeon and independent operating.

Those who had had prior orthopaedic training. So we deem those with more than six months as more likely to influence what sort of independent operating when they then got their national number. Yeah. We saw higher rates of rates of both lead and independent operating, but only in males, not in women.

Yeah, absolutely. Absolutely. And I think that, I think that, I think it was really nice to see those sort of sub-analysis if you were, because I think they are things that people think about and how they [00:11:00] affect both males and females, you know, in terms of taking time out of program or, or do it less than full-time training.

So if we sort of move on to the discussion, which I want to spend a. A bit more time on, you know, so, you know, I think the strengths, the importance of the study, you know, just very clear, you know, it's a large UK wide national collaborative study. Great to see another one of these out there and looking at a topic like this, I think is really important and it's looked to determine whether gender I operative training and surgical surgical autonomy.

For our UK orthopaedic trainees. And like you say, Sam has found that male trainees perform 3% more cases as lead surgeon than females. But that sort of difference in lead surgeon doesn't seem to appear to be related to higher rates for of time out of programme or for those in less than full-time training.

So maybe Deborah if I could come back to you, you know, what do you feel like the, the, the take home messages of the study are, and, and maybe was it what you anticipated you'd find? Maybe? So I think the key finding, I. Key findings are that there are differences in how many cases the male and the female trainees log and how many they log as [00:12:00] a, an autonomous operator.

So those are the key findings. And then there's the really interesting areas of whether that difference is smaller or bigger in with the different con confounders. Then there's of course, the key finding as, as Sam has alluded to, whether th this is clinically significant for all trainees. How many numbers do you have to do to be a trained surgeon?

And in this post COVID era where lots of trainees have less numbers, then there is a cohort where missing an extra 50 cases is potentially crucial. So I think that highlights again, that we mustn't treat all trainees the same, and we need to keep an eye on, on, on their, their training numbers. I think it mirrors what I expected to see.

Yeah. And it's better than I feared it might be. Yeah. So I think that was reassuring that there are a group of trainers out there who do treat female and male trainees [00:13:00] essentially the same. Maybe there are are things that we could do better, but that there, there are differences, but they're not necessarily hugely.

Significant overall in training, but we don't know that. We don't, yeah, we don't know that it might be very significant as, as Sam has said, so we don't, we don't know that Now I, and I think, you know, there's that little factor that the direct trainee who just comes in has done a bit, just cracks through and is male.

They have done more cases and they are more confident or overly confident. In saying that I am the bees, no, I'm not the bees knees, but I am the person and I can operate and I can operate alone and no, I don't need you to help me Miss Eastwood. I can do it myself. Whereas I think many of the other groups might feel slightly less confident and be happy to have a supervisor scrubbed, they just want another pair of hands.

We, we don't [00:14:00] know where these cases took place. We don't know how easy it was to get an assistant. Mm-hmm. Et cetera. And then I think finally, I think it, it is interesting the less than full-time trainee versus that who has been on research or out of programme for parental leave. Yeah, that's a sort of different than maybe the less than full-time trainee and

the less than full-time trainee did quite well, didn't they? Sam, you know, they got their operative numbers, but maybe so I was, or a trainer was prepared to let the female trainee operate, but maybe just not operate on their own so much because maybe they weren't so sure when they, I don't know. I don't know.

No, I, I think that, I think that's a brilliant, I like you say, I think it's a brilliant summary of all that. Deborah, I think, I thought, I think one thing that really homed to me, and it's something that you, you've written in the paper is, you know, interestingly the differences seem here, may, may reflect differences influenced by gender and how the cases are recorded.

And I, I, I do agree with that completely. You know, and, [00:15:00] and you, you, there's literature quoted there that despite similar rates of surgical competency as recorded by trainers themselves, female trainees are more likely to record inferior performance, demonstrate higher rates of imposter syndrome and are more likely to underestimate their capabilities than their male counterparts.

Mm. And I think that that is true, isn't it? I think we see that in, in and, and potentially why there is tho there, there could be some differences in that autonomy or perceived autonomy in those cases. I think that's really interesting. And Sam, I mean, if I could could come back, back to yourself, you know, it what, what did you feel in terms of, I mean the data set is huge, but did you feel there was any limitations to the data or something that you would've changed?

Maybe with hindsight, maybe. Yeah, I mean, you, you've always got to be honest about, you know over promising what, what a study shows. And I think what, what people have raised and, you know, peer review about this is that the estimated sort of 20, 21% response rate of the study, when you look at UK trainees in, in total it is possible that those who participate, participated were a biased group

with perhaps [00:16:00] particular reasons for signing up, either they thought their training was excellent and wanted to showcase that, or they had an agenda and felt that they were being unfairly biased for whatever reason. However, we did use the pilot study to inform a sample size and we sought to minimize that by reaching our predetermined sample size.

So with all that we could to minimize that, and we did seek to recruit all UK trainees, which is a very ambitious and I think was was unlikely to be achieved. But even so, I mean managing to recruit fifth of all UK trainees to contribute this really personal, important operative data was a massive contribution from all of our authors and we're really grateful for that.

Couldn't have done it. I, I totally agree, and I think it's a sign of a, I was saying to Deborah before, like, how, how, how collegiate and collaborative the trainee collective is. I think it's, I think it's a fantastic highlight a highlighter of what, of how good our trainee body is when it comes to things like this and the other studies that have been done in terms of collaborative by the trainees.

It's, it's, it's fantastic. And so maybe to, just to finish off, I'm just conscious of time here, you know, and I'll probably ask you [00:17:00] both. Maybe I'll start with you, Sam, then you, Deborah. What are your thoughts given this and, and maybe anecdotally personal experience in your training programmes or as a trainer about what, how we can potentially move forward or what future work is needed here?

Sam, what, what if I maybe go to you first? Okay. Yeah. So first we've already alluded to this, but we really need to highlight to both trainers and trainee the results of this study. We need to make sure everyone knows about it, particularly the excellent rates of operating that you get across the board, but particularly in those let on less than full-time training.

So does, and also for those who take time out of programme, despite the perhaps expected reduction in independent operating, operating when they come back to training that they quickly return to their prior competencies. Yeah. The other thing I'd want to highlight is, That we need to really explore what we can do to reduce the difference that we have seen and support all trainees.

So at the end of the day, we're training future consultants and we owe it to our patients to make sure that training is complete and fair for everybody. Not just, you know, your direct route trainees who've not taken any time out. But you know, [00:18:00] as Deborah's alluded to, I think the results are much better than many people had feared.

And there's always work to be done, but we're starting from a great position, I think. No, I think that's very well said Sam and Deborah, anything you would like to add to that? I think Sam's probably said it, but I think we, and I think some programmes do it better than others, but to, to individualize your training programme so the direct trainee, especially if they're male, has no problem or less of a problem at the moment.

So if we use that as a bit of a gold standard, yeah. Then others who are out of programme or have to juggle everything else, plus the hormonal effects of pregnancy. You know, they've, if they're going off and then they're coming back, we should perhaps work a bit harder to work out what they need and how we can deliver that and, and what methods they feel work best.

For them. Now we, if we're doing that for the lesson full-time trainees and the out of programme trainees we should of course do it for the direct entry sail through male. I mean, we should be[00:19:00] potentially individual. We can't do it for individuals, can we? But we can try and individualize the training to a certain extent and try and see what it is about the female trainee who may feel just more confident to have you or me scrubbed with the band, you know, Andrew or.

Whether we could encourage them to say, well, I will be in the coffee room, and I do mean I will just be in the coffee room and I will pop in without being asked just to see how you are doing. You don't need to say, I'm having trouble come and help me. It's more just reassurance that you are on the right track.

No, I, I totally agree, Deborah. I think I think that's right and I thought, like, like you, you, the, the team has alluded to in the study, I think may maybe some qualitative advance in the future. Cause actually I think talking to people who've been through the system who are about to go through the system or in the system is, is probably gonna inform things moving forward as much as anything isn't it.

And actually, like you say, and then that will actually allow us to bespoke training a little bit. Better to individuals needs. No, I totally agree. So well both, I'm, I'm afraid [00:20:00] that's all we have time to for today. And congratulations really on a, on a great study. And thank you so much for not only taking the time to join me today, but for highlighting a really important area for training in our specialty.

And it was great to have you both with us and to our listeners. We do hope you've enjoyed joining us and we encourage you to share your thoughts and comments through social media and the like. Feel free to tweet or post about anything we've chatted about here today. And thanks again for joining us.

Take care everyone.