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.

Keywords: critical care; gender disparities; graduate medical education; procedure training; residency.

Figure 1.

Observed versus expected number of procedures performed by women. (A) Program A. (B) Program B.

Figure 2.

Thematic analysis identified overlapping themes influencing gender disparities in resident procedural allocation. Our analysis revealed four causative themes contributing to gender disparities in procedural allocation (resident factors, supervisor factors, patient factors, and learning environment factors), in addition to mitigating factors that protected against disparities. Factors amplifying the unstructured procedure allocation highlighted in parentheses are paraphrased from longer direct resident quotes. Resident, supervisor, and patient factors (all of which represent individual or interpersonal factors) are likely under the influence of larger sociocultural forces.