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Abstract

Importance

Interest in equity, diversity, and inclusion (EDI) in medicine is growing, with women now making up 54% of Canadian physicians under the age of 40. Despite this, women in surgery remain underrepresented, facing challenges such as professional isolation. In response, a Women in Surgery in (WISE) Ear Nose and Throat (ENT) group was created to foster EDI. This is the first journal club of its kind described in the literature.

Objective

Our objective was to describe the creation and program evaluation of a WISE group.

Design

(1) Setting and Intervention: A quarterly journal club meeting was created in a hybrid format to discuss peer-reviewed articles on EDI. Grant funding was obtained from a physician association’s wellness budget. (2) Participants: Responses were from members of a Canadian University’s otolaryngology mailing list attending these sessions. There were multiple responses from some of the same individuals across the 7 meetings. (3) Outcome Measures: An anonymous web-based survey with Likert-style questions was administered to participants 1 week after each session. General self-efficacy scale (GSES) was also administered. Moore’s pyramid of effectiveness in continuing medical education was used as a framework for program evaluation.

Results

Eighty-two responses to the survey were collected over 7 meetings. Among the 75 who responded to the gender identification question, 57 (76%) identified as women and 18 (24%) identified as men. Responses included 38 (46%) attendings, 8 (10%) fellows, 29 (35%) residents, and 7 (9%) medical students. Ninety percent of the responses “agreed” or “strongly agreed” that the group promoted collegiality, 82% of the responses “agreed” or “strongly agreed” that the group supported the participants’ well-being, and 89% of the responses “agreed” or “strongly agreed” that the group provided a safe environment for discussion. The responses showed that the initiative was rated as outstanding by 48% and above average by 46%. From the responses, the GSES was high at 31.0 ± 4.3.

Conclusions

A WISE group has been created and highly rated. This initiative represents one step of the university’s ENT division’s commitment to EDI.

Graphical Abstract

Keywords

women in surgery gender disparities equity diversity inclusion (EDI) in healthcare

Key Messages

The creation of a Women in Surgery in ENT (WISE) group represents one step in our division’s commitment to equity, diversity, and inclusion.

A journal club program such as WISE was highly rated by attendees, both men and women, and supported the attendees’ sense of self-efficacy.

Introduction

Interest in equity, diversity, and inclusion (EDI) in medicine is growing. The latest data from the Canadian Medical Association demonstrate that 54% of Canadian physicians under the age of 40 are women.¹ The number of women entering medical careers has been steadily increasing, with the majority of graduates being women over the past 2 decades.² It is anticipated that by 2030, the workforce will be evenly balanced between men and women.² Research has shown that female surgeons and internists have outcomes that are comparable to their male counterparts, including lower postoperative complications and mortality rates.^3,4

Although the representation of women and other marginalized groups in the medical profession is improving, challenges related to discrimination and bias—both at the individual and systemic levels—can still impact one’s career progression, health, and overall well-being. Despite the positive trend in gender representation, this shift may not yet be fully reflected in all surgical specialties. In fact, women remain a minority in certain surgical fields, comprising less than 15% of applicants to residency programs in thoracic surgery, otolaryngology, urology, orthopedic surgery, and neurosurgery in the United States.⁵ In Canada, the Royal College of Physicians & Surgeons of Canada report that 23.8% of the otolaryngology—head and neck surgery workforce comprised women.⁶

The retention of female physicians in academic medicine is shaped by many factors, including the need for increased mentorship and role models, experiences of professional isolation, challenges with work–life balance, salary inequities, instances of bullying and harassment, and unconscious bias in the workplace.^7,8 These obstacles are particularly relevant to female surgical trainees and staff.⁹ A recent large-scale survey of Canadian otolaryngologists revealed that female otolaryngologists hold fewer leadership positions and experience higher levels of harassment compared to their male counterparts, both during and after training.¹⁰ Additionally, female otolaryngology trainees report perceiving lower levels of gender equity during training during their training compared to their male peers.¹⁰

In response to these challenges, institutions have been addressing these issues by developing guidelines, enacting policies, and implementing programs to promote gender equity and diversity.^11
-14 However, in Canada, there is limited data and few initiatives aimed at addressing the challenges faced by female surgeons and medical learners. In an effort to further build comradeship and support, a Canadian University’s Otolaryngology Division created a Women in Surgery in ENT (WISE) group in 2022. This group is the first journal club created for female surgeons reported in the scientific literature. While the group is primarily focused on supporting female surgeons, it is open to both male and female participants. All health care providers interested in equity diversity and inclusion was invited to participate. Thus, the objective of this study was to both describe and evaluate the creation of a WISE group seeking to encourage equity, diversity, and inclusion.

Methods

Curricular Design

A quarterly journal club meeting was created in a hybrid (in person/virtual) format by the Otolaryngology division at a Canadian University. The concept and objectives of WISE were introduced to the ENT faculty, trainees, and allied health care professionals through the ENT Division’s e-mail list in December 2022. The concept was to discuss scholarly, peer-reviewed articles on EDI pertaining to female ENT surgeons. The objectives of the WISE group were (1) To build collegiality among all participants, women and men; (2) To stimulate a learning environment; (3) To support the well-being of participants; and (4) To create a safe venue to openly discuss EDI topics.

Sessions were held in the evening for flexibility and to accommodate varying clinical and personal schedules of attendees. Speakers, ranging from residents to fellows to attendings, presented a peer-reviewed article on EDI in surgery. Topics covered included gender income disparity, misidentification as a microaggression, and ergonomics for female surgeons (Table 1).^15
-22 Of note, no topics were repeated throughout the academic year. The session coordinator, with the help of the senior administrative assistant to the head of the academic division, sent out the Zoom link and the article of discussion via e-mail approximately 3 weeks before each session. Participants included female trainees and staff surgeons, and invitations included male and nonbinary individuals to ensure inclusivity and broader perspectives on EDI discussions.

Table 1.

Topics and Articles Presented Thus Far in WISE (2022-2024).

Date	Topic	Article and DOI
December 7, 2022	Income Disparity	Dossa et al. Sex-Based Disparities in the Hourly Earnings of Surgeons in the Fee-for-Service System in Ontario, Canada. doi:10.1001/jamasurg.2019.3769
February 27, 2022	Misidentification as a Micro-aggression	Manzoor et al. Sexism in medical care: “Nurse, can you get me another blanket?” doi:10.1503/cmaj.191181 Davids et al. Female Representation and Implicit Gender Bias at the 2017 American Society of Colon and Rectal Surgeons’ Annual Scientific and Tripartite Meeting. doi:10.1097/DCR.0000000000001274
September 25, 2023	Structural Bias in Reimbursement for Surgical Care for Women	Chaikof et al. Surgical sexism in Canada: structural bias in reimbursement of surgical care for women. doi:10.1503/cjs.022121
November 27, 2023	Ergonomics for Women in Surgery	Bellini et al. A Woman’s Place Is in Theatre, but Are Theatres Designed with Women in Mind? A Systematic Review of Ergonomics for Women in Surgery. doi:10.3390/jcm11123496
February 12, 2024	Unpacking the Status-Leveling Burden for Women in Male-Dominated Occupations	Cardador et al. Unpacking the Status-Leveling Burden for Women in Male-Dominated Occupations. doi:10.1177/00018392211038505
May 27, 2024	Motherhood Penalty and Fatherhood Bonus	Bear et al. Breadwinner Bonus and Caregiver Penalty in Workplace Rewards for Men and Women. doi:10.1177/1948550616683016
August 15, 2024	Gender Diversity and Patient Outcomes	Hallet et al. Association between anaesthesia-surgery team sex diversity and major morbidity. doi:10.1093/bjs/znae097

Abbreviation: WISE, Women in Surgery in ENT.

The session coordinator, who is an attending otolaryngologist and founder of this initiative, was present to supervise the presentation during each session. She also helped choose the journal articles and moderated the discussion. Sessions comprised 30-minute presentation followed by a 1-hour interactive discussion. With regards to the article selection, topics and journals were selected after a thorough literature search. Of note, some topics were suggested by the participants. The focus was placed on topics that were more relevant to the majority of participants; hence, the sessions primarily featured Canadian studies (Table 1). This could introduce geographic bias and it may not be as generalizable to a broader, non-Canadian audience. It may also exclude important findings from other regions that could offer a different but equally pertinent perspective. Of note, Google’s search algorithms tend to prioritize content that is geographically relevant or more frequently accessed from a given location. Additionally, only research published in English were included due to the language skills of the participants, thereby introducing a language bias.

Grant funding was obtained from a physician association advocating for wellness. This covered the costs for speaker honorariums, administrative support with room booking and Zoom meetings, and in-person meals or food delivery gift cards (ie, Doordash®), thus alleviating the logistical burden. In fact, the first step in creating this initiative was securing grant funding to ensure its sustainability. As relying on organizers or participants to pay out of pocket would have been unsustainable, overcoming the financial barrier was crucial. Next, existing infrastructure was leveraged, such as the division’s electronic mailing list, to promote the initiative. The grant also provided administrative support. Both grant funding and administrative support were cornerstones in the success of this initiative.

Program Evaluation and Outcome Measurement

Following every journal club, participants were asked to provide formative feedback on the presentation and discussion on the topic chosen. Participation in these surveys was voluntary and without compensation. The program evaluation was created with attention to Moore’s pyramid of effectiveness in continuing medical education (CME).²³ An anonymous survey with Likert-style questions was administered to participants during the week following each session and were anchored on the 4 objectives of WISE (Supplement Table 1). The survey was created in Google® Forms and disseminated via e-mail to all participants. The names and email addresses of the survey participants were not collected. The only demographic information retained, such as the professional group, gender, and age range of the participant, was collected to have a complete picture of the diversity within the group.

Furthermore, in the same survey, the general self-efficacy scale (GSES) was administered.²⁴ The GSES is a validated tool used to quantify self-efficacy, which is defined as the optimistic self-belief that one has the ability to perform a novel task, overcome adversity, and adapt after experiencing stressors.²⁴ Ten items were asked on a scale from 1 to 4, with total scores ranging from 10 to 40, and a higher score represented higher self-efficacy.

Statistical Analysis

Demographic, Likert scale, and qualitative data were collected. Descriptive statistics were used to analyze the data. Questions elicited attitudes and perceived barriers to the participation of the journal club. A comment section was available in each survey, allowing for subjective feedback compilation.

The Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans states that program evaluation is not considered research and it does not require ethics review.²⁵

Results

From December 2022 to August 2024, a total of 7 WISE sessions have been hosted. A total of 82 responses were collected across the 7 meetings (Table 2). Of the 75 responses to the gender identification question, 57 (76%) were from women and 18 (24%) were from men. Responses included 38 (46%) attendings, 8 (10%) fellows, 29 (35%) residents, and 7 (9%) medical students. Of note, it is possible that some respondents attended multiple WISE sessions, resulting in repeated responses from the same individual across more than one evaluation. The survey responses were from sessional attendance and not unique participants.

Table 2.

Sample Size of Participants at Each WISE Session Since Its Creation.

Meeting	Sample size (n)
1	9
2	17
3	10
4	15
5	15
6	5
7	11
Total	82

Abbreviation: WISE, Women in Surgery in ENT.

The largest age group among responses were between the ages of 25 and 30 (34 responses—42%), in contrast to the smallest representation in the 36- to 40-year-old bracket (7 responses—9%) (Figure 1).

Figure 1.

Age distribution among all respondents to WISE surveys. WISE, Women in Surgery in ENT.

When prompted about the objectives of the WISE initiative following each session, 90% “agreed” or “strongly agreed” that the group promoted collegiality. Eighty-two percent of the responses “agreed” or “strongly agreed” that the group was a good venue for learning. Eighty-two percent of the responses “agreed” or “strongly agreed” that the group supported well-being. Finally, 89% “agreed” or “strongly agreed” that the group provided a safe environment for discussion (Figure 2).

Figure 2.

Likert questionnaire distribution of the 4 pillars: venue safety, well-being support, learning environment, and promotion of collegiality.

Overall, this initiative was rated as outstanding by 48% and above average by 46% of the responses. GSES was high at 31.0 ± 4.3, ranging from 19 to 40 (Figure 3).

Figure 3.

Overall progression of participants’ GSES. GSES, general self-efficacy scale.

Among the subjective feedback collected, the responses showed that in-person discussions were more effective than virtual ones, though the hybrid option remained valuable for those unable to attend in person. Many comments demonstrated appreciation of the support from male colleagues within the division who also attended these journal club meetings. The sessions were noted for providing practical solutions and incorporating ample time for discussion, as highlighted in participant feedback.

Discussion

The experiences of women in medicine and how they differ from men is well documented in the literature. WISE has successfully created a community to discuss topics, to focus on barriers and solutions, and to illuminate the reality of female surgeons.

WISE aligns itself well with the goal of institutions to implement programs to promote gender equity and diversity.^11,13,14 One of these initiatives was described by Bauman et al. They outlined the impact of the Women in Medicine and Health Science (WIMHS) program at the University of California Davis School of Medicine.¹¹ WIMHS was created in 2000 and organized annual workshops and lecture series on topics such as networking and internal career development (mentorship and leadership clinics).¹¹ Since the program’s inception, there has been a consistent rise in both the number and percentage of female faculty (170% between 2001 and 2011), along with an increase in the percentage of female department chairs (500% increase between 2001 and 2011).¹¹ Additionally, the departure rate for women at the school of medicine was lower than the national rate reported by the Association of American Medical Colleges.¹¹ In terms of mentorship programs, the Canadian Association of General Surgeons’.¹³ Women in Surgery Committee launched a mentorship program in 2019.¹³ This program offered 20 early-career female surgeons and senior residents the opportunity to develop a one-year mentorship relationship with an established surgeon to promote both career-related and personal growth.¹³ Mentorship covered areas such as research, work–life balance, transition to practice, career development, and more. There has not been published data on this initiative thus far.¹³ Similarly to CAGS’ program, Lin et al implemented a comprehensive strategy to recruit and retain women and underrepresented minority²⁶ faculty at Johns Hopkins’ Department of Otolaryngology—Head & Neck Surgery.¹⁴ The department regarded mentorship to be a key component in the retention of women and URM faculty. Their mentorship program resulted in a 4.1-fold increase in female clinical faculty and a doubling of URM faculty from 2004 to 2014.¹⁴ All these initiatives demonstrate a growing commitment to addressing gender disparities in medicine through targeted programs and mentorship opportunities. The continued success and expansion of such efforts highlight the importance of ongoing support and innovation in promoting gender equity within the medical field. As such, creating a WISE group to better understand career experiences of female otolaryngologists in surgery is essential in expanding the female surgical workforce, improving the professional environment in surgery, and encouraging and mentoring both current and up-and-coming female surgeons.

The evaluation of the WISE group was inspired from Moore’s conceptual framework for assessing CME outcomes.²⁴ Moore’s seven-level pyramid is composed of the following: level 1: participation; level 2: satisfaction; level 3 learning: A, declarative knowledge, and B, procedural knowledge; level 4: competence; level 5: performance in practice; level 6: patient health, and level 7: community health. Participation numbers account of level 1 (Table 2). The evaluation survey of WISE was tailored to meet level 2. In total, feedback was recorded with 82 of the survey responses. The higher levels of the pyramid may be more difficult to apply to EDI topics and are areas for future research.

WISE has diverse participants, ranging from attendings, fellows, residents, and medical students. The group was open to both men and women. The group wanted to encourage male attendees to foster allyship for the female members of the division. None of the female members voiced objections to having men join the journal clubs. While this was not formally quantified, audience members have spread beyond the field of ENT. Colleagues in obstetrics and gynecology, thoracic surgery, and orthopedic surgery, have attended the journal club meetings. Additionally, otolaryngologists from other Canadian institutions have inquired about this initiative. Of note, while the in-person sessions were appreciated for allowing a more intimate and effective setting for discussion, the hybrid option was convenient for participants attending from across the province of British Columbia, beyond Vancouver to other centers like Kelowna, Nanaimo, and Victoria.

The majority of faculty, fellow, resident and student respondents found the program to be a helpful supplement to their current curricula. WISE provided a safe environment to discuss topics and allow for networking opportunities, while promoting collegiality and well-being. Establishing groups such as WISE has been shown to lead to scholarship and increased support and mentorship of other women.^27,28

GSES was chosen as an outcome measurement due to its ability to predict an individual’s behavior, thought patterns, and emotional responses. GSES was also reported to be associated with professional efficacy. This score evaluates an individual’s self-belief in managing daily challenges and adapting to various stressful life events.²⁹ One’s general self-efficacy is found to be significantly related to mental health issues such as depression, anxiety, and helplessness.²⁹ People may experience lower burnout when they feel capable of controlling challenging demands or situations. Lower GSES is thus negatively and inversely correlated with increased exhaustion and high risk of job-related burnout. This has been demonstrated in multiple fields of healthcare, including in nursing, physical therapy, and surgical residency.^30
-32 Interestingly, a recent cross-sectional survey in the United States demonstrated that mentorship may help increase self-efficacy and is inversely proportional with burnout rates.³¹ Similarly, GSES was high throughout the first 7 WISE sessions. This current study’s GSES of 31.0 ± 4.3 was close to a score of 32.7 ± 5.7 as documented in a recent study evaluating female otolaryngologists’ experiences with gender bias and microaggressions.³³ Of note, the WISE GSES average may contain a small percentage of male participants. Overall, the higher GSES scores within the female Canadian otolaryngology population suggest a positive trend in professional efficacy, although potential survivorship and selection biases should be considered.

Interestingly, despite the favorable outcomes of the workshop/lecture series and mentorship programs addressing gender-related inequities, Caffrey et al argue that these programs might paradoxically perpetuate and reinforce gender inequity through their implementation.¹² They examined the Athena SWAN program (Scientific Women’s Academic Network), a framework designed to recognize and reward best practices in advancing gender equality in the United Kingdom.¹² It was observed that running the program led to gender inequity being reproduced, as female staff were disproportionately burdened with Athena SWAN-related tasks, though it is important to note that this is a tool to evaluate programs, and not a mentorship program itself.¹² Despite an increase in the number of women employed in academic medicine in the United Kingdom, econometric analysis has not attributed this increase to the Athena SWAN program. They specify, however, that more time and more medical schools are needed to better assess this finding.¹²

This concept has been called the “minority tax.”³⁴ Academic universities have good intentions with creating EDI initiatives and they often ask underrepresented in medicine (URiM) faculty members to volunteer substantial time to committee work, mentoring, and administrative responsibilities. This volunteer work, however, is often uncompensated, unrecognized, and not considered in academic promotion.³⁴ These responsibilities are extra work on top of the faculty members’ daily obligations. There is also the emotional toll, as the people who are most affected by bias and discrimination are the ones tasked to find solutions to fix it. There is the opportunity cost of time lost for academic work displaced by volunteer EDI work, income lost from clinical work, and the sacrifice of personal leisure and wellness time.³⁴ EDI should be viewed as an issue for everyone to address and all stakeholders should be engaged, including the majority. Academic institutions should consider redistributing the EDI work so that it is more equitable among all faculty members and consider recognizing EDI work for academic promotion. In fact, a quality improvement study done at the University of Wisconsin demonstrated that staff, while committed to EDI work, felt that this same “volunteer” work hampered their scholarly productivity necessary for promotion.³⁵ This led to a vicious cycle that hindered their advancement in academic medicine.³⁵ Financial compensation for time spent on these endeavors should be considered. This caution can be taken into consideration with the current expansion of the WISE program. The organizing committee may allow for both male and female staff to be considered in the task distribution. For example, 1 year we had very few female trainees in the program and subsequently, we did not have enough female presenters. A male otolaryngology resident volunteered to present a WISE journal club article and his diverse opinions on EDI topics were appreciated.

Despite the positive impact of the WISE journal club, women in surgery and otolaryngology may still encounter barriers. One of the primary challenges is the continued underrepresentation of women in leadership roles within both academic and clinical settings.³⁶ While initiatives like WISE offer important opportunities for discussion, mentorship, and networking, they may not be sufficient to directly address the underlying structural inequities that persist. This is particularly evident in surgical specialties such as otolaryngology, where women remain outnumbered by men in both faculty and department chair roles.³⁷ Another barrier is the persistence of unconscious bias in processes such as hiring, promotion, and performance evaluations, which can hinder women’s career advancement.^38,39 Additionally, the absence of gender-sensitive policies, such as adequate parental leave or flexible work arrangements, adds to these challenges.⁴⁰ While WISE does discuss these topics, with the participation of both men and women, achieving true gender equity in surgery will require ongoing, systemic changes at institutional, societal, and policy levels. Moreover, it is important to consider how a similar framework could be applied to address the needs of other minority groups. While WISE is contributing to the creation a supportive community for women, addressing the specific challenges faced by other equity deserving groups, such as racial minorities, LGBTQ+ individuals, and individuals with disabilities, is also an essential aspect of EDI efforts.

Limitations

This study has several limitations. The study was conducted at a single center, which inherently restricts the generalizability of the results to other institutions and geographical regions. There is a potential for nonresponse bias, as not all attendees of the journal club completed the survey. Those who chose not to complete the survey may have different opinions. There may be a selection bias, where individuals who felt particularly strongly about the topic were more inclined to respond, thereby over-representing certain views. Furthermore, there is the possibility that evaluations across all 7 sessions were not completed by unique participants, which could lead to repeated responses from the same individual. While there is a possibility that some participants attended multiple sessions and completed evaluations more than once, an effort was made to minimize this likelihood. The survey questions and 1-week timeframe to respond were designed to capture session-specific feedback, which would inherently vary depending on the unique content and dynamics of each session. The survey design ensured that participant anonymity was preserved, thus, it was unlikely that a participant answered more than once per session. Finally, it is important to note that while Moore’s conceptual framework served as a foundation for evaluating the program, incorporating assessments at level 3A (declarative knowledge) postsessions would provide more concrete and objective evidence of WISE’s impact. Finally, it is essential to recognize that gender is not a binary concept; it exists on a spectrum. Thus, the experiences of all individuals on this spectrum must also be considered as WISE continues to grow to be more inclusive.

Conclusion

A WISE group has been created and highly rated by both male and female survey responses. This study presents the encouraging results of a survey-based evaluation of the first journal club dedicated to women in surgery, conducted over the 2022 to 2024 academic years. Other institutions and specialties may use this program as a model to develop their own initiatives and expand this effort to support and empower women in surgery. After nearly 2 years since its creation, Vancouver Coastal Health’s Equality, Diversity, and Inclusion committee has adopted the WISE group and will fund this initiative for another year. The creation of WISE represents one step of the university ENT division’s commitment to diversity, equity, and inclusion.

Supplemental Material

sj-docx-1-ohn-10.1177_19160216251390414 – Supplemental material for Creation and Program Evaluation of a Women in Surgery in ENT (WISE) Group

Supplemental material, sj-docx-1-ohn-10.1177_19160216251390414 for Creation and Program Evaluation of a Women in Surgery in ENT (WISE) Group by Emily Oulousian, M. Elise Graham, Yvonne Chan, Jane Lea and Amanda Hu in Journal of Otolaryngology - Head & Neck Surgery

Footnotes

Acknowledgements

None.

Author Contributions

Amanda Hu: (1) conception and design, acquisition of data, analysis and interpretation of data; (2) drafting and revising the article; (3) final approval; and (4) accountable for all aspects. M. Elise Graham: (1) revising article (2) final approval of the version to be published; and (3) accountable for all aspects. Yvonne Chan: (1) revising article (2) final approval of the version to be published; and (3) accountable for all aspects. Jane Lea: (1) revising article (2) final approval of the version to be published; and (3) accountable for all aspects. Emily Oulousian: (1) data analysis and interpretation of data; (2) drafting and revising the article; and (3) accountable for all aspects.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: WISE is funded by the Small Steps Big Ideas Grant from the Vancouver Medical Dental Allied Staff Association and Vancouver Coastal Health’s Equity Diversity Inclusion committee. WISE is also supported by the Canadian Society of Otolaryngology – Head & Neck Surgery, Dr Elena M O’Connell Memorial Fund.

Ethical Approval

Program evaluation is not considered research and it does not require ethics review.

ORCID iDs

Emily Oulousian

M. Elise Graham

Amanda Hu

Supplemental Material

Additional supporting information is available in the online version of the article.

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