New study finds gender, racial/ethnic disparities in general surgery board certification

An analysis of a national cohort of recent medical school graduates may provide insight into why women and graduates of some minority groups are relatively underrepresented among general surgeons, particularly those certified by the American Board of Surgery (ABS). The researchers found that general surgery graduate trainees in selected pop-ulation groups are more likely to go off the general surgery career path and into other medical specialties or, if they remain in surgery, are more likely not to complete the surgery board-certification process, according to a report published in the May issue of the Journal of the American College of Surgeons.

The study findings could eventually help surgical leaders to develop strategies to encourage more women and minority graduates who enter general to attain certification by the American Board of Surgery (ABS), said study authors, Dorothy A. Andriole, MD, FACS, and Donna B. Jeffe, PhD, Washington University School of Medicine, St. Louis. The issue of keeping more graduates who enter general surgery training—particularly women (who constitute about 50 percent of U.S. medical graduates) and minority graduates—on track for ABS certification is significant for the specialty, Dr. Andriole noted, "because there are concerns both about the size and the composition of the surgery workforce." It is the ABS that administers board certification for surgery, she explained.

Study researchers analyzed the records of 3,373 medical school graduates in the classes of 1997-2002 who intended to become board certified in surgery at the time of graduation and entered general surgery training programs. Follow-up data for these graduates, through July 2009, charted how they fared in pursuing board certification in the years since graduation. The analysis followed all graduates for at least seven years because, after completing general surgery residency training, the ABS-certification process itself can take several years, Dr. Andriole said. Overall, Drs. Andriole and Jeffe reported, 60 percent of the graduates in the study went on to achieve ABS certification and 10 percent were certified by another American Board of Medical Specialties (ABMS)-member board, while 30 percent were not certified by any ABMS member board.

The researchers found that women who expressed intent at the time of medical school graduation to become certified in surgery were more likely than men who had similar intentions at graduation to become certified by ABMS-member boards other than the ABS, Dr. Andriole noted. "That women were more likely than men to leave the surgery workforce to pursue certi-fication in other specialties is an issue worthy of attention by the profession and the American College of Surgeons, which seeks to recruit and retain women surgeons as Fellows in the organization," Dr. Andriole explained. Besides women, the study found that older graduates were also more likely to become certified by ABMS-member boards other than the ABS.

Among graduates who remained in the surgery workforce, women, Asian/Pacific Islander graduates, and graduates from racial/ethnic groups historically underrepresented in medicine were more likely to be non-board certified, as were graduates who had initially failed Step l or Step 2 of the U.S. Medical Licensing Examination sequence.

The findings regarding characteristics of medical school graduates who were retained in the surgery workforce but were not ABS certified are concerning, the study authors noted. "Physicians who are not board certified are becoming increasingly marginalized in the work-force," co-author Dr. Jeffe said. "They may not be able to access the same quality of medical services for their patients as can board-certified physicians. Many practicing physicians from underrepresented groups in medicine provide care for other underrepresented or disadvantaged populations, so this speaks to the disparities in health outcomes for their patients as well."

Dr. Andriole explained that non-board-certified physicians "may not necessarily be less well qualified to practice medicine than board-certified physicians," but they may face obstacles in pursuing opportunities available to board-certified colleagues, including hospital privileges and leadership positions in academic medicine. "We know there has been concern in the profession of surgery about the lack of diversity in the senior leadership roles of academic surgery," she noted. "Perhaps disparities in board certification are contributory."

However, the researchers did not evaluate why medical school graduates who had planned to become certified in surgery became certified in other specialties or remained in surgery but did not obtain ABS certification. Dr. Andriole noted that the level of a medical school graduate's debt was not associated with board certification and that, with longer follow-up, additional graduates in their sample might become certified, either by the ABS or by other ABMS-member boards.

Defining explanatory factors for the outcomes they observed would be a next step in using their research, according to Drs. Andriole and Jeffe. "Understanding what contributes to those gaps in ABS certification is really necessary in order to design interventions to maximize the likelihood that the diverse population of U.S. medical graduates who enter graduate medical education in intending to become certified in will go on to fully com-plete the pathway to becoming board certified by the ABS," Dr. Andriole said. Specifically, that step would involve a closer analysis of the variables that influence women graduates to become certified in other specialties and also variables that may contribute to the differences by gender and by race/ethnicity that the study authors observed in ABS certification among practicing surgeons.

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