Gender imbalance amongst promotion and leadership in academic surgical programs in Canada: A cross-sectional Investigation.

BACKGROUND: Women are underrepresented at higher levels of promotion or leadership despite the increasing number of women physicians. In surgery, this has been compounded by historical underrepresentation. With a nation-wide focus on the importance of diversity, our aim was to provide a current snapshot of gender representation in Canadian universities.
METHODS: This cross-sectional online website review assessed the current faculty listings for 17 university-affiliated academic surgical training departments across Canada in the 2019/2020 academic year. Gender diversity of academic surgical faculty was assessed across surgical disciplines. Additionally, gender diversity in career advancement, as described by published leadership roles, promotion and faculty appointment, was analyzed.
RESULTS: Women surgeons are underrepresented across Canadian surgical specialties (totals: 2,689 men versus 531 women). There are significant differences in the gender representation of surgeons between specialties and between universities, regardless of specialty. Women surgeons had a much lower likelihood of being at the highest levels of promotion (OR: 0.269, 95% CI: 0.179-0.405). Men surgeons were statistically more likely to hold academic leadership positions than women (p = 0.0002). Women surgeons had a much lower likelihood of being at the highest levels of leadership (OR: 0.372, 95% CI: 0.216-0.641). DISCUSSION: This study demonstrates that women surgeons are significantly underrepresented at the highest levels of academic promotion and leadership in Canada. Our findings allow for a direct comparison between Canadian surgical subspecialties and universities. Individual institutions can use these data to critically appraise diversity policies already in place, assess their workforce and apply a metric from which change can be measured.

Introduction

The importance of the social discussion and scientific study of diversity has never been as prevalent as it is today. In Canada, our government demonstrates the importance diversity has to Canadians by promoting policies that eliminate workplace discrimination and gender inequity at the provincial and federal levels [1-4]. Evidence from the corporate world shows that increasing diversity improves organizational success and the financial bottom line across disciplines [5-8]. If industries continue to advance gender equity, studies predict improved outcomes could add an additional 4–9% to the Canadian GDP [5].

Medical organizations have placed an increasing importance in diversity. A simple Google search yields a plethora of diversity statements and policies from provincial and national medical organizations, individual hospitals, regional health authorities, and the Public Health Agency of Canada. They recognize that gender diversity research shows patients treated by women physicians had lower rates of mortality, and women surgeons had decreased rates of 30-day post-operative mortality; and know that, as in the business world, increasing gender diversity within their organizations would benefit their patients [9, 10]. However, the metrics on the success of implemented diversity statements and policies are only just emerging and unclear in the literature [11-14].

Increasingly, academic institutions, and their affiliated medical faculties, are focusing on this topic. Each Canadian university has a diversity statement and/or office to represent ongoing engagement. However, the expanding wealth of international research in gender diversity within academic medicine reveals that women are underrepresented around the world in academic faculty positions and leadership roles [15-18]. For women scientists, they must also contend with institutional systemic gender biases to get access to grants, have their work published and then receive credit for their published work compared to their men peers [19-21]. Important Canadian funding agencies, including the Canadian Institute for Health Information and Canadian Institutes of Health Research, have published 3 independent studies in 2018 and 2019 citing gender bias against women grant applicants, grant peer-review and personnel awards [22-24].

When it comes to clinical academic medicine, surgical specialties present their own historic gender diversity challenges. While surgery used to be traditionally men, Canadian surgeons have seen the proportion of women within their ranks increase to 30%, and women trainees have increased from 32% to 43% of surgical residents in the last decade [25, 26]. There has been increasing interest in research related to gender inequities that exist in surgical careers and training programs [27-31]. Many surgical subspecialties have contributed to this expanding literature related to the gender disparities faced by trainees, surgical faculty, the lack of women in leadership positions, and represented in academic authorship or on editorial boards in their respective fields [32-57]. However, comparisons between subspecialties and different university academic or training environments are lacking. There is very limited data examining the gender distribution and achievements of Canadian surgeons. Of the existing Canadian research, it has been shown that women surgeons are less likely to ascend to higher ranks of academic faculty or to leadership positions, and they make statistically significantly less money than their men colleagues [41, 58, 59].

With these ongoing challenges in mind, our primary aim was to evaluate gender diversity within all Canadian surgical academic departments, and our secondary aim was to compare differences across specialties and between universities.

Methods

Publicly available website sources were used to collect information on surgical faculty for the 17 medical schools in Canada in the 2019/2020 academic year. Data extraction was checked in duplicate by other author(s) in a random sample of fields across the 17 medical schools. Specialties were included when they were listed as a division under the department of surgery in 10 or more out of the 17 medical schools. The following nine specialties met this requirement (≥10/17): General Surgery, Vascular Surgery, Cardiac Surgery, Plastic Surgery, Otolaryngology, Thoracic Surgery, Orthopaedic Surgery, Urological Surgery, and Neurosurgery. Other specialties that did not meet the threshold of membership (i.e. listed as a division under the department of surgery in <10/17 medical schools) and hence were not included were specialties such as: Ophthalmology, Obstetrics and Gynecology, and Interventional Radiology, among others with variability by site.

Each faculty member was listed according to the departmental or divisional website, and the variables recorded were gender, specialty, university appointment, and additional education (Masters, PhD, and other). Provincial college listings were used to cross reference gender when needed.

Leadership positions were collected as reported freeform, with an unlimited number recorded per faculty member. These were later subcategorized as follows: Department Head—University, Associate Department Head—University, Division Head—University, Section Head (subsection. of Division)—University, Director Post-Graduate Medical Education, Director Continuing Medical Education, Director Under-Graduate Medical Education, Hospital Chief of Surgery, Hospital Chief of Staff or Medical Director, Leader of Hospital Department/Division, and other University, Research or Hospital Leadership role. For analysis, these were subcategorized as Higher levels of Leadership (Department Head, Division Head, Section Head, Associate/Vice Head), and Educational Roles (Director Post-Graduate Medical Education, Director Continuing Medical Education, Director Under-Graduate Medical Education).

Resident information was procured from the residency programs for each specialty; it was made available with variable specificity given differential privacy concerns. In all cases, specialty, school, and gender were available.

All statistics were performed by a graduate level trained statistical consultant. All analyses were performed using R (R Core Team, 2019) including univariate analysis and regression modeling and prediction construction [60]. Summary statistics are reported when needed. Differences in proportions were tested using a two-tailed Z-test. Chi-squared tests were used to test independence between two categorical variables. For the regression modelling, generalized linear models were used with appropriate link functions depending on the type of response variable. Logistic regression was used when the outcome was binary, and ordinal logistic regression was used for ordered categorical responses. Adjusted odds ratios are reported for logistic and ordinal logistic regression models and appropriate confidence intervals are given. All tests were performed at the p = 0.05 significance level.

Results

There were 3,220 academic surgical faculty members affiliated with nine surgical specialties and distributed across all 17 medical schools in Canada. There were 2,689 men (0.84) and 531 women (0.16) (S1 Table). The gender distribution by specialty ranged from a high of 0.26 women (General Surgery) to a low of 0.05 (Cardiac Surgery) (p<0.0001) (Fig 1).

Fig 1

Proportion of women to men academic surgeons by specialty.

Ordered from highest proportion of women surgeons to lowest proportion. Significant differences exist between specialties (p<0.0001).

The gender distribution by university ranged from a high of 0.24 women at the Université de Sherbrooke, to a low of 0.12 at the University of British Columbia (p = 0.05) (Fig 2). A higher proportion of women (0.29) than men (0.23) surgical faculty hold an additional higher university degree (Masters and or PhD) (p = 0.0023).

Fig 2

Proportion of women to men academic surgeons by university.

Ordered from highest proportion of women surgeons to lowest proportion. Significant differences exist between universities (p<0.05).

Academic appointment/promotion

Reported academic faculty promotion levels were assessed. Some departments classified their faculty into either ‘clinical’ or’ academic’ streams, while others did not have formal distinctions classifying their entire faculty into a single stream. Univariate comparison between gender of surgical faculty and level of promotion showed a strong statistical significance (p<0.001) (Fig 3). Women faculty are most frequently seen in the lowest levels of promotion (none, Lecturer, Clinical Instructor, Clinical Assistant Professor, Assistant Professor). Among all listed faculty, women were nearly twice as likely (0.11) than men (0.06) to not have a specified faculty rank even though they were included in faculty lists. In academic promotion, women faculty are relatively clustered at Assistant Professor, accounting for (0.36) of the entire women faculty nationally, and the highest relative representation to men colleagues (Fig 3). As a proportion of their own gender, men and women are equally likely to be at the academic rank of Associate Professor (0.16); however, only 0.17 of Associate Professors overall are women (Fig 3).

Fig 3

Proportion of women to men surgical faculty by level of academic promotion.

Univariate comparison between gender of surgical faculty and level of promotion showed a strong statistical significance (p<0.001). * = Combined category of Professor Emeritus/Honorary Associate Professor/Distinguished Professor.

Women are least represented at the highest levels of promotion, Clinical Professor (0.017) and Professor (0.055), and absent from the Professor Emeritus rank (p<0.001). Of the 376 professors of surgery across Canada, 29 are women surgeons (0.01 of all faculty) compared with 347 men surgeons (0.11 of all faculty) (p<0.001). Regression modeling to account for the impact of university, specialty and higher degrees and gender on attaining the highest levels of promotion (Professor, Professor Emeritus) showed women had a much lower likelihood of being at the highest level of promotion (OR: 0.269, 95% CI: 0.179–0.405). Similarly, when considering promotion on an overall 5 level categorical scale, and accounting for the same factors, women were less likely to be at a higher level of promotion (OR: 0.54, 95% CI: 0.456–0.661).

A prediction model to assess the impact of university affiliation in women attaining the highest level of promotion while controlling for specialty and higher degrees was run. The reference university was that with the highest univariate proportion of women at the highest level of promotion (University of Toronto, 0.15) (Fig 4).

Fig 4

Prediction modeling of the impact of university affiliation on likelihood of women academic surgeons attaining highest levels of promotion (Professor, Professor Emeritus/Honorary Associate Professor/Distinguished Professor).

Controlled for specialty and higher degrees. Odds ratio with 95% confidence interval graphed for each university compared to the reference university (University of Toronto, 0.15, highest proportion of women at the highest levels of promotion).

This prediction analysis was also performed by specialty, with the reference specialty being Cardiac Surgery, as the specialty with the highest univariate representation of women at the highest level of promotion (0.22) (Fig 5).

Fig 5

Prediction modeling of the impact of specialty on likelihood of women academic surgeons attaining highest levels of promotion (Professor, Professor Emeritus/Honorary Associate Professor/Distinguished Professor).

Controlled for university and higher degrees. Odds ratio with 95% confidence interval graphed for each specialty compared to the reference specialty (Cardiac Surgery, 0.22, highest proportion of women at the highest levels of promotion).

Leadership roles

Within the national surgical faculties, 762 surgeons were noted to hold at least one position of leadership. Men held 0.85 (n = 649) of these positions and women 0.15 (n = 113). The difference in proportion of men (0.32) and women (0.26) in some kind of leadership position was statistically significant (p = 0.002).

Women are more frequently found in education roles. The gender distribution of the residency program directors is 112 (0.042) men and 24 (0.047) women across the specialties (p = 0.815). Two specialties, Vascular Surgery and Cardiac Surgery, had no women in this educational leadership position. Although the role is less reliably reported, of those that reported undergraduate education directors they are disproportionately women, with 0.23 being women (p = 0.04).

Within the institutional academic leadership positions of Division Head/Chair or Department Head/Chair, men were statistically more likely to hold these positions than women (p = 0.0002), with 157 men and only 13 women leading their peers across the country. Specifically, of 27 departments reporting a head, there are only 2 women sitting as a Department Head across the country.

Regression modeling to account for the impact of university, specialty and higher degrees and gender on attaining the higher levels of Leadership (Department Head, Division Head, Section Head, Associate/Vice Head) showed women had a much lower likelihood of being in higher levels of leadership (OR: 0.372, 95% CI: 0.216–0.641).

Prediction modeling was again used to assess the impact of university affiliation in women attaining the highest level of leadership, while controlling for specialty and higher degrees. The reference university was that with the highest univariate proportion of women at the highest level of promotion (Université de Sherbrooke, 0.17) (Fig 6).

Fig 6

Prediction modeling of the impact of university affiliation on likelihood of women academic surgeons attaining highest levels of leadership (Department, Division or Section Head).

Controlled for specialty and higher degrees. Odds ratio with 95% confidence interval graphed for each university compared to the reference university (Université de Sherbrooke, 0.17, highest proportion of women at the highest levels of leadership).

A similar leadership analysis was performed by specialty, with the reference specialty being Thoracic Surgery, as the specialty with the highest univariate representation of women at the highest levels of leadership (0.14) (Fig 7).

Fig 7

Prediction modeling of the impact of surgical specialty on likelihood of women academic surgeons attaining highest levels of leadership (Department, Division or Section Head).

Controlled for university and higher degrees. Odds ratio with 95% confidence interval graphed for each specialty compared to the reference specialty (Thoracic Surgery, 0.14, highest proportion of women at the highest levels of leadership).

Canadian surgical resident cohort

There were 1694 surgical trainees enrolled across eight surgical specialties within Canada in the 2019/2020 academic year. The gender breakdown of this group was 1,060 men surgical trainees (0.63) and 634 women surgical trainees (0.37) (S2 Table). There is a significant difference in the gender breakdown of residents across the differing specialties (p<0.00001). The proportion ranged from a high of 0.53 women (General Surgery) to a low of 0.20 (Cardiac Surgery) (Fig 8).

Fig 8

Proportion of women to men surgical residents by specialty.

Ordered from highest proportion of women surgeons to lowest proportion. Significant differences exist between specialties (p<0.00001).

There was also a significant difference between universities in the proportion of women to men residents (p = 0.0029). The proportion of residents by university revealed the highest proportion of women residents at Memorial University (0.64) and the lowest proportion at McGill University (0.31) (Fig 9).

Fig 9

Proportion of women to men surgical residents by university.

Ordered from highest proportion of women surgeons to lowest proportion. Significant differences exist between universities (p<0.01).

Regression modeling demonstrated that the number of women surgeons in higher leadership roles did not influence the number of women residents at a given university (p = 0.9194). However, regression modeling showed that the more women in educational roles for a specialty results in a larger proportion of women residents in that specialty (p = 0.046).

Discussion

To borrow from the words of Nonet Sykes: “equity is the provision of opportunity, networks and resources that support each of us to reach our full potential.” Diversity and inclusion, while not the sole components of equity in the workplace or in medicine, play important roles in having the opportunity for equity. Diversity among those who work in the medical field matters to our patients. This is supported by evidence showing that diversity can produce improved health outcomes for patients and that a more diverse health-care workforce can help reduce racial and ethnic disparities in patient care [61]. Gender is just one component of diversity in healthcare that has been increasingly studied, and highlighted in importance, in recent years.

Continued lack of diversity within the academic faculty leads to a persistent opportunity gap between the genders. Increases in the number of women surgeons overall have not translated directly to increased representation at the highest academic promotion or leadership levels, with a study showing no narrowing of the gap over the last 35 years [62]. It is recognized that a certain representation is needed to see ‘shift’, and in surgery in Canada we fall below the “critical mass” of 30% representation at higher levels of leadership and academia which would lead to culture change [63].

This study joins others among surgical subspecialties in highlighting ongoing gender disparity with regards to women surgeons within academia [32–37, 40, 41, 43–48, 51, 52, 54–58, 64]. While our investigation highlights the current Canadian environment, the themes of ongoing gender disparity are not isolated to this country; with specific studies noting that inequities exist in Plastic Surgery, Neurosurgery and General surgery across North America, the EU and Oceania [39, 45, 46, 65, 66]. Barriers to academic progression are multi-faceted and complex. Previous studies suggest that women are less likely to be invited to speak at grand rounds, they face significant bias when contending with their peers for grants or funding, are often underrepresented on editorial boards and are underrepresented and under cited within published literature of their field [19–24, 67, 68]. These factors are reflected in metrics that promotions committees use when assessing a surgeon’s consideration for faculty promotion and leadership roles, and can put women at a disadvantaged position. Equally importantly, as advocacy and mentorship have been identified as crucial to career development, we note that women surgeons are less likely to have gender-specific mentorship given the lack of women at more advanced promotional rank as cited extensively above [69-72].

Barriers to gender equity also exist at the leadership level with the Canadian surgical specialties. Our study shows that men predominantly hold leadership positions amongst surgical faculty, and that this holds true across all specialties and universities, which mirrors findings of smaller specialty specific studies in the literature [64]. It also mirrors work published by our international colleagues showing that women are underrepresented in medical leadership in the EU, Australia/Oceania and all over North America [17, 18, 66]. Studies on leadership, promotion and performance evaluation have been widely published fields outside of medicine. Studies by leaders within the business world have identified that men will apply for a position if they have satisfied 60% of the application criteria but women will limit their application until they check off 100% of the criteria; thus, contributing to women applying to 20% fewer jobs than men [73]. Studies on workplace biases also reveal that women are promoted or hired based on their previous experience whereas men are considered for their future potential making it difficult to break into leadership roles [74]. In the United States military, objective evaluations showed no difference in performance between genders but subjective evaluations showed significant gender biases in the language used in evaluations [75]. These implicit biases that exist in evaluating men versus women job applicants are difficult to mitigate as they are by definition unconscious. Strategies to help reduce implicit biases in hiring processes have been studied and are effective at increasing gender diversity. At an academic health care center, departments that received a brief self-assessment and educational session on implicit biases increased the hiring rate of women to twice that of departments that received no training [76]. In addition to individual bias training, larger initiatives that include university-based policy changes and leadership training may have a greater impact on addressing implicit biases [77].

Our study shows that the number of women surgical residents in Canadian training programs surpasses the number of academic staff by far, but that women remain greatly underrepresented in the highest levels of promotion and leadership. Advocacy and mentorship from early career stages will serve to bolster our community longitudinally [69-72]. Within our own networks, we must encourage women to take on leadership positions as studies show less than 10% of women are encouraged to apply for leadership positions by their superior [78]. At higher institutional levels, departments and universities alike need to formally consider what biases their current policies continue to propagate during hiring and promotion processes.

Limitations

This cross-sectional study is limited by the quality, accuracy, and current standings of publicly available information on university websites. While more public facing roles such as department head or residency program director are consistently and reproducibly found on university-affiliated websites, the same cannot be said for every other academic or leadership role across all the specialties or schools and is at the discretion of each faculty. However, this represents an accurate assessment of the public reporting of leadership and promotion- which represents the forward-facing image of each organization. Also, these data provide a snapshot of the currently publicly listed Canadian surgical environment and cannot answer the questions of how this has changed over time. While the dataset is large in its entirety, at the highest levels of leadership and promotion, the absolute number of women remains low. In some instances, only a small n was available for the regression modelling and may impact the strength of the model. However, the models themselves have shown results in keeping with the global findings of the study, supporting the results along with those published by our peers with similar work in this field. Lastly, this study is limited to investigating gender and thus misses other diversity sectors. There are surgeons who identify as members of other minority groups of race, sexual orientation, ethnicity or religious affiliation who are equally importantly at risk of bias and intersectional bias in their career.

Conclusion

Gender diversity within the Canadian surgical specialties continues to be an evolving issue. This study demonstrates that overall, women surgeons are underrepresented at the highest levels of academic promotion and leadership. Our data also allows for a direct comparison between surgical subspecialties and universities. Recognizing where a specialty or university stands compared to Canadian counterparts provides those in leadership positions the ability to critically appraise diversity policies already in place, assess their workforce and have a metric from which change can be measured. Having women surgeons proportionally represented at every level of promotion and leadership can help instigate culture change and progress Canadian surgical departments toward true gender equity. In doing so, it will bring work environments into line with the diversity directives as espoused by collective institutional policies, governments and Canadian health agencies.

All academic surgical faculty across 17 medical schools in Canada.

(XLSX)

Click here for additional data file.

All resident surgeons across 17 medical schools in Canada.

(XLSX)

Click here for additional data file.

29 Jun 2021

PONE-D-21-18263

Gender imbalance amongst promotion and leadership in academic surgical programs in Canada: A cross-sectional review

PLOS ONE

Dear Dr. Lefaivre,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Your study is interesting, the results as wells as comments/interpretations are relevant all over the world. I invited women only for review. Please follow their recommendations to improve the manuscript. From my side, I suggest to change the title: The term "review" my be misleading. In a review you describe what other authors have already published. Furtheermore, rreviewa are not very welcome in PLOS ONE. Your study, hosever, is a real investigations. I suggest to chage the title:.....a cross.sectional investigation.

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Reviewer #3: Yes

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Reviewer #1: • This study describes a cross-sectional online website review of the current faculty of surgical departments in Canada with the focus on gender distribution. The aim was to analyse the proportion of female in promotion and leadership

• The data is put in relation to the politic of Canada, which tries to avoid gender disparity, as well as in context to the literature available to the topic and important networks like linkedIn.

• The data do support an underrepresentation of woman in surgery for promotion and leadership in general and relative to the number of trainees. The regression models may have been performed with very small numbers (n), leading to large confidence intervals. Therefore It would be important to show a flow chart of the numbers assessed (initially and for each surgical specialty) and the numbers excluded (e.g. Obstetrics and Gynecology) and to add n to the figures (especially fig 4 to 7). With small n the regression may not be adequate statistically.

• Although the findings of the study are not new, it is impressive how we still underuse the potential of diversity: diverse team get better results, which is essential in research and patient treatment. Moreover, we as a society cannot afford to train and develop females and not benefit from their knowledge. Therefore it is crucial to acknowledge how low the percentage of female is in position of promotion or leadership

• The study conforms to the STROBE guidelines

• The details are sufficient for the study to be reproduced

• The manuscript is well organized, but some improvement ist suggested for better understanding:

o Lines 300 to 303: make clear that women are 20% less likely to apply for a given job

o Label the x-axis in the figures 4-7, so it is self-explaning

o Report all n

o Show a flow chart and a chart with all the data according to PLOS ONE policy

o Some abbreviations are not explained, please elaborate

Reviewer #2: The authors performed a cross-sectional online website review of current faculty listings for 17 university-affiliated academic surgical training departments across Canada in the 2019/2020 academic year. They conclude that women surgeons are significantly underrepresented at the highest levels of academic promotion and leadership in Canada.

This is an interesting manuscript adressing gender representation of surgeons in academic leadership positions. I have the following questions

1. Were the academic positions in any way correlated with measurable output, e.g. publications ?

2. What do the authors believe is the reason for gender inequality in high posititions in the surgical field, the lack of access of women to training positions, lack of actual scientific output for various reasons (e.g. lack of funding, family obligations, lack of mentorship, etc.)

3. In the few cases in which women had leadership positions, was there a different situation with regards to promotion of women in their teams ?

Reviewer #3: The authors present an interesting manuscript on gender disparity among Canadian surgeons.

Please find my comments per section below:

Introduction:

Well done.

Methods:

- As correctly mentionned by the authors in the limitations section, publicly available website sources might have a potential for information bias. However, the approach seems reasonable to me as this source of potential bias is probably rather small.

- "Normally" age is adjusted for in most regression analysis. It would be interesting to see whether age plays a role. As a confounder or as an interaction term.

Results:

- It would be nice to have a "Table 1" displaying the raw data.

Discussion:

- The discussion is focussed on the situation in Canada (and sometwhat U.S.). It would be interesting so see some comparison with other countries discussed.

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Reviewer #1: Yes: Eliane Angst

Reviewer #2: No

Reviewer #3: No

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30 Jul 2021

Academic Editor

From my side, I suggest to change the title: The term "review" may be misleading. In a review you describe what other authors have already published. Furthermore, reviews are not very welcome in PLOS ONE. Your study, however, is a real investigation. I suggest to change the title:.....a cross sectional investigation.

Response: Thank you for this suggestion.

Action Taken: We have changed the title to:

“Gender imbalance amongst promotion and leadership in academic surgical programs in Canada: A cross-sectional investigation”

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We noted this request. We reviewed our reference list to ensure it is complete and correct. Regarding citations that have potentially been retracted, to the best of our knowledge, we are unaware of any of our citations that have been retracted. However, if the reviewers or editors have concerns that we may have missed or are not aware of, we are happy to make further edits to the list.

Action Taken: The reference list was reviewed, and in the process of double-checking, relevant links have been updated as necessary for applicable citations (#’s 3 and 4). Additionally, #16 has been updated to reflect the most current version of the Association American of Medical Colleges’ review of the status of women in academic medicine.

Based on the Reviewer’s comments/suggestions, new references have been included in this manuscript. They are as follows: #’s 65 and 66 (see below). This also required re-numbering the reference list; the changes are reflected both in the reference list and the main text of the manuscript.

65. Wolfert C, Rohde V, Mielke D, Hernandaz-Duran S. Female Neurosurgeons in Europe—On a Prevailing Glass Ceiling. World Neurosurgery. 2019;129: 460-466. doi:10.1016/j.wneu.2019.05.137

66. Wu B, Bhulani N, Jalal S, Din J, Khosa F. Gender Disparity in Leadership Positions of General Surgical Societies in North America, Europe, and Oceania. Cureus. 2019; 11(12): e6285. doi: 10.7759/cureus.6285

Reviewer #1

This study describes a cross-sectional online website review of the current faculty of surgical departments in Canada with the focus on gender distribution. The aim was to analyse the proportion of female in promotion and leadership. The data is put in relation to the politic of Canada, which tries to avoid gender disparity, as well as in context to the literature available to the topic and important networks like LinkedIn.

Response: Thank you for this positive summary.

The data do support an underrepresentation of women in surgery for promotion and leadership in general and relative to the number of trainees. The regression models may have been performed with very small numbers (n), leading to large confidence intervals. Therefore, it would be important to show a flow chart of the numbers assessed (initially and for each surgical specialty) and the numbers excluded (e.g. Obstetrics and Gynecology) and to add n to the figures (especially fig 4 to 7). With small n the regression may not be adequate statistically.

Response: Thank you for this feedback. All three reviewers made some form of request for further information regarding our data, and we have interpreted this as a request to improve our overall data transparency. To clarify: the data collected for each surgeon was completed as stated in the methods and all of the collected data was included in the analysis, without exclusions. With respect to the regression models, thank you for your robustness in verifying the statistical analysis. Unsurprisingly, the general results have shown that there is an underrepresentation of women at the highest levels of promotion and leadership in surgical specialties across Canada. There are few women who have achieved these positions, leading to small absolute numbers. Despite the sample size, the regression analysis was able to additionally support our findings and show that gender continues to be a major driver of inequity at the highest levels of promotion and leadership even when accounting for other known factors. For this reason, we have included the regression in our paper as supporting evidence for our global findings. It is also in keeping with similar results from other works published in the field.

Action Taken: To improve our data transparency, we have submitted Supporting information files S1 Tables 1a and 1b (academic surgical faculty) on Page 7 and S1 Tables 2a and 2b (resident surgeons) on Page 12 in the Results section. These are large datasets, so we have submitted the data organized by both specialty and by university. We felt as though, due to their size, these Tables were better suited as essential supporting files rather than as tables to feature in the Results section. Of course, we are happy to discuss this further with the PLOS ONE Editor(s).

As requested, figures 4-7 have been amended; x-axis labels were added, along with n-values to the y-axis.

Also, we have added a statement about the statistical regression to our Limitations section on Page 16, noting the potential for small numbers (n) to impact the analysis:

“While the dataset is large in its entirety, at the highest levels of leadership and promotion, the absolute number of women remains low. In some instances, only a small n was available for the regression modelling and may impact the strength of the model. However, the models themselves have shown results in keeping with the global findings of the study, supporting the results along with those published by our peers with similar work in this field.”

Although the findings of the study are not new, it is impressive how we still underuse the potential of diversity: diverse teams get better results, which is essential in research and patient treatment. Moreover, we as a society cannot afford to train and develop females and not benefit from their knowledge. Therefore it is crucial to acknowledge how low the percentage of female is in position of promotion or leadership

Response: Thank you for these comments. We agree wholeheartedly.

The study conforms to the STROBE guidelines.

The details are sufficient for the study to be reproduced

Response: Thank you for noting this.

The manuscript is well organized, but some improvement is suggested for better understanding:

Lines 300 to 303: make clear that women are 20% less likely to apply for a given job

Response: Thank you for your diligence. We agree that this phrasing could be improved, and we returned to the original source to ensure we had clarity on the correct phrasing for the reader.

Action Taken: Page 15, Lines 309-310 have been revised for clarity and understanding:

“…thus, contributing to women applying to 20% fewer jobs than men.”

Label the x-axis in the figures 4-7, so it is self-explaining

Response: Thank you for pointing this out.

Action Taken: As noted above in our previous response, we have revised figures 4-7 by adding x-axis labels.

Report all n

Response: We want to ensure that we are reporting our data according to the standards of PLOS ONE’s policy. As such, we have added this information into the manuscript.

Action Taken: As noted above in our previous response, please refer to Supporting information files S1 Tables 1a and 1b (academic surgical faculty) on Page 7 and S1 Tables 2a and 2b (resident surgeons) on Page 12 in the Results section. These are large datasets, so we have submitted the data organized by both specialty and by university. We felt as though, due to their size, these Tables were better suited as essential supporting files rather than as tables to feature in the Results section. Of course, we are happy to discuss this further with the PLOS ONE Editor(s).

Show a flow chart and a chart with all the data according to PLOS ONE policy

Response: We note the requests for data transparency and want to ensure that we are submitting our data according to PLOS ONE Policies. All of the data we collected was used in the analysis and sub-analyses -- there was no data excluded.

Action Taken: See our responses above, and the submitted Tables 1a and 1b and Tables 2a and 2b with all of the data displayed. If there is further information that the reviewers and editors require, please let us know.

Some abbreviations are not explained, please elaborate

Response: Thank you for bringing this to our attention.

Action Taken: The manuscript was reviewed throughout. Abbreviations were elaborated/changed to full-length text in multiple locations; please see the tracked changes for details.

Reviewer #2

The authors performed a cross-sectional online website review of current faculty listings for 17 university-affiliated academic surgical training departments across Canada in the 2019/2020 academic year. They conclude that women surgeons are significantly underrepresented at the highest levels of academic promotion and leadership in Canada. This is an interesting manuscript addressing gender representation of surgeons in academic leadership positions.

Response: Thank you for this encouraging overview.

I have the following questions

1. Were the academic positions in any way correlated with measurable output, e.g. publications ?

Response: This is an interesting question. Unfortunately, the information required to answer this question is not available on publicly listed departmental websites and was not collected during our data-collection process to answer it fully within this investigation of all Canadian surgeons. However, we did note that academic positions for women were not correlated to attainment of a higher level of degree (Masters or PhD) despite proportionally more women than men having attained this level of additional education (page 6). In a similar study of Canadian General Surgeons, measurable outputs such as publications were not different between men and women (Reference #41, for interest).

Action Taken: None required.

2. What do the authors believe is the reason for gender inequality in high positions in the surgical field, the lack of access of women to training positions, lack of actual scientific output for various reasons (e.g. lack of funding, family obligations, lack of mentorship, etc.)

Response: Ongoing gender inequity in the surgical fields is a product of many intersecting issues. Research has shown increasing numbers of women in training and entering surgical careers over the last decades without similar increases in the number of women in leadership roles disproving the theory that this is purely a “pipeline” problem; we note this in the discussion on page 13. Instead, it is likely the ingrained culture of systemic biases that exist both in interpersonal work relationships and also in the metrics surrounding scientific achievement (grants, publications etc). These different aspects are reviewed in the discussion in some detail.

Action Taken: None required. As it currently stands, we feel as though we have postulated on the reason(s) as noted by Reviewer 2. If this is not sufficient, we would be happy to clarify further in the Discussion to highlight these multifaceted issues. However, to best enable this supplementary action, we are requested that Reviewer 2 please highlight specific changes/actions so we can tailor our response/edits accordingly.

3. In the few cases in which women had leadership positions, was there a different situation with regards to promotion of women in their teams?

Response: Interesting question. The nature of our data collection would unfortunately not be able to determine if the method of promotion was different from one academic institution, or one surgical department, to another. However, as the number of women in leadership roles was so low, we did observe that there does not appear to be any trend related to surgical specialty or to academic institutions.

Action Taken: None required.

Reviewer #3

The authors present an interesting manuscript on gender disparity among Canadian surgeons.

Response: Thank you for this affirmative synopsis.

Please find my comments per section below:

Introduction:

Well done.

Response: Thank-you.

Methods:

- As correctly mentioned by the authors in the limitations section, publicly available website sources might have a potential for information bias. However, the approach seems reasonable to me as this source of potential bias is probably rather small.

Response: Thank you for this comment. We acknowledge this limitation, but as you say, we feel that the potential bias is probably rather small.

- "Normally" age is adjusted for in most regression analysis. It would be interesting to see whether age plays a role. As a confounder or as an interaction term.

Response: Our variables of interest in the data set were categorical (man vs. woman; leadership position, yes or no; then what kind) and based on the data we could collect through the publicly available faculty websites. Age was unfortunately a variable that could not be reliably collected through our methodology. As such, we were unable to run a regression analysis with age as an interaction term.

Action Taken: None required.

Results:

- It would be nice to have a "Table 1" displaying the raw data.

Response: We want to ensure that we are reporting our data according to the standards of PLOS ONE’s policy as such we have added this information into the manuscript.

Action Taken: Thank you Reviewer 3 for this feedback. This was noted by other reviewers as well. As such, please see our response to the previous reviewer. To improve our data transparency, we have supplied Supporting information files S1 Tables 1a and 1b (academic surgical faculty) on Page 7 and S1 Tables 2a and 2b (resident surgeons) on Page 12 in the Results section. These are large datasets, so we have submitted the data organized by both specialty and by university. We felt as though, due to their size, these Tables were better suited as essential supporting files rather than as tables to feature in the Results section. Of course, we are happy to discuss this further with the PLOS ONE Editor(s).

Discussion:

- The discussion is focused on the situation in Canada (and somewhat U.S.). It would be interesting to see some comparison with other countries discussed.

Response: Thank you for this comment. As our data reflects the current Canadian surgical environment, much of the discussion had reflected the comparative Canadian or North American surgical/medical academic literature. However, we agree with you that the world is becoming ever more connected and that the perspective of how this relates to the international surgical community is of interest and highly relevant. Much of our cited supporting literature reflects the status of gender in surgery and medicine from other nations beyond the US or Canada.

Action Taken: We have taken steps to highlight previously cited literature that reflects the international surgical community. Additionally, a literature review of gender and surgery was completed with a focus on international content. Relevant literature as it related to academia or leadership of women and women surgeons in medicine has been identified and the Discussion section on Page 14 was updated accordingly:

“While our investigation highlights the current Canadian environment, the themes of ongoing gender disparity are not isolated to this country; with specific studies noting that inequities exist in Plastic Surgery, Neurosurgery and General surgery across North America, the EU and Oceania [39, 45, 46, 65, 66].”

“It also mirrors work published by our international colleagues showing that women are underrepresented in medical leadership in the EU, Australia/Oceania and all over North America [17, 18, 66].”

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

16 Aug 2021

Gender imbalance amongst promotion and leadership in academic surgical programs in Canada: A cross-sectional investigation

PONE-D-21-18263R1

Dear Dr. Lefaivre,

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Reviewers' comments:

19 Aug 2021

PONE-D-21-18263R1

Gender imbalance amongst promotion and leadership in academic surgical programs in Canada: A cross-sectional Investigation

Dear Dr. Lefaivre:

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