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The Laryngoscope V C 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Otolaryngology Training Programs: Resident and Faculty Perception of the Mentorship Experience

Sandra Y. Lin, MD; Kulsoom Laeeq, MD; Adeel Malik, BS; David A. Diaz Voss Varela, MD; John S. Rhee, MD, MPH; Harold C. Pillsbury, MD; Nasir I. Bhatti, MD

Objectives/Hypothesis: The purpose of this study is to compare faculty and trainees’ perceptions of their mentorship experience in otolaryngology training programs in order to identify areas where improvements could yield more productive mentorship. Study Design: Cross-sectional survey design. Methods: Residents and faculty from three otolaryngology–head and neck surgery programs were surveyed regarding their perceptions of their mentoring relationship. Trainees were asked about the characteristics of their mentorship experi ence. Separately, faculty were asked to describe their mentorship relationship, available resources to provide effective mentor ship, and to identify areas in which formal training would improve their mentoring skills. Results: Forty-eight trainees (72%) and sixty-one faculty members (73%) completed the survey. Ninety percent of resi dents meet with their mentors at least twice a year. Faculty and residents ( > 80%) agreed that career planning was the most commonly addressed topic in mentorship sessions. However, faculty and residents differed in their perceptions of providing mentorship in other areas including clinical judgment ( P 5 0.003). The majority of faculty (56%) felt that formal mentorship training would improve their mentorship skills. While 95% of mentees agreed that their mentor is accessible, only 46% of faculty believed they have enough time to dedicate to mentoring ( P < 0.001). Conclusions: Mentees are generally satisfied with the mentoring they receive, while most mentors are not satisfied with the time they have to provide mentorship. Further insights into differences in faculty and trainee perceptions may improve the mentorship experience. KeyWords: mentorship, training, mentee, career planning, education. Level of Evidence: 4. Laryngoscope , 123:1876–1883, 2013

INTRODUCTION Mentorship has traditionally been regarded as an im portant facet of training, career progression, and professio nal development in surgical residency programs. The Standing Committee on Postgraduate Medicine in the United Kingdom recently described mentorship as “a pro cess whereby an experienced, highly regarded, empathetic person (the mentor) guides another (usually younger) indi vidual (the mentee) in the development and re-examination of their own ideas, learning and personal and professional development. The mentor, who often but not necessarily works in the same organization of field as the mentee, From the Department of Otolaryngology Head & Neck Surgery ( S . Y . L ., A . M ., D . A . D . V . V ., N . I . B .), Johns Hopkins School of Medicine, Balti more, Maryland; the Department of General Surgery ( K . L .), Creighton University Medical Center, Omaha, Nebraska; the Department of Otolar yngology Head & Neck Surgery & Communication Sciences ( J . S . R .), Medi cal College of Wisconsin, Milwaukee, Wisconsin; and the Department of Otolaryngology Head & Neck Surgery ( H . C . P .), University of North Caro lina School of Medicine, Chapel Hill, North Carolina, U.S.A Editor’s Note: This Manuscript was accepted for publication January 17, 2013. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Sandra Y. Lin MD, Department of Otolar yngology head & Neck Surgery, Johns Hopkins School of Medicine, 601 N. Caroline St, £6254, Baltimore MD 21287. E-mail: Slin30@jhmi.edu

achieves this by listening or talking in confidence to the mentee.” 1 This current definition of mentorship contrasts with traditional approach to surgical education established by Halstead, 2 an apprenticeship model in which education and development of the trainee occurred passively through the role modeling provided by the senior, a surgeon. Hal stead’s model was a framework on which in the traditional American surgical advising programs were modeled. Mentorship in training programs can be provided on an informal or formal basis. The differences in infor mal and formal mentoring are clearly delineated in an article by Patel et al. 3 Informal mentorship occurs on a flexible basis with low expectations, without training required, goals not previously determined, and with self selection of dyads. Formal mentorship is provided with a well-defined mentoring schedule, with support from the organization, clear goals defined for the relationship, and ideally expert training and support of the mentor. Previously, many surgical training programs relied on spontaneous, informal methods of mentorship. However, formal mentorship supported by an organization allows for a greater numbers of individuals to have mentorship, as well as to provide access to mentorship to underrepre sented groups such as women and minorities. 3 Formal, structured mentorship that emphasizes indi vidual development with guidance beyond the improve ment of clinical skills is arguably a recent development in

DOI: 10.1002/lary.24043

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surgical training programs. The breadth of formal mentor ship can include research mentorship, career planning/de velopment, counseling on the development of interpersonal skills, and guidance on work-life issues. The definition used by Ronald A. Berk et al. 4 appropriately elucidates the aspects and particularities involved in a mentoring rela tionship; the mentor is generally perceived as a role model who assists in the emotional, psychological, and professio nal development of the mentee. On both professional and personal platforms, the influence of formal mentorship for mentor and mentee is acknowledged as positive and beneficial. 5 In surgical residencies there is a genuine need for a positive mentoring relationship to facilitate residents’ learning of procedures, techniques, and the general craft of surgery from their faculty mentors. 6,7 With a para digm shift from the apprenticeship model of surgical training to a more learner-centered model, an appreci ably greater amount of research is being conducted to maximize the effectiveness of mentorship experiences. 8 Buddeberg-Fischer and Herta found that between the years 1981–1990 there were 335 research publications regarding mentorship listed in the Medline database, while in 2001 alone there were 391 publications. 6 This underscores the increased focus on mentoring relation ships. There has not, however, been a similar increase in the implementation of formal mentoring programs. 9 Providing effective mentorship has become increas ingly challenging due to work-hour restrictions that have limited the time available for formal and informal mentorship. 5 Previous studies show that although resi dents highly rank the value of mentorship, they are unsatisfied with the mentorship experience provided to them during their residencies. 7 In a recent survey of oto laryngology chief residents, 63% of respondents reported that the mentorship they received in their residency influenced their career decisions. The study also showed variability in the quality of the mentorship experience. 10 The purpose of our study is to survey and compare the faculty’s and trainees’ perceptions of their mentorship experience in otolaryngology training programs, and to identify areas in which improvements may yield more productive mentorship relationships. To our knowledge, this is the only study that directly compares faculty and resident opinions of their mentorship experiences in otolaryngology training pro grams. Specifically, this study compares the areas that faculty feel they need improvement in mentoring to the areas with which mentees are unsatisfied. Identifying strengths and weaknesses that are consistent from the mentor and mentee perspective is important in the de velopment and refinement of mentorship programs. MATERIALS AND METHODS A questionnaire was designed to survey residents/fellows and faculty of otolaryngology residency programs at Johns Hop kins University (JHU), University of North Carolina (UNC), and Medical College of Wisconsin (MCW). These sites were selected because the programs are medium- to large-sized oto laryngology programs in geographically distinct areas of the United States, and no sites were excluded due to type of men

TABLE I. Response Rate Within Individual Institutions.

JHU

MCW

UNC

Resident/Fellows

86% 84%

56% 84%

64% 40%

Faculty

torship program. After approval from the institutional review board, a participation request was sent electronically via Survey Monkey (Palo Alto, CA) to 76 faculty mentors (37 from JHU, 20 from UNC, and 19 from MCW) and 70 resident and fellow mentees (32 from JHU, 22 from UNC, and 16 from MCW). Residents were asked a total of 20 survey questions, 12 of which were scaled using a 5-level Likert item scale (Appendix A). The other eight provided demographics and background on the residents and their mentoring relationships. In a separate survey consisting of 13 questions, faculty were asked to describe their mentorship relationship, whether they have the appropri ate resources to provide effective mentorship, and to identify areas in which further training would improve their mentoring skills (Appendix B). The surveys were sent to participants via e-mail with writ ten directions regarding survey completion. Participants were assured of the anonymity of their responses and response data were deidentified. Nonrespondents were e-mailed reminders requesting their completion of the survey. Data was collected from May 2011 through June 2012, and was analyzed with STATA 10.0 (StataCorp LP, College Station, TX), using Chi squared and Fischer Exact Tests. P values less than 0.05 were considered significant. RESULTS The response rate was 72% among residents/fel lows, and 73% of faculty responded (Table I). The train ees who responded consisted of 44 Residents and four fellows, with 90% identifying a formal mentor (in which the relationship with the mentee has a defined schedule, clear goals, and organizational support) who is a faculty member of their training program. The analysis was undertaken only for those trainees who identified a fac ulty mentor. Of the 61 faculty members that responded to the survey, 57 (93%) reported that they provide men torship to residents. Data was reported in three catego ries: positive response ( Strongly Agree and Agree categories), negative response ( Strongly Disagree and Disagree), and neutral. The majority of mentees (90%) reported meeting with their mentors twice or more yearly (Table II). Mentees most commonly reported meeting twice a year (42%) with mentors. Of those mentees who selected “other” rather than selecting a specific option, several described that they formally meet their mentor only twice, but had informal encounters on a weekly basis. Mentors most commonly marked “other” (42%) for fre quency of mentorship sessions; a recurring theme in the comments was that meetings were variable and many times depend on the progress of ongoing research proj ects, or are simply done on an as needed basis. While 95% of mentees agreed that their mentor is accessible, only 46% of faculty believed they had enough time to dedicate to mentoring ( P < 0.001).

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TABLE II. Frequency of Formal Meetings as Reported by Mentor versus Mentee.

Amount Reported byMentor

Amount Reported byMentee

Frequency of Meetings

Twice a month

16%

Once a month

Every 3 months

20%

23%

Twice a year

13%

42%

“Other”

42%

Mentees and mentors were asked to identify spe cific areas in which their mentorship is provided (Table III). They were given six options and allowed to choose all that applied: career planning, clinical judgment, research, work-life balance, professionalism, and emo tional well-being. “Career planning” was most com monly selected by both groups (90% mentor, 81% mentee). However, there was a disagreement in mentor ship provided in “clinical judgment,” with a signifi cantly larger number of mentors reporting mentorship in this area ( P 5 0.003) when compared to mentee responses. Fifty-six percent of mentors had not received any formal training on how to provide mentorship. On the mentoring topics of research, providing feedback, clinical judgment, professionalism, career planning, emotional well-being, and work-life balance, a range of only 4% to 31% of mentors had training. Fifty-six percent agreed with the statement that formal training in providing mentorship would make them more effective mentors (Fig. 1.). Mentors identified the top three areas in which training would most benefit their skills as career planning, providing feedback, and emotional well-being (Table IV). Eighty-eight percent of trainees strongly agreed that their mentor answers their questions satisfactorily, and 70% agreed that their contributions and achieve ment are appropriately acknowledged by their mentors (Table V). Sixty-five percent of faculty was confident that they are effective mentors, and 88% agreed that their mentor ship plays an important role in the personal and career development of their mentee.

Fig. 1. Response distribution to the statement, “I would be a more effective mentor with formal training in how to provide mentorship.”

A subanalysis conducted to see whether there was a significant difference in mentee responses between JHU, MCW, and UNC revealed no significant difference for any question by institution ( P > 0.15). A similar test was done for mentor responses between all three institutions; again, no significant differences were found ( P > 0.20). While there are not statistically significant differences noted between programs, there were differences in responses between programs as well as response rate. An additional analysis was conducted to see whether choosing a mentor had any effect on the quality of mentorship, as 58% of mentees chose their mentor while 42% were assigned mentors. Mentor selection ver sus assignment had no significant impact on mentee responses ( P > 0.15). DISCUSSION Formal mentorship programs beginning to be imple mented in training programs, and, while a greater amount of studies on the topic is being conducted, there is still a need for further investigation. 4–7 With an aim to advance research on formal mentorship programs, the goal of this study was to assess three existing

TABLE IV. Ranking Order of Areas in Which Mentors Feel Formal Training Would Most Benefit.

TABLE III. Areas of Mentoring as Reported by Mentors versus Mentees.

Proportion of Mentor’s Selection

Proportion of Mentee’s Selection

Areas of Mentoring

P value

Career planning

90%

81% 0.197

Research

78%

63% 0.093

Clinical judgment

86% 63%

58% 0.003 56% 0.303

Work-life balance

Professionalism

65%

53% 0.174

Emotional well-being

43%

42% 0.546

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Mentors and mentees closely agreed on the quantity of mentoring provided in the areas of career planning and emotional well-being in our study, but for every other topic mentors reported relatively greater propor tions of mentorship than mentees (Table III). A possible explanation for the disparities could be that mentors are overestimating the mentoring they provide or that there is a level of miscommunication between residents and faculty. Such miscommunications can be avoided by establishing and clearly defining goals and objectives of the relationship. In the study conducted by Huskins et al., a junior researcher described that “good mentors articulate what their expectations are of you.” 15 The study concluded that identifying and aligning expecta tions between mentor and mentee is important to build ing a mentoring relationship. Such efforts would also minimize the differences between mentor and mentee perceptions of certain aspects of their relationship and result in greater retention and value for the trainee. It is interesting to note that the perception of men tor and mentee, as far as quantity of mentorship pro vided, demonstrated that the greatest disparity is in the area of clinical judgment. This may represent a mis alignment of expectations as the mentors may feel they need to provide advisement in clinical training, as per the classic Halstead model of surgical education. The contemporary mentees may not be looking for this tradi tional model of education with emphasis on clinical skills and judgment in their interactions with their mentors. This may reflect a shift in the mentees’ perception of the purpose of mentorship to meet broader needs beyond traditional surgical education. There is no evidence in the current study suggesting that choosing a mentor leads to a significantly better men torship experience than having one assigned ( P > 0.15). However, consideration should be given for mentees to have the flexibility to choose their mentor if they wish; prior studies indicate mentee preference is important in the potential success of a mentoring relationship. 13,16 Previous studies have shown that residents have expressed greater satisfaction with mentors through for mal mentoring programs than through informal mentor ing. 12,15 The structured formal relationship provides a dedicated setting for residents to discuss their careers and objectives. However, informal mentorship interac tions have also been demonstrated as being important to the development of a mentor-mentee relationship; such relationships are defined not only by career development but also by personal rapport. 16–18 Informal relationships are important grounds for continuous growth of the rela tionship, and more easily executed without the need for mandatory structure and scheduling. 17 Ideally, a men torship relationship would encompass both a formal pro gram with additional informal relationship building. Past mentorship studies have focused primarily on mentees, but to improve the mentoring relationship a stronger focus needs to be paid to the mentor side of the relationship as well; the relationship will primarily change from their side. 19,20 Recognizing this importance, the current study gave equal attention to mentors, eval uating both the mentor and mentee side of the same

TABLE V. Proportion of Mentee Agreement on Various Mentor Qualities.

Proportion of mentees in agreement

Mymentor…

Is approachable

98%

Is supportive and encouraging

95% 79%

Motivates me to improve my work product Challenges me to extend my abilities Provides constructive critiques of my work

79%

Is helpful in providing direction and guidance

72%

otolaryngology mentorship programs by analyzing the differences in how mentors and mentees perceive their relationship. The results are useful to identify areas of potential disagreement and weakness in order to improve the effectiveness of mentorship programs. The results demonstrated at least 90% of mentees meet with their mentor at least twice a year, with 48% meeting more frequently. Both faculty and trainees were questioned about the time availability of the faculty men tor. While only 46% of mentors agreed they have an appropriate amount of time to mentor, 95% of mentees agreed that their mentor is accessible, demonstrating that they believe their mentor is able to allot enough time for mentoring ( P < 0.001). The disparity in the per ception of availability of the mentor may indicate that faculty believe that with greater availability, they would be able to provide even better and more effective mentorship. 11 Mentees in the current survey appear to be gener ally satisfied with the mentoring they receive; however, mentors do not appear equally satisfied with the mentor ing they provide as only 65% of faculty members agreed that they are effective mentors. Fifty-six percent of sur veyed faculty said that they believe they would be better mentors with some formal training. Other studies have found that providing resources such as training to men tors is an important factor in the success of mentoring programs. 11–14 Mentees were least satisfied with men tors for providing effective critiques, offering helpful guidance, and inspiring motivation (Table V). Mentors agreed they could improve in the areas for providing feedback and emotional well-being with more training. A push for mentorship training for faculty could increase the value of the experience. However, time is again an obstacle when it comes to the planning and implementa tion of such courses. A mentor involved in a study con ducted by Straus et al. stated, “It’s a wonderful idea to have training. The challenge is that people don’t have the time to mentor, never mind to learn how to do it.” 11 This concern was also expressed by the faculty involved in the current study. Across all three institutions, the major hurdle in providing effective mentorship as expressed by mentors was lack of time. Greater empha sis and support at the institutional level are needed to address the issues of time and training for mentors.

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experience. This direct comparison is useful in identify ing weaknesses and misperceptions in the relationship and correcting them. One of the limitations of our study is a small sam ple size. Additional limitations include survey design, which may have failed to capture negative mentorship experiences and potential reasons for any such experien ces. Future studies should include a larger sample size, and mechanisms designed to capture and better identify negative mentorship interactions. In addition, future studies should examine the impact of mentorship pro grams as far as mentor/mentee satisfaction and contri bution to well-being and productivity of the mentee. CONCLUSION This study evaluated both the mentor and mentee side of the same experience in otolaryngology training programs. Overall, there was agreement on most aspects of mentorship from the mentee and mentor perspective. However, while mentees felt that they were being given enough time by their mentors, faculty felt that time restrictions impacts their ability to provide mentorship. Mentors felt formal mentorship training would improve their mentorship skills. The overall mentorship experi ence in the surveyed programs was noted as positive and beneficial by both mentors and mentees. BIBLIOGRAPHY 1. Standing Committee on Postgraduate Medical and Dental Education. Sup porting Doctors and Dentists as Work: An Inquiry into Mentoring. Lon don, UK: SCOPME;1998. 2. Halstead W. The training of the surgeon. Bull Johns Hopkins Hosp 1904;15:267–275. 3. Patel AM, Warre O, Ahmed K, Humphris P, Abbasi S, et al. How can we build mentorship in surgeons of the future? ANZJSurg 2011;81:418–424.

4. Berk RA, Berg J, Mortimer R, Walton-Moss B, Yeo TP. Measuring the effectiveness of faculty mentoring relationships. Acad Med 2005;80: 66–71. 5. Sambunjak D, Straus SE, Marusic A. Mentoring in academic medicine: a systematic review. JAMA 2006;296:1103–1115. 6. Buddeberg-Fischer B, Herta KD. Formal mentoring programmes for medi cal students and doctors—a review of the Medline literature. Med Teach 2006;28:248–257. 7. Flint JH, Jahangir AA, Browner BD, Mehta S. The value of mentorship in orthopaedic surgery resident education: the residents’ perspective. J Bone Joint Surg Am 2009;91:1017–1022. 8. Marangoni G, Morris-Stiff G, Deshmukh S, Hakeem A, Smith AM. A mod ern approach to teaching pancreatic surgery : stepwise pancreatoduode nectomy for trainees. J Gastrointest Surg 2012;16:1597–1604. doi: 10.1007/s11605-012-1934-2. Epub 2012. 9. Donovan A. Views of radiology program directors on the role of mentorship in the training of radiology residents. AJR Am J Roentgenol 2010;194:704–708. 10. Hsu AK, Tabaee A, Persky MS. Mentorship in otolaryngology residency: the resident perspective. Laryngoscope 2010;120:1263–1268. 11. Straus SE, Chatur F, Taylor M. Issues in the mentor-mentee relationship in academic medicine: a qualitative study. AcadMed 2009;84:135–139. 12. McKenna AM, Straus SE. Charting a professional course: a review of men torship in medicine. J Am Coll Radiol 2011;8:109–112. 13. Feldman MD, Arean PA, Marshall SJ, Lovett M, O’Sullivan P. Does men toring matter: results from a survey of faculty mentees at a large health sciences university. Med Educ Online 2010;15. doi: 10.3402/ meo.v15i0.5063. 14. Feldman MD, Huang L, Guglielmo BJ, et al. Training the next generation of research mentors: the University of California, San Francisco, Clini cal & Translational Science Institute Mentor Development Program. Clin Transl Sci 2009;2:216–221. 15. Huskins WC, Silet K, Weber-Main AM, et al. Identifying and aligning expectations in a mentoring relationship. Clin Transl Sci 2011;4: 439–447. 16. Healy NA, Cantillon P, Malone C, Kerin MJ. Role models and mentors in surgery. Am J Surg 2012;204:256–261. doi: 10.1016/j.amj surg.2011.09.031. Epub 2012. 17. Macafee DA. Is there a role for mentoring in Surgical Specialty training? Med Teach 2008;30:e55–e59. 18. Kalen S, Ponzer S, Silen C. The core of mentorship: medical students’ experiences of one-to-one mentoring in a clinical environment. Adv Health Sci Educ Theory Pract 2012;17:389–401. 19. Gurgel RK, Schiff BA, Flint JH, et al. Mentoring in otolaryngology train ing programs. Otolaryngol Head Neck Surg 2010;142:487–492. 20. Doucet S, Andrews C, Godden-Webster AL, Lauckner H, Nasser S. The Dalhousie Health Mentors Program: introducing students to collabo rative patient/client-centered practice. J Interprof Care 2012;26: 336–338.

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APPENDIX A. Mentee Survey.

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APPENDIX A. (Continued)

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APPENDIX B. Mentor Survey.

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1282610 EAR XXX10.1177/01455613241282610Ear, Nose & Throat Journal DeSisto et al. research-article 2024

Original Research

Ear, Nose & Throat Journal 1–7 © The Author(s) 2024 Article reuse guidelines:

You Can’t Be What You Can’t See: The Progression of Women in Otolaryngology-Head and Neck Surgery

https://doi.org/10.1177/01455613241282610 sagepub.com/journals-permissions DOI: 10.1177/01455613241282610 journals.sagepub.com/home/ear

Nicole G. DeSisto, MD 1 , Rahul K. Sharma, MD 1 , Elizabeth S. Longino, MD 1 , Alexandra S. Ortiz, MD 1 , Leslie R. Kim, MD, MPH 2 , Sarah L. Rohde, MD 1 , and Shiayin F. Yang, MD 1

Abstract Objective: To examine trends in the gender composition of residents and faculty in Otolaryngology-Head and Neck Surgery residency programs in the United States and to investigate the correlation between women’s representation in leadership positions and the proportion of women faculty and residents. Methods: A literature review was first performed to analyze trends in the gender composition of residents and faculty in Otolaryngology-Head and Neck Surgery (OHNS) residency programs. Current residency programs were then identified using the Electronic Residency Application Service 2023 Participating Specialties and Programs website. The following data was collected from each program website: gender of associated medical school dean, gender of department chair, gender of residency program director, and total number and gender of fellowship directors, faculty, and residents. Wilcoxon rank sum test and Fischer’s exact test were used to analyze relationships between the number of women in leadership positions and the proportion of women faculty and residents. Results: An increase in the number of women chairs, residency program directors, residents, and faculty over the past decade is documented across published literature. One hundred twenty three current academic residency programs were identified. Women accounted for 42%, 30%, 27%, and 8% of current residents, residency program directors, faculty, and department chairs, respectively. Department chair gender was significantly correlated with number of women faculty ( P = .01). Any women in a leadership position were correlated with a statistically significant increase in median percent of women faculty ( P = .006). Conclusion: Further understanding of how the mentorship of women promotes gender equity is necessary to promote gender diversity in OHNS.

Keywords women in medicine, mentorship, promotion, academic medicine, leadership

Introduction The number of women entering medical school has steadily increased since 2003. In 2021, 55.5% of medical school matriculants and 46.4% of resident physicians in the United States were women. 1 Despite this, few women reach top leadership positions in academic medicine. In 2019, women made up 41% of academic physicians in the United States but only accounted for 18% of medical school deans and department chairs. 2 Furthermore, a lack of women in leadership positions is more prevalent in gen eral surgery and most surgical specialties. In Otolaryngology-Head and Neck Surgery (OHNS), women represented 36% of residents as of 2019. 2 Although women also represented about 36% of full-time academic

OHNS faculty at this time, multiple studies have demon strated a decline in the proportion of women leaders as aca demic rank increases. 3-5 In 2020, women Otolaryngologists held 26% of residency program directorships, 14.7% of 1 Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA 2 Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA Received: May 22, 2024; revised: July 22, 2024; accepted: August 22, 2024 Corresponding Author: Shiayin F. Yang, MD, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Nashville, TN 37232, USA. Email: Shiayin.yang@vumc.org

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

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fellowship directorships, and less than 5% of department chair positions. 4 The only specialty with a lower represen tation of women in department chair positions in Orthopedic Surgery, with only 1 female department chair (0.8%) as of 2019. 2 Although improvements have been made in the number of women medical students and OHNS residents, the lower numbers of women OHNS faculty in leadership positions may indicate that the promotion of women in OHNS is lagging. Factors such as higher burnout rates, mistreat ment of women surgeons, and lack of women mentors are frequently cited as reasons for suboptimal retainment and promotion in most surgical specialties. 6-8 The importance of women mentors has been well dem onstrated in academic medicine. 8,9 Women medical stu dents are more likely to specialize in OHNS when their medical school has full-time OHNS women faculty. These students are also more likely to choose a residency pro gram with a higher proportion of women residents across all specialties. 9 Another recent study demonstrated a sig nificant correlation between plastic surgery faculty gender and plastic surgery resident gender. 10 Early career women faculty frequently cite a lack of female role models as a barrier to promotion and voice the importance of same-sex mentorship more frequently than their male counterparts. 7,8 Despite this, to our knowledge, no study has comprehen sively investigated trends in gender diversity and the cor relation between leadership gender diversity and resident and faculty representation in OHNS. This study aims to examine the gender composition of residents and faculty in academic OHNS residency programs in the United States over the past decade and to investigate any associa tion between female representation in leadership positions and gender diversity among faculty and residents. Exemption status was obtained from the Institutional Review Board at Vanderbilt University Medical Center. A comprehensive literature review of the PubMed, SCOPUS, and EMBASE online databases was performed in May of 2023 using variations of the terms “Otolaryngology-Head and Neck Surgery,” “Female Surgeon,” and “Internship and Residency” (Supplemental Appendix 1). There was no limitation on the initial years queried. Each search was run separately, and all references were uploaded to Endnote reference software, where duplicates were removed. Title and abstract screening were completed by a single reviewer (N.D.). All articles investigating the gender diversity of residents and faculty in OHNS residency programs within the past 10 years were included for final review. Full-text review and data extraction were performed by the same Methods Study Design and Data Collection

reviewer. Article inclusion was finalized by the senior author (S.Y.). Data on total numbers and percent represen tation of women OHNS department chairs and residency program directors, OHNS faculty, and OHNS residents was collected from each of the selected articles. These numbers were analyzed to determine trends among the number of women within different ranks in OHNS resi dency programs. A cross-sectional study of the gender composition of residents and faculty in OHNS residency programs in the United States was performed in August 2022. Residency programs were identified using the Electronic Residency Application Service (ERAS) 2023 Participating Specialties and Programs website. The following data was collected for each residency program: gender of associated medical school dean, gender of OHNS department chair and resi dency program director, and total number and gender of fellowship directors, OHNS faculty, and OHNS residents. Data was collected from program websites, as the Accreditation Council for Graduate Medical Education (ACGME) and the Association of American Medical Colleges (AAMC) do not publicly release individual pro gram data. The gender of each resident and faculty mem ber was recorded based on pronouns used and provided photographs on each departmental website. The gender of the department chair and program director for each pro gram were recorded in the same manner. If program web sites were incomplete, social media accounts and other public listings for each program were explored. Program coordinators were also contacted to complete the data set if needed. Data on total number and gender of OHNS fellows was not collected, as fellowship programs are typically limited to 1 to 2 years, not all fellows are part of programs accred ited by the ACGME, and fellows are not consistently listed on department websites. In addition, fellowship director’s gender was only collected for OHNS fellowships associ ated with a residency program. When OHNS was not a department but a division of Surgery, the gender of the chair of the department of Surgery was included. The following relationships were investigated: correla tion between chair gender and program director gender, fellowship director gender, faculty gender, and resident gender; correlation between program director gender and resident gender; correlation between faculty gender and resident gender; correlation between medical school dean gender and department chair gender, faculty gender, and resident gender. Statistical Analysis Trends in gender diversity at the department chair, resi dency program director, faculty, and resident level were analyzed using the quick analysis and chart functions in

DeSisto et al.

Microsoft Excel. Analysis of the cross-sectional portion of this study involved stratification of program character istics (percent women residents, percent women faculty, etc) by program chair gender. A Wilcoxon rank sum test was used to determine differences in categorical variables and a Fisher’s exact test for continuous variables within this stratification. Similar analysis was conducted after stratification between gender of medical school deans as well as gender of program directors. Pearson’s correlation was used to analyze the relationship between percent women faculty members and the percentage of women residents. All analysis was performed using R (R. Studio, Boston, MA) version 4.1.2. Results Three hundred thirteen unique references were identified. Of these, 20 studies included a description of gender com position of residents and faculty in OHNS residency pro grams with the earliest publication being from 1979. There was an overall trend of an increasing number of women within all ranks of OHNS. The total number of women chairs published in current literature increased from 3 in 2013 to 10 in 2022 (Figure 1). 4,11-16 Similarly, over this time frame, the percentage of women residency program direc tors reported increased from 16% to 30% (Figure 2). 4,11-16 An increase in the reported number of women residents was seen with 19% of OHNS residents being women in 2001 compared to 42% in 2022 (Figure 3). 12-16 A single article published in 1979 indicated that less than 1% of OHNS fac ulty were women. 17 This published number increased to 25% in 2019 and 27% in 2022. 12,14,18 One hundred twenty-three academic OHNS resi dency programs were identified on cross-sectional anal ysis. No programs were excluded. The gender composition of residents, faculty, and academic leader ship positions within OHNS residency programs is dis played in Table 1. As academic rank increases, the number of women in each position decreases. Forty-two percent of residents are women, whereas 26.6% and 8.1% of faculty and department chairs are women, respectively. Women accounted for 30% and 18% of residency program directors and fellowship directors, respectively. The fellowship director gender composi tion for all 8 recognized OHNS fellowships associated with academic residency programs may be found in Table 2. Ten women OHNS department chairs were identified, 1 of whom was in an interim position. Gender of OHNS department chair was significantly correlated with proportion of women faculty. Of the pro grams with a female department chair, 33% of faculty were women and 67% were men compared to 27% women and 73% men for programs with a male OHNS or General Surgery department chair ( P = .01). In fact, any woman in

Figure 1. Published number of female Otolaryngology-Head and Neck Surgery department chairs by year.

Figure 2. Published percentage of female Otolaryngology Head and Neck Surgery residency program directors by year.

Figure 3. Published percentage of female Otolaryngology Head and Neck Surgery resident physicians by year.

Table 1. Academic Positions by Title and Gender (2022-2023 Academic Year). Academic Title Women Men % Women OHNS Department Chair 10 113 8.1 OHNS Residency Program Director 37 86 30.1 OHNS Fellowship Director 36 156 18.8 OHNS Faculty 772 2130 26.6 OHNS Residents 735 1000 42.3 Medical School Dean 32 91 26.0

Abbreviation: OHNS, Otolaryngology-Head and Neck Surgery.

Ear, Nose & Throat Journal 00(0)

Table 2. OHNS Fellowship Directors Associated with Residency Program by Gender (2022-2023 Academic Year). Fellowship Women Men

% Women

Head and Neck Surgery (n = 38)

8 3 2 8 3 4 0 1

30 23 24 19 24 15

21.1 11.5

Facial Plastic and Reconstructive Surgery (n = 26)

Rhinology (n = 26) Pediatrics (n = 27)

7.7

29.6 11.1 21.1

Otology/Neurotology (n = 27)

Laryngology (n = 19)

Sleep (n = 2)

2 3

0.0

Endocrine (n = 4)

25.0

Abbreviation: OHNS, Otolaryngology-Head and Neck Surgery.

women in all levels of OHNS training and academic medicine. Despite fewer women in the highest OHNS leadership positions, there has been increasing gender representation documented in the literature. In the 1980s, less than 1% of practicing Otolaryngologists were women with only 6 being represented in full-time academic positions. 17 In 2008, 29.8% of OHNS residents were women, a number that has steadily increased to 35% in 2019 and 42% in 2022. 12,21 In fact, a recent analysis concluded that OHNS has the highest rate of women residents of any of the surgi cal specialties other than obstetrics and gynecology. 22 Despite these advances and the consistent rise in the num ber of woman residents, the proportion of women is smaller as academic rank increases. 3 Pereira et al found that women made up 37% of assistant and associate pro fessors but only 10% of full professors in 2022 and male gender was a statistically significant predictor of full pro fessorship ( P < .001). 3 In 2013, 16% of program directors were women with a rise to 27% in 2019 and 30% in 2022. 11,12,14,16 However, there remains a significant decline in gender representation at the highest academic rank with less than 5% of department chairs being women prior to 2021. 12,14 Although our study demonstrates a rise in this number to 8.1%, there is still significant room for improvement. Despite a discrepancy in gender diversity at the highest leadership levels, our study demonstrates an association between women in any academic leadership position and an increased percentage of women OHNS faculty at that institution. This highlights the need for improvement in gender diversity across leadership positions. However, it is important to consider factors that may impact the gender representation disparity seen at higher leadership levels. The number of women medical school matriculants has rapidly increased over the past several decades from 11% in 1970 to 56% in 2021. 1,23 Similarly, the number of women OHNS residents has steadily increased. This increase has resulted in a greater total number of women OHNS faculty members, but discrepancy at the mid to

a leadership position (medical school dean, program direc tor, fellowship director, and department chair) was corre lated with a statistically significant increase in the percentage of women faculty. Programs with no women in leadership positions had a lower median percent of women faculty (23%) than programs with a woman in a leadership position (30%; P = .006). Gender of OHNS department chair was not associated with the gender of OHNS residents or the gender of the fellowship director. There was also no association between the gender of the program director and the proportion of women residents or the percentage of women faculty and percent of women residents. Discussion The importance of women mentorship and role models in the recruitment, retention, and promotion of women in medicine has been well demonstrated in academic gastro enterology, urology, and plastic surgery. 10,19,20 The find ings in our study corroborate those of prior studies. There was a strong association between women in any academic leadership position, including OHNS department chair, and the number of women OHNS faculty. In contrast to other studies completed in surgical specialties, there was no association between OHNS chair gender and program director or fellowship director gender. 10,19 There was also no association between the chair, program director, or fac ulty gender and the gender composition of current resi dents. These findings are consistent across recent publications that have investigated gender disparity across Otolaryngology leadership positions. 12,14,16 This may be explained by the relatively low number of total woman chairs (8.1%) compared to a relatively higher number of woman residency program directors (37, 30.1%), fellow ship directors (36, 18.8%), and residents (42%). The num ber of woman OHNS chairs has increased from less than 5% in 2019 to 8.1% in August 2022. 4,12 It is possible that the growing number of women in leadership positions may contribute to the observed increase in the number of

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both sales and profits. 30 The importance of gender diver sity, women mentorship, and women representation cannot be understated, and academic medicine should continue to focus on strategies to improve gender diversity. There has been a significant amount of interest in the cause of inadequate promotion and retention of women. One hypothesis is the lack of adequate executive-level spon sorship, which inhibits high-achieving women from advanc ing into the highest leadership positions. 31 In medicine, lack of woman role models, decreased research productivity, harassment, and burnout have been cited as reasons for fewer women in these positions. 4,6,32-34 When women in aca demic leadership positions are asked to examine their own experience with tenure and promotion, the most common reasons for gender disparities are poorly defined goals, lack of standard promotion procedures, and vulnerability to dis crimination. 34 Successful women also emphasize the per ception that their male counterparts experience advancement differently. 34 Gender discrimination has been reported by 65.1% of women residents, who also report more frequent feelings of fatigue and burnout than men. 6,34 Numerous organizations have aimed to improve upon these disparities with targeted mentorship and leadership programs. A recent systematic review of mentorship pro gram implementation found these programs were consis tently highly rated, with one program reporting an 85% retention rate for participating woman faculty. 35 Additional programs also report improvement in retention and recruit ment into the department or specialty, highlighting the impact that formalized mentorship programs can have on women in academic medicine. 35 In 2017, the Society of General Internal Medicine successfully implemented the novel Career Advising Program, a longitudinal experience intended to foster the advancement of women in academic medicine by assisting woman faculty in the navigation of the academic promotion process. 36 The success of this and other mentorship programs highlights the impact of men torship and sponsorship on increasing representation, retention, and promotion of women. Although we are aware of several mentorship programs within OHNS that aim to promote the advancement of women in the spe cialty, to our knowledge, no studies examining the impact of these initiatives have been published. We have recently implemented a Women in Otolaryngology leadership and mentorship curriculum for female residents within our institution and aim to publish on the effectiveness of this program. Future research on the impact of mentorship pro grams focused on women in OHNS is needed. There are several limitations to our study. First, this is a cross-sectional study of current OHNS residency pro grams, which limits our analysis to a snapshot in time rather than an analysis of trends. The current study design also limits conclusions on causation and does not ade quately assess the career motivations of residency program

late-career level remains. OHNS department chairs appointed within the past 6 years have an average of 18 years of post-residency/fellowship experience, result ing in a significant time lag between initial faculty mem bership and department chair appointment. 13 Consequently, the increase in the number of OHNS residents and faculty over the past decade should result in growth at the highest leadership levels in the coming years. It is also important to consider differences in attrition rates between male and female surgeons. Recent research has demonstrated that women are up to 2 times more likely to leave academic surgery departments compared to men. 24 Although this has not been explored in OHNS specifically, it is likely that increased attrition rates among women in OHNS may impact the gender diversity seen at higher academic lead ership ranks. Future research on factors impacting the retention of women in OHNS is needed. Gender diversity in OHNS subspecialties is also vari able. A recent query of 1421 members of the American Academy of Facial Plastic Surgery (AAFPRS) found 13.0% of members to be female compared to 86.9% male. 25 A similar study demonstrated that women more frequently apply for pediatric otolaryngology fellowship positions and less frequently for head and neck fellowship positions, with women fellowship applicants outnumber ing men only in pediatric otolaryngology. 26 In addition, women account for only 12% of society leaders and 17.7% of editorial board members for major Otolaryngology journals. 3,27 However, despite some persistent discrepan cies in the number of woman subspecialty surgeons, there has been an increase in gender diversity from 3% of Head and Neck fellowship graduates in 2008 to 33% in 2018. 28 Gender diversity and the availability of role models who are women may significantly impact diverse recruit ment and overall organizational success in both medicine and business. Recent literature has demonstrated that women value and understand the importance of same-sex mentorship at a rate higher than their male counterparts. 7 Women medical students are more likely to specialize in OHNS when their medical school has at least some full time women faculty and enter residency programs with higher proportions of women residents. 9 Data from the urology match confirms this finding, with there being a statistically significant correlation between the proportion of matched women applications and the proportion of women faculty. 20 The impact of female representation on organizational success has also been well demonstrated in the areas of finance and business. Women in C-suite posi tions catalyze fundamental shifts in tolerance, openness to change, and creation strategies, with companies having strong woman leadership generating a return on equity of 10.1% per year compared to 7.4% for those without. 29,30 In fact, field experiments have found that teams with an equal gender mix perform better than male-dominated teams in

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