Abstract

Background: Recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic represents an important negative impact on global training of neurosurgery residents. Even before the pandemic, discrimination is a challenge that neurosurgical residents have consistently faced. In the present study, we evaluated discriminatory conditions experienced by residents during their neurosurgical training in Mexico before the SARS-CoV-2 pandemic.

Methods: An electronic survey of 18 questions was sent among residents registered in the Mexican Society of Neurological Surgery (MSNS), between October 2019 and July 2020. Statistical analysis was made in IBM SPSS Statistics 25. The survey focused on demographic characteristics, discrimination, personal satisfaction, and expectations of residents.

Results: A response rate of 50% (132 of 264 residents’ members of MSNS) was obtained and considered for analysis. Median age was 30.06 ± 2.48 years, 5.3% (n = 7) were female and 16.7% (n = 22) were foreigners undergoing neurosurgical training in Mexico. Approximately 27% of respondents suffered any form of discrimination, mainly by place of origin (9.1%), by gender (8.3%) or by physical appearance (6.1%). About 42.9% (n = 3) of female residents were discriminated by gender versus 6.4% (n = 8) of male residents (P = 0.001); while foreign residents mentioned having suffered 10 times more an event of discrimination by place of origin compared to native Mexican residents (36.4% vs. 3.6%, P

Conclusion: This manuscript represents the first approximation to determine the impact of discrimination suffered by residents undergoing neurosurgical training in Mexico before the SARS-CoV-2 pandemic.

Keywords: Discrimination, Mexico, Neurosurgery, Resident, Women

INTRODUCTION

Over the past two decades, progress has been observed for gender equality in neurosurgery. An increase in the number of women in neurosurgical training has been expanding in North American programs including the American Board of Neurological Surgery (ABNS)[ 20 ] and the Accreditation Council for Graduate Medical Education (ACGME).[ 1 , 2 ] In Mexico, the Mexican Society of Neurological Surgery (MSNS) [ 14 ] database reported between 2019 and 2020 that 14.5% of the residents in training were women. Despite a legitimate effort to balance opportunities, gender discrimination rates suffered by women in neurosurgery (WINS) continue to be high with an estimation of 31–77% in published surveys.[ 7 , 10 , 11 , 18 ]

A genuine intention for gender equality with better training opportunities and facilities has been reflected by an increased number of foreign countries residents receiving international neurosurgical training. The United States represents one of the main countries selected by residents to perform neurosurgery, and this has been reflected on published rates of up to 8.9% of foreigner doctors graduated in neurosurgery.[ 3 , 4 ] Mexico represents the most important destination for Latin America.

Foreign residents usually have a solid research background with greater number of publications and a higher H-index compared to residents of the United States. Even though, their average match rate represents <50% for postgraduate studies in the United States.[ 3 , 4 ] Discrimination by place of origin represents a substantial disadvantage for foreign residents that have been underestimated and not yet been extensively studied.

In Mexico, there is no history of publications evaluating the impact of discrimination suffered by residents during neurosurgical training before the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. In this study, we applied for the 1^st time a survey to evaluate the discriminatory conditions experienced by residents during their neurosurgical training in Mexico to identify areas of opportunity to improve educational conditions in our country.

MATERIALS AND METHODS

Data were collected from an original online survey created using Google Forms Survey. This survey was sent by email to 264 native and foreigners’ residents during neuro-surgical training in Mexico registered in the MSNS between October 2019 and July 2020. The survey consisted of 18 questions and three sections and was answered anonymously [Supplemental Appendix 1]. All results were collected in a Google forms database.

Statistical analysis

Statistical analysis was performed using IBM SPSS Statistics 25. Descriptive analysis was made, and bivariate analysis was carried out with a Pearson’s Chi-square test. The impact of discrimination suffered by women and foreigners’ residents during neurosurgical training in Mexico was analyzed. In addition, academic and technological resources, specialty and surgical resources, number of operating rooms, monthly admissions, and number of major surgeries were analyzed to observe the impact on the degree of academic and training satisfaction, as well as current and future expectations.

RESULTS

Survey responses: Demographic information

The survey was sent to 264 Mexican residents in training through email and we obtained a response rate of 51.14% (n = 135). Three surveys were eliminated due to incomplete fulfilling of all the fields required. A total of 132 responses were considered for the analysis. Median age was 30.06 ± 2.48 years, 5.3% (n = 7) were female, and 16.7% (n = 22) were foreigners. About 74.2% (n = 98) of the responders were junior residents (PGY 1-3) [ Table 1 ].

Table 1:

Socio-demographic information.

Gender: Female and male

About 42.9% (n = 3) of female residents were discriminated by gender against 6.4% (n = 8) of male residents (P = 0.001) [ Figure 1 ]. However, 85.7% of female residents mentioned high expectations of having a formal job at the end of their residency, compared to 75.2% of male residents (P = 0.040) [ Figure 2 ]. Additional variables were not statistically significant [ Table 2 ]. Only seven women answered the survey, two were foreigners. About 84% (n = 105) of the male residents were Mexican while 16% (n = 20) were foreigners. A higher response rate of junior residents was observed regardless of gender (85.7% of women [n = 6] and 73.6% of men [n = 92] were junior residents).

Figure 1:

Gender discrimination. *Statistically significant variables (P < 0.05), P-value obtained by Pearson’s χ².

Figure 2:

Analysis by gender of the expectations of getting a formal job at the end of the residence. *Statistically significant variables (P < 0.05), P-value obtained by Pearson’s χ².

Table 2:

Results by gender.

Place of origin: Foreign and Mexican resident trainers

More than three-quarters of Mexican residents reported being satisfied with the tutoring of their professors compared to 54% of foreign residents (P = 0.027). Foreign residents mentioned having suffered 10 times more an event of discrimination by place of origin compared to Mexican residents (36.4% vs. 3.6%, P < 0.001) [ Figure 3 ]. Mexican residents prefer to work in private institutions at the end of their training (64.5% vs. 40.9%, P = 0.038). However, most foreign residents wanted to take a subspecialty or fellowship course (81.8% vs. 79.1, P = 0.772). About 45.5% of foreign residents mentioned that the second level is adequate for the development of neurosurgical practice compared to 19.1% of Mexican residents (P = 0.008) [ Table 3 ].

Figure 3:

Discrimination of residents by place of origin. *Statistically significant variables (P < 0.05), P-value obtained by Pearson’s χ².

Table 3:

Results by place of origin.

Junior and senior residents

Most of the survey respondents were junior residents (74.2%). Junior residents answered that they had a predilection for taking a sub-specialty or fellowship course after completing their residency (86.7% vs. 58.8%, P = 0.001) [ Figure 4 ], while most senior residents wanted to work in a private institution (67.6 vs. 58.2%, P = 0.329). The rest of the variables were not statistically significant.

Figure 4:

Analysis by year of neurosurgical training and work plans at the end of the residency. *Statistically significant variables (P < 0.05), P-value obtained by Pearson’s χ².

Discrimination

The main causes of discrimination were discrimination by place of origin, followed by discrimination by gender and discrimination by physical appearance [ Figure 5 ]. However, more than 70% of those surveyed mentioned not being discriminated against. Women presented higher rates of discrimination compared to men (57.1% vs. 25.6%, P = 0.68), mainly discrimination by gender (42.9% vs. 6.4%, P < 0.001). Mexicans presented the lower discrimination rates compared to foreign residents with neurosurgical training in Mexico (45.5% vs. 23.6%, P = 0.036). The year of neurosurgical training did not present differences for discrimination. The residents who did not suffer discrimination presented higher rates of academic satisfaction, mainly in the teaching given by their teachers (77.3% vs. 22.7%, P = 0.049), a greater balance between workload and training (78.9% vs. 21.1%, P = 0.020), and contradictorily the residents who did not suffer from discrimination agreed with the sanctions applied to the residents for indiscipline (76.5% vs. 23.5%, P = 0.003). Discriminated residents had the lowest rates of expectations of getting a job at the end of their residency (100% vs. 0%, P = 0.013), while almost three-quarters of residents who did not suffer from discrimination had high expectations of getting a formal job at the end of their residency (P = 0.013), mainly in a public institution (80.6%, P = 0.039) [ Table 4 ].

Figure 5:

Main causes of discrimination.

Table 4:

Results by discrimination.

Characteristics of neurosurgical training centers

Respondents mentioned an average number of operating rooms per hospital of 2.7 SD ± 1.23 (Range 1–4), a mean of monthly admissions of 105.48 SD ± 90.5 (Range 54–200), and a mean of major surgeries performed monthly of 63.73 SD ± 33.2 (Range 21–136). We observed that centers with four operating rooms had larger educational resources, more subspecialties facilities, and a greater amount of technological resources [ Figure 6 and Appendix 2]. However, it was not observed that the volume of surgeries and hospital admissions reflected in the number of operating rooms influenced the discrimination rates suffered by residents with neurosurgical training in Mexico (results are not shown because they were not statistically significant).

Figure 6:

Hospital characteristics: Technological and multidisciplinary resources. *Statistically significant variables (P < 0.05), P-value obtained by Pearson’s χ².

DISCUSSION

Discrimination is a problem of global impact in surgical residencies. A recent study carried out in Latin America by the AO Spine Latin America association reported that only 12.11% of the members are women (n = 27). Gender discrimination is an important topic and approximately 67% of the women reported having been discriminated against by gender (66.67% vs. 1.02%) and 81% of the women mentioned being discouraged from becoming spinal surgeons or neurosurgeons (81.48% vs. 0.51%) in this study.[ 8 ] In turn, women reported higher rates of sexual harassment (44.44% vs. 7.65%) and more often felt fewer job opportunities (55.56% vs. 2.55%).[ 8 ] In Mexico, gender discrimination has been previously mentioned in an historical context.[ 13 ] However, no studies have been published evaluating discrimination and its impact on women and foreigners who carry out their residency in Mexico.

Conventionally, in medical literature, neurosurgical centers have been classified into low and high volume; by the amount of patients, annual admissions, number of major surgeries performed, subspecialties or technological resources, and the number of subarachnoid hemorrhages admitted per year.[ 15 , 25 ] However, an association between the size of the center and the impact on the degree of discrimination suffered by residents has not been investigated. In our results, it was not observed that the volume of surgeries and hospital admissions reflected in the number of operating rooms influenced discrimination rates suffered by residents with neurosurgical training in Mexico.

WINS training

The ABNS reports that 66 female neurosurgeons were trained between the years 2011–2016 (an average of 11 neurosurgeons per year). Before this data, the ABNS mentions an annual rate of 7.58 neurosurgeon women trained between the years 1964 and 2013.[ 20 ] The ACGME mentions an increase from 11% in 2008[ 1 ] to 19.3% in 2020[ 2 ] of female neurosurgery residents in the last 12 years. The aforementioned data support the increase in the number of women and their growing impact on neurosurgery today representing an advance in gender equality within medicine. The MSNS reported that 14.5% of neurosurgery residents are women in 2020.[ 14 ] Nevertheless, in our survey, only seven women responded, two women were foreigners, and five were natives of Mexico, which prevents us from knowing the real impact that women experience in our country. This report makes us aware of the persistence around this taboo due to the low response of women to the survey (this is partly because cultural practices may be implicated). Despite advances obtained in the past two decades with an increase in the number of WINS, it is important to highlight that female population within neurosurgery is still <20% even on first world countries.[ 11 ]

Foreigner in training in neurosurgery

In our study, 16.7% of the participants were foreigners who are undergoing their neurosurgery residency in Mexico. In contrast, <9% of graduated neurosurgeons in the United States are foreigners.[ 4 , 12 , 22 ] We consider that Mexico represents one of the most important destinations for neurosurgical training for the rest of the Latin American countries. The results of the survey identify a clear perception of discrimination concerning the place of origin among foreign residents compared to native Mexican residents. About 37% of foreign residents reported feeling discrimination at some point during the training compared to 4% of Mexican residents (P < 0.001). Gadjradj et al. published that ethnic minorities presented a 3.8 times risk of being victims of discrimination (odds ratio [OR] 3.8, 95% confidence interval [CI] 2.3–6.2).[ 10 ] There is no previous report in Latin America about the subject.

Discrimination in neurosurgery training

Despite recent advances that report an increase in the presence of WINS[ 1 , 2 , 20 ] and the fight for equal opportunities for foreigners,[ 4 , 12 , 22 ] achieving gender and race equality is an unavoidable challenge for Mexico as an inclusive society and for Neurosurgery at a global level. Nowadays, discrimination is an undeniable problem.[ 5 , 7 , 9 - 11 , 19 , 24 ] The survey identified that women presented higher rates of discrimination compared to men (57.1% vs. 25.6%, P = 0.68), mainly discrimination by gender (42.9% vs. 6.4%, P < 0.001). Mexicans presented lower discrimination indices compared to foreign residents with neurosurgical training in Mexico (45.5% vs. 23.6%, P = 0.036).

The previous studies have reported that men surpass academic and occupational productivity compared to women. We consider that these results may be biased by a gender-based discrimination and reduced presence of women in these reports.[ 16 , 23 ] Other authors have published that racial and gender diversity has been associated with better patient outcomes and quality of care.[ 11 , 17 , 21 , 26 ] Although this was not an objective in our study, we consider that our results constitute areas of opportunity to be considered in subsequent studies. Our study provides initial information to analyze in a further research the causes related to the association between discrimination and academic productivity affected by gender or ethnicity.

Several authors have documented support against discrimination experienced by WINS.[ 5 , 7 , 9 , 11 , 19 , 24 ] Our results show that approximately 7 times more women suffer gender discrimination than men (42.9% vs. 6.4%, P < 0.001). Recently, an analysis of women in academic departments of surgery, indicates that women were up to 10 times more likely than men to notice gender discrimination.[ 5 , 11 ]

Gender discrimination experienced by WINS has been evaluated globally. Gupta et al. (2020)[ 11 ] describes a discrimination perception rate from 31% to 77% (n = 126) by WINS. It is disappointing that 77% of women who are planning to have children are concerned about being segregate by their colleagues. Although we did not explore the origin of discrimination in our survey, this is an important issue because the majority of neurosurgery residents are traditionally male, and perhaps this resumes a tendency to assume conventional sexist attitudes in the specialty.

In Mexico, the MSNS[ 14 ] database reported a presence of WINS of 14.5% between 2019 and 2020. The response rate of women in our survey did not meet our expectations and was only 2.6% (n = 7). Even though, the rate of perception of gender discrimination among women in our survey was significantly higher compared to men (42.9% vs. 6.4%, P < 0.001). Another study from India describes a total of 69 women registered in neurosurgery practice, of which 34.54% (n = 19) were residents and 40% of those who answered the survey mentioned being discriminated by gender (n = 22).[ 18 ] A conducted survey distributed among members of the congress of neurological surgeons (CNS) showed that 61.4% of respondents were victims of abusive behavior and 47.9% suffered any form of discrimination. Women surveyed were 2.5 times more likely to be victims of abuse (OR 2.5; 95% CI: 1.4–4.6) and 19.8 times more likely to be victims of discrimination (OR 19, 8, 95% CI: 8.9–43.9); followed by ethnic minorities who had 3.8 times the risk of being victims of discrimination. (OR 3.8, 95% CI 2.3–6.2).[ 10 ] In addition, they observed that victims of abuse presented approximately 2 times the risk of presenting burnout (OR 1.7, 95% CI 1.1–2.6).[ 10 ] We must emphasize that this was not a topic evaluated in our survey.

A perception of disadvantage for being women compared to men is clear. Factors such as a paucity of women mentors in neurosurgery, lack of work-life balance, absence of support in academic fields, perception of a reduced access to professional opportunities due to gender, and a sense of having to work harder than men for the same prestige[ 7 , 8 ] coupled with the high rates of gender discrimination, abuse, and sexual harassment are some of the problems that have been detected in most of the responses obtained in the multiple surveys applied internationally.[ 7 , 8 , 10 , 11 , 18 ] This information has inspired the creation of several women’s advocacy associations, such as the Women’s Committee in AO Spine.[ 8 ] Although the organization WINS was established 30 years ago to promote the inclusion and advancement of women in the field, only in 2014 was it recognized as a joint chapter of the American Association of Neurological Surgeons and the CNS.[ 11 ] This reflects a reluctant recognition of the important role of WINS and the current challenge facing gender discrimination.

Strengths and limitations of the study

In another study (De la Cerda-Vargas et al., 2021), we evaluated the impact of COVID on neurosurgery residents in Latin America and Spain.[ 6 ] 67% of residents reported that COVID negatively impacted their residence while 54% mentioned that their physical and mental health were compromised. However, the impact of discrimination suffered by residents was not identified. The results of the present survey obtained before SARS-COv-2 pandemic identifies alternative areas such as discrimination which negatively impact neurosurgical training and have been present for decades. In Mexico, there is no history of publications evaluating the impact of discrimination suffered by residents during neurosurgical training before the SARS-CoV-2 pandemic.

Due to the restricted number of women and foreigners undergoing neurosurgical training in Mexico who responded to the survey, our results do not allow us to enunciate strong conclusions. Nevertheless, this study represents an initial assessment of the problem which requires a greater number of respondents to calculate the real impact in Mexico or even in Latin America. We did not evaluate the burden of discrimination on the burnout rates suffered by residents,[ 10 ] abuse, mistreatment, or sexual harassment.[ 10 ]

CONCLUSION

Our results determine the situational diagnosis that neurosurgery residents experienced in Mexico before the SARS-CoV-2 pandemic. We believe that identifying issues that our residents face on a day-to-day basis is essential to upgrade educational and social relationships. This study pretends to recognize areas of opportunity to reduce the rate of discrimination suffered by residents who receive neurosurgical training in Mexico. Specific strategies targeted to our neurosurgical community aimed at improving a balance of opportunities among residents are a priority to reduce discrimination by gender and place of origin. Our study represents the first approach to determine the impact of discrimination suffered by women and foreign residents with neurosurgical training in Mexico before the SARS-CoV-2 pandemic.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Declaration of patient consent

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix 1: Survey

National Survey of Neurosurgery Residents in Training

Neurosurgical training center:

PGY:

Age:

Gender:

Country of Origin:

Situational diagnostic:

Has your neurosurgical training center its own academic program?

Yes () Not ()

Appendix 2:

Results by hospital group.

Acknowledgments

We would like to thank all residents, professors, Centers, and Hospitals that contribute to this project.

References

1.

2.

3. Chandra A, Aghi MK. Strategies to address projected challenges facing foreign applicants in the U. S. neurosurgery match. World Neurosurg. 2020. 138: 553-5

4. Chandra A, Brandel MG, Wadhwa H, Almeida ND, Yue JK, Nuru MO. The path to U.S. neurosurgical residency for foreign medical graduates: Trends from a decade 2007-2017. World Neurosurg. 2020. 137: e584-96

5. Cochran A, Hauschild T, Elder WB, Neumayer LA, Brasel KJ, Crandall ML. Perceived gender-based barriers to careers in academic surgery. Am J Surg. 2013. 206: 263-8

6. de la Cerda-Vargas MF, Stienen MN, Soriano-Sanchez JA, Campero A, Borba LA, Nettel-Rueda B. Impact of the Coronavirus disease 2019 pandemic on working and training conditions of neurosurgery residents in Latin America and Spain. World Neurosurg. 2021. 150: e182-202

7. Enchev Y, Brady Z, Arif S, Encheva E, Peev N, Ahmad M. Sexual discrimination in neurosurgery: A questionnaire-based nationwide study amongst women neurosurgeons in Bulgaria. J Neurosurg Sci. 2019. p.

8. Falavigna A, Ramos MB, de Farias FA, Britz JP, Dagostini CM, Orlandin BC. Perception of gender discrimination among spine surgeons across Latin America: A web-based survey. Spine J. 2021. p. S1529-9430(21)00182-0

9. Fujimaki T, Shibui S, Kato Y, Matsumura A, Yamasaki M, Date I. Working conditions and lifestyle of female surgeons affiliated to the Japan neurosurgical society: Findings of individual and institutional surveys. Neurol Med Chir (Tokyo). 2016. 56: 704-8

10. Gadjradj PS, Ghobrial JB, Booi SA, de Rooij JD, Harhangi BS. Mistreatment, discrimination and burn-out in neurosurgery. Clin Neurol Neurosurg. 2021. 202: 106517

11. Gupta M, Reichl A, Diaz-Aguilar LD, Duddleston PJ, Ullman JS, Muraszko KM. Pregnancy and parental leave among neurosurgeons and neurosurgical trainees. J Neurosurg. 2020. 134: 1325-33

12. Lu VM, Menendez I, Levi AD, Komotar RJ.editors. Letter to the editor: Lessons to learn from the Coronavirus disease 2019 (COVID-19) pandemic for international medical graduate applicants and United States neurosurgery residency programs. World Neurosurg. 2020. 141: 571-2

13. Mejia-Perez SI, Cervera-Martinez C, Sanchez-Correa TE, Corona-Vazquezo T. The woman in neurosurgery at the national institute of neurology and neurosurgery. Gac Med Mex. 2017. 153: 279-82

14.

15. Muehlschlegel S. Subarachnoid hemorrhage. Continuum (Minneap Minn). 2018. 24: 1623-57

16. Mueller C, Wright R, Girod S. The publication gender gap in US academic surgery. BMC Surg. 2017. 17: 16

17. Nassar ME. Racial and ethnic disparities in health care. Ann Intern Med. 2005. 142: 153

18. Palanisamy D, Battacharjee S. What it is to be a woman neurosurgeon in India: A survey. Asian J Neurosurg. 2019. 14: 808-14

19. Park J, Minor S, Taylor RA, Vikis E, Poenaru D. Why are women deterred from general surgery training?. Am J Surg. 2005. 190: 141-6

20. Renfrow JJ, Rodriguez A, Wilson TA, Germano IM, Abosch A, Wolfe SQ. Tracking career paths of women in neurosurgery. Neurosurgery. 2018. 82: 576-82

21. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: A meta-analytic review. JAMA. 2002. 288: 756-64

22. Scheitler KM, Lu VM, Carlstrom LP, Graffeo CS, Perry A, Daniels DJ. Geographic distribution of international medical graduate residents in U.S. Neurosurgery training programs. World Neurosurg. 2020. 137: e383-8

23. Shaikh AT, Farhan SA, Siddiqi R, Fatima K, Siddiqi J, Khosa F. Disparity in leadership in neurosurgical societies: A global breakdown. World Neurosurg. 2019. 123: 95-102

24. Steklacova A, Bradac O, de Lacy P, Benes V. E-WIN project 2016: Evaluating the current gender situation in neurosurgery across Europe-an interactive, multiple-level survey. World Neurosurg. 2017. 104: 48-60

25. Vespa P, Diringer MN. Participants in the International Multi-Disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. High-volume centers. Neurocrit Care. 2011. 15: 369-72

26. Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: A population based matched cohort study. BMJ. 2017. 359: j4366