Why the Gap? Analyzing the Etiology of Gender-based Performance Discrepancy in Laparo-endoscopic Skills

Background: Completion of the Fundamentals of Laparoscopic (FLS) and Endoscopic Surgery (FES) Programs has been required by the American Board of Surgery (ABS) for general surgery certification for several years. While validity evidence exists to support these assessments as high stakes examinations, retrospective studies on pass rates have noticed an alarming trend in gender-based performance discrepancy, with men consistently outperforming women. Purpose: The purpose of this study was to investigate the following questions: 1) What is the relationship between demographic variables and performance of endosurgical skills? 2) What is the relationship between visuospatial aptitude and performance? 3) What is the underlying etiology of gender-based discrepancy? 4) Does the robotic platform minimize gender-based performance discrepancy? Methods: Sixty-nine novice participants completed a visuospatial aptitude assessment and a series of tasks on an endoscopic simulator, robotic simulator, laparoscopic box trainer, and robotic dome trainer. Bivariate analyses were performed to analyze the relationship between performance and demographic variables, which guided subsequent multivariate linear regression analyses. Results: While performance on the laparoscopic tasks was less uniform, men outperformed women on all 3 FES tasks (18.1 points, p < 0.001 for FES Navigation, 19.9 points, p < 0.001 for FES Retroflexion, and 18.3 points, p < 0.001 for FES Tool Manipulation). Men also scored higher in the visuospatial aptitude assessment by 4.7 points (p < 0.001). After controlling for gender, visuospatial aptitude, the interaction between gender and visuospatial aptitude, glove size, hand dominance, height, ethnicity and ergonomics, visuospatial aptitude remained the only significant variable associated with all three FES tasks (Table 1). There was also no gender-related difference with regards to the robotic simulator or dome trainer, suggesting that when known differences between genders relating to grip strength and physical motor behavior are mitigated through an ergonomically unbiased platform, performance differences dissipate. Discussion: Our study supports the conclusion that previously observed gender differences in surgical performance are the result of visuospatial aptitude difference, not gender, and perpetuating the false belief that men are inherently better than women in surgical domains further amplifies the stereotype threat women in surgery face.