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Objective Gender bias has been identified in letters of recommendation (LOR) in many different surgical training fields. Among surgeons, women comprise over 30% of the full-time faculty positions nationally and surgical oncology is one of the most gender diverse surgical subspecialties. We sought to determine if bias existed in LOR submitted to a Complex General Surgical Oncology (CGSO) fellowship. Design LOR for the CGSO fellowship were retrospectively analyzed from applicants at a single institution over an 8-year period (2013-2020). The linguistic content of the letters was analyzed using Linguistic Inquiry and Word Count (LIWC2015), a validated text analysis program. Using multivariable analysis, LOR were compared by gender of both applicant and letter writer to explore the association between gender and the characteristics of the applicants and letter writers. Setting University of North Carolina at Chapel Hill (UNC), Division of Surgical Oncology and Endocrine Surgery. Participants Applicants interviewed for the CSGO fellowship program at the UNC from 2013 to 2020 as well as all applicants from the 2018 application cycle, regardless of interview status. Results About 841 letters from 219 interviewed applicants throughout the 2013 to 2020 surgical oncology fellowship application cycles were included. No difference in authenticity, clout, analytic thinking, or emotional tone of the letters was seen when comparing men and women applicants. Of the 41 word categories analyzed, only “references to achievement” in LOR written for women was significantly higher when compared to LOR written for men (p = 0.01). Interestingly, significantly more women applicants had at least 1 LOR written by a woman (p = 0.04). A subset analysis of all applicants regardless of interview status from the 2018 cycle included 294 LOR from 77 applicants. With the inclusion of noninterviewed applicants, LOR for men had more analytic tone than LOR for women (p = 0.02), otherwise there were no significant differences between the groups. Conclusions Very few differences in LOR were found for applicants at a CGSO fellowship program based on applicant or letter writer gender. The lack of gender bias demonstrates progress within the field of surgical oncology, likely a result of recent work and educational effort in this area. Efforts to expand this progress into other surgical sub-specialties are necessary.

Background In the era of coronavirus disease 2019 (COVID-19), many Complex General Surgical Oncology (CGSO) fellowship programs implemented virtual interviews (VI) during the 2020 interview season. At our institution, we had the unique opportunity to conduct an in-person interview (IPI) prior to the pandemic-related travel restrictions, and a VI after the restrictions were in place. Objective The goal of this study was to understand how the VI model compares with the traditional IPI approach. Methods Online surveys were distributed to both groups, collecting feedback on their interview experience. Responses were evaluated using a two-sample t test assuming equal variances. Results Twenty-three of 26 (88%) applicants completed the survey. Most applicants reported that the interview gave them a satisfactory understanding of the CGSO fellowship (100% IPI, 92% VI) and the majority in both groups felt that the interview experience allowed them to accurately represent themselves (92% and 82%, respectively). All participants in the IPI group felt they were able to get an adequate understanding of the culture of the program, while only 64% in the VI group agreed with that statement (p = 0.02). IPI applicants were more likely to agree that the interview experience was sufficient to allow them to make a ranking decision (92% vs. 54%; p = 0.04). Conclusions While the VI modality offers several advantages over the IPI, it still falls short in conveying some of the more subjective aspects of the programs, including program culture. Strategies to provide applicants with better insight into these areas during the VI will be important moving forward.

BACKGROUND: Inflammatory breast cancer (IBC) has historically been characterized by high rates of recurrence and poor survival, however, there have been significant improvements in systemic therapy. We sought to investigate modern treatment of IBC and define the yield and prognostic significance of axillary lymph nodes after neoadjuvant chemotherapy (NAC). METHODS: Women with clinical stage T4d, N0–N3, M0 IBC from 2012 to 2016 in the National Cancer Database (NCDB) were included. Kaplan Meier survival curves and Cox regression were used to assess mortality by receptor subtype and nodal status. RESULTS: We identified 5,265 patients; 37% hormone receptor (HR)+/HER2−, 19% HR+/HER2+, 18% HR−/HER2+, and 26% triple negative (TN) and five-year overall survival was 51.6%. Only 34% were treated according to guidelines with neoadjuvant chemotherapy (NAC), modified radical mastectomy, and adjuvant radiation. Pathologically positive lymph nodes (ypN+) after NAC varied by subtype and clinical nodal status (cN) ranging from 82% in cN+ HR+/HER2− patients to 19% in cN0 HR−/HER2+ patients. ypN+ strongly correlated with survival in all subtypes with the most pronounced impact in HR+/HER2+ patients, with 90% five year overall survival in ypN0 vs 66% for ypN+ (HR 4.29, 95% CI 1.58–11.70, p=0.03). CONCLUSIONS: Five-year survival in M0 IBC is 51.6%. Positive nodes after NAC varied by subtype and clinical N status but is sufficiently high and provided meaningful prognostication in all subtypes to support continued routine pathologic assessment. Future study is warranted to identify reliable, less morbid, methods of staging the axilla in IBC patients appropriate for de-escalation of axillary surgery.

Background Studies have shown poorer health outcomes for people who identify as sexual and/or gender minority (LGBTQ+) compared to heterosexual peers. Our goal was to establish baseline levels of LGBTQ Ally Identity Measure (AIM) scores: (1) Knowledge and Skills, (2) Openness and Support, and (3) Awareness of Oppression of the LGBTQ+ in surgical trainees, and implement a pilot training in LGBTQ + cultural competency. Materials and methods General surgery residents from a single academic medical center participated in a 2-h educational training developed from the existing Health Care Safe Zone training at our institution. Utilizing the previously validated LGBTQ Ally Identity Measure (AIM), residents responded to 19 items on Likert-type scales from 1 to 5 pretraining and 6 wk posttraining. The residents’ perceptions of the utility of the training were also assessed. Data were analyzed by MANOVA, repeated measures MANOVA, and subsequent univariate analysis. Results 27 residents responded to the pretraining survey (52%), 22 residents participated in the training, and 10 responded at 6 wk posttraining (19%). The average baseline scores were Knowledge and Skills 19.38 ± 4.64, Openness and Support 25.96 ± 4.31, and Awareness of Oppression 17.15 ± 2.20. Participants who identified as women scored 4.46 (95% CI 0.77-8.15) points higher in Openness and Support compared to males. Of those respondents who completed pretraining and posttraining surveys (n = 10), training had a significant effect on AIM scores with an improvement in Knowledge and Skills (P = 0.024) and Openness and Support (P = 0.042). Residents found the training relevant to surgery patient care (71%), increased their competency in LGBTQ + patient care (86%), and all participants indicated they were better LGBTQ allies following the training. Conclusions Assessing LGBTQ + allyship in surgical residents, we found that training improved AIM scores over time with significant improvement in the Knowledge and Skills, and Openness and Support scales, suggesting a viable and valuable curriculum focused on sexual and gender identity-related competencies within the graduate medical education for surgical trainees.