Perceived Gender Bias Erodes Medical Students’ Sense of Belonging in Surgery

Women now graduate from medical school in numbers equal to men, yet they remain strikingly underrepresented in surgical specialties and in the leadership ranks of academic surgery. A new prospective cohort study suggests that one of the decisive moments where that pipeline leaks may be the six-week general surgery clerkship, the required third-year rotation when many students first decide whether a surgical career is realistic for them. The research, conducted at Virginia Tech Carilion School of Medicine and published in Global Surgical Education, the Journal of the Association for Surgical Education, finds that the more gender bias students perceive in the surgical training environment, the weaker their sense of belonging and the worse their well-being during the rotation.

The study team, led by Farrell C. Adkins of the Department of Surgery at Virginia Tech Carilion School of Medicine with colleagues including Sophia K. McKinley of Massachusetts General Hospital, set out to test a specific psychological hypothesis. They proposed that women medical students who perceived greater gender bias and who were more susceptible to stereotype threat would report a lower sense of belonging within the surgical team and poorer well-being. Stereotype threat, a concept from social psychology, describes the anxiety individuals experience when they fear confirming a negative stereotype about their social group, in this case the long-standing and well-documented stereotype questioning women’s aptitude for technical fields. Sense of belonging, by contrast, captures a person’s felt connection to the people, places, and experiences around them, and psychologists have argued that it emerges from the interaction between a social environment and an individual’s perceptions and identity.

To measure these constructs rigorously, the researchers enrolled essentially the entire third-year class. Of the 49 students eligible during an 11-month window between May 2023 and March 2024, 48 completed identical paper surveys at both the start and the end of the clerkship, a 98 percent response rate. The 31-item instrument drew on four previously validated tools: the Equity and Fairness subscale of the Employee Environment Diagnostic Survey to gauge perceived gender bias, the Social Identity and Attitudes Scale to assess gender-stigma consciousness and gender identity centrality as precursors of stereotype threat, the psychological-experience subscale of the Sense of Belonging Index, and the Medical Student Well-Being Index, a screening tool for distress and burnout. All items used five-point Likert scales, and every subscale showed strong internal consistency with Cronbach’s alpha values exceeding 0.80. Participants were 63.8 percent women, 54.4 percent White, and 37.0 percent Asian, with an average age of 27.0 years.

The statistical architecture of the analysis was deliberately layered. The team ran correlation analyses across the psychosocial domains at both time points, built baseline-adjusted standardized linear regression models to predict post-clerkship outcomes, and fitted linear mixed models with gender as a between-subjects factor, time as a within-subjects factor, and a gender-by-time interaction, estimated with restricted maximum likelihood and a compound symmetry covariance structure. The results of the correlation analyses were unambiguous. Perception of gender bias was negatively correlated with sense of belonging both before the clerkship began (r = −0.55, 95% CI −0.72 to −0.30, p < 0.0001) and after it ended (r = −0.65, 95% CI −0.79 to −0.44, p < 0.0001). The same construct correlated negatively with well-being at both time points (r = −0.42 pre-clerkship, p = 0.003; r = −0.40 post-clerkship, p = 0.005). Susceptibility to stereotype threat showed weaker and less consistent correlations, tracking with well-being but not reliably with belonging.

The regression models sharpened the picture considerably. In the model predicting post-clerkship sense of belonging, higher post-clerkship perceived gender bias was a significant negative predictor (standardized β = −0.57, 95% CI −0.85 to −0.32, p < 0.001), and the model explained 48 percent of the variance in belonging. Notably, participant gender itself was not a significant predictor of either post-clerkship belonging or well-being once baseline levels were accounted for. The well-being model, which explained 64 percent of the variance, was dominated by baseline well-being (standardized β = 0.73, p < 0.001), suggesting that a student’s emotional state during the rotation is anchored more strongly to pre-existing resilience and factors outside the rotation than to the clerkship environment itself. Belonging, in contrast, appears to be shaped by what actually happens on the surgical teams.

Gender differences emerged clearly on the stereotype-threat measures. Women reported significantly greater susceptibility to stereotype threat than men both before the clerkship (mean difference = 0.79, p = 0.005, Cohen’s d = 1.09) and after it (mean difference = 0.70, p = 0.034, Cohen’s d = 0.83), effect sizes that are large by conventional standards. In the adjusted mixed-effects models, women scored higher on awareness of gender-based treatment (β = 0.62, p = 0.016), identification with their gender (β = 1.01, p = 0.005), and susceptibility to stereotype threat (β = 0.82, 95% CI 0.32 to 1.32, p = 0.001). Women also reported greater perception of gender bias favoring men, though the adjusted estimate for that domain was small and imprecise, with a confidence interval that crossed zero (β = 0.37, 95% CI −0.02 to 0.76, p = 0.018). No significant gender differences appeared in sense of belonging or well-being at either time point, a finding that contrasts with some earlier work but aligns with studies of general surgery residents.

One of the most intriguing results was temporal. Students’ awareness of gender-based treatment declined significantly over the six weeks (mean difference = −0.41, p = 0.003, Cohen’s d = −0.47), even as the other domains remained stable. The authors offer two possible explanations. Clerkship participation may have changed how students interpreted potentially gendered interactions, or students may simply have encountered fewer overtly gendered behaviors than they had anticipated, reflecting either the local culture of the Department of Surgery at Virginia Tech Carilion or a broader shift in surgical culture. Because the survey was designed to preserve anonymity, the team did not record team compositions or specific experiences such as microaggressions, feedback quality, or operative participation, so the drivers of this change cannot be pinned down. The authors also note that the marginal, non-significant decline in stereotype threat raises the possibility that exposure to medical teams with many women members may buffer students against self-doubt, an idea consistent with the stereotype inoculation model, which proposes that contact with ingroup experts acts as a social vaccine for the self-concept, particularly during transitional periods like the third-year clerkships.

The practical implications for surgical educators are concrete. Because perceived gender bias tracked so tightly with sense of belonging, interventions that reduce students’ perceptions of inequity in the surgical environment may be especially valuable for cultivating inclusion and sustaining interest in surgical careers. The authors point to system-level changes such as inclusive feedback practices and standardized evaluation rubrics, motivated by prior literature showing that narrative evaluations of medical students differ by gender and minority status. The regression findings also suggest a second, distinct lever: since well-being appears anchored to pre-existing factors, students may benefit from pre-clerkship resiliency training as preparation for the clinical curriculum. Future work could test longitudinal growth mindset interventions or microaggressions-response frameworks such as XYZ, in which a person states what they feel, what prompted it, and why, and GRIT, which stands for Gather, Restate, Inquire, Talk it Out.

The study’s limitations are acknowledged candidly by its authors. It was conducted at a single academic institution with a relatively homogeneous participant pool, and the small class size likely left it underpowered to detect more nuanced relationships, restricted the covariates that could be added to the mixed models without overfitting, and precluded a path analysis or the inclusion of gender-by-race interaction terms, which would have produced unstable estimates given the distribution of participants across racial categories. The authors emphasize that the data do not permit causal inference and that a multi-institution study capturing variation in local training environments could clarify how local culture shapes these psychological domains. Even so, the core message stands on solid ground: perceived gender bias is a consistent negative correlate of belonging and well-being during the surgical clerkship, women perceive more of it and carry a heavier burden of stereotype threat, and the clerkship itself, not merely what students bring into it, appears to shape whether they feel they fit in with surgeons. As the authors conclude, reducing perceptions of gender bias may be one of the most actionable targets for increasing gender parity in the surgical specialties, and attending carefully to the local training milieu is essential when evaluating how these forces interact at the undergraduate medical education level.

Subject of Research: The impact of medical student gender on perceptions of gender bias and stereotype threat during the general surgery clerkship

Article Title: The impact of medical student gender on perception of gender bias and stereotype threat during the general surgery clerkship: a prospective cohort study

Article References: Adkins, F. C., Karp, H. Q., Hankey, M. S., & McKinley, S. K. (2026). The impact of medical student gender on perception of gender bias and stereotype threat during the general surgery clerkship: a prospective cohort study. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 156. https://doi.org/10.1007/s44186-026-00562-y

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00562-y

Keywords: gender bias, stereotype threat, general surgery, medical education, clerkship, sense of belonging, well-being, surgical careers, gender equity, medical students, prospective cohort study, surgical training