Surgical Clerkships Still Exclude Many Medical Students, Major Review Finds

Surgical clerkships are often described as the crucible of medical education: the rotation where students first scrub into operations, absorb the rhythm of the operating room, and decide whether a career in surgery is within their reach. Yet a sweeping new narrative review published in Global Surgical Education, the journal of the Association for Surgical Education, argues that for many students—particularly those from historically excluded groups—the clerkship is less a crucible than a filter, one that quietly screens people out through inaccessible environments, fragmented accommodation systems, and a culture steeped in hierarchy and bias. Drawing on a structured search of more than 1,800 records, the research team identified 25 studies published between 2014 and 2025 that directly address accessibility, inclusion, or belonging in surgical clerkships, and their synthesis paints a picture of barriers that are systemic, persistent, and deeply intertwined.

The researchers, led by Sarah E. Hughes of the University of California San Francisco together with colleagues at the University of New Mexico, the University of Michigan Medical School, and Penn State Milton S. Hershey Medical Center, searched PubMed, Embase, and Web of Science for literature published between January 2014 and October 2025. Two reviewers independently screened titles, abstracts, and full texts, with a third reviewer resolving disagreements, and data were extracted using a standardized REDCap form. From 1,828 identified records, 259 duplicates were removed, 1,569 records underwent title and abstract screening, 223 full texts were assessed, and 25 studies ultimately met the inclusion criteria. The most frequently examined domains of inclusivity were gender, race, ethnicity, and disability, with smaller bodies of work addressing sexual orientation and socioeconomic status. Several studies examined multiple identity domains simultaneously, reflecting an emerging but still limited attention to intersectionality.

A central methodological choice of the review was to treat identity itself not as a barrier but as a context through which barriers are experienced. The authors defined accessibility as the extent to which medical students can equitably participate in required surgical clerkship activities—operative, clinical, didactic, evaluative, and team-based learning—without avoidable physical, sensory, communication, curricular, policy, or structural obstacles. Belonging was defined as a student’s perceived sense of acceptance, psychological safety, and legitimacy as a member of the surgical team. Barriers were then sorted into three domains: structural, institutional, and cultural. This framework allowed the team to synthesize a heterogeneous literature—surveys, qualitative analyses, mixed-methods studies, and programmatic reports—into a coherent conceptual map that educators can use to locate points of intervention.

Structural barriers emerged most prominently in studies of students with disabilities, particularly those with mobility and sensory impairments, but they also affected students navigating pregnancy, lactation, and gender-related needs. Recurrent challenges included operating room layouts designed around sterile workflow that leave little room for adaptation, limited access to adaptive technologies such as assistive listening devices and real-time captioning, and inconsistent availability of basic facilities like locker rooms and lactation spaces. Reports involving deaf and hard-of-hearing trainees underscored the absence of reliable communication access in the operating room, while studies of left-handed learners documented equipment and ergonomic design that implicitly assume right-handedness. Even seemingly mundane details—scrubs and instruments available only in a narrow range of sizes—restricted full participation. These limitations are intensified during clerkships, when students rotate rapidly across sites with heterogeneous infrastructure and little opportunity for anticipatory planning.

Institutional barriers cut across nearly every identity group studied. A central finding was the lack of standardized accommodation processes: students were repeatedly required to disclose their needs and navigate fragmented systems that differed from one clerkship site to the next. Multiple studies also documented inequities in evaluation, including bias in narrative assessments, differential grading patterns by gender and race, and variability in the autonomy and feedback students received. One study found that standardized oral examinations could assess clinical knowledge while reducing racial grading differences in a surgery clerkship, suggesting that assessment design itself is a modifiable lever. The stakes are heightened in the clerkship context precisely because evaluations are high-stakes, supervisory relationships are brief and longitudinal continuity is limited, and students have few chances to establish credibility before being graded.

Cultural barriers were the most frequently reported category and were pervasive across nearly all identity domains. Students described bias, microaggressions, stereotype threat, and exclusion from team dynamics, often in subtle but cumulative forms that eroded psychological safety over the course of a rotation. Studies of women in surgical environments documented gender-based microaggressions and inequitable access to procedural opportunities, while research involving underrepresented racial, ethnic, and religious groups highlighted isolation, lack of role models, and challenges to belonging. The hierarchical structure of surgical teams, combined with the transient and evaluative nature of clerkships, amplified these dynamics by limiting opportunities for trust-building and discouraging students from speaking up. For sexual and gender minority students, concerns about disclosure and identity management added a further layer of cognitive and emotional burden during an already demanding rotation.

The review is not solely a catalog of failures; it also maps a growing arsenal of strategies. For students with disabilities, the most effective approaches emphasized proactive planning and individualized accommodation, including early coordination among students, clerkship leadership, and disability services before the rotation begins. Documented solutions included assistant models that preserve participation in sterile procedures, adaptive technologies such as communication access real-time translation captioning and assistive listening devices, and modifications to operative workflows that maintain both access and autonomy. Standardized yet flexible accommodation processes proved critical to reducing the burden of repeated self-advocacy, a burden that falls disproportionately on students who are already navigating unfamiliar environments.

Efforts targeting gender and racial inequities converged on mentorship, representation, and evaluation reform. Structured mentorship programs—including near-peer models in which residents support medical students during the clerkship, and programs pairing students with faculty—were repeatedly associated with improved belonging and reduced isolation. Assessment reforms such as standardized grading rubrics, structured evaluations, and in some cases pass-fail models aimed to strip subjective bias out of high-stakes grading. Increasing representation and early exposure to diverse role models were linked to stronger engagement and a greater sense that surgical careers were attainable. On the cultural front, studies emphasized psychologically safe learning environments built through structured onboarding, clear expectation setting, faculty development in inclusive teaching, normalized help-seeking, and transparent pathways for reporting bias or mistreatment. Across all domains, the strategies that worked shared three features: they were implemented early, applied consistently across rotation sites, and integrated into clinical workflows rather than bolted on as exceptions.

Perhaps the review’s most important argument is that single-level interventions are insufficient. Structural improvements may enhance physical access but leave biased evaluation systems untouched; mentorship may improve belonging but cannot compensate for inconsistent accommodations. The authors argue that meaningful progress requires alignment across structural, institutional, and cultural levels simultaneously—a multilevel framework that surgical educators can use to identify gaps, design interventions, and evaluate outcomes. The timing is notable: most included studies were published after 2021, reflecting a post-pandemic era in which psychological safety, burnout, and learning-environment culture have moved to the center of surgical training debates. Because clerkships are a critical period in which students form perceptions of surgical culture and assess their own fit within the field, persistent barriers during this window likely shape not only day-to-day learning but long-term career trajectories and specialty choice, with downstream consequences for the diversity of the surgical workforce itself.

The authors are candid about the limitations of the evidence base. Studies are unevenly distributed across identity domains, with comparatively little attention to students with disabilities, those from low-income backgrounds, and those navigating religious or caregiving responsibilities; few examine intersectionality; and most are single-institution and descriptive, offering limited evaluation of intervention effectiveness or long-term outcomes. The review itself was restricted to English-language, North American literature, and its narrative design synthesizes themes rather than pooling effect estimates. Still, the framework it offers is a practical starting point: by naming barriers as structural, institutional, or cultural, and by insisting that solutions operate at all three levels simultaneously, the review gives surgical educators a shared vocabulary for change. Ensuring that every student can fully participate in—and belong within—the surgical clerkship, the authors conclude, is essential not only for the students of today but for building a more equitable and representative surgical workforce for the decades ahead.

Subject of Research: Barriers to accessibility and belonging in surgical clerkships and multilevel strategies to promote equity in surgical education

Article Title: Barriers and multilevel strategies for accessibility and belonging in surgical clerkships: a narrative review

Article References: Hughes, S. E., Wang, M.-L., MacEachern, M., & Cooper, A. B. (2026). Barriers and multilevel strategies for accessibility and belonging in surgical clerkships: a narrative review. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 165. https://doi.org/10.1007/s44186-026-00571-x

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00571-x

Keywords: surgical clerkship, medical students, medical education, accessibility, inclusion, belonging, equity, disability accommodations, mentorship, bias in evaluation, psychological safety, surgical workforce diversity