The research team, led by Sohail Khan of Touro College of Osteopathic Medicine together with collaborators at George Mason University, Stony Brook Medicine, Columbia University and other institutions, constructed a cross-sectional cohort of 892 directors. It included 179 medical student clerkship directors, 366 general surgery residency program directors, and fellowship directors in complex general surgical oncology, surgical critical care, minimally invasive surgery and endocrine surgery. Leadership identities were compiled from publicly available sources and national accreditation databases, including the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, the National Resident Matching Program and the American Medical Association’s FREIDA database, supplemented by the Fellowship Council and the American Association of Endocrine Surgeons.

Demographic characteristics were ascertained using automated facial analysis with investigator adjudication, an approach that has become increasingly common in workforce diversity research where self-reported race and gender data are unavailable for public-facing professionals. The team used the Betaface API, version 2.0, with human reviewers confirming classifications. Categorical comparisons relied on Pearson chi-squared and Fisher exact tests, while multivariable logistic regression identified factors independently associated with holding leadership roles. All analyses were performed in STATA version 18E. Because the study relied exclusively on publicly available, aggregated data with no patient-level or identifiable private information, institutional review board approval was deemed exempt.

The headline numbers are unambiguous. Among the 892 directors, White surgeons predominated at 67.8 percent, followed by Asian surgeons at 18.2 percent, Middle Eastern surgeons at 5.3 percent, Hispanic surgeons at 4.8 percent and Black surgeons at 3.9 percent. Female representation across the entire cohort stood at 34.5 percent, but the figure varied dramatically by subspecialty, a difference that reached statistical significance at P less than .001. Endocrine surgery led the way with 48.0 percent female fellowship directors, while minimally invasive surgery sat at the bottom with just 20.3 percent. Asian surgeons were most visible at the fellowship tier in complex general surgical oncology, at 31.4 percent, and endocrine surgery, at 24.0 percent, while international medical graduates were most prevalent among directors in complex general surgical oncology at 20.0 percent and minimally invasive surgery at 18.3 percent.

Perhaps the most revealing structural signal came from academic rank. Rank distribution differed markedly across leadership tiers, again with P less than .001. Assistant professors constituted the plurality of clerkship directors at 44.1 percent, suggesting that the entry point of the educational pipeline is staffed disproportionately by junior faculty. At the opposite end, full professors were most common among fellowship directors in complex general surgical oncology at 40.0 percent and minimally invasive surgery at 33.3 percent. Institutional setting followed a similar gradient: residency program directors were predominantly community-based at 58.8 percent, whereas fellowship directors were primarily university-based. In other words, as leadership roles become more senior and more concentrated in elite academic centers, they become demographically narrower.

The pipeline benchmarking makes the attrition vivid. Between 2022 and 2025, across 214,411 medical school applicants and 5,988 matched general surgery residents, women accounted for 56.8 percent of applicants and 55.1 percent of matched residents. Black trainees represented 9.4 percent of matriculants and 7.2 percent of matched residents, and Hispanic trainees 6.4 percent of matriculants and 12.0 percent of matched residents. Every one of those proportions exceeds the corresponding group’s share of surgical education leadership. Black surgeons, at 3.9 percent of directors, hold leadership roles at less than half their rate of residency entry. Hispanic surgeons, at 4.8 percent of directors, fare even worse against their 12.0 percent share of matched residents. Women, the statistical majority of incoming residents, remain a one-third minority of directors overall and barely one in five in minimally invasive surgery.

The authors frame this discordance as demographic consolidation within senior academic ranks and university-based institutions across the surgical training continuum. The mechanism is consistent with the well-documented leaky pipeline literature cited in the study, which traces how underrepresented-in-medicine trainees encounter compounding barriers from undergraduate education through faculty advancement. Prior work has shown that mentorship alone is insufficient without active sponsorship, that early-career scholarly productivity gaps set the stage for unequal academic advancement, and that leadership demographics of training programs are themselves associated with trainee diversity. A leadership tier that does not reflect the trainees beneath it risks perpetuating itself, since directors control recruitment, evaluation, promotion and the informal networks through which opportunities flow.

The timing of the study lends it particular urgency. The published literature it draws on includes recent warnings that health care has become a new battlefront for anti-diversity, equity and inclusion attacks, and that anti-DEI legislation threatens both equitable surgical care and workforce diversity. In that climate, the study’s demonstration that gains at the trainee level are not being converted into governance-level representation provides an empirical baseline against which any policy retreat or advance can be measured. It also matters for patients: prior research has linked surgeon sex to long-term postoperative outcomes for common operations, and a diverse physician workforce is associated with improved trust and communication among racially and ethnically diverse patient populations.

Methodologically, the continuum-wide design is what distinguishes this analysis from earlier single-tier studies. Previous investigations have examined gender gaps among residency program leadership, diversity within individual fellowship directorships, or racial trends in specific subspecialty pipelines, but few have connected clerkship, residency and fellowship leadership into a single cross-sectional frame and benchmarked each tier against national applicant and match data. That design exposes the gradient directly: diversity is highest where the pipeline is widest and lowest where the funnel is narrowest, with the fellowship director tier, the most university-concentrated and most senior, showing the greatest consolidation. The subspecialty contrasts are equally instructive, since endocrine surgery’s near-parity female leadership and complex surgical oncology’s relatively high Asian and international medical graduate representation demonstrate that different structural cultures within surgery produce different outcomes from the same national pipeline.

The study’s limitations are those inherent to its design. Facial analysis, even with investigator adjudication, is an imperfect proxy for self-identified race and gender, and the cross-sectional snapshot cannot establish causation or track individuals over time. The fellowship analysis covers four subspecialties rather than the full breadth of surgical fellowship training. Still, the data availability statement notes that all figures derive from publicly accessible sources and are included in the published article and its supplementary files, making the findings independently verifiable. What the analysis delivers is a precise, reproducible map of where the surgical education system loses its diversity, and the map points unambiguously to the terminal bottleneck: the senior, university-based directorships that shape who enters the profession, how they are trained, and who among them will one day hold the levers of surgical governance. Until representation at that tier reflects the majority-female, increasingly diverse residency cohorts now moving through the pipeline, the study suggests, the demographic gains of the past decade will remain stranded at the bottom of the ladder.

Subject of Research: Demographic and structural disparities in U.S. surgical education leadership across the training continuum

Article Title: The terminal bottleneck: a continuum-wide cross-sectional analysis of demographic and structural disparities in U.S. surgical education leadership (2025–2026)

Article References: The terminal bottleneck: a continuum-wide cross-sectional analysis of demographic and structural disparities in U.S. surgical education leadership (2025–2026). (n.d.). https://doi.org/10.1007/s44186-026-00548-w

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00548-w

Keywords: surgical education, leadership diversity, academic surgery, workforce disparities, gender equity, underrepresented in medicine, fellowship directors, residency program directors, clerkship directors, leaky pipeline, medical education, health equity

Consultation-liaison psychiatry, often abbreviated CLP, sits at the intersection of psychiatry and the rest of medicine. Its practitioners evaluate and manage psychiatric conditions in patients who are primarily receiving medical or surgical care, addressing problems such as delirium, dementia with behavioral disturbances, decision-making capacity, and the psychological dimensions of serious illness. Because these issues arise in virtually every corner of the hospital, exposure to CLP during medical school can benefit future clinicians well beyond those who choose psychiatry as a career. Prior research has suggested that medical student rotations in consultation-liaison psychiatry correlate with increased interest in psychiatry careers and with greater psychiatric knowledge among students pursuing other specialties, making the quality and availability of these experiences a matter of broad educational significance.

The historical context makes the new survey particularly notable. The last broad survey of consultation-liaison undergraduate education in the United States was published in 1976, when 83 percent of programs offered CLP experiences ranging from single-digit seminars or consultations to multiple weeks of clinical CLP. A UK study from 1983 found that only one school in twenty-five offered formal clinical psychosomatic medicine or CLP experience, although many taught related didactic content. A Canadian survey published in 1984 showed that fewer than 10 percent of students were assigned primarily to CLP settings during their psychiatry clerkship. With comparable data from the United States and elsewhere remaining sparse in the decades since, the authors of the new study set out to characterize current CLP undergraduate opportunities and identify strategies to strengthen student education.

To do so, the research team designed a survey for psychiatry clerkship directors covering clerkship structure, class size, faculty characteristics, and affiliated CLP fellowships and electives. The instrument also assessed the scope of each school’s CLP didactic topics, perceived barriers to expanding CLP training, attitudes toward student exposure, and interest in centralized resources. It combined multiple-choice questions with Likert scales and was distributed in 2024 through the listserv of the Association of Directors of Medical Student Education in Psychiatry, which included 56 self-identified clerkship directors. To broaden participation, the survey was redistributed in 2025 using publicly available email addresses of clerkship directors and associate staff. The team sought contact information for the 200 medical schools operating in summer 2024, identified from the American Association of Medical Colleges and the American Association of Colleges of Osteopathic Medicine, and located addresses for 148 of them. Because listserv membership was anonymous, the investigators could not determine whether these schools overlapped with those reached in the first round. The survey closed automatically for respondents who reported having already completed it, and all responses were anonymous, with the project approved by the VA Boston Research and Development Committee and data managed through REDCap electronic capture tools hosted at the Veterans Health Administration.

The final sample comprised 54 of the 200 existing medical schools, a response rate of 27 percent. Responding schools were predominantly allopathic at 91 percent, and all US Census Bureau geographic regions and all quartiles of medical school class size were represented. Twelve respondents, or 22 percent, had formal CLP training or board certification, while 42 schools, or 78 percent, had at least one CLP-trained faculty member. Nineteen schools, or 35 percent, had an affiliated CLP fellowship. These institutional characteristics matter because faculty expertise and fellowship infrastructure are closely tied to the depth and breadth of the educational experiences a school can offer its students.

The headline finding is that consultation-liaison psychiatry is broadly represented in the clerkship landscape. Forty-nine of the 54 responding schools, or 91 percent, offered CLP core clerkship options. Inpatient CLP was the most common format, offered by 96 percent of those 49 schools, while outpatient CLP was the least frequent, offered by only 20 percent. Yet availability did not translate into universal participation. Among schools offering CLP clerkship options, the proportion of students actually participating in a CLP experience ranged from just 7.5 percent to 100 percent of each class, meaning that at many institutions the majority of students complete their psychiatry training without direct clinical exposure to the subspecialty.

Didactic teaching showed a similar pattern of uneven coverage. Across all 54 responding schools, the most frequently taught CLP topics were delirium at 87 percent, dementia with behavioral disturbances at 70 percent, and capacity assessment at 59 percent. At the other end of the spectrum, psycho-oncology was taught at only 5.6 percent of schools and transplant psychiatry at just 3.7 percent. These low figures are striking given that delirium, capacity evaluation, and the psychiatric dimensions of cancer care and organ transplantation are relevant to nearly every specialty a medical student might enter, from surgery to oncology to internal medicine. Even the most common topics were not universally taught, leaving room for improvement in core content that applies across the hospital.

The survey also probed the barriers standing in the way of expanded CLP education. The top identified obstacles were lack of dedicated CLP services, cited by 33 percent of respondents, lack of institutional support, cited by 26 percent, and insufficient CLP faculty, also cited by 26 percent. When asked to rate the number of CLP opportunities at their schools on a scale from far too few to far too many, 43 percent of respondents felt their schools had too few clinical opportunities and 39 percent felt there were too few CLP didactics. At the same time, 63 percent of respondents agreed with the statement that all medical students should have clinical exposure to CLP. The authors suggest that this variation in opinion reflects the identified institutional limitations as well as the opportunity cost that universal CLP rotations could impose by limiting student exposure to other areas of psychiatry.

Perhaps the most actionable finding concerns what educators want next. The preferred strategies to enhance CLP student exposure were centralized online didactics, favored by 70 percent of respondents, and CLP student handouts, favored by 80 percent. These handouts are described as printable, student-level educational guides summarizing key CLP topics or offering tips on how to contribute to a CLP team. The authors note that this enthusiasm for shared resources is intuitive given reported shortages in both faculty and specific didactic topics. If it is not feasible for every student to rotate clinically in CLP, or for each school to provide specialized didactics on its own, increased online resources could help fill the educational gap. Some centralized materials already exist, including resources on the Academy of Consultation-Liaison Psychiatry website and the ADMSEP Clinical Simulation Initiative modules, but the survey results suggest substantial interest in developing and more widely distributing student-level CLP content.

The study’s limitations warrant careful interpretation. With a response rate of 27 percent, the authors suspect their results overrepresent consultation-liaison psychiatrists or educators with preexisting enthusiasm for CLP, since such individuals would presumably be more inclined to open and complete a survey on the topic. Without information on which schools responded, it is difficult to quantify these potential biases, and didactics taught outside of psychiatry, such as a delirium lecture embedded in the surgery curriculum, may not have been captured by respondents. Even so, the survey provides unique and updated information on a question left unanswered since the mid-1970s. Its central message is clear: not all medical students receive clinical exposure to consultation-liaison psychiatry, meaningful barriers stand in the way of expanding that exposure, and there is a strong, documented desire among clerkship leaders for centralized, student-level resources that could bring this medically integrated field to every future physician, regardless of the specialty they ultimately choose.

Subject of Research: A national survey of US psychiatry clerkship directors on medical student education experiences in consultation-liaison psychiatry.

Article Title: Current Medical Student Education Experiences in Consultation-Liaison Psychiatry: A Survey of US Psychiatry Clerkship Directors

Article References: Kao, L. E., Shenai, N., Zabinski, J. S., Sarin, A., Topor, D. R., & Kasick, D. (2026). Current Medical Student Education Experiences in Consultation-Liaison Psychiatry: A Survey of US Psychiatry Clerkship Directors. Academic Psychiatry. https://doi.org/10.1007/s40596-026-02433-6

Image Credits: AI Generated

DOI: 10.1007/s40596-026-02433-6

Keywords: consultation-liaison psychiatry, medical education, psychiatry clerkship, clerkship directors, undergraduate medical education, survey research, delirium, capacity assessment, ADMSEP, Academic Psychiatry, psychosomatic medicine, curriculum design