Previous investigations into gender gaps in surgical training have relied largely on summary-level data captured at a single moment: graduation. Those studies consistently found that female trainees finish residency with lower Accreditation Council for Graduate Medical Education (ACGME) case totals and report lower intraoperative autonomy than male colleagues. But such snapshots could not answer a critical question that has vexed educators for years—do these disparities exist from day one, or do they develop over the five-year arc of surgical apprenticeship? The new research, published in Global Surgical Education, the journal of the Association for Surgical Education, set out to trace exactly when and how these differences emerge.

The scale of the dataset is what sets the study apart. Researchers analyzed 569,761 individual ACGME case log entries generated by residents at six programs, matching them to 415 attending surgeons, of whom 141, or 34 percent, were women. Crucially, the team obtained resident and attending gender through self-reported data from the SIMPL platform, a smartphone-based surgical performance feedback system, since gender is not recorded in standard ACGME case logs. Nearly half of the residents, 234 of 473, were women. The programs themselves reflected national demographics, with female resident representation ranging from 42 to 58 percent across sites.

Each case entry captured the resident’s post-graduate year, the operative role recorded, and the identity and gender of both trainee and attending surgeon. ACGME case roles fall into distinct categories: first assistant, in which the resident helps another surgeon; surgeon junior and surgeon chief, which together constitute primary surgeon roles; and teaching assistant, in which a chief resident supervises a junior resident through an operation. These designations matter enormously. The American Board of Surgery and program clinical competency committees use case log data to judge whether residents are ready to graduate and to practice independently.

The headline finding was stark. On average, female residents logged 8.1 percent fewer total cases than male residents—1,153 versus 1,255, a statistically significant difference. Yet the more revealing pattern emerged when the researchers stratified cases by operative role and training year. There were no meaningful differences between male and female residents in how often they logged cases as primary surgeon. The divergence appeared instead in first assistant entries, and it widened dramatically with seniority. Female residents were 1.57 times more likely than male peers to log a case as first assistant in their third year of training, with an odds ratio of 1.57 and a 95 percent confidence interval of 1.14 to 2.16. By the fourth year that odds ratio climbed to 2.76, and by the fifth and final year it reached 3.72—meaning senior female residents were nearly four times as likely to record themselves in the assisting role.

The temporal pattern is what makes the finding so consequential. In the early years of residency, serving as first assistant is expected and appropriate; PGY1 residents in the dataset logged 15,047 first assistant cases, a figure that fell to just 212 among PGY5 residents as trainees assumed the surgeon’s role. But a substantial minority of residents continued logging first assistant cases deep into senior years—52 percent of PGY3 residents, 33 percent of PGY4 residents, and 14 percent of PGY5 residents did so. Among this persistent group, women were markedly overrepresented. The most frequently logged first assistant cases included laparoscopic cholecystectomy, laparoscopic appendectomy, inguinal hernia repair, ventral hernia repair, and colectomy—core general surgery procedures in which senior residents should be operating with increasing independence.

The study also examined whether the gender of the attending surgeon shaped these patterns, a question no prior case log analysis had been able to address. Overall, cases performed with female faculty were less likely to be logged as first assistant, with an odds ratio of 0.79. Yet among senior residents the association reversed: PGY4 residents operating with a female attending were 1.68 times more likely to log first assistant cases, and PGY5 residents were 2.46 times more likely. Notably, the researchers found no significant differences between gender-concordant and gender-discordant resident-attending pairings, suggesting that simple matching of trainee and faculty gender does not explain the observed trends. The authors caution that the mechanisms behind these attending-level effects—whether they reflect differences in teaching style, entrustment behavior, or documentation habits—remain outside the scope of the current data and merit dedicated investigation.

Why would female senior residents log more first assistant cases? The authors emphasize that the dataset cannot establish causation, and they lay out competing explanations that likely operate in combination. Extrinsic factors could include faculty perceptions, institutional culture, or the timing of cases within the academic year, while intrinsic factors might involve self-perception, confidence, and how residents understand the role definitions themselves. Teaching assistant and first assistant categories lack the strict criteria, such as post-graduate year level, that govern primary surgeon designations, making them more vulnerable to misinterpretation. Indeed, since primary surgeon cases showed no gender difference at all, the researchers suggest that some of the disparity may stem from inconsistent application of logging guidelines rather than unequal operative opportunity. At the same time, they are careful to note the well-documented literature on gender-based discrimination in surgical training, acknowledging that the uneven distribution of operative roles may reflect faculty bias or structural inequities that limit women’s chances to operate as lead surgeon.

The study carries important limitations that the authors confront directly. The data contain no information about case complexity beyond procedural codes, which are known to be inaccurately recorded, and the analysis excluded residents whose gender data was missing or reported as other or prefer not to answer, leaving the experiences of non-binary trainees unexamined. Race and ethnicity data were absent entirely, a significant gap for any work on equity. The sample was also confined to large university-based programs, which may limit generalizability, although the consistency of the trends with national-level data lends credibility to the findings. One resident, for example, logged an exploratory laparotomy as a teaching assistant case during the first year—a clear misclassification that illustrates the noise inherent in self-reported logs, even as subtler errors likely permeate the data.

The implications reach well beyond the operating room. As surgical education shifts toward competency-based training and Entrustable Professional Activities, understanding how different trainee subpopulations use measurement tools becomes essential to interpreting quantitative data fairly. The authors call for future research pairing ACGME case logs with faculty EPA assessments and resident self-evaluations, alongside qualitative studies of how residents actually decide which role to record. In the meantime, they offer a pragmatic recommendation: individual programs can apply the same analytical methods to their own case log data, monitoring for disparities by gender, PGY level, and even rotation site in real time. Such local surveillance, the researchers argue, could allow program leadership to identify senior residents who continue logging first assistant cases, clarify the correct application of role definitions, and address any underlying inequities before they calcify into a training record—and perhaps a career trajectory—that understates a surgeon’s true capabilities.

Subject of Research: Gender disparities in operative case logging and surgical training roles among general surgery residents

Article Title: Gender disparities among general surgery residents’ ACGME case logs develop over the course of training

Article References: Gender disparities among general surgery residents’ ACGME case logs develop over the course of training. (n.d.). https://doi.org/10.1007/s44186-026-00575-7

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00575-7

Keywords: general surgery, residency training, ACGME case logs, gender disparities, operative autonomy, surgical education, first assistant, attending surgeon gender, SIMPL, graduate medical education, operative experience, competency-based training

The American Board of Pediatrics recently announced a plan to alter pediatric subspecialty fellowship training, moving toward a competency-based framework that would, for neonatal-perinatal medicine, condense what has traditionally been a three-year fellowship into a shorter pathway. Proponents of such reforms point to workforce shortages, the financial strain of prolonged training, and evidence that clinical competence can be demonstrated and certified through entrustable professional activities rather than time served. The board’s stated goal, articulated in its 2026 announcement on ensuring readiness for practice, is to advance competency-based subspecialty training so that physicians enter independent practice sooner without sacrificing skill. For a field grappling with persistent recruitment challenges and rising demand for neonatal intensive care, the appeal is obvious.

Yet Kukora and her colleagues argue that this framing overlooks something fundamental: professional identity formation, often abbreviated as PIF in the medical education literature. Drawing on decades of scholarship, including the influential schematic model developed by Richard and Sylvia Cruess and colleagues at McGill University, the authors describe professional identity formation as the process through which trainees internalize the values, behaviors, and norms of medicine, gradually coming to think, feel, and act like the physicians they are training to become. This transformation does not occur through the mere accumulation of procedures or checklists. It unfolds within what educational theorists call a community of practice, an immersive social environment in which novices learn by participating alongside experienced mentors, absorbing not only explicit teaching but also the hidden curriculum of daily clinical life.

Neonatal-perinatal medicine presents a particularly demanding context for this transformation. Neonatologists care for infants at the very margins of viability, make life-and-death decisions under profound uncertainty, and navigate emotionally charged relationships with families in crisis. The ethical terrain is notoriously difficult: decisions about initiating, withholding, or withdrawing life-sustaining treatment; the interpretation of aggregate outcome statistics for individual counseling; and the negotiation of family-centered care in settings where evidence is often incomplete. The authors emphasize that the entrustable professional activities defined for neonatology, the specific tasks considered essential for independent practice, are themselves deeply rooted in professional identity formation. Competence in these activities presupposes mature moral reasoning, the capacity to experience and manage distress, and the resilience to sustain a career in an emotionally punishing environment.

The literature on moral distress in neonatology underscores why this matters. Studies by Prentice, Janvier, Gillam, and colleagues have documented high levels of moral distress among neonatal clinicians, the anguish that arises when providers know the ethically appropriate course of action but feel constrained from pursuing it. Repeated episodes of moral distress leave behind what Epstein and Hamric have described as moral residue, a cumulative erosion that contributes to the crescendo effect of escalating distress over time. Compassion fatigue, secondary traumatization, and burnout are well documented among neonatologists, and physician burnout has been linked in multiple studies to increased medical errors and worse patient outcomes. Professional identity formation, the authors argue, is one of the key mechanisms through which clinicians develop the meaning and purpose that buffer against these occupational hazards. Research by Toubassi and colleagues has explicitly linked professional identity formation to well-being, suggesting that a coherent sense of professional self is not a luxury but a protective factor.

Against this backdrop, the prospect of condensing fellowship raises a series of ethical concerns. First, there is the problem of time itself. Identity development is longitudinal and cannot be reliably compressed without consequence. Qualitative longitudinal research on how residents develop virtues suggests that character formation in medicine depends on sustained experience, reflection, and mentorship over time. A trainee who spends fewer months in the neonatal intensive care unit has fewer opportunities to witness and internalize how seasoned clinicians handle uncertainty, communicate bad news, repair errors, and honor the values of family-centered care. Second, the authors point to the discontinuity problem in medical education, a topic recently analyzed in the New England Journal of Medicine by Warm and colleagues. Shortened, fragmented training pathways risk disrupting the continuity of relationships, between trainees and mentors, and between trainees and the patients and families they follow over weeks and months, that make deep learning possible.

Third, the perspective highlights the hidden curriculum, the informal and often unspoken lessons trainees absorb from their environments. When institutions signal that training is primarily a throughput problem to be optimized, trainees may internalize a transactional view of their profession. Conversely, when programs deliberately protect time for reflection, ethics education, and relationship-building, trainees are more likely to develop the habits of moral attention that neonatal practice demands. Ethics education in neonatology, as recent work in NeoReviews by Sullivan and colleagues illustrates, increasingly integrates theory, multimodal teaching methods, and even artificial intelligence innovation, but it requires protected space within the training structure to take root. A compressed pathway that crowds out these formative experiences may produce technically competent graduates who are nonetheless underprepared for the ethical weight of their role.

The authors are careful to acknowledge the legitimate pressures motivating reform. The pediatric subspecialty workforce faces genuine shortages, and neonatal intensive care admissions in the United States have risen steadily, according to National Center for Health Statistics data covering 2016 through 2023. Burnout and workload concerns have prompted serious discussion of hours-based scheduling in neonatology, and some have argued in the Journal of Perinatology that the field should indeed move to two-year fellowships. A companion critical appraisal by Vergales and colleagues examined the American Board of Pediatrics’ proposed two-year pathway in detail, questioning whether the required competencies can realistically be achieved in the condensed timeframe. The debate is thus not between reform and stagnation, but between competing visions of what fellowship is ultimately for.

What distinguishes the Kukora paper is its insistence that the answer must be framed in ethical rather than merely operational terms. The authors argue that it is an ethical imperative for neonatal-perinatal medicine fellowship programs to nurture the evolving professional identities of their learners, because those learners will guide future innovation and progress in the field while providing ethical, family-centered, high-quality clinical care. If professional identity formation is foundational to every essential entrustable professional activity in neonatology, then any reform that undermines it risks compromising not only individual careers but the profession’s core mission. The stakes, in other words, are borne ultimately by newborns and their families, who depend on physicians trained not just to perform interventions but to deliberate wisely about when interventions serve the patient’s best interests.

The perspective closes with a call for the pediatrics community to take these risks seriously before implementing the new pathway. Rather than treating identity formation as an intangible byproduct of training, the authors suggest it should be treated as an explicit outcome to be protected and measured, alongside clinical competence and procedural skill. As the American Board of Pediatrics moves forward with competency-based subspecialty training, the challenge will be to design programs that achieve efficiency without hollowing out the human and moral development that makes a neonatologist more than a technician. The paper’s central message is stark: how the profession trains its future members will shape, for better or worse, the care that the smallest and most vulnerable patients receive for decades to come.

Subject of Research: Ethical implications of condensing neonatal-perinatal fellowship training for neonatologists' professional identity formation

Article Title: Threats to neonatologists’ professional identity formation: ethical implications of condensing neonatal-perinatal fellowship

Article References: Kukora, S. K., Gray, M. M., McLean, C. K., & Krick, J. (2026). Threats to neonatologists’ professional identity formation: ethical implications of condensing neonatal-perinatal fellowship. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02899-0

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02899-0

Keywords: neonatology, professional identity formation, medical education, fellowship training, American Board of Pediatrics, moral distress, medical ethics, neonatal-perinatal medicine, competency-based training, burnout, family-centered care, Journal of Perinatology