The review, led by M. Muska Nataliansyah and Callisia N. Clarke, screened literature published between 2015 and 2025 using PubMed searches supplemented by selective citation chaining on Google Scholar. Studies qualified if they examined retention, attrition, advancement, or equity-related mechanisms within surgical training, and the pool included qualitative and quantitative research, program evaluations, and review and perspective papers. Twenty-one studies made the final cut. The authors followed SANRA, a scale for assessing the quality of narrative reviews, and grouped their findings into five domains drawn from Bronfenbrenner’s model: the microsystem, mesosystem, exosystem, macrosystem, and chronosystem. The choice of framework is itself a departure from the dominant metaphor in the field, the leaky pipeline, which implies that diverse trainees drip out at discrete, fixable points. An ecological model suggests something more entangled: trainees are embedded in overlapping systems that can either reinforce one another or work at cross purposes.

At the innermost level, the microsystem, the review found that the daily texture of training carries enormous weight. Mentorship quality emerged as a decisive factor, alongside biased feedback, microaggressions, and psychological safety, the shared belief that one can speak up, ask questions, or admit uncertainty without punishment. Disparities in mentorship have been documented across surgical residency education and linked to resident wellness, and qualitative work with women and minority surgeons has shown that access to sponsors and role models is unevenly distributed. The authors’ own prior research, an anonymous reporting study of micro and macroaggressions experienced by Black surgical trainees, underscores how routine slights accumulate into a climate that erodes belonging. In an environment as hierarchical and high-stakes as an operating room, psychological safety is not a soft perk; it is the precondition for learning technical skills under pressure.

The mesosystem, which describes how a trainee’s various environments connect, revealed a subtler pathology: misalignment. A resident might experience supportive, inclusive didactic sessions in one setting and a hostile clinical space in another, and the inconsistency itself becomes corrosive. The review also flagged insufficient linkage between mentorship programs and program leadership, meaning that even well-intentioned mentoring can float free of the institutional authority needed to act on what mentors learn. Existing models attempt to bridge these gaps, from integrated mentorship programs that weave clinical training with structured support, to national and specialty-specific efforts such as coaching programs for women surgeons and mentorship networks for LGBTQ+ surgeons, to a framework proposed by the Society of Black Academic Surgeons specifically aimed at improving the retention of Black surgical trainees. The mesosystem lesson is that isolated programs, however good, cannot compensate for environments that contradict them.

One level out, the exosystem, the review turned to institutional structures that trainees do not directly control but that shape their daily lives: equity infrastructure, faculty diversity, and the design of evaluation and promotion systems. The evidence here is strikingly quantitative. Studies have found that greater faculty diversity is associated with lower general surgery resident attrition at programs sponsored by LCME-accredited medical schools, and similar associations have been reported in orthopaedic surgery. Research on women in leadership has examined how female program leadership influences the gender diversity of academic plastic surgery programs, and analyses of faculty characteristics have linked them to trainee attrition more broadly. The Diverse Surgeons Initiative, a national program assessed longitudinally since 2015, offers one template for institutional intervention. The implication is that retention is partly a property of the organization, not merely of the individual’s resilience.

The macrosystem captures the forces that dwarf any single hospital or university: structural racism, gender norms, and policy restrictions. The review’s timing is significant here. With the end of race-conscious admissions in the United States, commentators have argued that sealing the leaky pathway in academic surgery has become more urgent than ever, since programs can no longer rely on affirmative action to diversify their applicant pools. The macrosystem also includes the demographic reality that the physician workforce does not reflect the U.S. population, a gap documented by Association of American Medical Colleges workforce data. Intersectionality compounds these forces; studies of attrition among U.S. general surgery trainees and of the pipeline for Black academic surgeons show that racial, gender, and socioeconomic identities interact rather than simply add up, producing distinct barriers for trainees who sit at multiple margins.

Perhaps the most novel contribution is the chronosystem, the temporal dimension that earlier pipeline metaphors ignored. The review describes early-stage vulnerabilities, cumulative experiences, and shifting equity climates as determinants of long-term advancement trajectories. Attrition research has shown that the timing of departure is associated with both individual resident and programmatic factors, and studies of attrition across surgical subspecialties have documented racial and sex disparities in when and whether trainees leave. Experiences are not one-off events but deposits in a ledger: a microaggression in intern year, a biased evaluation in the third year, a hostile rotation in the fourth, each accumulating into a decision about whether surgery is a profession worth staying in. Meanwhile, the equity climate itself shifts over time, with policy changes and institutional commitments rising and falling across a trainee’s five to seven years of residency.

Why should anyone outside surgical education care? Because workforce diversity is not just a matter of fairness; it is increasingly tied to measurable patient outcomes. Studies have associated sex diversity within anesthesia-surgery teams with lower rates of major morbidity, compared postoperative outcomes between male and female surgeons in large population-based cohorts, linked patient-physician gender concordance with reduced mortality among female heart attack patients, and examined surgeon-patient sex concordance in complex cancer surgery. Broader reviews have concluded that diversity improves organizational performance and outcomes. A surgical workforce that reflects the population it serves is, on the current evidence, a safer one, which transforms retention of diverse trainees from an equity aspiration into a patient-safety imperative.

The review’s conclusion is deliberately systemic: retention and advancement of diverse surgical trainees are not determined by isolated factors but by interacting ecological systems, and effective, sustainable change requires coordinated action across interpersonal, organizational, cultural, and temporal levels simultaneously. In practice, that means pairing individual-level supports such as high-quality mentorship and bias-aware feedback with institutional investments in faculty diversity and equitable evaluation, while advocating within the policy sphere and attending to the cumulative timing of trainee experiences. The authors offer their ecological perspective as a roadmap rather than a verdict, a way to design interventions whose effects reinforce one another instead of canceling out. For a specialty in which the pipeline has leaked for decades, the message is that patching one hole is not enough; the entire weather system around the pipe has to change.

Subject of Research: Retention and advancement of diverse surgical trainees analyzed through Ecological Systems Theory

Article Title: Strategies to retain and advance diverse surgical trainees: a narrative review

Article References: Nataliansyah, M. M., Lawson, G. E., Madramootoo, S., & Clarke, C. N. (2026). Strategies to retain and advance diverse surgical trainees: a narrative review. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 152. https://doi.org/10.1007/s44186-026-00554-y

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00554-y

Keywords: surgical education, surgical trainees, retention, attrition, diversity, equity, mentorship, ecological systems theory, psychological safety, faculty diversity, intersectionality, workforce