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

The analytical framework behind the study rests on two well-established pillars of organizational psychology. The first is social identity theory, originally formulated by Henri Tajfel and John Turner, which holds that people categorize themselves and others into in-groups and out-groups and then favor their own group in subtle but measurable ways. In the workplace, age functions as a powerful social identity: younger and older employees form implicit cohorts, attach stereotypes to each cohort, and interpret the same organizational events through those stereotype-tinted lenses. The second pillar is the concept of organizational climate, the shared perception employees hold about the policies, practices, and behaviors that are rewarded and expected in their organization. Prior research has shown that when the climate is inclusive of age, diversity tends to improve performance; when it is not, diversity can degrade cooperation and trust. Bennett’s study tests whether these theoretical predictions hold when younger and older American workers are asked directly about their lived experiences.

The headline finding is a strikingly symmetric perceptual divide. Older workers, those aged 50 and above, report experiencing age-based disadvantage more frequently than their younger colleagues. They describe being passed over, patronized, or assumed to lack technological fluency, consistent with a long line of research documenting ageist stereotypes that cast older employees as less adaptable, less trainable, and less valuable to invest in. Yet the same older workers are markedly more supportive of the idea that older employees should remain in the workforce for as long as they wish. In other words, the group that suffers most from age bias is also the group most committed to extended working lives, a combination that suggests older workers see continued employment as both an economic necessity and a source of identity and purpose, even while they acknowledge the friction it generates.

Younger workers tell a different story. Rather than reporting age-based exclusion, they express greater anxiety about delayed promotions and stalled career progression, a concern that researchers have long linked to perceived resource scarcity between generations. When senior positions remain occupied by employees working into their late sixties and seventies, younger workers may interpret the bottleneck as unfair competition, a dynamic documented in earlier work on intergenerational tension and subtle older-worker exclusion. The study’s results give this concern empirical weight in a nationally representative sample: younger respondents were significantly more likely than older respondents to worry that extended careers for their seniors would slow their own advancement up the organizational ladder.

A second major axis of divergence involves flexible work arrangements. Younger employees in the survey reported considerably higher engagement with flexible options, including remote work, adjustable schedules, and compressed hours, reflecting what the author characterizes as a generational shift in workplace norms rather than a simple difference in individual preference. This finding aligns with a broader body of research showing that flexibility practices interact with employee age in complex ways. Studies of hybrid and remote work have found productivity gains under geographic flexibility, while reviews of working-at-home effects note that older workers experience the health and social consequences of remote arrangements differently from younger ones. The survey data suggest that organizations offering flexibility primarily in formats designed around younger workers’ lives may unintentionally signal that these benefits belong to one cohort, reinforcing the very in-group boundaries that age-diversity programs aim to dissolve.

Perhaps the most consequential conclusion of the study is a caution against the popular corporate assumption that age diversity is automatically good for business. The analysis underscores that age diversity is not inherently beneficial; its impact depends on inclusion, climate, and proactive management. This echoes a substantial experimental and meta-analytic literature. Research on age-diversity climate has shown that age-inclusive human resource practices and the attitudes of senior leaders predict firm-level performance outcomes, while studies of age discrimination climates find negative performance consequences when bias goes unaddressed. Broader meta-analyses of workplace diversity similarly conclude that demographic differences translate into positive outcomes only under specific conditions, such as task relevance, supportive leadership, and open communication climates. The new survey results bring these laboratory and firm-level findings into the realm of ordinary workers’ perceptions, showing that the conditions for success are not yet widely met in the United States.

The practical implications for human resource leaders are concrete. Bennett points to bias-reduction strategies, inclusive flexibility policies, and cross-generational mentoring as the three most promising levers for converting potential intergenerational friction into collaborative advantage. Bias-reduction efforts draw on the intergroup contact tradition, which demonstrates through decades of meta-analysis that structured, cooperative contact between groups reduces prejudice, particularly when it unfolds under equal status and with institutional support. Mentoring programs that run in both directions, pairing older workers’ institutional knowledge with younger workers’ technological fluency, operationalize this contact principle while directly attacking the competence and warmth stereotypes that social psychology has shown people attach to both ends of the age spectrum. Inclusive flexibility, meanwhile, ensures that flexible arrangements are designed and marketed to workers of every age, preventing benefits from being coded as the property of a single generation.

The study is notable for its methodological position as one of the first nationally representative analyses to directly compare younger and older U.S. workers’ perceptions of age-related disadvantage and flexible work adoption, addressing what the author identifies as a critical gap in organizational psychology and aging research. Much of the existing evidence comes from single-firm samples, convenience surveys of older workers alone, or European datasets whose labor-market institutions differ substantially from the American context. By testing four formal hypotheses about generational differences in workplace perceptions against nationally representative data, the study provides a benchmark that future research can replicate and extend. At the same time, the cross-sectional design of the 2019 survey means the findings capture a snapshot rather than a trajectory, and the dichotomy between workers under and over 50 inevitably smooths over differences within each broad group.

Looking forward, the study closes by charting an ambitious research agenda: longitudinal designs that track how perceptions evolve as cohorts age, multi-level models that connect individual attitudes to team and organizational outcomes, and cross-cultural comparisons that test whether the American pattern of generational perception holds in societies with different retirement norms and cultural attitudes toward aging. The stakes of this agenda are rising. Labor force projections indicate that older workers will remain a growing share of the American workforce for decades, driven by longer life expectancy, changes to retirement security, and the shifting composition of available jobs. As the demographic reality of the five-generation workplace solidifies, the question is no longer whether organizations will be age-diverse but whether they will manage that diversity deliberately. The evidence from the 2019 Working Longer Survey suggests that without intentional effort, the default outcome is a workplace divided by silent, mutually reinforcing stereotypes, with older workers feeling sidelined and younger workers feeling stuck. With it, the same demographic mix could become a source of complementary skills, durable knowledge transfer, and genuine competitive advantage.

Subject of Research: Perceptions of age diversity and generational differences among younger and older U.S. workers based on the 2019 Working Longer Survey.

Article Title: Age Diversity and Workplace Perceptions: Insights from the 2019 Working Longer Survey

Article References: Bennett, J. (2026). Age Diversity and Workplace Perceptions: Insights from the 2019 Working Longer Survey. Trends in Psychology. https://doi.org/10.1007/s43076-026-00529-4

Image Credits: AI Generated

DOI: 10.1007/s43076-026-00529-4

Keywords: age diversity, workplace perceptions, generational differences, ageism, flexible work, organizational climate, social identity theory, aging workforce, inclusion, extended working lives, Diversity, Workplace