Increasing access for underrepresented learners in surgery: A perspective from building the UpSurge program

BACKGROUND Learners from communities underrepresented in medicine (URiM) face unique barriers in pursuing surgical careers. Factors such as lack of mentorship, financial constraints, and noninclusive admissions processes contribute to lower rates of successful residency applications, higher attrition, and fewer academic promotions for these groups.1,2 As a result, female and visible minority groups are underrepresented in surgical departments across North America.2–4 The medical school pathway is a metaphor describing the path from elementary school to medical training. For several reasons, along this educational journey, members of “at-risk” groups leave, contributing to underrepresentation among medical school applicants, matriculants, and physicians in highly competitive subspecialties at the end.5 Access to culturally appropriate mentorship can improve success rates for residency applications and retention of junior faculty from underrepresented backgrounds.1 As such, urgent efforts are required to enhance representation in surgery, and structured mentorship programs may be an effective solution.1,6 To address these disparities, UpSurge was created. The initiative focused on providing mentorship, conducting research to better understand barriers faced in the pursuit of surgical careers, and engaging the community of URiM learners. Since 2022, UpSurge has paired over 200 Canadian and international medical graduates (IMGs) with surgeon mentors, hosted workshops, established scholarships for URiM learners with financial need, secured over $140,000 in funding, and expanded across Canada.7 In this surgical perspective, we describe the framework UpSurge has used and the outcomes of our program. We describe the approach to developing a learner-led advocacy initiative that may serve as a template for initiatives aimed at improving access to surgical careers for underrepresented groups. APPROACH UpSurge is organized into 4 strategic arms: mentorship, community outreach, quality improvement (QI) and research, and sustainability. Mentorship Program The cornerstone of UpSurge is its mentorship program. The initiative pairs underrepresented medical students with academic and community surgeons across Ontario, Canada. The program runs annually from November to August, recruiting Canadian medical students and IMGs through student advocacy groups, surgical interest groups, and public social media. Medical students in all years of study are eligible. However, efforts are made to advertise and recruit mentees from first- and second-year classes to build relationships and strengthen the curriculum vitae of students early on in their academic journey. This is particularly relevant for students wishing to pursue smaller hyper-competitive surgical subspecialties. Mentors are recruited through the University of Toronto listservs, surgical division chairs, and hospital surgeons-in-chief. Participating subspecialties are represented from the Department of Surgery (includes the divisions of Anatomy, Cardiac Surgery, General Surgery, Orthopedic Surgery, Plastic Surgery, Thoracic Surgery, Urology, and Vascular Surgery), the Department of Otolaryngology–Head & Neck Surgery, and the Department of Obstetrics & Gynecology. Upon registration, both mentees and mentors complete intake forms that collect demographic data, training background, mentorship interest, and capacity for mentorship. Mentor-mentee matches are facilitated through an online platform where mentees can select mentors based on their needs. This platform supports registration, video meetings, group chats, and quarterly surveys, allowing streamlined data collection and real-time program improvements. In addition to mentorship, the program offers simulation sessions and workshops to prepare for clerkship and residency applications. The relationship between mentors and mentees is unstructured and pragmatic, allowing the goals, frequency of meetings, and areas of support to evolve naturally.8 Community Outreach UpSurge’s outreach arm introduces underrepresented students to surgical careers, partnering with organizations like the University of Toronto’s Office of Access and Outreach, Toronto Community Housing, and local simulation centers. These collaborations have brought programming to elementary and high school students from marginalized communities (Supplemental Table 1, https://links.lww.com/AOSO/A529). UpSurge also oversees underrepresented medical students in organizing outreach events, fostering near-peer relationships and leadership opportunities, and providing students with role models in medicine. By partnering with community-based organizations close to the target population, UpSurge extends its impact. For example, Toronto Community Housing—North America’s second-largest social housing provider—helps UpSurge deliver high-quality programs to underrepresented students. QI and Research Quality improvement (QI) is central to UpSurge’s ongoing success. Data is collected at every event and throughout the mentorship program to evaluate impact and identify areas for improvement. These QI principles allow UpSurge to adapt dynamically to the needs of students, faculty, and administrators. We also ensure transparency within our community to ensure mentors and mentees are informed about UpSurge QI priorities. Consent is obtained for all surveys, and potentially sensitive sociodemographic characteristics collected at baseline have the option “prefer not to say” as a response. It is communicated to participants that data is for internal QI, and when research comes out of the work, several steps to ensure anonymity are taken. Participants have the option to revoke responses at any time, and all data is kept secure with only access to the UpSurge team. The UpSurge Research Group (URG) was also created to disseminate the evidence generated by the program, presenting findings at national and international meetings. The URG facilitates research and includes surgeon-scientists, clinician-investigators, and URiM medical students, integrating mentorship into the research process itself. This bidirectional mentorship model is key to fostering a collaborative and sustainable research culture. Sustainability UpSurge is positioned for long-term impact through strategic partnerships, executive committee structuring, funding, and social media engagement. By integrating early with the University of Toronto’s Department of Surgery and gaining support from leadership, UpSurge has secured stakeholder buy-in (Supplemental Figure 1, https://links.lww.com/AOSO/A529). The executive committee, led by resident co-chairs serving 2-year terms, oversees the program’s various strategic arms to ensure growth and alignment with goals. Each strategic arm of UpSurge corresponds with a subcommittee to ensure continued growth in line with the program’s goals. Through university partnerships, a premedical undergraduate student has served as a work-study student, providing administrative support to the executive committee (Fig. 1).9 This multi-level approach allows for mentorship within the committee itself.FIGURE 1.: UpSurge committee succession planning flow chart.Longitudinal funding is key to sustainability. UpSurge secures support from local, provincial, and national sources, including charitable donations through partnerships with surgical specialty foundations (ie, Canadian Association of General Surgeons Foundation), who also support outreach programming at surgical conferences. UpSurge also leverages social media to disseminate knowledge, advertise opportunities (eg, workshops, scholarships, events), recruit members, and engage with the broader community. With over 1000 followers and 10,000 monthly impressions, UpSurge shares its work widely. OUTCOMES To continually assess our impact, UpSurge has defined specific outcome measures and key deliverables along each of its strategic arms (Supplemental Table 2, https://links.lww.com/AOSO/A529). Mentorship and Community Outreach Goals The mentorship program goals are to improve the experience of mentees, achieve over an 80% match rate for Canadian medical students, and successfully match 1 IMG to a surgical specialty per residency application cycle. To assess these outcomes, UpSurge initiates quarterly and annual check-ins with mentees in both survey format and virtual town-hall formats. Our preliminary findings on mentor-mentee interactions suggest that over the first 2 years of the program, connections occur 1 to 2 times per month. Most meetings with mentors are virtual (89.5%), or in person (26.3%), with few happening in the operating room (10.5%), in clinic (10.5%), or via telephone (5.3%). Future analysis will explore satisfaction with the program and outcomes related to matching to surgical specialties. For high school-related community outreach programs, the long-term goal is to have at least 25% of the high school students registered in outreach programs enrolled in a STEM-based undergraduate degree in university. The target number was developed in consultation with access programs experts (coauthor I.O.), recognizing the diverse pathways students consider for an undergraduate degree, including parallel planning for other professions. Furthermore, as students enrolled in medical school are increasingly coming from programs outside of STEM (including the arts, business, and professional programs like nursing), the target of 25% was meant to reflect this shift. To assess these outcomes, UpSurge works closely with the community partners to track matriculation patterns of students involved in events through our research arm. Research and Sustainability Goals For research and operational sustainability, goals are to maintain a minimum yearly research and operational budget of $25,000 and $35,000, respectively. Currently, UpSurge has research grant funding support through a hospital-based foundation for $50,000 and $70,000 in operation funding through university support. A budget for annual research costs is displayed in Supplemental Table 3, https://links.lww.com/AOSO/A529. Research funds are allocated towards student research assistants, subscriptions, and software to carry out qualitative work, and statistical support for quantitative work. Grants are continually sought through various surgical subspecialty governing bodies, foundations, and physician advocacy groups. Funding is used for administrative support and infrastructure to carry out high-quality research. The primary academic goals are to produce 1 to 2 academic papers per year. The other major sustainability goals are (1) maintaining existing faculty relationships, (2) ensuring diverse surgical subspecialty representation on the executive committee, and (3) expanding our social media engagement. Monitoring of faculty engagement and relationships is facilitated by the aforementioned quarterly check-ins. Currently, UpSurge has 8 of 10 Canadian Resident Matching Service (CaRMs)-recognized specialties on our executive committee and is actively seeking to expand to the outstanding specialties. Finally, UpSurge aims to grow its social media (@uoft_upsurge) engagement by 2 thousand monthly impressions annually, and 200 to 500 new social media followers annually.7 Supplemental Table 2, https://links.lww.com/AOSO/A529 outlines UpSurge’s goals, processes of organization, and evidence of impact along each of its strategic arms. NEXT STEPS A more diverse workforce is associated with improved patient outcomes, increased cultural competency, and enhanced community trust in the healthcare system.10 Diversity improves the bottom line and, therefore, should be a priority within medical education. By improving pathways for URiM learners to enter surgical specialties, UpSurge contributes to building a surgical workforce that better reflects the diversity of the patient populations it serves.5 The work is just beginning. Future steps in the program include: (1) developing a structured practical/hands-on curriculum for mentees in the mentorship program, (2) developing a national UpSurge committee to strengthen support of local chapters and mobilize trainees across the country, (3) strengthening the research output to address gaps in knowledge at the intersection of access to medical education, surgery, and equity-deserving populations, and (4) strengthening partnerships to ensure broader impact, sustainability, and scalability. As independent chapters in faculties of medicine across the country develop (see @uofc.upsurge, @ubc_upsurge, @mb_upsurge), we envision synergy with the founding Toronto site to coordinate a shared strategic vision and sharing of information and resources, while respecting each chapter’s operational independence to adapt programming as needed to their local environment. Furthermore, future iterations of programs will incorporate strategies to compensate mentors for their time. For faculty, this could include credit towards continuing medical education activities, full-time equivalent hours towards education, or academic credit for promotion. For fellows or resident-mentors enrolled in competency-based medical education programs, compensation could include educational credits towards competency-based medical education activities. To our knowledge, UpSurge is the largest initiative of its kind in North America and is growing. This perspective reviewed the UpSurge approach to developing a learner-led advocacy initiative, which can serve as a template for other health professions to enhance equity in surgery. ACKNOWLEDGEMENTS The members of The UpSurge Research Group are as follows: Adom Bondzi-Simpson, MD, MSc; Betel Yibrehu, MD; David-Dan Nguyen, MDCM, MPH; Armaan K. Malhotra, MD; Kennedy Ayoo, MD; and Savtaj Brar, MD, MSc. AUTHOR CONTRIBUTIONS A.B.-S., B.Y., and D.-D.N. did the initial drafting of the manuscript. A.B.S. and B.Y. contributed to the configuration of tables and figures, editing, revision of the manuscript, and are the co-founders of UpSurge. D.-D.N. and A.K.M. are the co-research leads of UpSurge. K.A. is the chair and resident lead of UpSurge. A.B.-S., B.Y., D.-D.N., A.K.M., K.A., I.O., N.A., and S.B. contributed to editing of manuscript and revision of manuscript. S.B. is the faculty co-founder and program director of UpSurge.

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