Summary
This study addresses the gap in evidence regarding gender-based disparities in procedural training in Poland, where women constitute most medical students yet remain underrepresented in procedure-intensive specialties. In a nationwide survey of 720 medical trainees, women reported significantly less hands-on experience with key procedures such as intubation, suturing, and surgical assistance, despite having comparable theoretical knowledge. These findings demonstrate that numerical gender parity in medical school enrollment does not eliminate inequities in clinical training, suggesting that systemic and cultural factors within learning environments create this “experience gap”. Addressing this imbalance through competency-based curricula, enhanced mentorship programs, and inclusive training strategies is essential for ensuring equitable skill acquisition and may ultimately influence career trajectories and healthcare workforce diversity.
Introduction
The acquisition of procedural competency stands as a fundamental pillar of medical education, directly impacting patient safety, quality of care, and physician confidence [1–3]. Modern medical pedagogy has evolved from the traditional “see one, do one, teach one” apprenticeship model toward structured, evidence-based frameworks that emphasize deliberate practice and objective assessment [4, 5]. This paradigm shift reflects the profession’s commitment to ensuring not merely baseline competence, but reliable performance across diverse clinical scenarios [6]. Despite this pedagogical evolution, a concerning “experience gap” persists between curricular expectations and training realities [7]. Studies consistently demonstrate that substantial proportions of medical trainees complete their education without performing essential procedures, with surveys revealing that majorities of graduating students have never performed critical interventions such as central line placement, chest tube insertion, or lumbar puncture [7, 8]. This deficit in hands-on experience correlates directly with diminished self-confidence, creating a dual disadvantage at the crucial transition to independent practice.
The challenge of procedural training intersects meaningfully with persistent gender disparities in medical specialization [9]. While women now constitute most medical students in many countries, they remain significantly underrepresented in procedure-intensive specialties [10–12]. This pattern suggests a complex interplay between training experiences and career trajectories [11–17]. Research indicates that female trainees often encounter subtle barriers to hands-on opportunities and report lower procedural confidence despite equivalent academic performance [13, 18]. These disparities may create a self-reinforcing cycle where limited procedural exposure during training influences specialty selection, which in turn perpetuates the scarcity of female role models in surgical fields [18, 19].
Poland presents a unique context for examining these dynamics. With women comprising over 76% of medical students – among the highest proportions globally – the Polish medical education system offers a natural experiment that decouples numerical representation from cultural influence. If gender-based disparities in procedural training persist despite female numerical dominance, it would provide compelling evidence that systemic and cultural factors, rather than simple representation, drive training inequities.
Aim
This nationwide cross-sectional study aimed to investigate gender-based disparities in self-reported theoretical knowledge and practical experience with 18 core medical procedures among Polish medical students and junior doctors.
Material and methods
This cross-sectional survey was conducted between April and May 2025 across medical universities in Poland. Eligible participants included medical students enrolled in their fifth or sixth year of study during the 2024–2025 academic year and junior doctors within their 12-month mandatory post-graduate internship. E-mail invitations were sent to student scientific societies at 22 Polish medical schools with fifth- and sixth-year students, as well as to student governing bodies and student associations. The survey was also distributed through social media platforms (Facebook, X). Data were collected anonymously using Google Forms to ensure participant confidentiality. Participation was voluntary, and no formal consent was obtained. International students in English-language programs were excluded due to potential curriculum differences.
Data were collected using a structured, anonymous online questionnaire. The instrument evaluated two distinct aspects of clinical training for 18 specific medical procedures: 1) theoretical exposure – participants indicated whether each skill had been “discussed or demonstrated” during their training; 2) practical experience – participants rated their hands-on experience on a three-point scale: “never performed”, “performed 1–2 times”, or “performed 3 or more times”. For procedures such as surgical assistance or childbirth observation, practical experience was categorized as “never participated”, “participated 1–2 times”, or “participated 3 or more times”. These 18 clinical procedures were selected based on review of the national medical education curriculum standards. Additionally, demographic data were collected including age, university attended, training stage, and planned specialization. For this analysis, participants were stratified by self-reported gender (woman or man). The survey platform was configured to require complete responses before allowing submission.
Statistical analysis
Categorical variables were presented as counts (percentages), while continuous variables, expected to follow non-normal distributions, were summarized as medians with interquartile ranges (IQR). Differences between gender groups were assessed using the Pearson χ2 test, Fisher exact test, or Mann-Whitney U test, as appropriate. Spearman’s correlation coefficient was calculated to assess the association between the number of procedures marked as “not discussed or demonstrated” in the theoretical/demonstrative domain and the number marked as “never performed/never participated” in the practical domain. The primary outcome – number of procedures “never performed/never participated” – was treated as a count variable with non-normal distribution bounded at zero. To assess factors associated with this outcome, we used a negative binomial regression model, chosen over Poisson regression to account for overdispersion in the count data (variance exceeding the mean). The model included gender, year of study, planned specialization, age, and the number of procedures marked as “not discussed or demonstrated” in the theoretical/demonstrative domain. Results are presented as incidence rate ratios (IRRs) with 95% confidence intervals (CIs). A two-tailed p-value < 0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics version 29.0.2.0 (IBM Corp, Armonk, NY, USA).
Results
Of the 720 participants, 506 (70.3%) were women and 214 (29.7%) were men. The median age was 25.0 years (IQR: 24.0–26.0) for both groups (p = 0.38). Participants represented multiple medical universities across Poland, with the largest proportions from Medical University of Silesia (n = 110; 15.3%), Medical University of Lodz (n = 96; 13.3%), Medical University of Warsaw (n = 77; 10.7%), Medical University of Lublin (n = 64; 8.9%), and Wroclaw Medical University (n = 59; 8.2%). Smaller numbers came from other universities, each representing less than 8% of the sample. Only 3 (0.4%) participants chose not to disclose their university affiliation. No significant differences in university distribution were observed between genders. Respondents were distributed relatively evenly across the final stages of medical training: 278 (38.6%) were sixth-year students, 223 (31.0%) were fifth-year students, and 219 (30.4%) were completing their post-graduate internship. No gender differences were observed in training stage distribution. Regarding planned specialization, 427 (59.3%) respondents indicated interest in non-surgical specialties (internal medicine, pediatrics, family medicine, or oncology), 217 (30.1%) planned to pursue surgical specialties (surgery, urology, gynecology, or otolaryngology), and 76 (10.6%) remained undecided. Gender analysis revealed notable differences in specialty preferences: women were more likely to be undecided (12.5% vs. 6.1%) and to choose non-surgical specialties (44.6% vs. 14.7%), and less likely to select surgical specialties (24.1% vs. 44.4%) compared to men (p < 0.001).
Most respondents reported receiving theoretical or demonstrative coverage for key clinical procedures, with rates exceeding 75% for nearly all items (Table I). The most frequently covered procedures included ultrasound and ECG recording (both 95.1%), oropharyngeal airway insertion (93.9%), and endotracheal intubation (90.7%). No significant gender differences were found for 17 of 18 procedures investigated. The sole exception was gastric tube insertion, which male respondents reported more frequently than female respondents (64.5% vs. 55.9%; p = 0.033). The median number of procedures marked as “not discussed or demonstrated” was comparable between women and men: 2.0 (IQR: 0.0–4.0) vs. 1.0 (IQR: 0.0–4.0); p = 0.16.
Table I
Self-reported theoretical or demonstrative coverage of clinical procedures by gender
Practical experience with clinical procedures varied considerably (Table II). Basic non-invasive procedures, such as blood pressure and oxygen saturation measurement, were performed multiple times by most respondents (> 79%), with no significant gender differences (p > 0.05). Male respondents reported higher practical experience with male urinary catheterization (p < 0.001), oropharyngeal airway insertion (p < 0.001), endotracheal intubation (p < 0.001), and surgical wound suturing (p = 0.044). Men also reported more frequent active participation in surgical assistance (p = 0.019). Night duty participation showed no gender differences: 83.0% of women and 81.8% of men had never participated, with similar proportions for 1–2 times (8.9% vs. 9.8%) and 3+ times (8.1% vs. 8.4%) participation (p = 0.91).
Table II
Self-reported practical experience with medical procedures by gender
The median number of procedures marked as “never performed/never participated” was higher among women than men: 11.0 (IQR: 8.0–14.0) vs. 10.0 (IQR: 7.0–13.0); p = 0.013. A moderate positive correlation existed between theoretical gaps and practical gaps (Spearman’s r = 0.434; p < 0.001). Negative binomial regression revealed that higher numbers of theoretical gaps were significantly associated with more practical gaps (IRR = 1.05, 95% CI: 1.03–1.08; p < 0.001). Gender, year of study, planned specialization, and age showed no significant associations with the outcome (Table III).
Table III
Negative binomial regression analysis of factors associated with lack of practical experiencea
| Predictor | IRR | 95% CI | P-value |
|---|---|---|---|
| Intercept | 11.19 | 3.15, 39.70 | < 0.001 |
| Gender | |||
| Female | 1.06 | 0.89, 1.26 | 0.51 |
| Male | Reference | – | – |
| Year of study | |||
| 5th year | 1.23 | 0.98, 1.53 | 0.07 |
| 6th year | 1.11 | 0.91, 1.35 | 0.31 |
| Post-graduate internship | Reference | – | – |
| Planned specialization | |||
| Undecided | 1.08 | 0.82, 1.42 | 0.59 |
| Non-surgical | 1.08 | 0.91, 1.28 | 0.40 |
| Surgical | Reference | – | – |
| Age (per year) | 0.98 | 0.94, 1.03 | 0.51 |
| Theoretical gapsb | 1.05 | 1.03, 1.08 | < 0.001 |
Discussion
This nationwide study of medical trainees in Poland reveals a significant and paradoxical finding: in a medical education system where women constitute over 70% of trainees, they still report substantially less hands-on experience in key procedural skills compared to their male colleagues. This “experience gap” is not explained by deficits in theoretical knowledge, as self-reported didactic exposure was nearly identical between genders. The disparity is most pronounced in procedures central to surgery and acute care – endotracheal intubation, male urinary catheterization, surgical wound suturing, and active surgical assistance – suggesting that the gap is concentrated in traditionally male-dominated domains. Notably, some procedures included in our questionnaire – such as endotracheal intubation and lumbar puncture – are rarely performed by undergraduates within the formal curriculum. The small proportion of respondents reporting such experience likely acquired it through extracurricular activities, including voluntary duties, scientific societies, or extended rotations. Unequal access to these informal opportunities may contribute to systemic disparities, as student initiative intersects with faculty encouragement, mentorship availability, and institutional culture.
The Polish context serves as a crucial “natural experiment” that challenges the global assumption that achieving gender parity in medical school enrollment will automatically resolve downstream inequities. The persistence of this experience gap in a female-majority system demonstrates that numerical representation alone is insufficient to ensure equitable training opportunities. This finding aligns with research on practicing Polish specialists showing that female interventional cardiologists perform significantly fewer procedures than their male counterparts despite having comparable scientific achievements, suggesting that these disparities extend beyond training into professional practice [17]. These results indicate that barriers to equitable procedural training are rooted in systemic and cultural factors within clinical learning environments rather than simple demographics [19]. Extensive qualitative research describes medical training as a “gendered community of practice” where female trainees receive fewer “workplace affordances” – opportunities to engage in challenging cases, have their professional authority recognized, and be addressed by professional titles rather than first names [18, 20, 21]. This accumulation of subtle biases and microaggressions can create a “chilling effect”, undermining confidence and steering talented female trainees away from procedural fields [20, 21].
While our regression analysis found that gender was not a statistically significant predictor of total unperformed procedures after controlling for planned specialization, this result requires careful interpretation. Rather than negating the existence of a gender gap, it highlights the complex interplay between specialty choice and training experiences. This raises critical questions about causality: does limited procedural exposure drive women from surgical specialties, or do pre-existing preferences influence pursuit of hands-on opportunities? The literature suggests a more nuanced, cyclical relationship [11, 13, 14, 16–18]. Early clinical experiences characterized by fewer procedural opportunities and subtle bias can diminish self-efficacy, leading female students to internalize these limitations as personal unsuitability for surgical careers [13, 14, 16–18]. This perception then influences specialty selection, which further limits procedural exposure, perpetuating a self-reinforcing cycle. The confidence gap accompanying these experiential disparities is particularly concerning. Studies demonstrate that procedural experience strongly correlates with confidence, and that women consistently report lower procedural confidence than men despite equivalent academic performance [7]. This disparity is not merely self-perceived; independent observers also rate female students as less confident, suggesting that environmental factors shape both internal and external perceptions of competence [7, 15, 22]. When combined with evidence of “imposter syndrome” being more prevalent among female medical trainees, these findings illuminate how systemic biases can be internalized, affecting career trajectories long after initial training experiences [23–25].
The implications extend beyond individual career choices to impact healthcare quality and workforce diversity [11, 12, 22]. Procedural competency is fundamental to physician effectiveness, and disparities in training may compromise the ability of female physicians to provide optimal care in acute situations. Furthermore, the underrepresentation of women in surgical specialties perpetuates the scarcity of female role models and mentors, maintaining barriers for future generations [13, 14, 16–19, 22, 23]. Addressing these disparities requires comprehensive systemic interventions. First, medical curricula must transition from opportunistic clinical exposure to structured, competency-based frameworks that guarantee proficiency for all students [26]. Evidence-based pedagogical models such as Peyton’s four-step method and simulation-based training can standardize skill acquisition while minimizing the influence of clinical environment biases [27, 28]. Second, institutions must actively cultivate inclusive cultures through mandatory bias training for faculty and staff, implemented using validated frameworks that raise awareness and promote equitable teaching practices [29]. This includes ensuring that training materials and simulation equipment represent diverse patient populations and avoid embedding gender stereotypes [29, 30]. Third, robust mentorship programs connecting female trainees with women in procedural specialties are essential. Research demonstrates that mentorship, particularly gender-concordant mentorship, significantly impacts career success and specialty choice [15, 23, 31, 32].
Future research should employ longitudinal designs tracking trainees from medical school through residency to definitively establish causal relationships between procedural experience, confidence, and specialty selection [33–35]. Qualitative studies exploring the lived experiences of female trainees within the Polish system would provide deeper insights into specific cultural and environmental factors driving observed disparities [36–38]. Additionally, objective assessment of procedural competency would strengthen our understanding beyond self-reported measures.
This study’s primary limitation is its reliance on self-reported data, which introduces potential recall bias and subjective interpretation. Self-assessed procedural experience and theoretical knowledge may not correlate with objective competency, and the identified “experience gap” reflects perceived rather than demonstrated proficiency. Gender-related differences in self-evaluation patterns may further influence reported confidence levels. The cross-sectional design precludes causal inference. While associations between gender, specialty preference, and procedural experience emerged, we cannot determine whether limited procedural exposure drives women from surgical specialties or whether pre-existing preferences influence pursuit of hands-on opportunities. Also, selection bias is a concern given the online distribution method and absence of response rate data. Respondents may have had particularly strong views about their training experiences. Additionally, the concentration of responses from five institutions, while reflecting Poland’s medical education landscape, may limit generalizability. Regional variations in training approaches could influence the findings. The binary gender classification oversimplifies gender identity and excludes non-binary individuals, potentially obscuring important experiences of gender-diverse trainees. Furthermore, unmeasured confounders including individual motivation, mentor relationships, and specific rotation assignments could influence procedural exposure independently of gender. Additionally, our three-point scale for categorizing practical experience (‘never performed,’ ‘performed 1–2 times,’ ‘performed 3 or more times’) represents a simplification that cannot capture the full range of exposure (e.g., distinguishing between 3 and 10 attempts). We adopted this approach to minimize recall bias and ensure feasibility in a large nationwide survey. Future studies should employ more granular assessment methods, such as procedure logbooks or objective skills evaluations, to provide deeper insights. Another limitation is the predominance of women in our cohort (70.3%), reflecting the demographics of Polish medical schools where women comprise over 76% of students. While this gender imbalance could theoretically affect statistical comparisons, we addressed this concern by applying appropriate non-parametric tests and conducting regression analyses that controlled for both gender and specialization. Notably, gender was not a statistically significant independent predictor of unperformed procedures in the negative binomial regression analysis, suggesting that this demographic imbalance did not compromise our main conclusions. Finally, focusing on quantity of procedures performed may not capture quality of learning experiences, including supervision level, case complexity, or educational support received during training.
Conclusions
This nationwide study of Polish medical trainees reveals significant gender disparities in hands-on procedural experience, with female students reporting less practical training than their male peers despite demonstrating comparable theoretical knowledge and comprising the majority of trainees. These findings challenge the assumption that numerical parity ensures equity, pointing instead to systemic biases within clinical environments that limit opportunities for women, subsequently impacting their confidence and career trajectories. Medical institutions must therefore implement structured, system-level interventions, including structured competency-based training and mentorship programs, to address this experience gap. Addressing these disparities is crucial for maintaining the quality of medical education and ensuring the confidence and competence of the entire future physician workforce.
