Differential Attainment in Higher Surgical Training: A Systematic Review of Contributing Factors And Interventions

• This is the first systematic review to evaluate both causes and interventions for differential attainment in higher surgical training. • Five key contributors to differential attainment were identified: representation disparities, burnout, financial barriers, work-life balance conflicts, and harassment. • Composite scoring and heatmap visualization revealed regional variation in the diversity of differential attainment. • Despite widespread recognition, most interventions remain unevaluated, under-theorized, and not co-designed with affected trainees. • The review offers actionable insights and policy recommendations to support equity-driven reform in surgical education. Differential attainment (DA) reflects persistent disparities in surgical training outcomes across gender, ethnicity, and socioeconomic status and has been increasingly recognized in surgical training. This systematic review aimed to synthesize existing evidence on contributory factors and evaluate interventions designed to mitigate DA in higher surgical training. systematic review was conducted in accordance with PRISMA guidelines and registered on the Open Science Framework (DOI: 10.17605/OSF.IO/RC54V). Inclusion criteria comprised studies focusing on causes or solutions to DA in higher surgical training. Exclusion criteria included studies not exploring causes/solutions, studies focused solely on faculty, and non-peer reviewed literature. MEDLINE, Embase and Scopus were searched (2004-2024). Eligible studies analyzing contributory factors or interventions targeting DA were included. Quality was appraised using CASP, Newcastle-Ottawa Scale, or MMAT tools. A thematic synthesis categorized findings at individual, institutional and systemic levels. No external funding was received for this study. Forty-three studies met inclusion criteria, including 33 quantitative, 6 qualitative, and 4 mixed-methods studies. Common contributors to DA included gender and ethnic disparities, burnout, financial barriers, work-life balance, and workplace harassment. Interventions such as structured mentorship, financial support, competency-based assessment, and anti-harassment policies were frequently proposed. However, few were formally evaluated or co-designed with affected trainees. No studies provided conclusive evidence of reduction in DA outcomes. Despite widespread recognition, DA in surgical training remains poorly addressed. Most interventions are unevaluated, under-theorized, and not co-designed with affected trainees. Systematic, evidence-based approaches are urgently needed to achieve equity in surgical education. This review provides actionable insights for surgical educators, policymakers, and training programs aiming to achieve equity.