Limitations
fatigue
This study has limitations. Voluntary participation may have created selection bias. This study enrolled only participants who identify as women, so outcomes among individuals who identify as men is unknown. There could have been selection bias of sites, a process that was dependent on leadership buy-in, which is vulnerable to bias. We did not use cluster randomization given our interest in individual rather than group-level changes in outcomes, and we also wanted to avoid loss of statistical power. This study is unique in that the intervention was administered digitally by a centralized entity and not separately at each site as in more traditional clinical trials. However, we may consider cluster randomization in future studies. Contamination was possible because each site had participants in control and intervention groups, although mitigation efforts were implemented (eg, password access to intervention materials).We had substantial loss to follow-up. Control participants were significantly more likely to respond to the survey than intervention participants, perhaps due to email fatigue (the intervention group received 2emails weekly), or control participants may have been more motivated in anticipation of receiving the intervention. There were racial, gender identity, and PGY differences between follow-up survey responders and nonresponders. This finding may be related to previously established observations that those with higher time constraints (ie, participants in PGY 1) may feel marginalized, and those who are underrepresented in medicine due to their race and/or gender identity may feel less socially connected and less inclined to complete surveys.