Abstract
Background
This study aimed to examine the prevalence of gender bias in the field of cardiothoracic vascular surgery in India and compared women surgeons and trainees in India and abroad.
Methods
This was a comparative, cross-sectional analytical study using an online questionnaire. The survey included questions about demographics, career choice, training, academic and leadership opportunities, and the impact of choosing cardiothoracic-vascular surgery as a career on personal life.
Results
A total of 203 practicing surgeons and trainees participated in the study and included 121 (59.6%) men and 82 (40.3%) women. Out of the 82 women, 48 (58.5%) were from India, and 34 (41.5%) were from other countries. Satisfaction with the specialty was similar among men and women (105 (86.7%) vs. 68 (82.9%), p = 0.44 respectively). Majority (n = 30, 62.5%) of the female surgeons in India reported being discriminated against, as well as receiving favored treatment 11 (22.9%). Compared to men, women surgeons in India were more frequently advised against pursuing a career in cardiothoracic and vascular surgery (p < 0.001) and were more frequently subjected to gender-related references (p < 0.001). In addition, they had fewer presentation opportunities (p = 0.016) at national or regional meetings during their training compared to men. Additionally, 50% (24) of the women in India reported being single, in contrast to 7% (6) of men, and only 15 (31.3%) women reported having a child, compared to 57 (66.3%) of the men.
Conclusion
The study revealed significant gender disparities within the field of cardiothoracic vascular surgery in India and highlights the urgent need to address gender disparities and bias in cardiothoracic vascular surgery.
Keywords: Gender disparities, Bias, Career advancement, Workforce diversity, Cardiothoracic surgery
Introduction
In this era of inclusivity, diversity, and equity, gender discrimination has been in the spotlight, across professions. The existence of implicit gender bias and gender discrimination among physicians, especially surgeons, has been identified and reported in other parts of the world but has been seldom studied in India [1]. According to the Society of Thoracic Surgeons (STS) Workforce Report 2019, while 50% of the medical school graduates were females, they constituted < 5% of the American Board of Thoracic Surgery-certified cardiothoracic surgeons [2]. A very similar situation exists in India, where, despite female medical graduates consistently outnumbering their male counterparts for the last few years, their representation in Cardio-Thoracic and Vascular Surgery (CTVS) remains extremely low [3]. According to current membership data of the Indian Association of Cardio-vascular Thoracic Surgeons (IACTS), roughly 5% of the registered members are women. However, when analyzed across different categories, such as students, residents, and full-fledged surgeons, considerable variability is likely to exist.
Visibility of women in academic and leadership roles is extremely important as it allows them to become role models for other women to join the specialty and pursue excellence [4]. The lack of mentorship or role models is not only a deterrent to entry into the specialty but is also a reason for the attrition of women from the specialty, and the impact of gender-concordant mentorship cannot be undervalued [5, 6]. Women cardio-thoracic and vascular surgeons in India have rarely obtained the highest academic and leadership roles, with no woman cardiothoracic surgeon ever being the president of the IACTS. In the last 15 years, there have been only three women on the executive committee of the IACTS. No woman has ever held the post of editor-in-chief of the Indian Journal of Thoracic and Cardiovascular Surgery since its launch in 1982. Even the current editorial board of the journal consists of only two women out of the 35 board members. Of the 45 lifetime achievement awardees by the IACTS, there have been only four women.
The presence of women surgeons as speakers at the plenary sessions of IACTS annual conferences remains a rarity. This is in contrast to organizations like the American Association of Thoracic Surgeons (AATS), the European Association of Cardiothoracic Surgeons (EACTS), and the STS, which, over several years now, have facilitated female participation through formal leadership training courses like the AATS Leadership Academy and the STS Leadership Institute. Further, in 2022, the AATS had its first woman president, and the Annals of Thoracic Surgery, also for the first time, appointed a woman as the editor in chief.
Perceptions of gender discrimination, a gender-driven hostile work environment, and a lack of opportunities for academic and leadership roles are important deterrents against women joining the specialty. It is therefore essential to evaluate the current status of women in the specialty, the presence and extent of gender-based discrimination, as well as understand the challenges faced and the impact of personal commitments and responsibilities that deter a woman’s career progression. Through our study, we aim to identify the prevalence of gender-based discrimination among cardio-thoracic vascular surgeons in India, if any, in terms of academic, employment, and leadership opportunities. We also aim to compare the experiences of the Indian female CTVS trainees to those of trainees across the world.
Materials and methods
This was a comparative, cross-sectional analytical study using an online questionnaire that aimed to identify the prevalence of gender bias (discriminatory behavior or favored treatment) among cardio-thoracic and vascular surgeons in India. The primary objective was to identify the presence of any bias between male and female cardio-thoracic vascular surgeons in India. The secondary objective was to compare the experiences of female surgeons in India and abroad. We also sought to identify differences between those who were satisfied with the specialty and those who were not. A willingness to complete the questionnaire was taken as consent to participate, and ethics committee approval was not sought.
We designed a 33-item questionnaire (Table 1). Questions were designed to capture demographic details and identify gender bias with regard to career choice, training, academic, and leadership opportunities. The survey questionnaire included predetermined fixed-response multiple-choice questions and some with binary responses (yes/no). The survey questionnaire included questions related to surgical training—like the board of certification, subspeciality training, deterrents to join the specialty, and bias, if any, faced during training. Questions related to subspeciality and sector of practice, remuneration, time spent at the workplace, bias faced at practice, and years of practice after specialty training were included to assess bias faced during practice. There were also subjective questions related to satisfaction with career choice, willingness to encourage junior aspirants into the specialty, and eagerness to move abroad for better career prospects. The prevalence of gender bias in academic opportunities was determined by assessing time spent on research, publications, or presentations during training or practice. The questionnaire was sent to practicing Indian cardiac surgeons via email obtained from hospital websites and personal contacts. We used social media platforms like WhatsApp to contact individual residents training in India. We used Twitter to contact cardio-thoracic and vascular surgeons and trainees abroad based on their credentials. The questionnaire was shared with the surgeons after explaining to them the objective of the survey and ensuring their willingness to participate. The survey was closed 1 month after mailing the questionnaire. Participation in the survey was voluntary and anonymous.
Table 1.
Survey questionnaire
| Demographics | Age (years) | < 30; 30–50; 51–65; > 65 |
| Sex | Male; Female; Non Binary; Prefer not to say | |
| Have you completed/ are you training in any of the following postgraduate qualifications in CTVS? | Mch; DNB/DrNB; FRCS (Cth); American Board Certified; Other-please specify | |
| What is your current specialty?—if more than one, choose the predominant option. If in training, what is your most preferred specialty? | Adult cardiac; Congenital; Thoracic; Vascular; Aortic; Heart failure; Academic | |
| Where are you working now? | Government Hospital; Private Hospital; In training | |
| How many hours on an average do you work every week? | ≤ 48; 49- 72; > 72 | |
| What is your yearly income? (In USD) | < 12,000; 12,000–50000; > 50,000–85000; > 85,000; Prefer not to say | |
| Years in specialty after specialist training | Still in training; < 10 years; 11–25 years; > 25 years | |
| Career Choice | Was CTVS your first career choice? | No/Yes |
| Are you satisfied with your career choice? | No/Yes | |
| Were you ever advised against choosing CTVS as a career choice because of your gender? | No/Yes | |
| Would you advise a female aspirant to pursue CTVS? | No/Yes | |
| Would you advise a male participant to pursue CTVS? | No/Yes | |
| Would you move to another country for better academic/career opportunities? | No/Yes | |
| Opportunities at Training | Did you publish papers during your specialty training? | No/Yes |
| Did you present at National or Regional meetings during your training? | No/Yes | |
| Gender discrimination | Did you ever feel isolated/not accepted freely by others during your training | No/Yes/Maybe |
| Did you face verbal or non-verbal references to your gender by others during your training or practice? | No/Yes/Maybe | |
| Have you felt discriminated against due to your gender? | No/Yes/Maybe | |
| What percentage of your work time do you spend on research and academics? Please enter a number (1–100) | ||
| Academic and Administrative opportunities | Are you a member of any of the following professional societies? | IACTS; AATS; STS; EACTS; SCTS; Others-please specify |
| Have you ever held or do you hold any of the following posts in any of the above professional societies? | President; General Secretary; Treasurer; Have held other posts; have not held posts | |
| Have you held any of the following posts in IJTC or similar academic journals? | Editor in Chief; Associate Editor; Section Editor; Reviewer; Not held any posts | |
| Personal Life | What is your current relationship status? | Single; Married; Not married, but in a committed relationship; Divorced; Others |
| At what age did you get married? | ||
| Did you have to change your place of work to stay with your family? | Yes/No | |
| Did you have enough support at home for household work/ childcare? | Yes/No | |
| Do you feel your personal life may have hindered your professional progress (eg-not accepting a different job to stay with your family) | Yes/No | |
| Do you have children? | Yes/No | |
| At what age did you have your first child? (Years) | < 30; 30–40; > 40; No children | |
| Are you happy with the time you spend with your children? | Yes/No/Not applicable | |
| Do you find time to pursue hobbies outside work? | Yes/No |
Definitions
“In-training” was defined as surgical residents who were enrolled but had not completed the course leading to accreditation. “Women Surgeons” included both in-training and accredited women. “Discrimination against gender” was defined as unfair or unequal opportunities in academics, training, employment, and leadership opportunities based on gender. “Favored treatment” was defined as preferential treatment in terms of academics, training, employment, and leadership opportunities based on gender. “Academic post” was defined as an editorial role in various scientific journals. “Administrative post” was defined as leadership positions in various scientific societies of cardio-thoracic vascular surgeons.
Statistical analysis
It was performed using SPSS 22. Categorical variables were represented as numbers and percentages. Pearson chi-square test and Fisher’s exact test were used wherever applicable to compare the categorical variables. For continuous variables, Student’s t-test was used. A p-value of < 0.05 was considered significant.
Results
The survey questionnaire was completed by 205 practicing surgeons and trainees specializing in CTVS. Responses were received from various countries, including Australia, Belgium, Brazil, Finland, France, Italy, other European nations, India, Mexico, South Africa, Spain, Tunisia, the UK, and the USA (Fig. 1). Two respondents chose not to disclose their gender and were therefore excluded from the analysis. Among the respondents, there were 121 (59.6%) men and 82 (40.3%) women. Out of the 82 women, 48 (58.5%) were from India, and 34 (41.5%) were from other countries. Among the men, 86 (71.1%) were from India, and 35 (28.9%) were from other countries.
Fig. 1.
Distribution of participants across the globe
The majority of respondents, regardless of gender, expressed satisfaction with their choice of CTVS as a specialty, with 105 (86.7%) males and 68 (82.9%) females indicating satisfaction (p = 0.44), as detailed in Table 2.
Table 2.
Comparison between men and women participants in the entire cohort
| Overall (n = 203) | Men (n = 121) | Women (n = 82) | p-value | |
|---|---|---|---|---|
| Demographics | ||||
| Age | ||||
| < 30 | 41 (20.1%) | 14 (11.6%) | 27 (32.9%) | < .001 |
| 30–50 | 131 (64.5%) | 79 (65.3%) | 52 (63.4%) | |
| 51–65 | 25 (12.3%) | 23 (19%) | 2 (2.4%) | |
| > 65 | 6 (2.9%) | 5 (4.1%) | 1 (1.2%) | |
| Hours of work (per week) | 0.342 | |||
| ≤ 48 | 19 (9.4%) | 13 (10.7%) | 6 (7.3%) | |
| 49–72 | 87 (42.9%) | 47 (38.8%) | 40 (48.8%) | |
| > 72 | 95 (46.8%) | 59 (48.8%) | 36 (37.9%) | |
| Years in the speciality after specialist training | ||||
| Still in training | 76 (37.4%) | 30 (24.8%) | 46 (56.1%) | < .001 |
| < 10 years | 66 (32.7%) | 41 (33.9%) | 25 (30.4%) | |
| 11–25 years | 46 (22.6%) | 36 (29.8%) | 10 (12.1%) | |
| > 25 years | 15 (7.3%) | 14 (11.6%) | 1 (1.2%) | |
| Career choice | ||||
| Are you satisfied with your career choice?—yes | 173 (85.2%) | 105 (86.7%) | 68 (82.9%) | 0.448 |
| Do you find time to pursue hobbies outside work?—no | 81 (40.1%) | 42 (34.7%) | 39 (47.5%) | .06 |
| Would you advise a female aspirant to pursue CTVS?—yes | 156 (76.8%) | 95 (78.5%) | 61 (74.3%) | 0.49 |
| Would you advise a male aspirant to pursue CTVS?—yes | 168 (82.7%) | 102 (84.2%) | 66 (80.4%) | 0.48 |
| Would you move to another country for better opportunities?—yes | 136 (66.9%) | 77 (63.6%) | 59 (71.9%) | 0.216 |
| Personal details | ||||
| Relationship | < 0.001 | |||
| Married | 135 (66.5%) | 101 (83.4%) | 34 (41.4%) | |
| Single | 47 (23.4%) | 10 (8.4%) | 37 (45.1%) | |
| In a relationship | 20 (9.8%) | 10 (8.4%) | 10 (12.2%) | |
| Divorced | 1 (0.5%) | 0 (0%) | 1 (1.2%) | |
| Did you have to change your place of work to stay with your family?—yes | 61 (30.8%) | 36 (29.7%) | 25 (30.9%) | 0.91 |
| Do you have enough support at home for household work/childcare?—yes | 155 (76.3%) | 94 (77.6%) | 61 (74.3%) | 0.58 |
| Do you feel your personal life may have hindered your professional progress?—yes | 88 (43.3%) | 54 (44.6%) | 34 (41.4%) | 0.655 |
| Do you have children?—yes | 108 (53.2%) | 81 (66.9%) | 27 (32.9%) | < .001 |
Gender differences in the entire study
Women surgeons in the study were significantly younger (p < 0.001) than their male counterparts, with the majority of them still in training (46 (56.1%) vs. 30 (24.8%), p < 0.001 respectively). The difference was also observed in relationship status, with a substantially higher percentage of women reporting being single compared to men (37 (45.1%) vs. 10 (8.4%), p < 0.001 respectively). In addition, a significantly lower number of women reported having children when compared to men (27 (32.9%) vs. 81 (66.9%), p < 0.001 respectively) (Table 2).
Gender differences in India
Similar trends were observed in the Indian subset of the study. In India, like in the overall cohort, a larger percentage of female CTVS surgeons was under the age of 30 years compared to men (21 (43.7%) vs. 10 (11.6%) respectively). Similarly, In India, majority of the women surveyed were still in training compared to men (27 (56.3%) vs. 20 (23.3%), respectively). Additionally, half of the female participants in India reported being single, in contrast to only 7% of men (Table 3).
Table 3.
Gender differences in India
| Men (n = 86) | Women (n = 48) | p-value | |
|---|---|---|---|
| Demographics | |||
| Age | |||
| < 30 | 10 (11.6%) | 21 (43.7%) | < .001 |
| 30–50 | 62 (72.1%) | 26 (54.2%) | |
| 51–65 | 11 (12.8%) | 0 (0%) | |
| > 65 | 3 (3.5%) | 1 (2.1%) | |
| Hours of work (per week) | 0.146 | ||
| ≤ 48 | 13 (15.1%) | 2 (4.2%) | |
| 49–72 | 31 (36.0%) | 18 (37.5%) | |
| > 72 | 42 (48.8%) | 28 (58.3%) | |
| Years in the speciality after specialist training | |||
| Still in training | 20 (23.3%) | 27 (56.3%) | |
| ≤ 10 years | 35 (40.7%) | 15 (31.2%) | < .001 |
| 11–25 years | 22 (25.6%) | 5 (10.4%) | |
| > 25 years | 9 (10.5%) | 1 (2.1%) | |
| Career choice | |||
| Was CTVS your first career choice? (yes) | 65 (75.6%) | 36 (75%) | 0.549 |
| Are you satisfied with your career choice? (yes) | 74 (86.0%) | 40 (83.3%) | 0.801 |
| Do you find time to pursue hobbies outside work? (no) | 50 (58.1%) | 17 (35.4%) | .022 |
| Would you advise a female aspirant to pursue CTVS? (yes) | 63 (73.3%) | 35 (72.9%) | 1 |
| Would you advise a male aspirant to pursue CTVS? (yes) | 71 (82.6%) | 40 (83.3%) | 0.890 |
| Would you move to another country for better academic/career opportunities? (yes) | 56 (65.1%) | 35 (72.9%) | 0.220 |
| Personal life | |||
| Relationship | < 0.001 | ||
| Married | 72 (83.7%) | 21 (43.8%) | |
| Single | 6 (7%) | 24 (50%) | |
| In a relationship | 6 (7.0%) | 3 (6.3%) | |
| Divorced | 2 (2.3%) | 0 (0%) | |
| Did you have to change your place of work to stay with your family? (yes) | 29 (33.7%) | 16 (33.3%) | 0.89 |
| Do you have enough support at home for household work/childcare? (yes) | 66 (76.7%) | 38 (79.2%) | 0.424 |
| Do you feel your personal life may have hindered your professional progress? (yes) | 37 (43.0%) | 16 (33.3%) | 0.244 |
| Do you have children? (yes) | 57 (66.3%) | 15 (31.3%) | < .001 |
Differences between women surgeons in India and abroad
Apart from the hours of work and the ability to pursue hobbies, there were no differences between women surgeons in India and abroad (Table 4). While 28 (58.3%) women surgeons in India reported working more than 72 h, this was reported by only 10 (29.4%) of the women surgeons abroad (p = 0.03). A significantly higher number of women surgeons abroad were able to pursue a hobby outside work compared to their Indian counterparts (25 (73.5%) vs. 17 (35.4%), p = 0.0006, respectively).
Table 4.
Differences between women surgeons in India and abroad
| Women surgeons in India (n = 48) | Women surgeons abroad (n = 34) | p-value | |
|---|---|---|---|
| Demographics | |||
| Age | 0.06 | ||
| < 30 | 21 (43.7%) | 7 (20.6%) | |
| 30–50 | 26 (54.2%) | 25 (73.5%) | |
| 51–65 | 0 | 2 (5.9%) | |
| > 65 | 1 (2.1%) | 0 | |
| Hours of work (per week) | 0.03 | ||
| ≤ 48 | 2 (4.2%) | 4 (11.8%) | |
| 49–72 | 18 (37.5%) | 20 (58.8%) | |
| > 72 | 28 (58.3%) | 10 (29.4%) | |
| Years in the specialty after specialist training | 0.58 | ||
| Still in training | 27 (56.3%) | 19 (55.9%) | |
| < 10 years | 15 (31.2%) | 9 (26.5%) | |
| 11–25 years | 5 (10.4%) | 6 (17.6%) | |
| > 25 years | 1 (2.1%) | 0 | |
| Career choice | |||
| Are you satisfied with your career choice? (no) | 8 (16.7%) | 5 (14.7%) | 0.81 |
| Do you find time to pursue hobbies outside work? (no) | 31 (64.5%) | 9 (26.5%) | 0.0006 |
| Would you advise a female aspirant to pursue CTVS? (no) | 13 (27.1%) | 7 (20.5%) | 0.49 |
| Would you advise a male aspirant to pursue CTVS? (no) | 8 (16.7%) | 8 (23.5%) | 0.76 |
| Would you move to another country for better academic/career opportunities? (yes) | 35 (72.9%) | 24 (70.6%) | 0.81 |
| What percentage of your working time do you spend on research and academics? | 15.5 ± 17.3 | 15 ± 14.2 | 0.89 |
| Personal details | |||
| Relationship | 0.07 | ||
| Married | 21 (43.8%) | 12 (35.3%) | |
| Single | 24 (50%) | 13 (54.1%) | |
| In a relationship | 3 (6.3%) | 8 (23.5%) | |
| Divorced | 0 (0%) | 1 (2.9%) | |
| Did you have to change your place of work for your family? (yes) | 16 (33.3%) | 10 (29.4%) | 0.55 |
| Do you have enough support at home for household work/childcare? (yes) | 38 (79.2%) | 22 (64.7%) | 0.07 |
| Do you feel your personal life may have hindered your professional progress? (yes) | 16 (33.3%) | 17 (50%) | 0.25 |
| At what age did you have your first child? | 0.82 | ||
| < 30 | 6 (12.5%) | 6 (17.6%) | |
| 30–40 | 8 (16.6%) | 6 (17.6%) | |
| > 40 | 1 (2.1%) | 0 | |
| No children | 33 (68.7%) | 21 (61.8%) | |
| Are you happy with the time you spend with your children? (no) | 11 (22.9%) | 6 (17.6%) | 0.57 |
Women in training
Among women in training, 19 (70.4%) trainees in India were under 30 years of age, compared to 7 (36.8%) trainees in other countries, p = 0.024. Apart from this age difference, no other significant distinctions were observed between trainees in India and those abroad, as presented in Table 5. Of the 27 women in training in India, 17 (62.9%) were pursuing the 6-year Diplomate of National Board (DNB)/Doctorate of National Board (DrNB) course as opposed to 10 (50%) of the male trainees in India who were pursuing the DNB/DrNB course, p = 0.37.
Table 5.
Differences between women in training in India and abroad
| Women trainees overall (n = 46) | Women trainees in India (n = 27) | Women trainees abroad (n = 19) | p-value | |
|---|---|---|---|---|
| Demographics | ||||
| Age | ||||
| < 30 | 26 (56.5%) | 19 (70.4%) | 7 (36.8%) | 0.024 |
| 30–50 | 20 (43.5%) | 8 (29.6%) | 12 (63.2%) | |
| Hours of work (per week) | 0.423 | |||
| ≤ 48 | 2 (4.3%) | 1 (3.7%) | 1 (5.3%) | |
| 49–72 | 17 (37%) | 8 (29.6%) | 9 (47.4%) | |
| > 72 | 27 (58.7%) | 18 (66.7%) | 9 (47.4%) | |
| Career choice | ||||
| Are you satisfied with your career choice? (no) | 11 (23.9%) | 8 (29.6%) | 3 (15.8%) | 0.279 |
| Do you find time to pursue hobbies outside work? (no) | 23 (51.1%) | 16 (61.5%) | 7 (36.8%) | 0.102 |
| Would you advise a female aspirant to pursue CTVS? (no) | 12 (26.7%) | 7 (25.9%) | 5 (27.8%) | 0.891 |
| Would you advise a male aspirant to pursue CTVS? (no) | 9 (19.6%) | 3 (11.1%) | 6 (31.6%) | 0.085 |
| Would you move to another country for better academic/career opportunities? (yes) | 38 (82.6%) | 23 (85.2%) | 15 (78.9%) | 0.583 |
| Relationship | 0.081 | |||
| Married | 14 (30.4%) | 9 (33.3%) | 5 (26.3%) | |
| Single | 26 (56.5%) | 17 (62.9%) | 9 (47.3%) | |
| In a relationship | 6 (13%) | 5 (26.3%) | 1 (3.7%) | |
| Did you have to change your place of work to stay with your family? (yes) | 14 (31.1%) | 8 (30.8%) | 6 (31.6%) | 0.954 |
| Do you have enough support at home for household work/childcare? (yes) | 34 (75.6%) | 23 (85.2%) | 11 (61.1%) | 0.066 |
Gender-based discrimination
Overall
In the overall cohort, 8 (6.6%) of male surgeons felt discriminated against as opposed to 56 (68.3%) of females (p < 0.001). At the same time, 27 (32.9%) of the females also reported receiving favored treatment on account of their gender, as opposed to 9 (7.4%) of the male surgeons (p < 0.001).
In India
Majority of the women reported being discriminated against due to their gender (n = 30, 62.5%) and 11 (22.9%) reported receiving favored treatment. Compared to men, women were more frequently advised against pursuing a career in CTVS (p < 0.001), reflecting a gender bias in career guidance. They were also subjected to gender-related references more frequently (p < 0.001) during their training or practice. Feelings of isolation were more common among women (p < 0.001), indicating challenges related to acceptance and inclusion within the field. In addition, they had fewer presentation opportunities (p = 0.016) at national or regional meetings during their training compared to men (Table 6).
Table 6.
Gender-based discrimination in India
| Men (n = 86) | Women (n = 48) | p-value | |
|---|---|---|---|
| Were you ever advised against choosing CTVS as a career because of your gender? (yes) | 7 (8.1%) | 41 (85.4%) | < 0.001 |
| Did you have to face verbal or non-verbal references to your gender by others during your training or practice? (yes) | 10 (11.6%) | 33 (68.8%) | < 0.001 |
| Did you ever feel isolated/not accepted freely by others during your training? (yes) | 22 (25.6%) | 29 (60.4%) | < 0.001 |
| Have you felt discriminated against due to your gender? (yes) | 7 (8.1%) | 30 (62.5%) | < 0.001 |
| Did you receive favored treatment because of your gender? (yes) | 4 (4.7%) | 11 (22.9%) | 0.003 |
| Did you present at national or regional meetings during your training? (yes) | 68 (79.1%) | 28 (58.3%) | 0.016 |
| Did you publish papers during your speciality training? (yes) | 61 (70.9%) | 28 (58.3%) | 0.182 |
Gender-based disparities in academic and administrative leadership roles
A significantly lower percentage of women, 53 (64.6%) were members of a professional body compared to men, 107 (88.4%) (p = 0.00004). A significant difference emerged in academic associations with journals as well, with a lower percentage of women 15 (18.2%) having such affiliations with journals compared to men 39 (32.2%) (p = 0.02) (Fig. 2). However, a similar proportion of women and men held administrative positions within committees, with 8 (9.7%) of women and 14 (11.5%) of men (p = 0.68) holding such roles (Fig. 2).
Fig. 2.
Academic and administrative leadership roles
Influence of satisfaction with the specialty choice on personal and professional outcomes
There were no significant differences (p = 0.28) observed between males and females in terms of satisfaction with their chosen specialty, as indicated in Table 2. Only 14 (17.1%) women surveyed reported being dissatisfied with their career choice in the overall study. Majority of the women (n = 11, 78.5%) who were dissatisfied with their career choice were trainees. This was similar across both women in India and abroad with 8 (29.6%) of the women in training surveyed in India and 3 (15.8%) of the women in training abroad reporting dissatisfaction with their career choice (Table 5).
All the women who were dissatisfied with their career choice were working more than 48 h per week, with 6 out of 14 (42.9%) reporting working hours of more than 72 h a week. Working hours was however not a determinant of satisfaction as 34 out of 68 (50%) women satisfied with their career choice were also working > 72 h per week (p = 0.62).
Women who were not satisfied with their career were less likely to be married (3 (21.4%) vs. 33 (48.5%), p = 0.06), and were also less likely to have children (1 (7.1%) vs 28 (41.1%), p = 0.01). While there was no difference in terms of recommending the specialty to a male aspirant (p = 0.94), there was significant reluctance against recommending CTVS to a female aspirant (p = 0.04).
There was also no difference between the surgeons who were dissatisfied with their career choice when compared to those who were satisfied, in terms of being able to pursue hobbies (5 (35.7%) vs 39 (57.3%), p = 0.13), having to change their place of work to stay with their families (5 (35.7%) vs. 20 (29.4%), p = 0.64), or willingness to migrate to another country for the better opportunity (12 (85.7%) vs. 48 (70.5%), p = 0.24). The perception that personal life hindered professional growth (5 (35.7%) vs. 30 (44.1%), p = 0.56) and availability of enough support (10 (71.4%) vs. 53 (77.9%), p = 0.59) was an important issue and was common to both the groups (Fig. 3).
Fig. 3.
Influence of satisfaction on personal and professional outcomes
Discussion
The study revealed significant gender disparities in CTVS, with a low representation of women in academic and leadership roles. Implicit gender bias and discrimination were identified, with women reporting both experiences of discrimination and favored treatment. While overall career satisfaction was high, it was found that motherhood and family responsibilities had an impact on career progression among women. Discouragement from joining the specialty and gender-related stereotyping were also reported.
The overall representation of women in CTVS remains extremely low in India, despite female medical graduates consistently outnumbering their male counterparts. This mirrors the STS 2019 Workforce Report, which showed that despite half of the medical school graduates being female, the representation of women in cardiothoracic surgery is woefully low [2]. Similar findings have been reported in a nationwide study in the UK, where only 10.1% of the consultants in cardiothoracic surgery were women [7]. It is, however, encouraging to note that 20% of the women in the survey were below the age of 30 years, suggesting that more women are choosing the specialty despite the prevalent prejudices. Interestingly, this change is not unique to India, and an increasing number of female trainees have been joining the specialty in the US as well [2, 8, 9]. A significant positive trend was also observed in the UK in terms of female representation among the trainees [7].
Majority of both male and female respondents expressed satisfaction with their choice of cardiothoracic vascular surgery as a specialty. However, a notable proportion of female trainees reported dissatisfaction, indicating potential challenges and barriers faced by women in their career progression. In our study, 82.9% of the women surveyed reported being satisfied with their career choice, which echoes the findings of the report provided by the STS 2019 Workforce. In this report, 81% of the women surveyed reported being satisfied with the specialty [2].
Majority (68.3%) of the women overall and 62.5% women surgeons in India reported facing gender-based discrimination in our study. Among the Indian female trainees, one-third reported being subjected to discrimination. Both in India and abroad, women also reported receiving favored treatment based on their gender. The issue of gender-based discrimination in cardiothoracic surgery has been consistently reported in studies all across the globe. In Europe, 65% of the women reported being discriminated against, with 35% contemplating leaving the specialty due to discrimination [10]. In a survey conducted by the STS and Women in Thoracic Surgery (WTS), assessing gender bias, the respondents reported a perception of disparate workplace treatment and unsupportive behavior among women [11]. Assessment of trainee performance has also been influenced by the gender of the trainee [12].
The perceived notion that long hours of work dissuade women from joining the specialty was not substantiated in our study. In fact, studies assessing overall satisfaction with the specialty have found no correlation between the total number of working hours, operating sessions, or the duration of being on call [13]. The finding that 45.1% of the women surveyed reported being single in our survey, compared to only 8.4% of men, is concerning. The negative impact of specialty on family life seems to have been observed in other studies too. In one study, 40% of those surveyed accepted that working as a cardiothoracic surgeon negatively impacted their family life, and a large number of women resorted to surrogacy, adoption, or assisted reproductive technology in order to have a child [14]. In our survey, 32.9% of the women reported having a child, compared to 66.9% of the men. This has an uncanny resemblance with the survey findings of the European Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery on gender bias in Europe, which showed that only 34% of the women reported having children compared to 81% of the men [10].
The underrepresentation of women in the cardiothoracic workforce also extends to key academic and leadership roles within the specialty. A similar disparity has been reported among cardiothoracic surgeons in the US, where women represent only 10% of all academic cardiothoracic surgeons [8]. In addition, their representation as senior authors and in leadership roles also remains low [15]. A study looking at authorship among men and women found that while there were a similar number of first-author publications, the number of last-author or senior-author publications was significantly lower. The overall h-index was also found to be lower among women compared to men [16]. The disparity in research opportunities and academic recognition can further perpetuate the gender gap in the field, and efforts have to be made to provide equal opportunities for women to contribute as authors and leaders. According to published data, the representation of women on editorial boards varies from 0% (Seminars in Thoracic and Cardiovascular Surgery) to 27.9% (Journal of Heart and Lung Transplantation) [17]. In this respect, the efforts of the Southern Thoracic Surgical Association have to be lauded, which has ensured increasing numbers of women presenting in the annual meeting, acting as session moderators, and forming part of the various committees [18]. Similar efforts must be made in the Indian cardiothoracic sphere.
Moreover, the need for role models and mentorship for female trainees cannot be overemphasized [19]. While this is applicable to all trainees, it has added importance for women in training. The lack of a mentor has been more commonly reported by women in cardiothoracic surgery [10]. It has been shown that participation in structured mentoring programs creates a supportive community for women trainees and enables them to achieve their career more effectively [6]. Fewer number of senior female cardiothoracic surgeons spread across a large geographical area is a definite barrier to same-sex in-person mentorship. However, studies have confirmed the effectiveness of social media platforms for enhancing networking and mentorship [20].
Limitations
While the present study provides valuable insights into the gender dynamics within cardiothoracic surgery in India, there are limitations that should be acknowledged. Currently, there is no database or directory of female cardiac surgeons which includes all the consultants as well as the trainees, and as a result, we were not able to reach out to all the women in the specialty. While we assessed the administrative and leadership roles at the national level, the survey did not include an assessment of leadership opportunities at the departmental and institutional level. In addition, even though the survey was anonymous, the risk of social desirability bias cannot be ruled out. The study also relied on self-reported data, which may be subject to recall bias. Sampling bias and suggestion bias are also inherent in any questionnaire survey and are limitations of our survey too. Decisions with regard to getting married and having children may be a personal choice and not necessarily an outcome of gender-based disparities, and our study did not differentiate between the two.
However, it also has to be acknowledged that personal choices, especially for women, are often a reflection of the broader environment in which they find themselves. Our study intended to shed light on these systemic factors and their implications on women’s participation in the field. It did not intend to imply that all women are actively discouraged or discriminated against in making these choices. Rather, the study attempts to draw attention to the fact that the opportunities and support available to women in cardiac surgery may differ from those available to their male counterparts.
Conclusion
The findings of our study highlight the need for addressing gender disparities, promoting inclusivity, and providing mentorship and support to women in the field of cardiothoracic surgery. By increasing female representation in authorship and leadership roles, the field of cardiothoracic surgery can benefit from diverse perspectives, innovative ideas, and enhanced patient care. It can foster an inclusive and equitable environment that encourages women to pursue and thrive in the specialty. Additionally, promoting gender diversity can serve as an inspiration for future generations of female surgeons and help break down systemic barriers that hinder their professional advancement.
Author contribution
SS contributed towards the conception of the study, designing the questionnaire, data acquisition, writing and revising the manuscript, and approval of the final version.
VS contributed towards data acquisition, revising the manuscript, and approval of the final version.
AD contributed towards data acquisition, revising the manuscript, analyzing the data, and approval of the final version.
MI contributed towards the modification of the questionnaire, data acquisition, revising the manuscript, and approval of the final version.
MB contributed towards the modification of the questionnaire, data acquisition, revising the manuscript, and approval of the final version.
PN contributed towards the conception of the study, designing the questionnaire, data acquisition, data analysis, writing and revising the manuscript, and approval of the final version.
Funding
None.
Data availability
All data supporting the findings of this study are available within the paper. Survey responses are available from the corresponding author upon reasonable request.
Declarations
Ethical approval
Not applicable.
Consent to participate
Agreeing to participate in the survey was taken as consent.
Conflict of interest
None.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data supporting the findings of this study are available within the paper. Survey responses are available from the corresponding author upon reasonable request.