Change is Hardest Right Before the Glass Ceiling Breaks: An Update on Women Pursuing Careers in Academic Surgery at a National Level

Structured Abstract:

Objectives:

This study aims to provide a comprehensive update on the representation of women in academic surgery by specialty, measuring progress and opportunity with regard to women “breaking” the glass ceiling at the trainee, faculty, and department chair levels.

Background:

Over the past two decades, initiatives have contributed to educational awareness, culture shifts, and a focus on inclusive excellence in surgery, leading to an increase in the number of women surgeons. Despite progress, a persistent gender gap in surgical faculty positions remains, and projections suggest that it will take more than a century to reach parity at the highest levels of academic surgery.

Methods:

Data from the Association of American Medical Colleges FACTS and Faculty Rosters and the American Medical Colleges and Graduate Medical Education reports from 2006 to 2023 were analyzed to assess gender representation in surgery. Linear regression analyses were used to describe trends in the proportions of women who are promoted along the professional development pathway (resident to faculty to department chair) from 2006 to 2023.

Results:

Over our 17-year study period, all included surgical subspecialties increased in the proportion of women trainees, with the largest average annual increase in the proportion of women trainees observed in pediatric, plastic, and vascular surgery training programs. Although all surgical faculty levels experienced growth in the proportion of women, the average annual change in the proportion of women decreased as seniority increased. At the observed trend, it is projected that surgical department chairs will not achieve equal proportions of men and women until the year 2102.

Conclusion:

Across the board, the proportion of women in surgery has increased. However, there remains opportunity for improvement, particularly at the senior faculty and department chair levels. There continues to be significant opportunity around retention and promotion of women.

Mini Abstract:

The Association of American Medical Colleges FACTS and Faculty Rosters and the American Medical Colleges and Graduate Medical Education reports from 2006 to 2023 were analyzed to assess gender representation in surgery. Across the board, the proportion of women in surgery has increased. However, there remains opportunity for improvement, particularly at the senior faculty and department chair levels.

Introduction

Over the past two decades, strong initiatives and broad culture shifts have led to positive change and women moving up the ladder to higher positions within academic surgery. Support for women in surgery has been bolstered by studies that demonstrate surgical residency programs with women faculty are associated with higher training program desirability, improved mentorship opportunities, and increased overall resident retention.^1,2 Past studies also have shown that a physician workforce that better represents its patient populations is associated with better surgical outcomes.^3,4 Examining representation in academic leadership is one measurable way to assess our progress towards gender parity.

The growth of women’s surgical organizations such as the Association of Women Surgeons (AWS), The Ruth Jackson Orthopedic Society, and the American College of Surgeons’ (ACS) Women in Surgery Committee has provided resources and support for women as they progress along surgical promotion pathways. Formal surgical mentorship programs and national initiatives from the American Surgical Association, American Medical Association, and the American College of Surgeons have contributed to educational awareness, culture shifts, and a focus on fostering excellence in surgery.^1-4 In addition, institutions have embraced local initiatives that support women in surgery, including interest groups, themed speakers and conferences, and policies that ensure diverse candidate pools for academic surgery positions.

Previous analyses indicated a significant increase in women surgeons between 1994 and 2015 but identified a persistent gender gap in surgical faculty positions.² Although the number of women general surgery trainees more than doubled between 1994 and 2015, women represented only 38% of all general surgery trainees in 2014, and less than 10% of full professor positions were held by women in 2015.² Based on these trends, it was projected there would not be equal proportions of women and men as full professors until 2136.² It has been nearly 10 years since the last comprehensive analysis, and the impact of recent policy changes and program efforts warrants review. As efforts continue to close the gender gap in the surgical workforce, this study aims to provide a comprehensive update on the representation of women in academic surgery and surgical subspecialties and measure progress toward “breaking” the glass ceiling in surgical leadership.

Study Design

Data from 2006 to 2023 were extracted in July 2024 from the Association of American Medical Colleges (AAMC) FACTS data tables, which present annual data on US medical school applicants, matriculants, enrollments, and graduates⁵; Graduate Medical Education (GME) reports published annually in the Journal of American Medical Association (JAMA); and the AAMC Faculty Rosters accessed through the Faculty Administrative Management Online User System, which contains records for approximately 185,000 active full-time faculty and over 300,000 inactive faculty.⁶

At each training level, subjects were considered eligible if they were US medical school graduates, resident physicians training in a specialty of interest in the US, or academic faculty in a specialty of interest in the US, respectively. Subjects with missing sex or missing self-reported gender data were excluded. Internal medicine resident data were collected to provide comparison for proportions of women trainees to those of surgery. Faculty rank data for internal medicine were collected to compare the proportions of women at various faculty levels to those of surgery. Outcomes of interest included the number and gender of subjects at each training level.

The number and gender of US medical school graduates were collected from the AAMC FACTS data tables, and the number and sex of general surgery trainees were obtained from GME reports. Since GME reports do not have specific gender data, self-identified sex data were used as a proxy in these cases to estimate the proportion of women. US medical school surgical faculty data on gender and rank were extracted from AAMC faculty rosters.⁵

Medical school graduate and surgical trainee data were published based on academic year; therefore, 2006 to 2023 data corresponded to the 2005-2006 to 2022-2023 academic years. Medical school graduate data were updated through July 2006 to 2023, and resident data were updated through December 2005 to 2022. Faculty data were recorded by calendar year, and those data were updated through December 2006 to 2023.

Surgical specialty and subspecialty trainee data were collected to provide a more nuanced description of women pursuing surgery. Combined trainee data for general surgery, plastic surgery, orthopedic surgery, neurologic surgery, and otolaryngology were available and were included. Fellowship data for colorectal surgery, pediatric surgery, critical care surgery, thoracic surgery, vascular surgery, and complex general surgical oncology (CGSO) were extracted, as these programs are accessible following the completion of general surgery residency and do not have subspecialty residency programs. The numbers of women trainees in both integrated and non-integrated specialties were summed when applicable to determine the proportion of women in each specialty. Data on the number of CGSO fellows were first reported in 2013 and therefore analyzed separately from 2013 to 2023.

Linear regression analysis was used to describe trends in the proportions of women medical school graduates, trainees, and faculty over the study period (2006 to 2023), except for data on CGSO trainees, which were analyzed separately (2012 to 2023). The slopes obtained from the linear regressions were used to estimate annual growth rates and forecast future values. Statistical significance was set at p<0.05 for all one-sided tests assessing linear relationships. All analyses were performed in R version 4.4.0 (2024-04-24). STROBE reporting guidelines were followed.

Results

This study provides a 2023 cross-sectional analysis of 20,233 women along the academic surgical pathway from medical school graduates to department chairs (Figure 1).

Figure 1.

2023 Cross-sectional analysis of women pursuing careers in academic surgery

Medical School Graduates

From 2006 to 2023, the number of medical school graduates increased by 31.3% (15,927 to 20,920). During the same period, the number of women graduates increased by 40% (7,747 to 10,849). Overall, the proportion of women medical school graduates increased over the study period (48.7% to 51.9%), growing on average less than 0.3% per year but notably exceeding 50% of overall graduates every year since 2021.

Surgical Residents and Subspecialty Fellows

From 2006 to 2023, the number of general surgery residents increased by 33.9% (7,628 to 10,211), and the number women general surgery trainees more than doubled (2,130 to 4,905). The proportion of women general surgery trainees experienced an average increase of 1% per year, and women constituted 48.0% of general surgery trainees as of 2023. In 2006, women constituted 27.9% of general surgery trainees and 42.2% of residents in internal medicine. As of 2023, the proportion of women general surgery trainees has increased by 20.1% and exceeded that of internal medicine since 2020. In contrast, the proportion of women internal medicine trainees ranged between 42.2% and 44.7%, changing by less than 3% over the study period (Figure 2).

Figure 2.

Proportion of women residents in Internal Medicine and General Surgery, 2006 to 2023

All surgical specialties and subspecialties included in our study experienced in the proportion of women trainees (Figure 3). The largest average annual increases were observed in plastic surgery, pediatric surgery, and vascular surgery (all at 1.4% per year), with pediatric surgery achieving an equal proportion of men and women trainees in 2022. The lowest average annual increase was observed in orthopedic surgery (0.4% per year), and it is anticipated to be the slowest specialty to achieve gender parity, predicted to not occur until 2102 (Table 1). CGSO fellows were analyzed separately from the other surgical subspecialties due to the shorter period of available data (2013-2023). Women constituted 30.8% of CGSO fellows in 2013 and 43.8% of fellows in 2023, increasing on average 0.55% per year. However, this linear trend was not statistically significant (95% CI: −0.47-1.58; p=0.25).

Figure 3.

Proportion of women residents and fellows by surgical specialty or subspecialty, 2006 to 2023

Table 1.

Growth in the proportion of women residents and fellows by surgical subspecialty, 2006 to 2023

Surgical subspeciality	Average increase per year (%)	95% CI	P value	% Women in 2006*	% Women in 2023**	Predicted year to reach 50%
Surgical Residency
General surgery	1.02	0.9, 1.13	<0.001	27.9	48	2027
Neurologic surgery	0.68	0.6, 0.76	<0.001	11.1	23.8	2065
Plastic surgery	1.44	1.33, 1.55	<0.001	22.2	45.1	2027
Otolaryngology	0.81	0.68, 0.94	<0.001	25.4	42.7	2035
Orthopedic surgery	0.41	0.33, 0.49	<0.001	11.0	20.4	2102
Surgical Fellowship
Colorectal surgery	0.89	0.6, 1.17	<0.001	26.7	49	2030
Critical care surgery	1.27	0.72, 1.82	<0.001	26.9	42.6	2026
Pediatric surgery	1.40	0.89, 1.91	<0.001	27.5	49.4	2022
Thoracic surgery	1.14	0.97, 1.3	<0.001	10.7	33.9	2041
Vascular surgery	1.39	1.02, 1.76	<0.001	16.8	37.4	2032

Note: Average increase in percent per year, 95% CI, and p-value were calculated from linear regression. Percentages of women in 2006 and 2023 reported were the observed values.

^*2006 values updates as of December 2005

^**2023 values updated as of December 2022

General Surgery and Surgical Subspecialty Faculty

Over the study period, the number of women assistant and associate professors of surgery increased nearly 300% from 2006 to 2023 (933 to 2,687 and 366 to 1,066, respectively). In addition, the number of women full professors of surgery increased 344% (202 to 694), and the number of women surgical chairs increased 640% (5 to 32).

Both the proportion and the average annual percent change of women surgical faculty decreased as seniority increased. The average annual growth in the proportion of women faculty was highest at the assistant professor level (0.74% per year), followed by associate professor (0.70% per year), surgical chair (0.52% per year), and full professor levels (0.51% per year). Compared to internal medicine faculty, surgery had lower proportions of women at all included faculty levels (Figure 4), and surgery associate professors, full professors, and chairs had lower average annual increases in the proportions of women than those of internal medicine (Table 2). However, the average annual growth in the proportions of women holding assistant, associate, and full professor positions in surgery were higher than those observed in previous publications (Abelson et al in 2016).² Looking at just the last eight years, the average annual growth in each of these positions increased, suggesting that expansion in the proportion of women in academic surgery continues to accelerate (Figure 5).

Figure 4.

Proportion of women faculty by rank in Internal Medicine and Surgery, 2006 to 2023

Table 2.

Growth in the proportion of women faculty by rank in Medicine and Surgery, 2006 to 2023

Rank	Average increase per year (%)	95% CI	P value	% Women in 2006*	% Women in 2023**	Predicted year to reach 50% women
Surgery
Assistant Professor	0.74	0.68, 0.80	<.001	20.9	33.0	2047
Associate Professor	0.70	0.64, 0.76	<.001	14.9	27.2	2058
Full Professor	0.51	0.47, 0.55	<.001	6.9	15.4	2091
Chair	0.52	0.42, 0.63	<.001	1.7	8.3	2102
Internal Medicine
Assistant Professor	0.44	0.38, 0.49	<.001	38.7	45.5	2031
Associate Professor	0.95	0.93, 0.98	<.001	27.0	43.0	2031
Full Professor	0.89	0.84, 0.94	<.001	14.4	28.9	2048
Chair	1.02	0.85, 1.18	<.001	11.7	28.5	2047

Note: Average increase in percent per year, 95% CI, and p-value were calculated from linear regression. Percentages of women in 2006 and 2023 reported were the observed values.

^*2006 values updates as of December 2006

^**2023 values updated as of December 2023

Figure 5.

Acceleration of growth in the proportion of women faculty by period

In addition to faculty rank, the number and proportion of women surgeons with tenure or who were on tenure track were analyzed. The absolute number of individuals on a tenure track increased by 6.0% over the study period, while the number of individuals with tenure decreased by 9.4% (2,201 to 1,982) during that same time. In 2023, women comprised 32.6% of surgeons on tenure track and 16.8% of tenured surgical faculty, and there were significant increases in the percent of women faculty members for both tenure track and with tenure over the study period (Table 3).

Table 3.

Growth in the proportion of women surgical faculty by tenure status, 2006 to 2023

Tenure Status	Average increase per year (%)	95% CI	P value	% Women in 2006*	% Women in 2023**	Predicted year to reach 50% women
Tenure Track	0.82	0.70, 0.94	<.001	18.9	32.6	2046
Tenure	0.49	0.46, 0.51	<.001	8.6	16.8	2092

Note: Average increase in percent per year, 95% CI, and p-value were calculated from linear regression. Percentages of women in 2006 and 2023 reported were the observed values.

^*2006 values updates as of December 2006

^**2023 values updated as of December 2023

Discussion

This study provides a comprehensive update on the representation of women pursuing careers in academic surgery and surgical subspecialties, revealing both significant progress and persistent challenges. As of 2023, the proportion of women entering general surgery residency is nearly equal to that of men and largely reflects the gender composition of medical school graduates. However, the proportion of women trainees significantly varies by surgical subspecialty, with the projected years to reach equal proportions of men and women surgical trainees ranging from 2022 (pediatric surgery) to 2102 (orthopedic surgery). At the surgical faculty level, there was significant growth in the proportion of women at all levels over the study period; however, the observed average annual percent change in the proportion of women decreased as seniority increased.

The proportion of women pursuing surgical careers not only has increased over the past two decades, but the growth rate is also accelerating. Comparing trends from 1994-2015, 2006-2023, and 2016-2023, the average annual growth in the proportion of women faculty continues to increase over time. The growing proportion of women in surgery is likely correlated with downstream effects of local, regional, and national initiatives implemented over the past two decades and the conscious efforts of general surgery programs and their institutions to support a diverse and qualified workforce. As more women enter the surgical workforce and there are more women visible as mentors and role models, more women in turn may choose to train in surgery.¹ Since the AWS launched their Early Career Women Faculty Mentorship program in 2005, mentorship programs aimed at supporting women surgeons have grown in number. In 2014, the Women in Surgery Committee of the ACS established the WiSC Mentorship Program, which matches early-career women surgeons with established women surgeons for a year-long mentorship plan.⁷ Marianna et al found that mentees in the WiSC Mentorship Program who met with their mentors at least four times per year reported a positive impact with regard to creating and achieving goals, setting expectations, providing network opportunities, and developing professional skills.⁸

While formal surgical mentorship programs for women have increased in number, disparities in the availability of women mentors across surgical subspecialties may be associated with the observed variation in the proportion of women trainees by subspecialty. Although some surgical subspecialties will have an unequal gender distribution due to self-selection or a desire to work with a patient population of the same gender, further investigation is warranted to examine whether there are subspecialty-specific barriers that impede recruitment efforts. For example, in 2021, the AAMC reported that only 5.9% of active orthopedic surgeons were female, and a 2016 survey of resident members of the Ruth Jackson Orthopaedic Society found that 69% of respondents perceived a lack of strong mentorship in medical school or earlier as a reason that women may not choose to pursue orthopedics.^9,10

Fruitful relationships with both men and women mentors are a critical tool for trainees navigating the challenges of surgical training. However, research suggests that an availability of women mentors may be particularly helpful for women navigating struggles related to gender discrimination, lack of role models, and lifestyle concerns.^11-15 It is also not uncommon for women in medicine to face assumptions based on their gender and to be strongly encouraged to pursue specialties that involve caring for patients of like gender, regardless of specific skill or interest.¹⁶ Further research should explore the unique experiences within surgical subspecialties and highlight specific components in addition to mentorship, such as subspecialty culture and inclusive equipment design, that impact the recruitment and retention of women trainees.

One such challenge for women surgeons is the balance of a surgical career with household and family responsibilities and aspirations. While family concerns can be an area of high importance for trainees in surgery regardless of gender, research suggests that women experience greater impact on their careers. Compared to male counterparts, women surgeons were found to be less likely to be a parent, more likely to have children later in their career, more likely to employ household support staff, and less likely to have a spouse whose primary occupation was a homemaker.^17-19 In a cohort study of all general surgery interns in the entering class of 2007-2008, women with children were 10 times less likely to pass their general surgery board certification in their first attempt than single women, but no such difference was observed between men with children and single men.¹⁷ The American Board of Surgery’s recently updated general surgery family leave policy, which increases the number of weeks residents can take off during training and adds flexible program options to meet the required time of clinical activity, likely has played a role in supporting women in surgery.^18-20 However, the perception of decreased bandwidth for leadership responsibilities and negative peer perception of motherhood may remain obstacles for women; in a survey of general surgery program directors, parenthood had greater perceived adverse effect on the training and well-being of female residents compared to male residents.²⁰ In addition, these policy changes also may not adequately address family caregiving and eldercare responsibilities, which disproportionately impact women surgeons who are more senior.²¹

In addition to programs and policies that improve the conditions for women surgeons, increased numbers of senior women faculty in academic surgery bolster the pathway as role models. Despite the increased proportion of women pursuing surgery over the study period, the proportion of women achieving senior faculty ranks and leadership positions in academic surgery remains strikingly low. Given that the timeline to promotion is typically six to eight years depending on appointment and institutional criteria, progress made in the last decade in increasing the proportion of women in surgery will be slower to reflect at the senior faculty level.^21,22 However, there remains a persistent difference in time to promotion to ranks of associate professor, full professor, and department chair by gender, with research showing that male faculty are promoted to senior ranks more often and more quickly than their female peers.^22-24. To ensure that the strides made in recruiting carry forward to representation at the senior faculty level, continuous and cohesive support for women along the surgical career pathway should be considered a priority

Recent studies have examined gender differences with regard to funding, awards, and research opportunities, all of which contribute to academic promotion opportunities, in an attempt to understand the reasons behind the slow growth of women in surgical leadership positions Nguyen et al found that the proportion of female academic surgeons funded by the National Institutes of Health slightly increased (1.8% vs 2.4%), and the proportion of male academic surgeons funded decreased (5.8% vs 3.6%).²⁵The mean time to first research project grant was two years earlier for female surgeon-scientists than for male surgeon-scientists. ²⁵ However, females were still 25% less likely than males to receive at least $750,000 in annual research funding in 2020.²⁵ Women surgeons are also less likely to receive achievement, research, and service awards from surgical societies compared to men.^26,27 From 1998 to 2017, only 25.6% of 1,222 awards presented by 20 surgical societies were awarded to women.²⁷ Of non-trainee specific awards, 20.6% were presented to women, with a significantly greater percentage of women receiving awards in the second decade of the study period (23.0% vs 15.8%).²⁷

When women are promoted, they are more likely to be promoted to roles that may not translate into future promotion to department chairs.²⁸ Iwai et al found that women are more likely to be promoted to service-oriented leadership positions, such as vice chair of Diversity Equity and Inclusion or Faculty Development rather than to clinically-oriented leadership positions that more closely reflect the responsibilities of chairs, such as division chiefs.²⁸ As highlighted by Weaver and Kibbe, if women within surgical departments are not given leadership opportunities along the pathway to be promoted to chair positions, equal opportunity for individuals to achieve the highest levels of academic leadership will not occur.²⁹ To close the gender gap in surgery, women must receive the necessary support and be directed early on to the appropriate pathways for promotion to the highest levels of academic surgical leadership. Future research should work to identify the points at which women academic surgeons are at risk of falling off the pathway to reach senior leadership.

Disparities in surgical leadership representation are further compounded by the intersection of race, ethnicity, and gender. According to Johnson et al, underrepresented in medicine (UIM) female faculty made up only 3.2% of surgical faculty and experienced the lowest rates of promotion and retention from 2005 to 2015.²² Mesiti et al. found that despite women constituting 34% of surgical trainees, UIM women made up less than 7% of trainees in 2015.¹ Examining the impact of intersectional identities, such as race, ethnicity, sexual orientation, and gender on the progression of women through the surgical ranks would highlight areas where more focused interventions are needed.

Limitations

There are limitations to our analyses. Data were collected from multiple sources, resulting in differences in the time points of data collection (academic year vs. calendar year) and reporting variables (sex vs. gender) across datasets. Ideally, all data would have been collected from a single source to ensure consistency and accuracy in data reporting. Faculty data were summarized by year, rank, and department. Since surgical faculty data were specified for surgery as a whole and did not include details at the subspecialty-level, this analysis was unable to examine if specific subspecialties were driving gender differences in academic ranks. In addition, faculty promotion timelines vary between ranks, such that progress observed at more junior levels may take significant time before being reflected at senior levels. A more thorough modeling process, which considers academic progression (i.e., promotion rates at each academic rank and the varying promotion timelines) would provide more detailed insights into understanding the academic advancement of women faculty.

Conclusion

The findings of this study serve as both a progress report and a call to action. Across the board, the surgical field has made substantial progress in increasing the proportion of women in surgery. However, there remains opportunity for improvement, particularly at the senior faculty and department chair levels; in the end, change appears to be slower at the top. These results suggest that efforts to increase inclusive excellence in academic surgery have accelerated progress, but there continues to be significant opportunity around retention and promotion of women. It is critical that qualified women who are recruited to surgery be actively and intentionally supported to make sure that the strides made at the trainee level are eventually reflected at senior levels of academic leadership. To effectively address disparities in academic surgery for all women, initiatives must consider the intersection of race, ethnicity, and gender.

Data Access Statement:

Data supporting this study are openly available from the Association of American Medical Colleges (AAMC) Faculty Rosters and Graduate Medical Education (GME) reports published annually in the Journal of American Medical Association (JAMA).