Women in Academic Surgery: A Double-Edged Scalpel

Abstract

Women continue to be underrepresented in academic surgery, especially at the leadership level. Surgical culture has been historically male-dominated and recently received negative attention for higher rates of mistreatment, sexual harassment, and attrition of women compared with other medical specialties. The authors examine factors that contribute to challenges in academic surgery, making it a potentially difficult environment for women and underrepresented minorities; these include surgical culture, work-life balance, and historic promotion timelines. Efforts to change social norms and structural biases are critical to improving gender parity in academic surgery.

A surgical career is undeniably a calling and a privilege—the privilege of connecting with patients in high-stakes moments, the trust that comes with separating individuals from their disease, the wonder of witnessing healing after trauma, and the awe-inspiring responsibility of injuring patients to restore their health. Because of this tremendous privilege, surgeons overwhelmingly and fiercely defend their craft. Yet, for many female surgeons this profession comes at great cost.

Surgical culture has historically been male-dominated. Only 20.6% of general surgeons are women,¹ and certain subspecialties, such as orthopedics, remain predominantly male. Although women constitute at least half of graduating medical students, only 10% of full professors within academic surgery are women. At current rates of slow growth, female full professors in surgery will not achieve gender equity for over a century.² Further, there are only 25 female chairs leading Departments of Surgery across the country according to Association of American Medical Colleges data.³

Prior research suggests that mistreatment, sexual harassment, and family pressures may be barriers to diversity and inclusion. A survey of over 7,400 surgery residents demonstrated widespread mistreatment of surgical trainees: 32% reported gender discrimination, 31% reported verbal and/or physical abuse, and 10% reported sexual harassment. Notably, rates of all mistreatment were higher among female surgery residents, with 65% reporting gender discrimination and 20% reporting sexual harassment experienced during the past year.⁴ Female trainees were significantly more likely to experience harassment and medical students reported harassment more frequently on surgery rotations than on other specialty rotations. Mistreatment extends beyond medical school and surgical training. In a survey of over 1,000 practicing surgeons, almost 60% of women reported experiencing sexual harassment in the previous year compared with 25% of men.⁵ Due to women’s fear of negative impact on their career, fear of retribution, or fear of being dismissed, few of these events are ever reported. As a consequence of sexual harassment, women at any level can develop burnout, depression, and other negative outcomes. To move forward, the culture that tolerates sexual harassment in surgery will need to change.

Challenges faced by women in surgery are not entirely tangible. The undercurrent of largely male-oriented social norms can result in belonging uncertainty for women and underrepresented or marginalized minorities. These undercurrents are often the result of implicit, explicit, or structural biases that result in attitudes or stereotypes that affect how people think and act. Bias related to gender can result in discrimination, microaggressions, and macroaggressions that impact women and their careers. Even amongst health care workers and surgeons, gender bias exists; a surgical career is largely associated with male physicians while women are often associated with having careers in family medicine. At the same time, female surgeons have been shown to have equivalent or superior outcomes compared with male surgeons, and patients treated by female surgeons have been shown to be less likely to die within 30 days of the operation.^6,7 Despite this, Sarsons⁸ demonstrated that following a surgical complication in a patient, female surgeons are more significantly more likely to lose referrals compared with male surgeons whose patients have similar complications. In addition, after controlling for years of training, subspecialty, faculty rank, and metrics of clinical and academic productivity, female surgeons make 8% less annually than their male counterparts, and this pay gap widens over the course of women’s careers.⁹ Notably, research has demonstrated that patients prefer female physicians with a nondirect, less aggressive communication style.¹⁰

The balance of responsibilities at both work and home remains an unspoken challenge for many women in academic surgery. Among young academic investigators, female surgeons have reported spending more time on domestic responsibilities than their male peers.¹¹ This unpaid effort at home is especially exacerbated among dual-professional families and has been labeled the “double burden.”¹² Surgical subspecialties with disproportionately low rates of female trainees and faculty demonstrate lower rates of intentional parenting: In a survey of female orthopedic surgery residents, over half of the respondents reported delaying childbearing until completion of their training, a decision they mostly attributed to bias and social norms from co-residents and faculty.¹³ A survey of over 300 female general surgeons who had at least one pregnancy during surgical residency unveiled concerns about work schedules during pregnancy, negative stigma associated with pregnancy during training, dissatisfaction with parental leave options, inadequate support for breastfeeding and childcare, and a desire for mentorship around work-life balance. Almost 40% of respondents reported seriously considering leaving surgical training, which is perhaps unsurprising given the overall attrition rate of 25% among women in general surgery training.¹⁴ Sadly, female surgical residents are more likely to experience pregnancy complications when compared to partners of their male peers.¹⁵

Importantly, women continue to be susceptible to delayed and limited leadership roles within academic surgery. Timelines for promotion and tenure have been inflexible and fixed across academic medicine. Arguably, professional milestones in academic surgery have reflected historical rites of passage accomplished by preceding surgeons, who were predominantly male. These metrics of success may fail to account for the pace or priorities of many female surgeons, which may encompass marriage/partnerships to individuals with competing professional pressures, caregiving responsibilities for children or family members, and professional efforts that are often disregarded or unpaid (e.g., committees, faculty development, kin-keeping at work).

Moving forward, cultural changes in the field of surgery and academic medicine will be necessary to avoid the privilege of a career in surgery becoming a double-edged scalpel for women and underrepresented minorities. Social media movements like #ILookLikeASurgeon and #NYerORCoverChallenge have already started to change the face of surgery and challenge social norms. Efforts and policies at the institutional and national organization levels will be needed to effect change. A diverse and equitable surgical workforce that is truly representative of the patients for whom we care is critical to drive innovation, research, and surgical treatment into the future.