Letter to the editor: The motivators and barriers to a career in cardiothoracic surgery: a cross-sectional study among surgical residents in India

To the editor: With great interest, we have read the comprehensive study by Idhrees et al. [1]. We would like to congratulate the authors for their effort to study the declining interest in the cardiovascular and thoracic surgery (CTS) residency program in India. The main reasons given among young general surgery residents to reject a career in CTS were the need for a hospital with required infrastructure and the dependence on a multi-disciplinary team. An important highlight of this study was, however, the gender disparity in CTS residency programs, which we would like to comment on.

Despite recent attention towards increasing diversity in general, this female/male imbalance in the surgical medical world remains apparent not only in the admission to the residency programs, but also in less career development options for female staff members, underrepresentation in scientific publications as the first or senior author, or as a presenter or even panelist at national and international scientific meetings.

The results of this survey clearly demonstrate that female residents are underrepresented in general surgery and also in CTS. The percentage of registered female cardiothoracic surgeons is less than 2.6% within the Indian Association of Cardiovascular-Thoracic Surgeons (IACTS).

This gender disparity is pervasive in academic medicine, especially in surgical specialisms. Even though the majority of students joining medical school are female, they are less likely than male to choose surgical specialties. Furthermore, the percentage of female residents in CTS residency programs is even lower than all other surgical specialties. Recently, Miller et al. conducted a study to identify gender differences in CTS exposure and interest among fourth-year medical students applying for general surgery residency [2]. This study demonstrated that for more than half of the female respondents, a career in CTS was likely or definitely out of question, while this was the case in only 30% of their male colleagues. The most important factor in their decision was a lack of mentorship. This has also been shown in several other studies. Even though there are excellent male thoracic surgeons willing to mentor both male and female trainees, lack of female cardiothoracic surgeons remains crucial.

Female mentoring programs — from women for women — would provide an opportunity not only for recruitment but also for retention of female thoracic surgeons. Globally, however, many CTS training programs do not have women faculty, leaving a void of mentorship from woman thoracic surgeons. Same-sex mentorship has been associated with career choice, academic success, and high job satisfaction [3]. Programs with more female faculty members and more women in leadership positions tend to have more female residents [4]. People go for what they can see, and if they can identify themselves with a mentor in a specialism they would not have regarded initially, this could influence their decision.

A second reason why women might not choose cardiothoracic surgery mentioned by Idhrees et al. was the inability to have good work/life balance and the possibility to take maternity leave during residency.

It is a fact that as the age of medical students increases, the number of women starting a family during their residency will climb too. Here, better opportunities for women (including a reduction in the stigmatization of having children) combined with family-friendly policies can be attractive. Important in this context is also the still frequently existing salary gender gap in CTS, which is particularly important in this phase of paying off student debts and starting a family [5].

Increasing gender diversity in cardiosurgical teams can also have a positive impact on the atmosphere in the teams and thus enable a step ahead in the direction of achieving a more balanced work environment.

To motivate medical students to choose cardiothoracic surgery as a profession, a multifaceted approach is necessary. Greater exposure to cardiovascular surgery during medical school and early general surgery residency years and introducing programs which offer mentoring for residents to address their doubts and to build their interest in the cardiovascular residency program are important for both female and male students. However, in order to attract more women to CTS, it is essential to increase the number of female faculty as role models and mentors and to give residents the opportunity to plan a family without restrictions and stigmatization.

Funding

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Conflict of interest

The authors declare no competing interests.