Gender and the surgical profession

In 2015 the surgical profession attracted a frenzy of media attention when a female vascular surgeon commented in an interview that female surgical trainees should “accept unwanted sexual advances because coming forward could ruin their careers”.1 The uproar regarding sexual harassment, bullying and discrimination in surgery that followed compelled the Royal Australasian College of Surgeons (RACS) to review the culture of surgery. The subsequent Diversity and Inclusion Plan identified, among other things, that there is gender inequity in surgery.2 Men can ascend the surgical hierarchy with fewer barriers than females and these need to be addressed to ensure men and women have the same opportunity regarding a career in surgery.

This viewpoint article will discuss the gender imbalance in surgery through three questions:

1. Why does a gender imbalance exist in the surgical profession?
2. what are they key issues that perpetuate this imbalance? and
3. why should the imbalance be addressed?

The overall purpose is to help individual surgeons understand how and why the gender disparity is perpetuated, and to support a positive, inclusive culture change within surgery.

Why does a gender imbalance exist in the surgical profession?

A key issue underpinning the gender discrepancy in surgery is the concept of gender itself, and how this plays out in the social milieu. ‘Gender expression’ is a socially constructed phenomenon that informs how a person should act, dress, behave and interact, and is based on traditional gender roles.3 This essay will use the term ‘gender’ to mean gender expression, as defined above. While there are different ways to express gender, this article will focus on the binary of man/woman.

There is no difference in competence between men and women in surgery,4 but there is a difference in the social construction, or what we expect of men and women. Traditional, stereotypical characteristics associated with men is that they are decisive, independent and goal orientated, and those associated with women are that they are community minded, caring and sensitive.5,6 In traditionally male-dominated occupations, male values are maintained as the standard for success for both sexes,7–9 therefore in surgery those characteristics deemed as important for a surgical career align with male characteristics. When a male strives for professional achievement, he meets our stereotypical expectation of him, and both men and women like him more, the result being that at each step of his career he is encouraged, congratulated and positively reinforced.5,10 In contrast, women are expected to be community minded, caring and sensitive, so when she strives for professional achievement by aspiring to become a surgeon she violates our stereotypical expectation of her. The result is that she is liked less by both men and women and it becomes more difficult to ascend the surgical hierarchy. Competence and likeability are positively correlated for men, but inversely correlated for women.5,10

What are they key issues that perpetuate this imbalance?

These stereotypical expectations perpetuate the gender imbalance because it is important to be liked for career progression. Gaining a mentor or advocate who will make introductions and endorse the aspiring surgeon depend in part on the trainee being liked: since competence and likeability are positively correlated for males, as a male ascends the surgical hierarchy these endorsements flourish.5,6 Compounding this is that people are judged in comparison to the traditional stereotypical expectations of them. Men who are communal may be accused of being ‘wimpy’ or ‘soft’ and women who are assertive may be accused of being ‘bossy’ or ‘domineering’;6 a male surgeon who has tantrums in the operating room is characterised as ‘temperamental’ or ‘high strung’, whereas a woman surgeon who throws a ‘doctor fit’ is described as a ‘bitch’.11 This puts women in a double-bind. On the one hand, they need to display the male-aligned characteristics seen as important in surgery to progress their career, but this violates what is expected of them as women and they face a social backlash that in turn impedes their career progression.5

These gendered social expectations determine what is acceptable behaviour by men and women so strategies that are employed by men are not always helpful if done by a woman. In response to the surgeon having a tantrum/doctor fit, nurses in the operating room tend to pay scrupulous attention to the male surgeon yet tend to become slow and sulky when this behaviour comes from the female surgeon.11 For aspiring male surgeons there is no discordance between social expectation and career, whereas aspiring female surgeons must negotiate the discord between female stereotypes and surgeon qualities, and the strategies that will make this negotiation successful. One way to do this is by learning from role models, however many specialties have a paucity of female surgeons, which can make learning these strategies difficult.12 In addition, if there is only one or very few female surgeons in a specialty, they are perceived as representing what all women must be like to be successful. If the junior doctor doesn’t see themselves reflected in this small cohort they may discount a career in surgery.12 In contrast, junior male doctors have a much greater number of male surgeons who they can look to for role modelling.

Another factor that perpetuates the gender imbalance is that when a profession is dominated by a single group, the dominant group becomes invisible.13 Surgery is a male-dominated profession and this phenomenon can be observed. For example, searching the literature using keywords ‘gender’ and ‘surgery’ return articles that almost solely focus on women. Yet men have a gender, and to progress a career in surgery a female must be selected by the people, mainly men, who are already there. A study from the American Association of Oral and Maxillofacial Surgeons (OMS) has investigated the male perception of women in residency programmes or as practice associates.14 Fifty-five percent of programme directors, 28% of male residents and 56% of male surgeon practitioners who were approached agreed to participate in this study. Ninety-eight percent of programme directors, 82% of residents and 91% of practicing surgeons agreed that women were as capable to practice OMS as men. While it is pleasing that almost all the programme directors believed women and men were equally capable it is disappointing to note that one in five residents thought women were not as capable as men. Reasons for this included that women lacked adequate physical strength, lacked emotional strength, did not work as fast as men or did not want to work as many hours as men. It would have been particularly interesting if this study had compared patient outcomes. If male OMS surgeons had better patient outcomes, then training programmes could be tailored to ensure females are acquiring the necessary skills. If females had better patient outcomes, perhaps those reasons identified by their male counterparts as being negatives may in fact be advantageous, and training programmes could be tailored to improve the practice and skill of males. For example, one female surgeon reported she spent more time communicating with patients and their families,11 meaning she may not “work as fast”, but if this were to result in lower rate of complications, mortality or other such outcomes this could be reinterpreted as working more safely and efficiently. This does provide evidence that there is some bias against women in the OMS field, and more research is needed to ascertain if this is isolated to OMS or if it represents widespread beliefs among male surgeons. If the latter is true these beliefs must be addressed in order to improve gender diversity.

When there is a particularly dominant group, such as males in the surgical profession, the lack of diversity and world views means that the system reflects the dominant group.13 In effect, it becomes a system that is designed by men, for men. This is reflected in the criteria for selection onto many surgical and education training programmes. The process for selection includes an examination, references, an interview and submission of a curriculum vitae. From the documents I was able to access it appears that there is a focus on ‘service’ or surgical performance: technical skill, work experience, clinical scenarios and publications/presentations. There appears to be little evidence of points being directly awarded for displaying collaboration, compassion, respect or integrity, the other four Values of the Royal Australasian College of Surgeons (service is the fifth value).15 While it is imperative that surgical performance is of the highest standard, formal assessment of these other values may reduce potential institutionalised barriers to female career progression, and enable stereotypical female characteristics and strengths to be formally regarded as positive traits for surgeons. It should be emphasised that I had limited access to documentation and that those with full access to the selection criteria, process and other relevant information could add to this topic and may have a different perspective on it.

Perpetuating the gender imbalance is the expectation that women will have children, and that the female will be the primary caregiver. Indeed, in her Presidential Address for the Association of Academic Surgery, Dr Caprice Greenberg16 states “the conceptualisation of the issues facing women in surgery are almost exclusively considered to relate to parenting and work-life balance”. Although cultural shifts are occurring, this remains the reality for many women: women do 80% of housework and childcare;5 perceive as having to choose between career and family, including deferring having a family due to work commitments or because it is perceived as a detriment to their career.17,18 When compared to the average population fewer women in surgery have children, indicating that the choice between family and work may be being made.17,19,20 Women in surgery who were married, and women in surgery with children reported being more emotionally exhausted than single women and women without children,21,22 presumably because women are supporting their spouse and children. Finally, male surgeons don’t recommend some surgical specialties to women because of the conflict between work and family life.23

In contrast, men in surgery have children at a rate equitable to the non-surgical male population,17,19 play a smaller role in housework and childcare, and those men in surgery who are in a committed relationship or who have children are significantly less emotionally exhausted than men without.21,22 This suggest that men in surgery do not have to choose between career and family but are able to have both comfortably, indeed it is protective. It is important to acknowledge that parental leave does place challenges on those left to provide cover: “If we have a female colleague [who] decides to take six months of maternity leave, all of a sudden my schedule goes from one in seven to one in six. Or there’s more [operating room] time that needs to be filled…”.24 Institutions should employ additional staff but if this does not happen these challenges may make it more difficult for colleagues to support parental leave, and therefore perpetuate the gender imbalance.

To truly move forward, the conversation about the gender imbalance in surgery needs redirecting. Firstly, surgery cannot claim to attract the best and brightest if the talent pool is reduced by half,25 so working out how career and family can be facilitated would help recruit the best candidates. Secondly, 40% of female surgeons do not have children16 so solely focusing on the balance between children and career detracts from the many other barriers faced by women. Thirdly, conceptualising surgery, parenting and work-life balance as solely being an issue for women reinforces the current gender stereotypes and perpetuates the existing gender imbalance. Interestingly, many men now regard the trend towards gender equity in the workplace as a positive shift, and there is a changing attitude from men towards wanting to and enjoying being more active in fulfilling family responsibilities.24 However, men wanting to take leave for family reasons and step outside their gender expectations may experience a professional and social backlash, creating a barrier for men in surgery to do this. Parental leave is a legal right in New Zealand and supporting new fathers to access this would start to shift the gender stereotypes for men, would help to balance gender expectations regarding career and family, and would better reflect the changing attitudes of men. Fourthly, the conversation needs to be redirected so that non-parental extracurricular activities are included as legitimate reasons for leave. Burnout is prevalent throughout the medical profession and is particularly high in the surgical specialties.26,27 When asked to identify what doctors would like to spend their leisure time doing, exercise, travel and time with family were the top three activities,27 so the ability for aspiring surgeons to take leave for such activities could help reduce burnout. Men and women are increasingly matching specialty choice to lifestyle, so support for extracurricular activities would also reflect the changing mentality around ‘live to work’.24,28

Why should the imbalance be addressed?

Addressing the gender imbalance in surgery reaches beyond the widely acknowledged and publicised ‘gender equity for women’ rhetoric to the very core of healthcare. Indeed, there is evidence to suggest that there may be a difference in patient outcomes depending on whether the surgical intervention is performed by a male or female surgeon. Three pertinent studies assessing this will be discussed here. A retrospective matched cohort analysis compared patient outcomes between male and female surgeons.29 Female surgeons were identified, and a corresponding male surgeon was matched 1:1 according to procedure, volume of these procedures performed by the surgeon in the preceding year, surgeon age, hospital, patient age, patient sex and patient comorbidities. After matching, more than 52,300 patients were included in this study. Rates of hospital readmission and complications were similar, but patients undergoing elective surgery who were operated on by a female surgeon had a significantly lower likelihood of death within 30 days of surgery.

The authors explained these findings by suggesting that female surgeons provide care that is more congruent with guidelines (less risk taking), is more patient-centred and involves superior communication (for example a greater willingness to collaborate, including a lower threshold for asking for a consultant opinion on a case). They also suggested that there are fewer barriers for men to overcome to become surgeons compared to women, resulting in female surgeons being more skilled, more motivated and harder working.

Interestingly, the authors advised that “these results do not support the preferential selection of a surgeon…”. If a large, well-conducted study demonstrated a surgical technique, componentry or implant that offered a significantly lower likelihood of death, surgeons would almost certainly want to adopt this new product or at least investigate further, so this statement seems inconsistent. Yet it is appropriate that the authors advise this, because rather than turn the gender conversation into a male versus female win-or-lose binary, it is crucial to build on each other’s strengths and work together to maximise patient care.

In the field of physicians, Tsugawa et al30 analysed 30-day mortality of over 1.5 million hospitalisations and readmissions. Patients were comprised of a 20% random sample of Medicare fee-for-service beneficiaries ≥65 years who were hospitalised with a medical condition between 2011–2014. Patients were quasi-randomised to physicians based on work schedules. Patients treated by female physicians had a statistically significant lower 30-day mortality and 30-day readmission than those patients treated by male physicians. This difference persisted across eight common medical conditions and across a range of illness severity. Confounders such as patient and physician characteristics and different hospitals were accounted for. A strength of this study is the random sampling of patients that will reduce selection bias, and that older patients with greater comorbidities were included, however the US system of healthcare with its fee-for-service must be considered when assessing generalisability to the New Zealand healthcare system.

Jerant et al (2013) researched whether the gender of a patient’s usual source of healthcare was associated with healthcare utilisation and mortality.31 This was a prospective observational study and data was obtained from the US Medical expenditure panel surveys, between 2002–2008. Respondents were aged ≥18 years, and a total of 21,365 respondents’ data was analysed. They found there was no difference between the gender of healthcare providers and total expenditure, number of office visits, emergency visits, hospitalisations or mortality.

Conclusions

The gender imbalance in the surgical profession finds its roots in our social expectations of men and women. Improving gender diversity will help to break down these rigidly held expectations and support women to pursue a career in surgery, encourage men to participate more fully in their family responsibilities, and allow both men and women to achieve their overall life aspirations. By doing this, surgery will undergo a positive culture change and will continue to attract the best and brightest to this prestigious career.

The positive impact of increasing women in surgery comes from combining the different characteristics, values and experiences women bring to surgery with those of men. With this approach we can appreciate our differences, learn from and build on each other’s strengths, and work together for improved patient care.

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