Published On October 19, 2021
Elizabeth H. Stephens once received cufflinks from a grateful family who wanted to thank the surgeon, who they assumed was male. She was once escorted to the nurses’ locker room to dress for an operation, because in the hospital she was visiting, the physicians’ locker room was for men only. “Sometimes it feels like you’re wading through mud while others are walking on a nice, smooth track,” says Stephens, a congenital and pediatric cardiac surgeon at the Mayo Clinic in Rochester, Minnesota, and the lead author of a 2020 JAMA Surgery review titled “The Current Status of Women in Surgery.”
Gender inequity is a persistent problem for women in the American workforce , including those who choose a career in medicine. A growing body of research, however, underscores the acute challenges faced by women who decide to become surgeons, who remain a small minority within the specialty, even though half of all U.S. medical students are female.
A recent, separate JAMA Surgery study showed that 80% of female U.S. surgical residents said they had experienced some form of gender discrimination during their training, such as being mistaken for a nonphysician by a patient. And 43% reported sexual harassment, usually in the form of crude, demeaning, or explicit comments.
Other recent investigations include a pair of papers by researchers at Massachusetts General Hospital. In one, published in March 2021 in The American Journal of Surgery, research fellow Ya-Wen Chen and colleagues found that female surgeons received 5.4 fewer new patient referrals per month, on average, compared to their male counterparts. The authors speculate that this disparity may be due to bias by referring physicians and partly explains findings from an earlier study, which showed that female surgeons are “under-employed,” that is, they perform fewer complex procedures than male surgeons, which can negatively affect compensation and career advancement.
Just 22 percent of general surgeons in the United States were women in 2019, the most recent year for which data are available from the Association of American Medical Colleges. In some subspecialties, women are even more rare; for instance, 6 percent of orthopedic surgeons are female. Meanwhile, women represent 36 percent of doctors across all specialties and outnumber men in some, such as endocrinology and obstetrics and gynecology.
The low representation is at least partly due to women being discouraged from pursuing careers in surgery, says pediatric surgeon Yue-Yung Hu, an assistant professor of surgery at the Northwestern University Feinberg School of Medicine co-author of the JAMA Surgery paper. “I remember thinking about surgery in medical school in the mid 2000s and being told by a surgical resident that it wasn’t a good career pathway for women,” says Hu. “I think that’s still a common message, so a lot of people select out of the field.”
Women who opt for surgery often struggle to advance their careers, adds Hu. Recent research shows that women are more likely to quit surgical residencies and less likely to become board certified as surgeons than their male counterparts. Women held just 28 of 354 chairs of academic surgical departments in the United States as of 2020. Even after adjusting for age, experience and other factors, women surgeons earn significantly less than male surgeons, too.
Hu published a second JAMA Surgery paper illuminating how surgical careers, in the way they are currently structured, can also discourage women. Female surgeons are more likely than male counterparts to delay having a child while undergoing their training, are twice as likely to have miscarriages compared to women in the general population and are significantly more likely than other women to experience pregnancy complications.
Female physicians from all specialties have historically delayed pregnancy until after completing training, but surgical residencies are longer than the majority of other medical specialties—five to seven years of training, compared to a residency in internal medicine, for instance, that lasts three. The JAMA Surgery survey found that women surgeons were more likely than their male counterparts to delay having their first child until age 33—when training would generally be completed—and delaying pregnancy is associated with a higher risk for complications.
Older pregnancies only partly explain the higher risk for complications and miscarriages among women surgeons, says Hu. “Surgery is physically demanding work,” she says. Surgeons often stand for hours and often lack access to fluids, notes Hu, both discouraged for pregnant women. The JAMA Surgery paper found the highest risk for pregnancy complications among female surgeons who spent 12 or more hours per week in the operating room (U.S. surgeons average 16 hours per week). Surgeons often work unpredictable hours, including nights, which other research has associated with higher risk of miscarriage. The authors note that “the physical working conditions of the profession [of surgery] likely have a substantial impact on pregnancy outcomes.”
Such risks could be mitigated with more pregnancy-friendly hospital policies. A 2018 survey of 347 surgical residents who became pregnant during training, published in JAMA Surgery, found that over three-quarters received six weeks or less of maternity leave, which most felt was inadequate. More than half quit breastfeeding earlier than desired because they lacked schedule flexibility or facilities to express milk.
But systemic problems go beyond being more accommodating to pregnant surgeons. “The gold standard for surgeons has always been male,” says the senior author of both MGH papers, pediatric general and thoracic surgeon Cassandra M. Kelleher. The ideal of a surgeon in the medical and patient community alike, she notes, is someone who is tough, stoic, and prioritizes work over personal life—all stereotypical male traits. Meanwhile, women in surgery who lack these traits are seen as having “deficits” that need to be fixed, argues Kelleher. Often, women surgeons are encouraged to take leadership training so they can better advocate for themselves. “But we don’t need additional leadership training,” she says. “What we need are systemic changes that make our work environment and employment equal.”
Some change is happening, such as hospitals implementing centralized scheduling systems, in which patients are assigned to the first surgeon available. Thanks to efforts by two residents, the University of Michigan Medical School adopted a lactation policy that gave new mothers in surgical training time and space to pump breast milk, which has been adopted by other institutions. But wider cultural change, such as more veteran male surgeons stepping up to mentor female surgical residents, would help too, says Stephens.
Some see signs of a gradual shift in the male-dominated culture of surgery, as the number of women in surgical residency programs grows. “Culture change follows policy change,” says gastrointestinal surgeon and surgical intensivist Erika Rangel, of Boston’s Brigham and Women’s Hospital, lead author of the study on pregnancy and motherhood in surgical residencies. “I think we’re starting to move the needle.”
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