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    Where are all the women in surgery?

    For decades, women have been discouraged from entering the surgical specialties. That’s changing.

    doctor wearing full scrubs

    Stephanie Bonne, MD, clearly recalls her first bout of sexism in surgery as a third-year medical student working in the operating room alongside a male student.

    “The attending surgeon looked at the resident and said, ‘Why don’t we let our future colleague make the skin incision?’ and handed the knife to the guy,” Bonne says.

    Fortunately, those kinds of comments didn’t dissuade Bonne, now an assistant professor of surgery at Rutgers New Jersey Medical School, from pursuing her career. But they are indicative of a field in which women must fight for recognition and equity.

    Even though women now comprise more than half of medical school enrollees and 35.2% of all active physicians, they are often scarce in the surgical field. According to 2017 data from the AAMC, women make up less than one-quarter of 10 surgical specialties, and are the least represented in orthopedic surgery, at 5.3%. Only in obstetrics and gynecology do women outnumber men, at 57%.

    Besides being outnumbered, women in surgery also often face discrimination, sexual harassment, and false assumptions about their abilities. A study published in April 2019 in Annals of Surgery shows that while sexual harassment in surgical training does happen, it often goes unreported. And implicit bias toward women in surgery may even come from other surgeons. A July 2019 study in JAMA Network Open found that regardless of gender, surgeons more strongly associated men with surgery and women with family medicine.

    But amid these obstacles, efforts are underway nationally and institutionally to encourage more women to go into surgery and help them thrive in their careers, from creating peer support networks to mentoring the next generation of women surgeons.  

    “Women in surgery are facing the same issues as women in other professions, like lawyers, bankers, and software engineers…. But we're just going to keep the pressure up until we fix it.”

    Sarah Blair, MD
    University of California, San Diego, School of Medicine

    “Women in surgery are facing the same issues as women in other professions, like lawyers, bankers, and software engineers — a lot of traditionally male dominated fields,” says Sarah Blair, MD, vice chair of academic affairs in the department of surgery and professor of surgery at the University of California, San Diego, School of Medicine (UCSD School of Medicine). “There aren't any easy solutions. But we're just going to keep the pressure up until we fix it.”

    Why are there so few women in surgery?

    Even as women have made significant inroads in medicine, surgery remains a specialty with numerous hurdles for women.

    A 2018 article in the International Journal of Surgery Global Health highlighted some of the social deterrents to surgical careers among women. It noted that women can be subjected to gendered expectations about work-life balance and steered away from a career that could take time away from starting families and raising children.

    Indeed, surgical residencies are long, and women are often faced with inflexibility and obstacles around taking time off, such as a lack of formal parental leave policies, according to a 2018 study in JAMA Surgery.

    However, “life happens while you’re a surgical resident,” says Sareh Parangi, MD, professor of surgery at Harvard Medical School and Massachusetts General Hospital and president of the Association of Women Surgeons. With many women discouraged from pursuing surgical residency during their childbearing years, it’s helpful for women to see others who have enjoyed both rewarding careers and parenthood, she says.

    At Rutgers, Bonne uses casual conversations to show students and residents — both women and men — that it’s possible to have a life outside the operating room.

    “While I'm not directly saying to them out loud, ‘Hey, you really can be a surgeon, and surgeons can be real people’ ... I feel like I'm demonstrating that by talking to them about my kids and my life and my research and the things that are interesting to me, and the problems that I see in the hospital and how I work to fix them,” she says.

    Rising to the highest levels of leadership within their institutions also remains a significant hurdle, which may discourage younger women from going into the field. Full surgical professorships and department chair positions are still mostly held by men, research shows. In fact, there are just 24 women chairs of surgery departments in the United States, according to AAMC data.

    “I do think it's a pipeline issue,” says Cherisse Berry, MD, associate trauma medical director and assistant professor of surgery at the New York University School of Medicine. “I think it's a mentorship and sponsorship issue, in the sense that you really need people in high leadership positions that are actually sponsoring and putting forth names of women in leadership roles.”

    Tackling institutional barriers

    As the director of the Women in Surgery Group at the UCSD School of Medicine, Blair and her colleagues are actively working to bring more women into surgical leadership. The peer mentoring group leads a yearly speaker series geared toward women in surgery and works toward institutional-level improvements. Whenever an issue comes up, such as improving operating room management, the women surgeons can come together to discuss the problem and brainstorm solutions through a gender equity lens.

    At the University of Michigan Medical School, women surgeons are also looking at ways to make their community more equitable. The Michigan Women’s Surgical Collaborative falls under the Michigan Promise initiative, supporting faculty and residents within the department of surgery at Michigan Medicine.

    Not only does the collaborative host the annual Women in Surgery Leadership Development Conference, but it has also taken a data-driven approach to ensuring women’s success. Members of the collaborative have conducted extensive research on barriers for success for women surgeons at the institution and are working on solutions to overcome them by addressing issues like work-life balance and unconscious bias. One effort is ensuring that each candidate pool includes one woman and one underrepresented minority.

    “There are 1,000 steps to get us to parity.”

    Sharon L. Stein, MD
    University Hospitals Cleveland Medical Center

    “If we don’t look like our stakeholders, it’s really hard to make equitable policies that don’t have blind spots,” says Dana A. Telem, MD, MPH, associate professor of surgery at the University of Michigan Medical School, general surgeon at Michigan Medicine, and a founding member of the Michigan Women’s Surgical Collaborative.

    Uplifting future generations of women in STEMM (science, technology, engineering, math, and medicine) is another important component of creating a solid pipeline of women leaders in surgery. UH Cleveland Medical Center’s Stein, for example, lends her time and expertise as facilitator and instructor through the FLEX Leadership program. FLEX convenes women throughout institutions affiliated with the Case Western Reserve University School of Medicine for leadership development and networking support. Women hone their skills in areas like executive presence, negotiation, and conflict resolution.

    “There are 1,000 steps to get us to parity,” says Sharon L. Stein, MD, program director for the colon and rectal surgery residency and associate professor of surgery at University Hospitals (UH) Cleveland Medical Center. Among those steps are asking women to take on opportunities instead of assuming they will be too busy and creating structured interviews that clearly define job characteristics before automatically looking for men to fill the role.

    “It’s a way of thinking differently, it’s a way of being open to different opportunities and the way that things change, and there will be some bumps in the road,” she says.

    Making national progress

    National organizations also are turning their attention to increasing the number of women in surgery. Parangi points to groups like the American College of Surgeons, which boasts strong women leadership and has developed solutions and benchmarks toward addressing equity, diversity, and inclusion in academic surgery.  

    “The fact that they are working on these kinds of equity and diversity issues is huge because that means the change is coming from the top,” she says.

    “Don’t let anybody tell you that being a woman or wanting to have a family or anything is a barrier. It’s not the easiest thing in the world to do, but it’s possible.”

    Stephanie Bonne, MD
    Rutgers New Jersey Medical School

    Her own organization takes part in a range of initiatives to support women at all stages of their surgical careers, from a signature speaker series for midcareer professionals to a coaching program to help women surgeon trainees avoid burnout. The association also works closely with the Society of Black Academic Surgeons (SBAS) to further their missions of bolstering diversity and inclusion in surgery.

    Berry chairs the committee for women in surgery at SBAS, which involves promoting the accomplishments of black women surgeons, writing them letters of recommendation, and connecting them to job opportunities and leadership positions. Such support is especially important for black women and women of color in surgery, who are not well represented.

    And despite the longstanding challenges for women in surgery, those in the field encourage aspiring women surgeons to be steadfast in reaching their goals.

    “Don’t let anybody tell you that being a woman or wanting to have a family or anything is a barrier,” says Bonne. “You make your life and you do the things that you want to do. And you take it a day at a time. It's not the easiest thing in the world to do, but it's possible.”