For the first time in the history of the American College of Surgeons (ACS), women hold the three highest leadership positions in the organization: Barbara Lee Bass, MD, FACS, as President; Leigh A. Neumayer, MD, FACS, as Chair of the Board of Regents (B/R); and Diana L. Farmer, MD, FACS, FRCS, as Chair of the Board of Governors (B/G). In addition, the ACS Committee on Trauma (COT) elected its first woman Chair, Eileen M. Bulger, MD, FACS, and the recently formed Qatar Chapter of the ACS elected Hiba Abdel Aziz, MBBCH, FACS, as its inaugural Governor.
In this article, these surgeons, as well as Mary H. McGrath, MD, MPH, FACS, Chair of the ACS Foundation Board of Directors, and Susan E. Pories, MD, FACS, Chair of the ACS Women in Surgery Committee (WiSC), describe the factors they believe contributed to their rise to prominence within the ACS, offer advice for young surgeons seeking to attain leadership positions, and provide a forecast on the future of surgical leadership.
Increasing presence in the profession
“Women’s role within the ACS certainly has changed a lot, largely reflecting the change in the surgical workforce,” according to Dr. Bass, the John F. and Carolyn Bookout Presidential Endowed Chair and chair, department of surgery, Houston Methodist Hospital, TX. “When I first became a Fellow in 1989, the number of women in the surgical pipeline was quite small. It wasn’t until the 1990s that we had that big jump from 10 percent to now 40 percent of the general surgery trainees. So, I think the change in the leadership of the ACS is reflective of who is in the pipeline and who become members.”
The numbers bear out this assertion. Women now comprise approximately 50 percent of all U.S. medical school graduates, a dramatic increase from 50 years ago, when they represented 10 percent of medical students.1 Furthermore, women now account for approximately 42 percent of active residents in all surgical training programs.2
In addition, more women are rising to top positions within their institutions. The Society of Surgical Chairs Membership Directory now lists 22 women chairs of departments of surgery in the U.S.,3 a marked contrast to 1987 when Olga M. Jonasson, MD, FACS, became the first woman to chair an academic department of surgery at the Ohio State University, Columbus.4
“There are currently more women entering the profession and more women of high accomplishment functioning nationally in medicine and in surgery. What we’re seeing at the College is commensurate with that. Women’s prominence within the organization parallels what is happening in the profession as they become more involved at many different levels,” said Dr. McGrath, the first woman to serve as Vice-Chair of the ACS B/R and a recipient of the ACS Distinguished Service Award (DSA).
Of the approximately 82,000 members of the ACS, 15.9 percent are women; 9.7 percent of Fellows are women, and 39.3 percent of Resident Members are women. Furthermore, the number of women surgeons who are becoming Fellows has escalated. In 2008, women comprised 16.65 percent of the Initiate class (198 of 1,189), whereas women accounted for 24.12 percent of the 2017 Initiate class (448 of 1,857).
Trailblazers and milestones
The evolution of women leaders in surgery has occurred over several decades.
“Those of us in our 50s and 60s represent the second wave of women in surgery,” said Dr. Farmer, an internationally renowned fetal and neonatal surgeon and chair, department of surgery, UC (University of California) Davis Health System, Sacramento. “The first wave of women in surgery were true rarities, and they paved the way for us,” she said, citing the following surgeons among the trailblazers:
- Dr. Jonasson, whom the ACS hired in 1993 to serve as Director of the Education and Surgical Services Department, was a renowned transplant surgeon. In addition to being the first woman to chair a department of surgery, Dr. Jonasson was the first woman member of the American Surgical Association (ASA), the first woman director of the American Board of Surgery (ABS), and the founder of what is now known as the ACS WiSC.
- Kathryn D. Anderson, MD, FACS, a respected pediatric surgeon, was the first woman President of both the ACS and the American Pediatric Surgical Association. She chaired the ACS Advisory Council for Pediatric Surgery, was ACS Secretary, and is a past-second vice-president of the ASA.
- Patricia J. Numann, MD, FACS, a general surgeon, was the second woman President of the ACS, a recipient of the DSA, the first woman chair of the ABS, a founding member and past-president of the Association for Surgical Education, and the founder and past-president of the Association of Women Surgeons (AWS).
That last act, Dr. Numann’s establishment of the AWS, is considered a watershed moment for women in surgery. It started humbly, with Dr. Numann, then a young surgeon at State University of New York (SUNY) Upstate Medical University, Syracuse, posting a sign inviting women surgeons and residents to breakfast at the 1981 Clinical Congress in San Francisco, CA.4 Initially, it was a group of fewer than 20 women gathered around a table.
“The AWS kind of lived in parallel with the College for a number of years, and once it got big enough, we had a Governor,” said Dr. Bass, an AWS member and Past-Chair of the ACS B/G. “That was a really important, transformative time for the College to realize that the AWS had enough Fellows as members to have a Governor and that this group could bring some fresh perspectives to the College. The AWS was an important and powerful group in telling women, yes, you belong in this profession, and not only that, but you belong in the mainstream and leadership of this profession.”
Another turning point for women attaining leadership positions in the ACS was when Margaret “Margo” Longo, MD, FACS, a general surgeon from Hot Springs, AR, became the first woman Regent in 1993. The second woman Regent was Dr. McGrath, a distinguished plastic surgeon, who was elected Vice-Chair of the B/R in 2006.4 Then, in 2012, Julie A. Freischlag, MD, FACS, FRCSEd(Hon), was elected the first woman Chair of the B/R. Dr. Freischlag is chief executive officer, Wake Forest Baptist Medical Center, and dean, Wake Forest School of Medicine, Winston-Salem, NC.
Leaders with foresight
As these milestone moments indicate, the ascension of women within the College has occurred largely in the last 20 to 25 years.
Dr. Neumayer, professor and chair, department of surgery, and Margaret and Fenton Maynard Endowed Chair in Breast Cancer Research, College of Medicine, University of Arizona, Tucson, recalled riding a shuttle bus in the early 1990s at Clinical Congress with a Past-President. She asked him when he thought a woman would be President of the ACS. “He asked me, ‘Well, what proportion of the Fellows are women?’ My best guess back to him was, ‘I believe about 6 percent.’ He said, ‘There will be a woman president of the ACS when 6 percent can outvote 94 percent.’ I am happy to say, we have now had three women Presidents [Drs. Anderson (2005–2006), Numann (2011–2012), and Bass (2017–present)], and we didn’t have to block the vote to get there,” Dr. Neumayer said.
“There also have been five women Chairs of the B/G [Amilu S. Stewart, MD, FACS (1998–1999, and Second Vice-President, 2002–2003); Dr. Bass (1999–2001); Valerie W. Rusch, MD, FACS (2006–2008, and Chair, B/R, 2015–2016); Lena M. Napolitano, MD, FACS (2011–2013); and Dr. Farmer (2016–present)], and we have, for the last eight years or so, had four to five women Regents” (at present, Dr. Neumayer; Margaret M. Dunn, MD, FACS; B.J. Hancock, MD, FACS; Linda G. Phillips, MD, FACS; and Beth H. Sutton, MD, FACS).
Dr. Bass, a recipient of the ACS DSA, said it was in the early to mid-1990s that “the College intentionally recognized that women and other underrepresented minorities in the profession of surgery were an important part of the future of American surgery.” She noted that Regents, Governors, and Executive Staff of the ACS, guided in particular by the efforts of Dr. Jonasson, understood “the strength of the future of the College would rely on embracing these new members in the profession. There were other important and vocal equity advocates in the ACS at that time, including Claude H. Organ, Jr. [MD, FACS, ACS Past-President], who spoke clearly on the barriers that women and people of color faced in our profession, and C. James Carrico [MD, FACS, Past-Chair, ACS B/R], who led the formation of the Resident and Associate Society (RAS-ACS), noting the importance of young surgeons in advancing the ACS.
“I believe some leaders in the ACS intentionally sought out young, accomplished members of these minority membership groups to eventually assume leadership positions in the College by appointing them to committees at a time when many other organizations weren’t thinking about that—by nominating them to ACS Advisory Councils or to other organizations like the ABS or the American Medical Association. I know my nomination to be a director of the ABS came from the College in the early 1990s,” Dr. Bass said. “I think that was an intentional example of introducing women and minorities to leadership roles in our profession.”
Many present-day Regents and Governors are carrying on this tradition, and Dr. Neumayer pointed to the Executive Staff’s leadership in this area. She noted that David B. Hoyt, MD, FACS, ACS Executive Director; Patricia L. Turner, MD, FACS, Director, ACS Division of Member Services; Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education; and Clifford Y. Ko, MD, MS, MSHS, FACS, Director, ACS Division of Research and Optimal Patient Care, “have questioned the status quo and created an intentionally inclusive culture.”
“The College leadership has been tremendously helpful and supportive of WiSC, especially Dr. Turner and Dr. Hoyt,” said Dr. Pories, director, Hoffman Breast Cancer Center, Mount Auburn Hospital, Cambridge, MA. “Take for example when WiSC decided to make a new award for inspiring women in surgery—the Dr. Mary Edwards Walker Inspiring Women in Surgery Award. We were thrilled that Dr. Hoyt would present the award at the Convocation. It gives it so much importance and so much attention. I don’t feel like we’re fighting to be heard. I feel like we’re really working hand in glove with the College administration and leadership.”
Moving forward, “We still have to be intentional about our choices, as there are many outstanding leaders amongst our Fellows, and without someone putting forward names of those who may not be the ‘usual suspects,’ we can easily return to a less diverse group in leadership of the ACS,” Dr. Neumayer added.
Advice for the next generation
ACS leaders have some advice for those residents and surgeons who want their names on the list of future leaders: seek out mentors, sponsors, and role models and get engaged.
“It’s all about mentorship and sponsorship,” said Dr. Bulger, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA. “I think those are the two things that are needed for any leadership position. You need a mentor—somebody who is going to help you get engaged and get involved early on and channel your energy. You also need somebody who is a sponsor, who will put your name forward.”
Dr. Farmer counts Nancy L. Ascher, MD, PhD, FACS, chair, department of surgery, University of California-San Francisco (UCSF) when Dr. Farmer was faculty there, among her mentors and role models. “She was one of those early pioneers. She was the first woman liver transplant surgeon. She stood for excellence. She was an excellent surgeon, better than most. She was unassailable in terms of her technical skills, and she was at the top of her game,” Dr. Farmer said. “She modeled that women should be excellent, and there was no excuse for being anything less. She was a tough chair at a time when she was the only woman chair in the institution.”
“I was certainly lucky to have excellent mentors who left long-lasting imprints on my life and career,” said Dr. Abdel Aziz, senior consultant, surgery, trauma surgery and critical care; chair, trauma guidelines committee; and acting program director, trauma critical care fellowship, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar. She trained in Europe and the U.S., completing her general surgery residency and fellowship in trauma and critical care at the Institutes of Case Western Reserve University, University Hospitals of Cleveland, and Metro Health Medical Center, OH, and noted that surgeons at these institutions “guided me throughout my training, never judging my abilities based on my gender.”
Most of Dr. Bass’s mentors and sponsors were men “who found me, believed in me, guided me, trained me,” she said, adding that mentors need not be gender-specific, but role models typically are. “You kind of want to see somebody who looks like you, who has run the gauntlet, to know that you can do this, too. It does make a difference to see somebody who looks like you to know that you can actually achieve that position of leadership, that you actually can achieve the goals that you aspire to, to know that it’s feasible. For me, that special person was Dr. Kathryn Anderson, the first woman surgeon I ever met. During my general surgery training, she was one of my amazing faculty members, and over the decades to follow, she became a lifelong mentor, sponsor, colleague, and friend. ”
Finding mentors, sponsors, and role models requires engagement. “You want to figure out what you’re most passionate about and where you can make the most difference. So, you need to define what that is and then build a relationship with people in your specialty. They’re all pretty small worlds when you get down to it. You’ve got to go to meetings, and you’ve got to build those relationships,” Dr. Bulger said.
“Young women need to get involved in their organizations. They need to get involved in their universities and practices and attain leadership positions and be responsible for changing the environment they work in. I encourage them to get on committees and just show up. Do the work, and that’s usually how you get ahead,” Dr. Farmer said. “They need to embrace their profession and their professional organizations. They should get involved in whatever professional society is closest to them, including the College,” she added.
“At the Qatar Chapter, we are encouraging women surgeons, residents, and medical students to become Fellows or members of the College. Currently, very few are,” said Dr. Abdel Aziz, a founding member of the Qatar Chapter established in 2017. “I encourage my mentees to get involved with the College and its different committees as early and as much as possible,” she said. “Definitely become a Fellow of the College and participate in your local chapter activities, and it would be even better if you start this relationship at the medical student or resident level. One thing I would change is to have started at an earlier phase in my career.”
Dr. Farmer agreed, stating, “Early involvement and networking are very important. Be dedicated. Put your heart and soul into your commitment. You will get out of it what you put into it.”
“I think that women should train for leadership roles in their home environments, in other words, by functioning in a leadership role in their hospital or university, community, or whatever their environment is, and get the experience to be able to bring more to leadership roles,” Dr. McGrath said. “I would encourage them to bring their clinical work and their research to all different levels of the College—to the chapter level, the Clinical Congress. Second, I would ask them to consider advocating for their patients and for better health care delivery at the national level,” she added.
Dr. Neumayer agreed that advocacy can be a good launching ground for a leadership position. “Not only is this an underpopulated area, it is also an area where you can excel and have an impact for your patients,” she said.
Opportunities for engagement
The College offers a number of venues for residents and young surgeons to get involved, make connections, and train for leadership roles. For individuals who want to hone both their ability to lead and to advocate for better patient care, the College offers the annual Leadership & Advocacy Summit in Washington, DC. This program offers opportunities to connect with ACS leaders, discuss innovative ways to face leadership and surgical challenges, and participate in professional development sessions. Attendees also learn about the pressing issues that Congress is debating and have an opportunity to meet with their legislators and congressional staff.
The College and other surgical organizations also have partnered to sponsor Health Policy Scholars who participate in the Leadership Program for Health Policy and Management at the Heller School for Social Policy and Management at Brandeis University, Waltham, MA. Dr. Bulger noted that she was an ACS/ASA Health Policy Scholar two years ago and found the weeklong intensive course helpful.
The RAS-ACS and Young Fellows Association have committees that focus on advocacy, communications, education, and membership. Leaders of these groups attend meetings of the B/G and the B/R and serve as liaisons to most of the College’s standing committees and Advisory Councils, providing a pipeline to the College’s highest-ranking staff officials. These groups also offer mentorship programs, as do the AWS and WiSC.
WiSC comprises several subcommittees that have been influential in helping women prepare for and attain leadership positions within the ACS. The Awards Committee, for example, “every year looks at all the leadership positions that are open in the College, any awards that are being given out, and keynote addresses and so forth. We write letters of support and nominate people for those positions,” Dr. Pories said. Among other activities, WiSC also offers leadership training at the Leadership & Advocacy Summit.
The ACS Division of Education offers the annual Surgeons as Leaders: From Operating Room to Boardroom Course for surgeons who serve in leadership positions or aspire to such positions and who seek to enhance their leadership skills across a range of settings.
In addition, about four years ago, the COT started the Future Trauma Leaders program. “We select four young trauma surgeons who are very early in their career every year,” Dr. Bulger said. “They serve on the COT for two years, and we provide them with an immersion experience. The COT provides them with mentors and gets them engaged with our committees and supports their attendance at the Leadership & Advocacy Summit, the Trauma Quality Improvement Program meeting, the Clinical Congress, and the COT annual meeting.”
Furthermore, the College offers scholarships for residents and surgeons around the world, enabling them to advance their clinical and research careers. Two of these fellowships honor the legacy of two previously named advocates for diversity: the Claude H. Organ, Jr., MD, FACS, Traveling Fellowship awarded annually to an outstanding surgeon from the Society of Black Academic Surgeons, the AWS, or the Surgical Section of the National Medical Association; and the C. James Carrico, MD, FACS, Faculty Research Fellowship for the Study of Trauma and Critical Care.
These programs are supported through the ACS Foundation, which also supports the 400 medical students who attend the Clinical Congress at no cost every year and has “a linkage to Doctors Day, where you can recognize and celebrate a mentor on the College website and in the Bulletin,” Dr. McGrath said.
“At present, 16 percent of the donors to the Foundation are women surgeons,” Dr. McGrath added. “My message is that giving to the Foundation is a form of activism. It says that you have identified something that you care about, something you want to get behind, and something you want to sustain—that as you move through your career, these are values that you want to support and that you want to express that support financially.”
Challenges remain
Despite the progress that women have made in medicine and surgery, they still face some inequities within their institutions. In 1966–2015, the proportion of women assistant professors, associate professors, and professors at medical schools grew nearly twofold,5 and women now account for 38 percent of full-time academic faculty in the U.S.; however, they often serve in lower-ranking positions. Only 21 percent of full professors are women.6
One possible challenge to achieving leadership positions in medicine is childbearing. “There is still frustration for women needing time away from full-time professional activities for pregnancy and childbearing, and we haven’t sorted this out completely. Part of why childbearing is such a touch point is that it occurs relatively early in women’s careers,” Dr. Farmer said.
“I think family care, especially care of young children and aging parents, is still a very big challenge in the U.S.,” Dr. McGrath added. “To do that so that you’re not shortchanging your family or job is still very difficult, and I think the answer is to have national and medical institutions pay more attention to providing child care and elder care flexibility. Men have this problem as much as women, but the burden does fall largely on women. I think that for both genders there needs to be workplace flexibility and personal support systems.”
In addition, a gap in salaries remains. “A sharp look shows that women surgeons are still compensated 10–17 percent less for equal work than their male colleagues,” Dr. Bass said in her 2017 ACS Presidential Address.7
“In my opinion, women surgeons still face a glass ceiling in general and specifically when it comes to leadership positions,” said Dr. Abdel Aziz. “They are expected to perform equally to their male counterparts; however, they are rewarded unfairly in both pay and promotion. Acknowledging and addressing these barriers and not shying away from having this discussion will help raise the awareness and hopefully minimize the gender gap.”
WiSC has developed statements on two of these issues. The ACS B/R approved the Statement on the Importance of Parental Leave8 at its February 2016 meeting in Chicago, IL, and the Statement on Gender Salary Equity, which WiSC developed with the AWS, at its June 2017 meeting in Chicago.9
“I applaud organizations like the ACS and AWS for their work in highlighting these predicaments and trying to educate and enlighten all parties involved,” Dr. Abdel Aziz said.
An increasingly diverse future
“I’m incredibly optimistic about the future,” Dr. Farmer said. “On the B/G, we have a total of three women on the Executive Committee [Dr. Farmer; Terry Buchmiller, MD, FACS; and Nicole S. Gibran, MD, FACS]. Women are not getting these jobs just because they are women. They are getting these jobs because they are the best people for the job,” Dr. Farmer said. “That’s when you know you’ve really overcome barriers, when it’s not tokenism anymore, but you’re an equal competitor based on merit.”
Dr. Neumayer agreed with that sentiment, saying that when it is no longer necessary to point out that a leader is of certain phenotype, but rather a leader because they have served the organization and were elected on their merit, it will be obvious that real progress has been made
“I think we can look 10 or 20 years ahead, and gender won’t be a noticeable feature of a leader,” Dr. Bass said. “We’ll just be able to look at a leader as a leader as opposed to a woman leader or a man leader or a leader of a certain ethnicity, and if you look at the diversity in training programs and medical schools, with continued intentional inclusion to ensure equal opportunities, I know we’re going to get there.”
Acknowledgment
The author gratefully acknowledges Dr. Turner, Director; Mark Chou, Administrator; and Emily Kalata, B/G Manager, Division of Member Services, for their assistance with this article.
References
- Association of American Medical Colleges. Active physicians by sex and specialty, 2015. Available at: www.aamc.org/data/workforce/reports/458712/1-3-chart.html. Accessed July 3, 2018.
- Accreditation Council for Graduate Medical Education. Data Resource Book Academic Year 2016–2017. Available at: www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book. Accessed July 6, 2017.
- American College of Surgeons. Society of Surgical Chairs Membership Directory. Available at: https://web4.facs.org/ebusiness/ssc/Default.aspx. Accessed July 11, 2018.
- Nahrwold DL, Kernahan PJ. Women Impact Surgery and the College. In: A Century of Surgeons and Surgery: The American College of Surgeons, 1913−2012. Chicago, IL: American College of Surgeons; 2012:351-359.
- Association of American Medical Colleges. Faculty diversity in U.S. medical schools: Progress and gaps coexist. Analysis in Brief. 2016;16(6):1-3.
- Pories SE, Turner PL, Greenberg CC, Babu MA, Parangi S. Leadership in American surgery: Women are rising to the top. Ann Surg. In press.
- Bass BL. Presidential Address: The joy and privilege of a surgical career. Bull Am Coll Surg. 2017;102(12):11-17.
- American College of Surgeons. Statement on the Importance of Parental Leave. Available at: facs.org/about-acs/statements/84-parental-leave. Accessed July 12, 2018.
- American College of Surgeons. Statement on Gender Salary Equity. Available at: facs.org/about-acs/statements/101-gender-salary-equity. Accessed July 12, 2018.
