Women leaders in surgery: Past, present, and future

Over the past 25 years the proportion of women entering medical school has increased dramatically, such that nearly half of today’s graduating medical students are women.¹ However, the number of women entering the surgical specialties remains relatively small. The reason for this discrepancy is multifactorial and has been attributed to unconscious bias, a lack of female role models, and perceptions regarding inability to achieve work-life balance. Although women have made great strides in medicine and more recently in surgery, a “glass ceiling” still exists for women surgeons when it comes to leadership roles at the departmental, institutional, and national level. Indeed, in the U.S., only 12 percent of department chairs in all specialties of medicine are women.²

Several notable women surgeons have, despite many barriers, achieved the highest levels of leadership in surgery. In this article, three remarkable women—Olga Jonasson, MD, FACS; Kathryn Anderson, MD, FACS; and Patricia Numann, MD, FACS—will be highlighted for their achievements in surgical leadership (see photos).

This article goes on to examine current initiatives in surgical training aimed at increasing the leadership potential of the next generation of women surgeons. In addition, the complexity of the glass ceiling, as it relates to women surgeons who are seeking promotions and leadership roles, will be explored. Finally, initiatives aimed at promoting the advancement of women into the upper echelons of surgical leadership will be discussed.

Prominent women leaders in surgery

Dr. Jonasson has long been hailed as a pioneer for women surgeons around the world. Born in 1934 in Illinois, Dr. Jonasson attended medical school and completed her surgical residency at the University of Illinois, Chicago, after being inspired by her mother’s nursing career. She then went on to complete research fellowships in immunochemistry at the Walter Reed Army Medical Center, Washington, DC, transplantation immunobiology at Massachusetts General Hospital, Boston, and cardiovascular and thoracic surgery at the University of Illinois.³

From 1967 to 1987, Dr. Jonasson was a surgical faculty member at the University of Illinois Hospital. As the first woman transplant surgeon, she developed one of Illinois’ first transplantation programs, and she performed the state’s inaugural kidney transplant. Dr. Jonasson also was a leader in histocompatibility testing. In 1987, Dr. Jonasson left Illinois for Ohio State University, Columbus, where she became the first woman in the U.S. to head an academic surgery department at a coeducational school of medicine.⁴

Dr. Jonasson received many awards and accolades over her illustrious career. She was the first female initiate of many surgical societies, including the Association for Academic Surgery, the American Surgical Association, and the Society of University Surgeons. She was the first woman to serve as director of the American Board of Surgery and the first woman appointed to an ACS executive committee.⁵ Dr. Jonasson held both editorial and reviewer roles at many prestigious surgical journals, including the Annals of Surgery, Journal of the American College of Surgeons, Journal of the American Medical Association, and the New England Journal of Medicine.⁵

Dr. Jonasson passed away after a brief illness in August 2006 at the age of 72. She will always be remembered for her contributions to clinical medicine, and she will be celebrated as an innovative and inspiring teacher. Her mentorship efforts helped to advance and develop the careers of many young surgeons, both male and female.

Likewise, Dr. Anderson paved the way for women leaders in surgery by becoming both the first woman Officer of the ACS in 1992 and subsequently advancing through the ranks to be elected as the first woman President of the ACS in 2005. Born in England in 1939, she moved to the U.S. in 1962 after marrying her husband, an American. After earning her medical degree at Harvard University, Boston, MA, Dr. Anderson completed her residency in general surgery at Georgetown University Hospital, Washington, DC.⁶

Throughout her training, Dr. Anderson encountered significant discrimination because of her gender. After being denied a surgical internship at her own medical school, she pursued a nonsurgical internship at Boston Children’s Hospital. In her general surgery residency, Dr. Anderson was assigned only seven cases in her first two years. Fortunately, she was able to advance her surgical training in community hospitals, where she assisted in more than 700 cases in the subsequent year. Even though she was an accomplished resident, she struggled to find a position in a pediatric surgery fellowship. She was offered a position only after the selected fellow was called away for military duty.^7,8

Despite the obstacles she faced early in her career, Dr. Anderson has gone on to have a distinguished career as a pediatric surgeon, practicing at Children’s National Medical Center in Washington, DC, and Children’s Hospital in Los Angeles, CA. She has held prominent positions in many pediatric and surgical societies, as well as on numerous medical and surgical journal editorial boards.⁶

Mentorship is a principle that Dr. Anderson believes in strongly, after being mentored by Dorothy Heard, MD, at the University of Cambridge, and W. Hardy Hendren III, MD, FACS, at Boston Children’s Hospital. She has continued to embrace the principles of mentorship in surgery during her professional career. Throughout her career she has helped many medical students, residents, and attending surgeons navigate their career paths.

Currently serving as the 92nd President of the ACS, Dr. Numann has been inspiring women surgeons for the past 40 years. After completing medical school and general surgery residency at the State University of New York (SUNY) Upstate Medical University in Syracuse, she decided to stay loyal to her alma mater by completing the rest of her professional career at the center where she trained.⁹

As an attending surgeon at SUNY, Dr. Numann held many leadership positions, including associate dean of the college of medicine, associate dean of the college of medicine clinical affairs, professor of surgery, medical director of the University Hospital, and the Lloyd S. Rogers Professor of Surgery. After retiring from clinical practice in 2007, SUNY awarded her emeritus status and in 2009 created the Patricia J. Numann, MD, Chair of Surgery, the first endowed chair for a woman surgeon in the U.S.⁹

Since becoming a Fellow of the College in 1974, Dr. Numann has worked tirelessly on numerous ACS committees and boards. She has also received countless awards over the years at local, national, and international levels. She is renowned for her approachable spirit and inspires all who have the honor of meeting her.

Dr. Numann is perhaps most recognized for her singular role in establishing the Association of Women Surgeons (AWS). In an effort to meet other women surgeons at the annual ACS Clinical Congress she organized a breakfast for women surgeons at the meeting in 1981.⁹ Growing interest in this annual event led to the establishment of the AWS, the mission of which is to “inspire, encourage, and enable women surgeons to realize their professional and personal goals.” The AWS has expanded tremendously since that first breakfast meeting, and now has a membership of more than 1,600 members in more than 15 countries.¹⁰

Training the next generation

It is well known that presently the majority of medical students, both in the U.S. and abroad, are female. Women have become an increasingly greater proportion of American medical school graduates throughout the last 50 years, with a growth from 6.9 percent in 1966 to 48.3 percent in 2010.¹ Even higher numbers have been reported in other areas of the world, with 62.1 percent of medical graduates in Switzerland identifying as women.¹¹

While a rapid progression in the proportion of total female medical school graduates has been observed, this trend has not extended into surgical residency. Although the number of women in general surgery training has increased markedly from 21.2 percent in 1999 to 35.2 percent in 2009, the number of women residents has failed to achieve parity with their male counterparts. Women’s representation is and has been even more discrepant in other specialties including orthopaedic surgery and neurosurgery.¹ In addition, enrollment in general surgery residencies has declined overall, which some individuals in the field attribute to the progressive increase in female medical school matriculates—who may be reluctant to pursue this rigorous career path.¹² As we face a projected shortage of general surgeons over the next decade, it is worrisome that some of the brightest and most talented medical school graduates are not entering surgical training programs.

Many studies have looked at various factors that may influence a female student’s thoughts regarding whether to pursue a career in the surgical specialties. Considerations such as lifestyle implications of career choice, the surgical culture, the lack of female mentors in academic surgery, and equity issues have been shown to play roles in female students’ career choices. In one recent study of more than 1,300 students, 24 percent of male and only 15 percent of female medical students expressed interest in a surgical career.¹³ Women, in particular, have indicated their reluctance to pursue a surgical career due to lifestyle implications, and were more prone than men to be dissuaded from a surgical career due to a decision to have children.¹²

However, women students who had strong female role models or faculty members in general were more likely to pursue a career in surgery.¹² These findings highlight the importance of female surgeons in academic practice and surgical leadership roles.

Not surprisingly, gender discrimination encountered during surgical clerkship had a negative influence on whether to choose a surgical career. In another study, male academic surgeons were more likely than their female colleagues to state that surgery was “not a good choice for women.”¹² Unconscious bias regarding traditional roles for males and females likely played a role in this finding. In the same study, women actually found increased career satisfaction in positions with predictable work schedules and that offer opportunities to achieve work-life balance.

Research suggests that attitudes are changing and that female medical students are, indeed, interested in surgical careers. The proportion of females entering surgical residency is growing, albeit at a slower rate than what has been observed in medical schools. It is clear that increasing the number of women surgeons available to act as mentors and role models will serve to increase female medical students’ enthusiasm for careers in surgery. In addition, a dynamic residency program with a less traditional surgical culture and more emphasis on collegiality, diversity, and flexibility is necessary to attract more female students.¹⁴

The leaky pipeline

It continues to be uncommon to find women in leadership positions across all specialties at most medical schools. In fact, the demographic has been so significantly skewed historically that various organizations have taken corrective actions. For example, in 1998 the Association of American Medical College’s (AAMC) Increasing Women’s Leadership Committee formalized a data collection process to quantify the advancement of women in academic medicine. Information was collected on a variety of data points that confirmed the lack of women in leadership positions at many medical schools. This information was used to make recommendations for the professional improvements for women in medicine.

In 2003, the Women in Medicine Coordinating Committee was established to develop new strategies for advancing women in academic medicine, and in 2009, this group was approved by the AAMC board of directors as an AAMC professional development group, now called the Group on Women in Medicine and Science. Of note, AAMC board recognition, which is a critical component for the advancement of women in academia, was formalized just three years ago.

Within the field of surgery, the paucity of women in positions of seniority is sobering, with women holding only four chairs in surgery departments in the U.S., while the number of female full professors in surgery rose to a meager 8 percent in 2010.¹ It is also interesting to note that there has yet to be a women president or recorder of the American Surgical Association.

Although the number of women surgeons in positions of power continues to be low, the rise in the number of women choosing a career in surgery is encouraging. To build upon this trend, efforts must be made to retain women in surgery and to accurately identify challenges unique to women. Programs aimed at building leadership skills and identifying and supporting prospects for promotion will improve women’s representation in positions of seniority.

In order for positive change to occur, it is important to acknowledge that even in 2012 gender disparities for women in surgery exist. The glass ceiling metaphor implies that women and men have equal access to entry- and mid-level positions but not more senior positions. In reality, this metaphor is not entirely accurate. A more appropriate analogy is the “leaky pipeline,” which reflects the fact that the percentages of women found at the end of the pipeline do not match the percentages of women found at the input. In 2009, across the board in medicine, 17 percent of full professors were women, even though women constituted 24 percent of medical school students in 1975.¹⁵ Furthermore, it has been well-established that the proportion of women who have advanced to senior ranks continually has been lower than that of their male counterparts.^16,17 This finding suggests that the scarcity of women in leadership positions is not the result of insufficient numbers; rather, it represents attrition of women along that pipeline. This loss of proportional representation at advancing stages of a woman’s career holds true in all fields of medicine—and is not limited to surgery.^16,17

The challenges women surgeons face are complex and difficult to measure and, as a consequence, problematic to resolve. Women in surgery face salary discrimination, slower promotion rates, conflicting cues regarding when to start a family, greater home-life conflict and depression, less research support, and restricted access to positions that lead to promotions and other forms of recognition.

What is behind this discrimination and the unconscious bias against women? Well-intentioned chairs and program directors may not consider a woman for positions due to concern about overburdening women faculty and residents. Although more women residents and fellows are having children, starting a family is still perceived negatively by both faculty and residents alike.¹⁸ Study after study in sociology, psychology, and business has pointed to the widely shared conscious and unconscious associations regarding the traits of women, men, and leaders. People tend to associate the traits of a good leader with the traits of men rather than with the personality traits of women. More research is needed to further define the challenges unique to women surgeons, so that a greater understanding of the impact of proposed interventions will achieve the goal of retaining and promoting this rich talent pool.

Advancing into leadership roles

In addition to teaching residents about surgery and patient care, chief residents, fellows, and established surgeons alike should seek out opportunities to develop their leadership skills and pursue positions that will lead to advancement and further job recognition. Over the past decade, various surgical societies have developed a number of programs to promote mentorship, develop leadership skills, and facilitate the advancement of women surgeons through the various stages of an academic career. The AWS has made this agenda a priority from its inception, and to this end, AWS offers networking breakfasts at the annual meeting, mentorship programs, and a variety of grants and awards targeted specifically toward the female surgeon.

The AWS leadership has also made a concerted effort to promote women surgeons through the leadership ranks of every major surgical society—such that many now have an AWS delegate or chair, including the ACS Board of Governors. In the past few years, the ACS Women in Surgery Committee has implemented an early-career mentorship program, which pairs prominent women surgeons with rising junior faculty in an effort to help these physicians navigate the somewhat challenging road to promotion and advancement in academic surgery. This program, and others like it, have brought together female surgical trainees and practicing surgeons alike from around the country to discuss many of the issues addressed in this article.

Conclusion

While women have achieved parity with men in terms of medical school enrollment over the past decade, the gender gap in surgical specialty training programs has only recently started to slowly close. The increased proportion of women entering surgical training programs may be attributed to a number of factors, including a steady rise in the number of female surgeon mentors and role models, along with the cultural changes in surgical training programs with respect to duty hours and work-life balance. In order for the advancement of women surgeons to continue, additional resources should be developed to ensure that more women rise through the ranks in their departments, institutions, and surgical societies, as exemplified by the notable women surgeons highlighted in this article. More programs than ever before are available to help women surgeons locate suitable mentors and build leadership skills among female surgical trainees and faculty alike.

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References

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