ACS WiSC addresses ongoing challenges for women in surgery

Women have practiced medicine in the U.S. for more than 160 years. Nonetheless, they remain an underrepresented part of the surgical community. A recent call for medical student applicants to fill seats on the American College of Surgeons (ACS) Women in Surgery Committee (WiSC) has shed some light on why this situation persists. This article examines the ongoing challenges women in surgery face, reports the results of the WiSC medical student call for applicants, and offers insights into how to make surgery a more welcoming profession for women surgeons.

Historical perspective

Elizabeth Blackwell, MD, is recognized as the first woman physician in the U.S. She graduated with honors from Geneva Medical College in Upstate New York in 1849. It is not widely known that Dr. Blackwell’s ultimate goal was to become a surgeon.¹ Unfortunately, Dr. Blackwell lost her left eye to infection, ending her dream of performing surgery. Nonetheless, she had a long and illustrious career.¹

Since Dr. Blackwell’s day, women have made considerable progress in realizing their aspirations in the medical professions. By 1934, 72 percent of U.S. medical schools opened their doors to women. By 1944, only 9 percent of medical schools continued to exclude women. Jefferson Medical College, Philadelphia, PA, was the last school to admit women, starting in 1960.² Since then, the number of women in medicine has grown exponentially. In fact, the number of women in medical school now is equivalent to men. According to data from the Association of American Medical Colleges, 21 percent of full professors are women, 15 percent of department chairs are women, and 16 percent of deans are women.³

Mary Edwards Walker, MD, is credited as being the first woman surgeon in the U.S, graduating from Syracuse Medical College, NY, in 1855 (see related story).⁴ Overall, surgery has been less welcoming to women than other specialties. As recently as 1980, only 2 percent of women medical students chose surgery as a specialty. Although these numbers have improved and increasing numbers of surgery residents are now women, the number of women in surgical leadership positions continues to lag far behind men.¹ Only 21.3 percent of all surgeons in the U.S. are women,⁵ less than 10 percent of full professors of surgery are women, and 5.7 percent of surgical chairs are women.^6,7

WiSC call for applicants

The mission of the ACS WiSC is to enable women surgeons of all ages, specialities, and practice types to develop their individual potential as professionals; promote an environment that fosters inclusion, respect, and success; develop, encourage, and advance women surgeons as leaders; and provide a forum and networking opportunities to enhance women’s surgical career satisfaction. WiSC includes members from a variety of specialties, medical students, and representatives from the ACS Board of Governors, the Resident and Associate Society of the ACS, and the Association of Women Surgeons (AWS).

Traditionally, one or two medical students a year were invited to join the committee, based on recommendations of committee members. However, in 2015, the WiSC Structure and Mission Subcommittee recommended a new and more transparent method of recruitment for all committee members, including medical students. As such, a call was sent out via the ACS and AWS e-newsletters inviting interested medical students to apply for the one open seat. A total of 55 medical students applied for this single vacancy.

Each interested student wrote a short essay describing her interest in the committee’s mission and activities. Notably, many of the essays commented on the fact that women medical students are still discouraged from pursuing a surgical career. Perspectives expressed by these student applicants described the ongoing challenges a woman faces when demonstrating interest in the surgical specialties. The applicants were from the U.S., including 29 states and the District of Columbia, and Canada.

The experiences described in the medical student essays were telling. One student wrote that at a specialty panel organized by her medical school, “The male surgeons were asked for the secrets of creating financially successful practices, while the female surgeons were asked only how long they chose to put off childbearing.” Another student commented, “On my surgery rotations, I could not help but notice the gender imbalance. This disparity was not only in numbers, but also in whose contributions were respected, valued, and seen as authoritative…. There is still a barrier to women in surgery, ultimately resulting in talent being lost to other specialties…. This barrier is entrenched in multiple ways—in traditions and biases.” Another wrote, “Having completed two general surgery and two subspecialty rotations thus far, I have seen firsthand the disproportionate underrepresentation of women in this field…. I have witnessed many talented young women choose not to follow their passion for surgery.”

Several other applicants expressed discouragement, noting a continuous thread of “naysayers who doubted, warned against, and questioned my ability to succeed in the field of surgery as a woman.” Almost all students were told how difficult it would be to be a surgeon, as well as a wife and mother. One wrote, “Since declaring my interest in surgery as a female medical student, people began warning me about how hard life would be, how difficult it would be to have a family. I can assure you that my male colleagues have not been subject to the same warnings, at least not with the same ardor.” Another applicant noted that she was told she could not have a successful surgical career given that she was a single mother.

Some applicants reported blunt skepticism, with comments ranging from, “You can’t do surgery—you are too nice,” to “You want a family. You want to be there for your kids. Do you really think you can do that when you are in the operating room all day?” One student wrote that she received plenty of unsolicited feedback about why she should reconsider her choice. She described one attending who spent nearly an hour trying to convince her to pursue another specialty because the female surgeons he knew were “miserable.” Another student noted that as a thirdyear medical student she didn’t have a single female preceptor during her surgery rotation. She noted that many residents and medical students lack female role models who can serve as mentors. Another wrote that throughout her core clinical year, the fact that she was a female was always brought up in some way when she would address her aspiration of pursuing surgery.

Another student noted that the reply when she said she wanted to be a surgeon was often, “Are you sure? You know that you are not going to have a life.” This applicant revealed that her brother, also an aspiring surgeon, was never asked these questions. “As my seriousness to pursue surgery became apparent the replies changed from questions to…statements such as: ‘You won’t be able to raise children. You won’t be happy,’” she wrote. Another student recounted an experience attending a surgery interest group meeting, which consisted of an all-male panel. She felt that every surgeon on the panel was intimidating and trying to scare off anyone with the slightest doubt about entering the field of surgery.

Barbara L. Bass, MD, FACS, chair, department of surgery, Houston Methodist Hospital, TX; ACS President-Elect; Past-Chair, ACS Board of Governors; and Past-Member, ACS Board of Regents, commented, “There was a time when there was serious doubt within the surgical community that women were capable of becoming surgeons—from technical concerns raised by one outspoken opponent to women in the surgical workforce, to simple common assumptions that women were not tough enough or committed enough to train in surgery or to engage in successful surgical careers. Surely the demands of ‘womanhood’—being a wife and mother—would undermine even the most committed person, not to mention weathering the bias of many surgeons who truly believed that being a surgeon was a privilege that should be reserved for men, who could be counted on to give it their all. These days, I think that…[those] who dissuade women from pursuing a surgical career are doing so based on a different set of assumptions and likely misconceptions. I do believe the vast majority of this [behavior] these days falls into the unconscious bias category.” (Personal communication with the authors, February 22, 2016.)

The power of mentorship

Some applicants offered positive comments about the power of mentorship from women role models. One student commented that one of her attendings, a surgical oncologist, led by example in the caring way she interacted with her patients and through her expertise in the operating room. “She spent time teaching me to tie knots late on a Friday night, while inviting discussion about the pros and cons of a career in surgery.” She also was appreciative of resident teaching. “One of my chief residents was a wife, mother of two daughters, and future transplant surgeon. She pushed me to make my presentations more concise, precise, and accurate. She taught me to suture…[and] I hope one day to emulate her as both a surgeon and a teacher,” she wrote. “There have been many more [mentors], including wonderful junior residents and fellows. Combined, the effect of these women as role models, mentors, and teachers is powerful.”

Another student wrote that while she learned something from every surgeon with whom she interacted, working with women surgeons—watching them scrub into cases she would one day lead—was empowering. One student highlighted the encouragement she received from women surgical residents. Another commented how much she valued working alongside exceedingly skilled, compassionate, confident women surgeons and that she hoped to emulate them professionally, as well as personally. As one student put it, “Mentoring and encouragement helped me feel great about choosing surgery as my career and be proud to be a female as well as a mother.”

Women are gradually achieving leadership roles in the surgical profession. However, there is clearly a long way to go, as the number of chairs, academic professors, and senior partners in private practices remains relatively small. The ACS has had two women Presidents in its more than 100-year history, and 10 women members of the Board of Regents.

Recommendations for further advancement

Female medical students comprise approximately 40 percent of the ACS student membership. Some surgical disciplines are particularly challenged, such as neurosurgery, orthopaedics, and plastics, with respect to women leaders. “Taking on these jobs does require a great deal of ambition and the support of one’s personal infrastructure—partner, family, spouse, and parents. And this is personal infrastructure—not infrastructure that one can count on as built into our professional environments,” Dr. Bass said. “Our society and culture still prioritizes the role of women in most responsibilities of home, and women embrace these roles, of course; it’s how we were raised and what we do—we want these roles as well as our lives as surgeons.”

With respect to starting a family and life outside of work, numerous advances have been made in the surgical profession. Many student applications echoed that through mentorship, they have learned how many women surgeons have found individual solutions to accommodate irregular hours, on-call duties, and so on with pregnancy and child care. Those women surgeons with strong mentors have learned how to focus on making the most of their time away from work. “Personal health, entertainment, hobbies can all be accommodated into a busy career, and we are fortunate that our financial positions are quite healthy compared to many others. Do we need to defer some activities at times? Of  course, but on balance I think I have seen more and more surgeons place appropriate and substantial effort into their activities outside of work—a very positive trend for women and men in the next generation of surgeons,” Dr. Bass noted.

Successfully encouraging women medical students to choose surgical careers may be achieved by the following:

• Continuing to foster an atmosphere in surgical training programs that is more accepting of the competing demands that trainees and attendings face with respect to balancing work and personal obligations regardless of gender
• Acknowledging that women face unique challenges but that creating a fulfilling harmony between work and personal life is a universal issue that is not gender-specific
• Fostering strong mentorship programs for women interested in surgery

As one student noted, “Without mentorship, I likely would not have had the inclination or desire to pursue a career in a surgical subspecialty.” To combat this feeling, Dr. Bass urges women to “hear the full story from multiple perspectives.”

Despite initial discouragement, all applicants shared a remarkable motivation and dedication to a surgical career as a calling. Our current task is to guarantee that women have equity in both opportunity and guidance as they shape their career choices.

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References

1. Wirtzfeld DA. The history of women in surgery. Can J Surg.2009;52(4):317-320.
2. Washington University School of Medicine. Bernard Becker Medical Library Digital Collection. The path to medical coeducation in the United States. Available at: beckerexhibits.wustl.edu/mowihsp/health/medcoedus.htm. Accessed September 27, 2016.
3. Association of American Medical Colleges. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership 2013–2014. Available at: members.aamc.org/eweb/upload/The%20State%20of%20Women%20in%20Academic%20Medicine%202013-2014%20FINAL.pdf. Accessed September 27, 2016.
4. Rehman A, Rahman NG, Harris SM, Cheema FH. Mary Edwards Walker: The soul ahead of her time. JAMA Surg. 2015;150(2):173-174.
5. Hoyt DB. Looking forward. Bull Am Coll Surg. 2015;100(7):7-9. Available at: bulletin.facs.org/2015/07/looking-forward-july-2015/. Accessed September 27, 2016.
6. Abelson JS, Chartrand G, Moo TA, Moore M,Yeo H. The climb to break the glass ceiling in surgery: Trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. 2016;212(4):566-672. Available at: www.americanjournalofsurgery.com/article/S0002-9610(16)30350-6/abstract. Accessed October 6, 2016.
7. Hofler LG, Hacker MR, Dodge LE, et al. Comparison of women in department leadership in obstetrics and gynecology with those in other specialties. Obstet Gynecol. 2016;127(3):442-447.