Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College leadership. The 2018 ACS Governors Survey, conducted in August 2018 by the B/G Survey Workgroup, had a 91 percent (263/289) response rate.
One of the survey’s topics was gender inequality and harassment. This article outlines the Governors’ feedback on this issue.
As defined by the Oxford Dictionary, gender inequality is a social process whereby people are treated differently and disadvantageously, under similar circumstances, on the basis of gender. Gender inequality goes beyond wage differentiation and includes equal access to work, promotion, and development. The 2018 ACS Governors Survey defined gender equality as the state of equal ease of access to resources and opportunities, regardless of gender, including economic participation and decision making and the state of valuing different behaviors, aspirations, and needs equally, regardless of gender.
The surgical profession is experiencing workforce shortages and other complex challenges. It is essential that the best and brightest are chosen to become surgeons, regardless of gender. With the development of modern surgical training in the early 20th century, the path of involvement and career development has been different for men and women. The ACS has incorporated women into its membership since its inception in 1913. However, women comprised less than 2 percent of the College membership until 1975. This percentage was a direct reflection of the era, as only 2 percent of surgical residents in the U.S. were women in the 1980s.
Until 1970, women never comprised more than 6 percent of any medical school class in the U.S. or Canada. In 2001, 14 percent of U.S. surgical residents were women, a low percentage in comparison with the number of women medical students at the time. Over the last 15 years, an increasing number of women have entered medicine and the surgical workforce. In 2017, for the first time, more women than men were enrolled in medical school—a trend that continued in 2018, with women representing the majority of both applicants and matriculants. In 2017, 40.1 percent of U.S. general surgery residents were women and 20.6 percent of general surgeons were women.
Although the number of women both in U.S. surgical residencies and at the attending level has increased in recent years, the total number of women practicing surgery remains low. According to the Association of Women Surgeons (AWS), in 2015, U.S. women represented only 8 percent of professors, 13 percent of associate professors, and 26 percent of assistant professors of surgery. However, one area of growth has emerged—chair positions. In 2014, only four women were chairs of surgery, yet by 2019, 21 women were chairs in the U.S and two in Canada. Additional growth was realized in 2017, with women representing 12 percent of professors, 21 percent of associate professors, and 29 percent of assistant professors. Since 2009, an increase in the percentage of women as professors (31 percent), associate professors (19 percent), and assistant professors (9.5 percent) has been realized.
At the time of this survey, 83 percent of the 2017–2018 ACS B/G were men (see Figure 1). This ratio was similar to the composition of ACS Fellows at the time: 79.4 percent men and 20.6 percent women. Internationally, of the 41 respondents from countries outside the U.S. and Canada, only one was a woman (2.4 percent), which is slightly less than the corresponding representation who are international Fellows (4.9 percent).
Figure 1. ACS Governors by gender
Further analysis revealed that women Governors were primarily younger than their male counterparts. For example, 51.1 percent of female Governors were age 55 or younger, while 33.4 percent of males were in that age group (see Table 1).
Table 1. ACS Governors by gender and age
Is there a problem?
Is gender equality in the surgical profession an issue that needs attention? According to 57.79 percent of the ACS Governors, it is (see Figure 2). Additional analysis revealed this assessment differs greatly by gender (see Table 2). For example, 46.5 percent of women respondents strongly agreed that gender equality is a problem, whereas only 11 percent of men respondents felt that way. Furthermore, 16.9 percent of male Governors did not believe gender equality is an issue in the surgical profession, versus only 2.3 percent of female Governors. Internationally, this statement was more divisive, with 34.15 percent of respondents strongly agreeing/agreeing and 34.15 percent strongly disagreeing/disagreeing that it is a concern.
Figure 2. Gender equality is a problem in the surgical profession
Table 2. By gender: Gender equality is a problem in the surgical profession
Equal pay and promotion
The Governors as a whole were fairly aligned on the question of whether men and women surgeons receive equal pay and promotion opportunities: 41.8 percent strongly agreed/agreed and 37.2 percent strongly disagreed/disagreed (see Figure 3), but their responses greatly differed by gender (see Table 3). Only 11.6 percent of women respondents strongly agreed/agreed that women and men receive equal pay and promotion, whereas nearly half (47.7 percent) of the male respondents strongly agreed/agreed. In comparison, 83.7 percent of female Governors strongly disagreed/disagreed with the statement compared with only 27.9 percent of male Governors. Most (68.29 percent) of the international Governors strongly agreed/agreed that equal pay and promotion was adhered to regardless of gender.
Figure 3. Equal pay and promotion regardless of gender is adhered to in the surgical profession
Table 3. By gender: Equal pay and promotion regardless of gender is adhered to in the surgical profession
Most of the Governors (74.14 percent) reported that their institution has equal pay and promotion plans (see Figure 4). Interestingly, only 27.91 percent of women Governors reported their institution has these plans versus 83.5 percent of male Governors. The results from the male respondents are in contrast to a recent publication from the AWS. According to the AWS report, after controlling for specialty, age, faculty rank, and metrics of clinical and research productivity, women surgeons annually earn 8 percent less than men surgeons. The AWS report also revealed that pay disparity only widens over time, with women surgeons earning almost 90 percent of what their men counterparts are paid until age 35. After age 35, median earnings for women surgeons drop to 82 percent of what men earn. The discrepancy between the Governors survey and the AWS report highlights the need for further evaluation and education on this topic.
Figure 4. My hospital/practice/facility actively considers gender equality/equal pay as it pertains to salaries and promotions
Support for gender equality
Another area that needs further evaluation and improvement involves advocating for gender equality at the institutional level. Whereas 67.68 percent of Governors have advocated for gender equality at their institutions, almost one-third (32.3 percent) of Governors indicated they have not (see Figure 5). This lack of engagement may be attributed to an absence of priority and/or awareness of the issue. Internationally, slightly more than half (53.66 percent) of the Governors indicated they have advocated for gender equality/equal pay at their practices or institutions, and 46.34 percent indicated they work at a medical practice or facility with the policies and procedures needed to identify and prevent harassment and to take the necessary steps to address cases of gender discrimination.
Figure 5. Have you advocated for gender equality/equal pay at your hospital/practice/facility?
Why does gender inequality still exist in surgery? More than one-third (35.74 percent) of respondents believed the biggest impediment was other surgeons (see Figure 6). Interestingly, more than half (53.49 percent) of these respondent were women. Of note, 28.5 percent of Governors did not believe that gender equality is an issue in the surgical profession. All of these respondents were men. Although 60.98 percent of international Governors indicated that they did not believe gender equality is an issue in the surgical profession, 19.51 percent did acknowledge that other surgeons are the largest impediment to gender equality.
Figure 6. What is the biggest impediment to gender equality in the surgical profession?
Only 15.6 percent of Governors reported that they have personally experienced harassment or negative treatment because of their gender, but one-third of Governors (34.6 percent) reported that they knew a colleague who had been harassed by peers or staff members (see Figure 7). Likely reflective of the discrepant international male/female ratio, only 2.4 percent of international Governors indicated they had been treated negatively or harassed by colleagues and staff because of gender, and only 10 percent knew of a colleague who had experienced negative treatment.
Figure 7. Has a colleague been treated negatively or been harassed by colleagues and staff because of gender?
An even greater number of Governors (38.4 percent) reported they have witnessed or have knowledge of a physician who was harassed by patients and/or the patient’s family because of gender (see Figure 8). Only 9.76 percent of international respondents have witnessed colleagues being treated negatively or harassed by patients and/or their family, and the vast majority (85.71 percent) intervened (see Figure 9). U.S. and Canadian Governors (who witnessed colleagues being treated negatively or harassed by patients and/or their family) also overwhelming intervened (78.89 percent and 100 percent, respectively).
Figure 8. Have you witnessed or have knowledge of physicians being treated negatively or harassed by patients and/or their family because of gender?
Figure 9. If you witnessed or had knowledge of physicians being treated negatively or harassed by patients and/or their family because of gender, did you intervene?
As a result of the high proportion of surgeons who have experienced harassment from patients and patient families, many hospitals have developed policies and procedures to address the problem. Furthermore, the American Medical Association (AMA) Organized Medical Staff Section recently recommended that protections against discriminatory behavior be incorporated into institutional bylaws.
Gender equity resources
In recent years, several medical organizations have made concerted efforts to evaluate their diversity and gender equity and to implement subsequent improvements. For example, the AMA, at the urging of the Women’s Physician section, conducted a gender analysis of its leadership. The study revealed limited female representation and participation from state society delegates. The analysis resulted in a series of policy changes to advance gender equity. For example, many states increased the percentage of women physicians on their delegations, and the overall number of female physicians in leadership roles increased to 30 percent.
Through a series of resolutions and study results, the AMA also developed a plan to improve gender equity in the organization and in medicine. For example, the AMA established a goal of increasing transparency in the selection of physicians and medical students for positions, as well as any relevant compensation. Other efforts focused on decreasing biases and increased education to improve negotiating skills.
In 2017, the College, in partnership with the AWS, developed a statement to support pay equity among surgeons, regardless of gender. The following guidelines provide a framework for a pay equity policy:
- Employers should promote transparency in defining the criteria for initial and subsequent physician salaries. To ensure equitable compensation, performance reviews and benchmark salaries of all surgeons should be reviewed routinely in both academic and clinical practice settings. Policies, procedures, leadership practices, and organizational culture should be assessed to ensure compliance with pay equity requirements. In addition, any identified pay disparity should be remedied.
- Implicit bias and compensation determination training should be provided for all individuals in a position to determine salary. These programs should specifically focus on how subtle differences in the evaluation of male and female surgeons may impede compensation and career advancement. Compensation training should provide a thorough understanding of compensation policies, how rates of pay are determined, and how to communicate compensation.
- Nondepartmental oversight of compensation models, metrics, and actual total compensation for all employed physicians should be encouraged. Information about compensation, including summary data by rank, years of employment, and gender should be made available to all surgeons within the department. Educational programs also should be established to help promote an understanding of self-worth and self-confidence. Both genders should be empowered to negotiate an equitable salary. These educational efforts should be extended to residents and medical students so that essential negotiation skills are fostered early in training.
Most recently, the ACS Women in Surgery Committee (WiSC) developed a Statement on Harassment, Bullying, and Discrimination to promote an environment in which patients, staff, colleagues, physicians, trainees, and all other individuals are treated with respect, civility, and tolerance (see Statement in this issue). All members of the surgical team have a shared responsibility to create a culture that values all individuals equally. The following guidelines provide a framework for surgical departments and practices to create a work environment free of bullying, harassment, and discrimination:
- It is essential to build a culture of respect and collaboration in all aspects of surgical practice.
- There should be zero tolerance for discrimination, harassment, or bullying based on personal attributes, including, but not limited to, age, sexual preference, gender, race, religion, culture, ethnicity, disease, disability, or religion.
- Administrators should develop and implement transparent policies to address bullying, discrimination, and harassment.
- Staff, physicians, and trainees must have access to nonpunitive reporting structures, counseling services, and remediation programs.
- Surgical training should include a curriculum to address implicit bias, bullying, harassment, and discrimination.
Many specialty societies also have recognized the importance of gender equity in their activities. For example, in 2017 the American Surgical Association’s Task Force on Equity, Diversity, and Inclusion produced a living document to identify issues and hurdles and develop a set of solutions and benchmarks to help the academic surgical community address historically significant deficiencies within surgery in the area of diversity, equity, and inclusion.
Increased recruitment efforts
While primary care disciplines, such as pediatrics and family medicine, have consistently attracted women physicians, in recent years several surgical specialties have developed strategies and tactics to recruit more women. As Figure 10 demonstrates, since 2013 a modest increase in the number of women residents has been realized in general surgery (2.6 percent absolute change, 6.9 percent relative increase), neurological surgery (1.8 percent absolute change, 11.3 percent relative increase), orthopaedic surgery (1.6 percent absolute change, 11.6 percent relative increase), plastic surgery (6.5 percent absolute change, 20 percent relative increase), and thoracic surgery (3.6 percent absolute change, 17.8 percent relative increase). Likewise, a gradual increase in active practice women surgeons has occurred in the following specialties: general surgery (3 percent absolute change, 17 percent relative increase), neurological surgery (1.1 percent absolute change, 15 percent relative increase), orthopaedic surgery (0.7 percent absolute change, 15.2 percent relative increase), plastic surgery (1.8 percent absolute change, 12 percent relative increase), thoracic surgery (1.5 percent absolute change, 27 percent relative increase ), and vascular surgery (3.5 percent absolute change, 36.4 percent relative increase) (see Figure 11).
Figure 10. Female residents 2013–2017
Source: AAMC Physician Specialty Data Books, 2014 and 2017
Figure 11. Active female physicians 2013–2017
Source: AAMC Physician Specialty Data Books, 2014 and 2017
Conclusion and next steps
The survey revealed that 82.5 percent of Governors believe gender inequality is an extremely important/moderately important issue and are supportive of the College continuing to focus on this topic (see Figure 12). The results revealed that gender inequality is a true concern within the field of surgery. From a lack of equal pay to difficulties with academic promotion, gender inequality is an issue that warrants continued discussion among the Fellows. Although 67.68 percent of Governors report that they have advocated for gender equality and equal pay, more than one-third have not. This is an opportunity and a call to action for all surgical colleagues. For more than 100 years, the College’s leadership has been instrumental in addressing the challenges in the profession, and its leadership will be critical to continue positive change in this area.
Figure 12. How important is it for the ACS to continue to address gender inequality and harrassment?
Medical organizations, practices, and institutions are encouraged to periodically conduct a comprehensive internal analysis of gender equity. In addition to issues such as compensation and representation, the recruitment of women into surgery and professional career development and mentorship should be examined. The results of the analysis should be used to develop and revise policies, as well as to establish goals to effect positive change. Companies that have encouraged gender equity have found themselves rewarded. For example, companies in the top quartile of gender diversity are 15 percent more likely to demonstrate financial returns above the national industry median. It is estimated that $12 trillion could be added to the global gross domestic product by 2025 by advancing women’s equality and leadership positions.
The surgical profession has come a long way from denying women admittance to medical schools and being barred from holding leadership positions in professional organizations. However, as the survey results and other contemporary research have shown, more must be accomplished before gender equity occurs in the surgical profession. Surgeons should be an active part of the solution and not part of the problem. Whether it is as a member of ACS or another medical organization or as staff at your institution, surgeons need to advocate and be leaders on this topic. Review your medical staff bylaws to see if they address gender inequality and harassment. If not, be a proponent for revisions to effect positive change. If you witness inappropriate behavior, speak up and support your colleague. Actively support the recruitment of women into surgery and their promotion to leadership positions. The business community offers several examples of how more women in management have brought positive changes to discussions, planning, and implementation. Medicine needs to follow suit and be more proactive.
The ACS and AMA already have proven to be leaders in these efforts, and more positive results are expected from them in the future, with continued focus and evaluation. Without action and strategic efforts by leaders in the surgical profession, positive change will not occur. The ACS has always been on the forefront of change. As a Fellow, you can facilitate positive change locally, regionally, and nationally.
The authors are grateful to the members of WiSC for sharing their expertise and insights, especially Nancy N. Baxter, MD, FACS, FRCSC; Christina Cellini, MD, FACS; Michele Ann Manahan, MD, FACS; and Susan E. Pories, MD, FACS.
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