Editor’s note: The following comments were received regarding recent articles published in the Bulletin.
Letters should be sent with the writer’s name, address, e-mail address, and daytime telephone number via e-mail to firstname.lastname@example.org, or via mail to Diane Schneidman, Editor-in-Chief, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611.
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The future of surgery is female
Over the last decade, the number of women entering surgical training has increased. In the U.S., the number of women in general surgery residency programs has doubled from 20 years ago.1 On the other side of the globe, the College of Surgeons of East, Central and Southern Africa saw a drastic increase in women trainees from 8 percent to 23 percent just in the last three years (see related story).2 Moreover, aspiring and new surgical trainees are emerging leaders, as shown in the student session on trainee involvement in global surgery at the American College of Surgeons Clinical Congress 2019, which was entirely organized by women medical students and residents.
Thanks to many trailblazing women, progress is clearly being made toward parity. With women often outnumbering men in medical schools, the future is promising for gender balance in surgery. However, has the surgical training environment and culture kept pace with this change? Can these women climb the ladder from trainee, to consultant, to professor in the same way as their male counterparts do?
A recent survey of practicing women surgeons in the U.S. showed that nearly 60 percent reported having experienced sexual harassment, versus 25 percent of men.3 Another study revealed gender bias in evaluations of women residents in surgical training programs.4 Beyond gender-based discrimination and aggression at the micro-level, systemic inequities and structural sexism persist in surgery.
Women are still paid significantly less than men. In Canada, women surgeons were found to be paid 24 percent less per hour spent operating than men.5 Itum and colleagues also found that only half of U.S. residency programs offer paid parental leave.6 These disparities create a toxic working environment that makes balancing surgical training with family life more difficult for women. It is no surprise that the attrition rate for women surgical trainees is higher than for men.7
The further we look on the hierarchical ladder, the fewer women we find. In the U.K., the percentage of women consultant surgeons in 2019 was 12.9 percent.8 In 2017, Epstein analyzed the literature on full professorships in surgery and found that the number of women was so low, and the increase so slow, that it would take 120 years to reach gender parity.9
It is important to celebrate the increase in the number of women entering surgery. However, we need to do more to retain, nurture, and maximize their potential. Women trainees and surgeons must be treated better. Accountability measures for sexual harassment, microaggressions, and all forms of gender-based discrimination must be implemented.
Policy changes should be made to accommodate family planning and to prevent the penalization of childbearing. This step will not only encourage more women to climb the career ladder, but also may improve their male colleagues’ quality of life because men also benefit from parental leave. The relationship between physician wellness and patient outcomes is clear.10 Thus, surgical training programs owe it to patients to make surgical training a period when trainees can thrive both professionally and personally, regardless of gender.
As we start a new decade, we should acknowledge that the future of surgery is female. It is time for surgery to shift away from its patriarchal norms and better accommodate the new, eager female workforce. Bringing gender parity to the surgical workforce is an opportunity to increase the attractiveness of surgical training and improve patient care.
Zineb Bentounsi, MD
Eliana E. Kim
San Francisco, CA
Xiya Ma, MSc
- 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):566-572.
- Odera A, Tierney S, Mangaoang D, Mugwe R, Sanfey H. Women in Surgery Africa and research. Lancet. 2019;393(10186):2120.
- Nayyar A, Scarlet S, Strassle PD, et al. A national survey of sexual harassment among surgeons. American Surgical Congress 2019. Abstract 85.06. Available at: www.asc-abstracts.org/abs2019/85-06-a-national-survey-of-sexual-harassment-among-surgeons/. Accessed June 5, 2020.
- Gerull KM, Loe M, Seiler K, McAllister J, Salles A. Assessing gender bias in qualitative evaluations of surgical residents. Am J Surg. 2019;217(2):306-313.
- Dossa F, Simpson AN, Sutradhar R, et al. Sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario, Canada. JAMA Surg. 2019;154(12):1134-1142.
- Itum DS, Oltmann SC, Choti MA, Piper HG. Access to paid parental leave for academic surgeons. J Surg Res. 2019;233(1):144-148.
- Liang R, Dornan T, Nestel D. Why do women leave surgical training? A qualitative and feminist study. Lancet. 2019;393(10171):541-549.
- The Royal College of Surgeons of England. Statistics. Women in surgery. Available at: www.rcseng.ac.uk/careers-in-surgery/women-in-surgery/statistics/. Accessed June 5, 2020.
- Epstein NE. Discrimination against female surgeons is still alive: Where are the full professorships and chairs of departments? Surg Neurol Int. 2017;8:93.
- Scheepers RA, Boerebach BC, Arah OA, Heineman MJ, Lombarts KM. A systematic review of the impact of physicians’ occupational well-being on the quality of patient care. Int J Behav Med. 2015;22(6):683-698.
As an older, white, heteronormative male, I am sure my opinion in the matter of women in surgery will receive little attention but in building our utopian, egalitarian society of total gender equality, we seem to be ignoring some basic biology. Women carry, birth, and breast feed babies. Despite the gains made by women in the workplace, women still assume the primary role of nurturing and raising children, at least in the first few, critical formative years. There are certainly examples of role reversal in which the professional woman is the working breadwinner, and the husband assumes the traditional motherly role. I suspect these cases are still by far the exception. I have seen scholarly discussions on the issue of who should raise our children and, it seems to me, that the traditional family model of breadwinner husband and stay-at-home mother is still the gold standard for raising well-rounded, emotionally healthy children, at least through the early formative years until around 4-5 years-old or so. One of our local female surgeons, a single mother, excellent general surgeon recently quit her surgical practice in order to spend more time with her young children, and who could blame her? Whether she will ever return to surgical practice remains to be seen. I submit that women in surgery will often not provide the “return on investment” in years of surgical service that men will. This is neither a good or bad thing; it just is. When we bemoan a shortage of surgeons, we need to take into account real life gender differences in priorities and goals. I suspect that many women do not pursue surgery, not because of obstacles placed in their way by patriarchal surgery programs, but rather because of the demands of a surgical practice. I have seen a number of female surgical colleagues limit or restrict their practice hours, or leave practice altogether in order to pursue their desire for a family and children, by choice, not due to sexual harrassment, discrimination, or microaggressions, as suggested in the letter. Sexual harrassment and discrimination should not be tolerated, but the issue of “microaggressions” is a muddy one. The concept of microaggresion has been abused by the progressive left to include literally anything that another person finds uncomfortable. We can, and should make adjustments to accomodate women in surgery, to a point. That point is where expediency and excellence intersect. We should not sacrifice the latter to the former. To expect “total equality” of the sexes, whether in surgery or in life, is neither realistic or even desirable, in my view.