Role of Women in Medicine: A Look at the History, the Present Condition and the Future Status of Women in the Surgical Field, Especially Neurosurgery

A Scoping Review of Professionalism in Neurosurgery

BACKGROUND AND OBJECTIVES

The Accreditation Council for Graduate Medical Education's Milestones provides a foundation for professionalism in residency training. Specific professionalism concepts from neurosurgery could augment and expand milestones for the specialty. We reviewed the current literature and identified professionalism concepts within the context of neurosurgical practice and training.

METHODS

We used a scoping review methodology to search PubMed/MEDLINE and Scopus and identify English-language articles with the search terms "professionalism" and "neurosurgery." We excluded articles that were not in English, not relevant to professionalism within neurosurgery, or could not be accessed. Non-peer-reviewed and qualitative publications, such as commentaries, were included in the review.

RESULTS

A total of 193 articles were included in the review. We identified 6 professionalism themes among these results: professional identity (n = 53), burnout and wellness (n = 51), professional development (n = 34), ethics and conflicts of interest (n = 27), diversity and gender (n = 19), and misconduct (n = 9).

CONCLUSION

These 6 concepts illustrate concerns that neurosurgeons have concerning professionalism. Diversity and gender, professional identity, and misconduct are not specifically addressed in the Accreditation Council for Graduate Medical Education's Milestones. This review could be used to aid the development of organizational policy statements on professionalism.

Social Perception and Academic Trends on Women in the Field of Neurosurgery: A Bibliometric Analysis

BACKGROUND

The ongoing trend of societal evolution in contemporary civilization has allowed increased inclusion of heterogenous identity groups into fields, such as neurosurgery, where certain groups have traditionally been underrepresented. In regard to the field of neurosurgery, the increasing recognition of the disparities faced by women is illustrated by a growing body of academic literature.

METHODS

We conducted a bibliometric analysis querying the PubMed, Web of Science, Scopus, and Embase databases for articles on women in neurosurgery using the MeSH terms "woman," "women," "gender," neurosurgery," neurological surgery," and "neurosurgeon." Articles were excluded if they did not concern societal impact of nonmale population in the context of neurosurgery. Total citations, mean citations per year, publishing journal information, and author demographics were abstracted from included reports. Associations between abstracted continuous variables were evaluated using the Pearson correlation coefficient. Derived P values < 0.05 were taken as significant.

RESULTS

A total of 49 articles were included. Total numbers of citations per report were positively associated with mean citations per year (r = 0.7289, P = 0.0253), the latter of which was slightly negatively associated with the age of the report (r = -0.0413, P = 0.0009). Age of publication year was found to be negatively correlated with the number of reports published per year (r = -0.648, P = 0.0066). Total citations per reports were significantly correlated with increased numbers of citations during the last completed calendar year (2019: r = 0.8956, P = 0.0397).

CONCLUSIONS

Recognition in societal evolutionary trends as evidenced by academic activity has shown increased focus on the explicit and intrinsic biases faced by women in neurosurgery. Recent years have seen significant increases in published reports concerning the subject, as well as rising academic impact per a given report. This phenomenon is speculated to continue, and understanding to broaden as societal perception continues to develop.

Women's role in neurosurgical research: is the gender gap improving?

OBJECTIVE

The percentage of women publishing high-impact neurosurgical research might be perceived as a representation of our specialty and may influence the perpetuation of the existing gender gap. This study investigated whether the trend in women taking lead roles in neurosurgical research has mirrored the increase in female neurosurgeons during the past decade and whether our most prestigious publications portray enough female role models to stimulate gender diversity among the new generation of neurosurgeons.

METHODS

Two of the most prominent neurosurgical journals-Journal of Neurosurgery and Neurosurgery-were selected for this study, and every original article that was published in 2009 and 2019 in each of those journals was investigated according to the gender of the first and senior authors, their academic titles, their affiliations, and their institutions' region.

RESULTS

A total of 1328 articles were analyzed. The percentage of female authors was significantly higher in Europe and Russia compared with the US and Canada (first authors: 60/302 [19.9%] vs 109/829 [13.1%], p = 0.005; and senior authors: 32/302 [10.6%] vs 57/829 [6.9%], p = 0.040). Significantly increased female authorship was observed from 2009 to 2019, and overall numbers of both first and senior female authors almost doubled. However, when analyzing by regions, female authorship increased significantly only in the US and Canada. Female authors of neurosurgical research articles were significantly less likely to hold an MD degree compared with men. Female neurosurgeons serving as senior authors were represented in only 3.6% (48/1328) of articles. Women serving as senior authors were more likely to have a female colleague listed as the first author of their research (29/97 [29.9%] vs 155/1231 [12.6%]; χ2 = 22.561, p = 0.001).

CONCLUSIONS

Although this work showed an encouraging increase in the number of women publishing high-impact neurosurgical research, the stagnant trend in Europe may suggest that a glass ceiling has been reached and further advances in equity would require more aggressive measures. The differences in the researchers' profiles (academic title and affiliation) suggest an even wider gender gap. Cultural unconscious bias may explain why female senior authors have more than double the number of women serving as their junior authors compared with men. While changes in the workforce happen, strategies such as publishing specific issues on women, encouraging female editorials, and working toward more gender-balanced editorial boards may help our journals to portray a more equitable specialty that would not discourage bright female candidates.

Women neurosurgeons around the world: a systematic review

OBJECTIVE

Gender disparities in neurosurgery have persisted even as the number of female medical students in many countries has risen. An understanding of the current gender distribution of neurosurgeons around the world and the possible factors contributing to country-specific gender disparities is an important step in improving gender equity in the field.

METHODS

The authors performed a systematic review of studies pertaining to women in neurosurgery. Papers listed in PubMed in the English language were collected. A modified grounded theory approach was utilized to systematically identify and code factors noted to contribute to gender disparities in neurosurgery. Statistical analysis was performed with IBM SPSS Statistics for Windows.

RESULTS

The authors identified 39 studies describing the density of women neurosurgeons in particular regions, 18 of which documented the proportion of practicing female neurosurgeons in a single or in multiple countries. The majority of these studies were published within the last 5 years. Eight factors contributing to gender disparity were identified, including conference representation, the proverbial glass ceiling, lifestyle, mentoring, discrimination, interest, salary, and physical burden.

CONCLUSIONS

The topic of women in neurosurgery has received considerable global scholarly attention. The worldwide proportion of female neurosurgeons varies by region and country. Mentorship was the most frequently cited factor contributing to noted gender differences, with lifestyle, the glass ceiling, and discrimination also frequently mentioned. Future studies are necessary to assess the influence of country-specific sociopolitical factors that push and pull individuals of all backgrounds to enter this field.

International trends in grant and fellowship funding awarded to women in neurosurgery

OBJECTIVE

Metric tracking of grant funding over time for academic neurosurgeons sorted by gender informs the current climate of career development internationally for women in neurosurgery.

METHODS

Multivariate linear trend analysis of grant funding awarded to neurosurgeons in the NIH and World Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) was performed. Traveling fellowships for international neurosurgery residents sponsored by the AANS and Congress of Neurological Surgeons (CNS) were also analyzed.

RESULTS

Within the US, funding awarded to female neurosurgeons has remained static from 2009 to 2019 after adjusting for inflation and overall trends in NIH funding (β = -$0.3 million per year, p = 0.16). Internationally, female neurosurgeons represented 21.7% (n = 5) of project leads for World RePORTER grants. Traveling fellowships are also an important building block for young international female neurosurgeons, of which 7.4% (n = 2) of AANS international traveling fellowships and 19.4% (n = 7) of AANS/CNS pediatrics international traveling fellowships are women.

CONCLUSIONS

Over the past decade, funding has increased in neurosurgery without a concordant increase in funding awarded to women. Recognition of this trend is essential to focus efforts on research and career development opportunities for women in neurosurgery. Worldwide, female neurosurgeons head one-fifth of the funded project leads and constitute a minority of international traveling fellowships awarded by organized neurosurgery.

Women in Neurosurgery: From a Matter of Fortuitous Occasions Toward a Conscious Choice

BACKGROUND

Medicine has made progress toward gender equality and has achieved almost equal distribution between men and women among graduates. However, more still needs to be done because most surgical subspecialties are still lacking adequate female representation and this persisting gender gap is particularly evident in both practical neurosurgery and the academic world. Gradual advancements have enabled a few women to pursue a successful career in neurologic surgery, pairing clinical practice with mentoring and involvement in academic research. These efforts show that more needs to be done to bridge the historic and current gap, which has recently aroused increasing interest among the neurosurgical community through internationally relevant studies. In neurosurgical societies worldwide, the existence of gender-related issues and women-reserved sections has started to attract attention and recognition on how to properly address this issue among present and future neurosurgeons.

METHODS

In this study, we discuss the timeline of women's road to gaining their place in neurosurgery, inspired by Hippocrates' motto "Declare the past, diagnose the present, foretell the future." Although neurosurgery had been traditionally considered too difficult a subject in which to engage, the first female neurosurgeons challenged themselves in this field, previously reserved only for men, at a time when society was not yet ready to embrace women's presence. Their successes paved the way for future generations of women, progressively shedding light on complex themes such as peer considerations, difficulty in reaching academic positions, and work-life balance.

RESULTS

Our aim is to analyze the historic reasons for inequality among men and women, which might be found in the themes of personal choice and willingness, aside from cultural bias or stereotypically based thinking.

CONCLUSIONS

Accordingly, if the difference in numbers were considered a reality related to personal inclination, perhaps, nobody would pay attention to this topic and the presence of even a few women in neurosurgery would be considered less strange. By thinking along those lines on a daily basis, we could all simply write about the history of valuable neurosurgeons in the past, present, and future without any distinction between men and women.

Herstory of the Korean Women Neurosurgical Society since 2008

The Korean Women Neurosurgical Society (KWNS) was founded in 2008. To commemorate its 10th anniversary, herein we review its history and the status of Korean Neurosurgical Society (KNS)-certified women neurosurgeons. Based on the academic and social activity of the KWNS, we can expect to promote professional work as members of the KNS, facilitate interaction among neurosurgeons, and sustain professional careers.

Georgette Kidess, the First Female Neurosurgeon in Palestine

OBJECTIVE

The aim of this study is to detail the background, training, and career of Dr. Georgette Kidess, the first and still the only female neurosurgeon in Palestine. In addition, we mention the obstacles that women face during their neurosurgical career and how to overcome them. Also, we discuss different methods to attract female medical students to neurosurgery.

METHODS

Information was gathered only from direct face-to-face interviews with Dr. Kidess.

RESULTS

Georgette Kidess was born on May 2, 1952, in Nablus, Palestine. She received the degree of Doctor of Medicine (M.D.) at Eberhard Karls Universität, Tübingen, Germany in 1979. She worked as a neurosurgeon at the Hadassah EinKarem Hospital in Jerusalem and subsequently established the first neurosurgical department at the Ramallah Governmental Hospital in Ramallah in 1986. Thereafter, she has continued a career in private practice, currently at Saint Luke's Hospital, Nablus. Dr. Kidess played a major part in establishing neurosurgery in Palestine. She was among the founders of the Palestinian Neurosurgical Society in 2014.

CONCLUSIONS

In this article, we recount Dr. Kidess's contributions and achievements to neurosurgery in Palestine. Her commitment, persistence, and diligence enabled her to overcome great odds and become the first female neurosurgeon in Palestine. We hope that her story will inspire and open the doors for subsequent women to enter and enhance neurosurgery, especially in the Middle East.

E-WIN Project 2016: Evaluating the Current Gender Situation in Neurosurgery Across Europe-An Interactive, Multiple-Level Survey

BACKGROUND

The proportion of women among neurosurgeons appears to be growing worldwide with time. Official data concerning the current situation across Europe have not yet been published. Thus, there are still concerns about gender inequality. The European Women in Neurosurgery Project 2016 was designed to recognize the current situation across Europe.

METHODS

The office holders of the national neurosurgical societies of 39 countries forming the European Association of Neurosurgical Societies were contacted to provide data stating the proportion of women in neurosurgery. Obtained data were supplied with the results of an online survey.

RESULTS

The response rate of national office holders was 90%. The number of reported neurosurgeons was 12,985, and overall proportion of women represented was 12%. Two hundred thirty-seven responses to online questionnaire were taken into account. The overall proportion of female respondents was 30%. There was no intergender variability in responses regarding amount of working time per week, exposure to surgeries, or administrative work. Male respondents reported dedicating significantly more time to scientific work and feeling more confident dictating own career direction. Female respondents reported being less often married, having fewer children, a stronger perception of gender significance level, and a higher appreciation of personal qualities.

CONCLUSIONS

Neurosurgery is a challenging field of medicine. The results of our survey did not imply an overall feeling of gender inequality among European respondents, although women believe that the gender issue to be more important than men do and that they have to sacrifice more of their personal lives.

Progress of women in neurosurgery

Despite advances in issues related to gender equity, barriers to recruiting and retaining women in neurosurgery continue to exist. At the same time, the overall projected shortage of neurosurgeons suggests that women will be vital to the long-term success of the field. Attracting women to neurosurgery can capitalize on strategies, such as mentoring, teaching leadership and negotiating skills, and job sharing or dual training tracks to name a few, that would benefit both men and women passionate about pursuing neurosurgery. Ultimately, personal and institutional accountability must be evaluated to ensure that the best and brightest candidates, regardless of gender, are recruited to neurosurgical programs to promote the health of our challenging but most satisfying profession.

Policy and attitude-related reasons for gender disparity in post allocation for graduate medical education in Austria

OBJECTIVE

A previous study found that in Austria 50.3% physicians (m: 43.2%, f: 58.6%) have not attained their chosen specialty. We aimed to explore the policy - and attitude-related reasons for gender disparity in training post allocation.

METHODS

This cross-sectional study used a quantitative and a qualitative method. A self-administered 12-item questionnaire was sent twice to all 8127 licensed Viennese physicians. Physicians' opinions regarding why the chosen medical specialty was not attained were analyzed. To estimate the responder bias respondents from the first and second mailing were compared.

RESULTS

A total of 2736 questionnaires (34%) were returned. When a specialty is favored by men, the chance for women to achieve that specialty decreases. According to the qualitative results, men were more often ready to accept training in a specialty different from the one originally desired. Female physicians were put at a disadvantage by consultants due to organizational considerations and sex-stereotyping.

CONCLUSIONS

According to physicians' self-reported opinions, consultants do not place female candidates at disadvantage as a result of an unconscious process but mainly based on reasoning about organizational aspects and sex-stereotyping. Several explanations for the phenomenon that men are more often ready to accept training in a specialty different from the one originally desired were identified.

The pediatric neurosurgical workforce: defining the current supply. Clinical article

OBJECT

The purpose of this study was to determine a reliable estimate of the size, demographic, and practice characteristics of the current pediatric neurosurgical workforce. The authors also sought to differentiate pediatric from nonpediatric neurosurgical practitioners and compare the demographic and practice characteristics of these 2 groups. The term "pediatric practitioner" will be used in this study to describe a practitioner whose practice is > 75% pediatric patients in accordance with the American Board of Pediatric Neurological Surgery (ABPNS) requirements for board certification in pediatric neurosurgery. Those practitioners with < 75% pediatric patients in their practice will be designated as "nonpediatric practitioners."

METHODS

The authors aggregated multiple databases of professional neurosurgical societies in an effort to identify pediatric neurosurgical practitioners. A 30-question survey was then administered to all identified practitioners, and responses were collected for 6 months. Primary analysis of pediatric versus nonpediatric practitioners was performed. Subgroup analyses of the characteristics of the pediatric practitioners were also performed to identify the effects of practitioner age, sex, and practice setting on survey responses.

RESULTS

A total of 342 practitioners received the survey, and 267 responded (78.1% response rate); 158 pediatric practitioners and 92 nonpediatric practitioners were identified. Seventeen respondents were excluded from analysis. Pediatric practitioners were more likely to be women, ABPNS certified, have completed a pediatric fellowship, do fewer operative cases per year, have a more frequent call schedule, practice in a freestanding children's hospital, be in academic practice, and in need of recruiting additional faculty. Pediatric practitioners spent fewer hours per week in patient care, and were less likely to have a productivity-based salary or salary incentive based on relative value unit-production. Among pediatric practitioners, American Board of Neurological Surgery and ABPNS certification rates differed significantly among age groups, with older age groups being more likely to be certified by the American Board of Neurological Surgery and ABPNS. The rate of pediatric fellowship completion was significantly higher in the younger age groups. Anticipating retirement by age 65 was significantly more likely in the younger age groups, and hours spent per week spent in teaching and administrative duties were lower in the younger age groups. There were 27 female and 131 male pediatric practitioners. The women were more likely to have completed a pediatric fellowship and performed fewer operative cases per year than the men. Nonacademic pediatric practitioners were more likely to have a relative value unit-based salary incentive, be reimbursed for call coverage, and spend more hours per week in patient care than academic pediatric practitioners. Academic pediatric practitioners spent more hours per week in clinical research.

CONCLUSIONS

The authors estimate that there are fewer than 200 pediatric neurosurgeons currently practicing in the United States. Current practice patterns unique to pediatrics may have important implications in recruiting and retaining the next generation of pediatric neurosurgeons.

From calling to a scheduled vocation: Swedish male and female students' reflections on being a doctor

BACKGROUND

All over the world an increasing number of women are entering medical schools. Soon women will constitute half of the physician workforce in Scandinavia. However, specialty segregation persists. Reports have shown different motives among male and female doctors to be, but the impact of gender, i.e. how ongoing social constructions of femininity and masculinity influence the development of professionalism, is not fully described.

AIM

The purpose of this study was to explore views and visions among second-year students at a Swedish Medical School, and to identify challenges for education and workforce planning.

METHODS

After receiving research ethics board approval, all students participating in the course 'Professional development', including a task to write a free-text essay on the theme 'to be a doctor', were invited to share their essays for analysis. Of 138 (40% men) students in 2002, 104 (39% men) accepted. The texts were analysed according to grounded theory.

RESULTS

Students held 'doctorship' to be an outstanding profession of commitment, authority and duty. Fears were exposed, especially among women, regarding how to fit demands of self-sacrifices and balancing a private life. Belonging to a new generation, they conceived gender equity as self-evident. Actual working conditions were met with disapproval, as did an all-embracing calling. A scheduled vocation was hoped for. They relied on the mass of women to implement change. Women's 'other' values, alluding to family orientation, were expected to alter working conditions and also give men more leisure time. Despite equity conviction, segregating gender patterns in students' representations, interactions with tutors and future prospects were disclosed.

CONCLUSIONS

Students' arguments raise challenges for medical educators and planners regarding professional values, medical socialization and specialty recruitment. The new generation requires a renewed Hippocratic Oath, gender-aware role models and practice sites. Swedish students' arguments are compared with current international literature.