The erasure of gender in academic surgery: a qualitative study

Women Surgeons: Barriers and Solutions

BACKGROUND

Underrepresentation and undertreatment of women in surgery continues to be highly prevalent, with major barriers to improvement. The aim of the study was to review the current state of women surgeons in Poland.

METHODS

Information from the various Polish databases on women surgeons in 9 medical universities in general, oncological, vascular, thoracic, and cardiac surgery was retrospectively evaluated. Demographics of residents and staff surgeons, academic ranks and leadership positions at universities, in surgical societies and on scientific journals editorial boards were analyzed. Descriptive statistics were used.

RESULTS

In 2020, 61% of 3,668 graduates of Polish medical universities were women. In 5 surgical specialties, 11.9% (1,243 of 10,411) of the surgeons were women, with the lowest numbers in cardiac (5.6%), and in vascular surgery (6.4%); 40.4% of general surgery residents were women, less in vascular (18.4%) and thoracic surgery (24%), more in oncological surgery (28.7%). In 35 surgical departments of 9 universities, all department chairs were men, all full professors were men; 7% of associate professors and 16% of assistant professors were women. Rectors of all universities were men; 27% of the vice-rectors were women. In the senates and university councils, 39% and 35%, respectively, were women. Presidents, vice presidents, and secretaries of surgical societies and Editor-in-Chief of 4 surgical journals were all men.

CONCLUSIONS

Polish women surgeons face major difficulties with representation in surgery, in departmental, institutional, and societal leadership, and on scientific journal editorial boards. A multifaceted approach to correct these serious inequalities is urgently needed.

Gender trends in Canadian medicine and surgery: the past 30 years

BACKGROUND

While the number of women entering medicine has steadily increased since the 1970s in Canada, the gender composition along each stage of the medical training pathway has not been comprehensively reported. We therefore sought to systematically examine the gender composition of students, residents, and practicing physicians over the past 30 years in Canada.

RESULTS

In this cross-sectional analysis of Canadian medical trainees including MD applicants (137,096 male, 169,099 female), MD students (126,422 male, 152, 967 female), MD graduates (29,413 male, 34,173 female), residents by the decade (24,425 male, 28,506 female) and practicing surgeons (total 7,457 male, 3,457 female), we find that increased female representation in medicine is not matched by representation in surgery, with the key being the specialty choice process. The likelihood of female applicants matriculating to medical school was less than male applicants in the 90s (OR 0.92, 95% CI 0.92-0.93), greater in the early 2000s (OR 1.03, 95% CI 1.03-1.04), and has since balanced out (OR 1.00, 95% CI 1.00-1.01), with medical school classes being nearly 60% female for the past two decades. Despite this, females have remained underrepresented in most surgical residency programs, with odds of female medical students entering surgical residency other than Ob/Gyn being about half that of male students (OR 0.56, 95% CI 0.44-0.71), resulting in a slow increase in practicing female surgeons of less than 0.5% per year in many surgical disciplines and projected parity decades or centuries in the future.

CONCLUSIONS

While undergraduate medical education has been majority female in Canada for nearly three decades, females remain greatly underrepresented in the physician workforce within surgical specialties. To build a representative medical workforce equipped to care for diverse patient populations, factors influencing the specialty choices of early career physicians will need to be examined and addressed.

Surgical Education: Disparities in Education May Impact the Quality and Likelihood of Completion of Training

Female surgical trainees experience bias that begins at the preclinical stages of medical school, extending into their surgery clerkships, and then into their residency training. There are important implications in terms of training opportunities and career advancement, mentorship, sponsorship, and ultimately burnout. Childbearing and lactation also impact the experiences and perceptions of female trainees who have children. There are limited interventions that have improved the experience of women in surgical training. Mentorship appears to play an important role in ameliorating some of the negative consequences of the training environment and improving outcomes for women surgeons.

Perceptions of Gender Stereotypes among Women Residents in Surgical and Nonsurgical Specialties

OBJECTIVE

The objective of this study was to determine whether and to what degree residents experience stereotype perception by gender and specialty type (surgical vs nonsurgical).

METHODS

A cross-sectional survey was sent to resident physicians across all specialties at a single academic institution in February 2021. The survey items asked whether participants believe residents, faculty, and the public expect men or women to be better physicians on a numerical scale from 1 to 7. A χ² test compared the calculated mean and standard error for each survey item. This study took place at Washington University School of Medicine in St. Louis, Missouri, a large academic tertiary care center.

RESULTS

A total of 411 (46% of total) residents participated; 13 were excluded because of nonbinary gender or missing demographic information, for a final sample of 398. Participants perceived all three groups to expect men to be better physicians than women. Regression analysis showed a significant effect of gender on stereotype perception, with women reporting stronger stereotype perceptions than men. There were no significant differences in stereotype perceptions by specialty type.

CONCLUSIONS

Women resident physicians in both surgical and nonsurgical fields reported higher levels of gender stereotype perception compared with men, making it imperative that graduate medical education leadership support changes to the current learning environment.

The Experiences of Motherhood in Female Surgeons: A Scoping Review

OBJECTIVE

The objective of this study is to systematically synthesize the existing literature on the experiences of motherhood in female surgeons both during surgical training and as staff physicians, to identify knowledge gaps, and to provide recommendations for institutional changes to better support pregnant female surgeons.

BACKGROUND

There are disproportionately fewer medical students pursuing surgical specialties, as surgery is often seen as incompatible with childbearing and pregnancy. However, no review has summarized the published literature on the collective experiences of female surgeons in navigating motherhood.

METHODS

Four databases were searched and 1106 abstracts were identified. Forty-two studies were included and a thematic analysis was performed.

RESULTS

Four themes were identified: path toward motherhood (n=18), realities of motherhood (n=25), medical culture and its impact on career and family life (n=24), and institutional reproductive wellness policies (n=21). Female surgeons are more likely to delay motherhood until after training and have high rates of assisted reproductive technology use. Pregnancy during surgical training is associated with negative perception from peers, pregnancy complications, and scheduling challenges. Maternity leave policies and breastfeeding and childcare facilities are variable and often inadequate. Many female surgeons would agree that greater institutional support would help support women in both their roles as mothers and as surgeons.

CONCLUSIONS

Both female residents and staff surgeons experience significant and unique barriers before, during, and after motherhood that impact their personal and professional lives. Understanding the unique challenges that mothers face when pursuing surgical specialties is critical to achieving gender equity.

Experiences of Canadian Female Orthopaedic Surgeons in the Workplace: Defining the Barriers to Gender Equity

BACKGROUND

Only 13.6% of orthopaedic surgeons in Canada are women, even though there is nothing inherent to the practice of orthopaedic surgery that favors men over women. Clearly, there is a need to identify, define, and measure the barriers faced by women in orthopaedic surgery.

METHODS

An electronic survey was distributed to 330 female-identifying Canadian orthopaedic surgeons and trainees and included the validated Gender Bias Scale (GBS) and questions about career burnout. The barriers for women in Canadian orthopaedics were identified using the GBS. The relationships between the GBS and burnout were investigated. Open-text questions explored the barriers perceived by female orthopaedic surgeons.

RESULTS

The survey was completed by 220 female orthopaedic surgeons and trainees (66.7%). Five barriers to gender equity were identified from the GBS: Constrained Communication, Unequal Standards, Male Culture, Lack of Mentoring, and Workplace Harassment. Career burnout correlated with the GBS domains of Male Privilege (r = 0.215; p < 0.01), Disproportionate Constraints (r = 0.152; p < 0.05), and Devaluation (r = 0.166; p < 0.05). Five main themes emerged from the open-text responses, of which 4 linked closely to the barriers identified in the GBS. Work-life integration was also identified qualitatively as a theme, most notably the difficulty of balancing disproportionate parental and childcare responsibilities alongside career aspirations.

CONCLUSIONS

In this study, 5 barriers to workplace equity for Canadian female orthopaedic surgeons were identified using the validated GBS and substantiated with qualitative assessment using a mixed-methods approach. Awareness of these barriers is a necessary step toward dismantling them and changing the prevailing culture to be fair and equitable for all.

CLINICAL RELEVANCE

A just and equitable orthopaedic profession is imperative to have healthy and thriving surgeons who are able to provide optimal patient care.

Is authorship by women in Brazilian academic surgery increasing? A five-year retrospective analysis

Women remain underrepresented in 80% of Brazilian surgical specialties, however, women representation within the Brazilian academic surgical literature remains unknown. This study aims to evaluate the gender distribution of first and last authors in Brazilian surgical journals. All publications between 2015 and 2019 from the five Brazilian surgical journals with the highest impact factor were reviewed. The first and last authors' names were extracted from each article and a predictive algorithm was used to classify the gender of each author. Authors were further classified by surgical field and geographic region to investigate patterns of female authorship among journals, specialties, and region over the study period. Multivariable logistic regression was then used to identify factors independently associated with female authorship. 1844 articles were analyzed; 23% (426/1844) articles had female first authors, and 20% (348/1748) had female last authors. Acta Cirúrgica Brasileira was observed to have the highest rates for both first and last female authors (37%, 138/371; 26%, 95/370)) and Revista Brasileira de Ortopedia (9%, 48/542; 10%, 54/522) had the lowest rates. Papers with a woman senior author were twice as likely to have a woman first author (OR 1.98, 95% CI 1.51-2.58, p≤0.01). Women's representation in medicine is increasing in Brazil, yet women remain underrepresented as the first and last authors in the Brazilian surgical literature. Our results highlight the importance of senior women mentorship in academic surgery and demonstrate that promoting female surgeon senior authorship through academic and financial support will positively impact the number of female first authors.

Experiences and Perceptions of Gender Discrimination and Equality among Korean Surgeons: Results of a Survey of the Korean Surgical Society

BACKGROUND

Previous studies that have focused on the challenges faced by female surgeons, such as the gender pay gap, gender biases, lower likelihood of promotion, and gender differences in the perception of discrimination against women, are reviewed. A more comprehensive understanding of explicit and implicit gender discrimination and experiences and perceptions of discrimination is needed. This study aims to determine the current prevalence and degree of gender discrimination in the Korean Surgical Society and to compare the experiences and perceptions of gender discrimination between male and female surgeons.

METHODS

We analyzed 400 responses from a survey sent to all members of the Korean Surgical Society. This electronic survey included 16 items on experiences of gender discrimination and 17 items on perceptions of gender discrimination. We conducted χ² tests and binary logistic regression on the data regarding these experiences and perceptions of gender discrimination.

RESULTS

Adjusted analyses found that female surgeons were more likely to experience gender discrimination than their male counterparts across all categories of discrimination. Further, adjusted analyses showed that female surgeons were more likely to confirm the presence of gender discrimination than male surgeons.

CONCLUSION

Female surgeons were more likely to experience implicit and explicit gender biases and discrimination throughout all stages of their career progression. We also discovered significant gender differences in the perception of gender discrimination, as well as the experience of it. Changing the male-dominated culture and raising awareness of gender biases and discrimination among male surgeons are crucial steps toward addressing gender discrimination in surgery.

Stemming the ‘Leaky Pipeline’: an investigation of the relationship between work–family conflict and women’s career progression in academic medicine

Background

Even though women outnumber men enrolled in medical school, making up 59% of entrants in the UK, they are significantly under-represented in academic medicine and senior positions. In the UK, 28.6% of academics overall are women. In the USA, while 51% of instructors are women, only 20% make it through the ‘leaky pipeline’ to become professors. One attributable factor is work–family conflict. The purpose of this study is to gain a deeper understanding of the relationship between work–family conflict and women’s career progression in academic medicine, and to provide a model to inform and change perceptions and practice in order to improve the ‘leaky pipeline’.

Methods

A systematic literature search was performed to identify qualitative studies which investigated this relationship. Studies were critically appraised, and data were analysed using thematic analysis. Themes identified in the data were used to develop a model to build on the understanding of this issue.

Findings

The findings of this research highlighted two main themes, one related to perceptions of gender (intrinsic or extrinsic), the way it impacts on work–family conflict and its relationship to women’s career progression. The second theme relates to structures which hinder or support women’s ability to have work–life balance. A model was developed that represents the inter-relationship between these factors.

Interpretation

Changes in both organisational culture and individuals’ perception in regard to gender roles, especially of those in leadership, are necessary to create an environment where the best talent in academic medicine is selected regardless of gender.

The Experience of Women in Hospital Medicine Leadership: a Qualitative Study

BACKGROUND

Since 2017, women have made up over 50% of medical school matriculants; however, only 16% of department chairs are women-a number that has remained stagnant and demonstrates the underrepresentation of women in leadership positions in medicine.

OBJECTIVE

To better understand the challenges women face in leadership positions and to inform how best to advance women leaders in Hospital Medicine.

DESIGN, SETTING, AND PARTICIPANTS

Using hermeneutical phenomenological methods, we performed semi-structured qualitative interviews of ten female division heads from hospital medicine groups in the USA, transcribed verbatim, and coded for thematic saturation using Atlas.ti software.

MEASUREMENTS

Qualitative themes and subthemes.

KEY RESULTS

Ten women hospitalist leaders were interviewed from September through November 2019. Participants identified four key challenges in their leadership journeys: lack of support to pursue leadership training, bullying, a sense of sacrifice in order to achieve balance, and the need for internal and external validation. Participants also suggested key interventions in order to support women leaders in the future: recommending a platform to share experiences, combat bullying, advocate for themselves, and bolster each other in sponsorship and mentorship roles. Finally, participants identified how they have unique strengths as women in leadership, and are transforming the culture of medicine with a focus on diversity and flexibility.

CONCLUSION

Women in leadership positions face unique challenges, but also have a unique perspective as to how to support the next generation of leaders.

The Gender Pay Gap in Oral Surgery

Men and women receive unequal pay for equal work, a gap of approximately 20% to 30% in income across most professions, including medicine and surgery. Inequality also exists in academic advancement, with far fewer women holding positions as full professors, program directors, or department heads. Women may be discouraged from pursuing surgery as a career, and they face unique challenges related to gender expectations in their role as surgeons. Steps to identifying gender bias and correcting the pay gap are important to ensure the growth and vitality of the specialty.

Women Surgeons' Perspectives on System-level Strategies to Address Interpersonal Workplace Conflict

OBJECTIVE

We sought to gain a comprehensive understanding of the current methods for conflict resolution and the ways in which women surgeons would prefer workplace conflicts to be adjudicated.

SUMMARY OF BACKGROUND DATA

Interprofessional workplace conflicts are poorly studied, particularly for women in surgery. These conflicts may negatively impact surgical team dynamic and be detrimental to patient safety. Moreover, workplace conflicts and their management are a proposed driver of decreased professional satisfaction and achievement. How women surgeons experience workplace conflicts and how these are managed remains unexplored.

METHODS

We conducted 30 semi-structured interviews with women surgeons across the United States who had experienced workplace conflict that resulted in action by a nonphysician. Surgeons were diverse with respect to demographics, specialty, and institutional settings. Through thematic analysis using NVivo, we analyzed and reported patterns within the data.

RESULTS

Although the majority of women asserted resilience in how they engage with these situations, many also cited ways in which these events could better be adjudicated. Recommendations included (1) more direct conflict resolution, (2) more transparency in reporting processes, (3) greater opportunity to address complaints, (4) explicit policies for events that repeatedly result in workplace conflict, and (5) divorcing interpersonal complaints from patient safety reporting mechanisms.

CONCLUSION

This study motivates and informs best practices around adjudication of workplace conflict to help protect women surgeons and nonclinicians. Going forward, best practices should include more objective criteria for how conflicts are adjudicated. Continued efforts at an institutional level are needed to help mitigate inequities against women surgeons.

Gender-Based Microaggressions in Surgery: A Scoping Review of the Global Literature

BACKGROUND

In addition to systemic gender disparities, women in surgery encounter interpersonal microaggressions. The objective of this study is to describe the most common forms of microaggressions reported by women in surgery.

METHODS

We conducted a scoping review using PubMed/MEDLINE, Ovid, and Web of Science to describe the international, indexed English-language literature on gender-based microaggressions experienced by female surgeons, surgical trainees, and medical students in surgery. After screening by title, abstract, and full-text, 37 articles were retained for data extraction and analysis. Microaggressions were analyzed using the Sexist Microaggression Experience and Stress Scale (MESS) framework and stratified by country of origin.

RESULTS

Gender-based microaggression publications most commonly originated from the United States (n = 27 articles), Canada (n = 3), and India (n = 2). Gender-based microaggressions were classified into environmental invalidations (n = 20), being treated like a second-class citizen (n = 18), assumptions of traditional gender roles (n = 12), sexual objectification (n = 11), assumptions of inferiority (n = 10), being forced to leave gender at the door (n = 8), and experiencing sexist language (n = 6). Additionally, attendings were more frequently reported to experience microaggressions than surgical trainees and medical students, but more articles reported data on attendings (n = 16) than surgical trainees (n = 10) or students (n = 4).

CONCLUSION

While recent advancements have opened the field of surgery to women, there is still a lack of female representation, and persistent microaggressions may perpetuate this gender disparity. Addressing microaggressions against female surgeons is essential to achieving gender equity in surgical practice.

Assessment of Autonomy in Operative Procedures Among Female and Male New Zealand General Surgery Trainees

Importance

The need for trainee sex equality within surgical training has resulted in an appraisal of the training experience in the New Zealand general surgery training program.

Objective

To investigate the association between trainee sex and surgical autonomy in the operating room in the New Zealand general surgery training program.

Design, Setting, and Participants

Retrospective cohort study conducted from December 10, 2012, to December 10, 2017, examining all endoscopic, major, and minor procedures performed by all New Zealand general surgery trainees in every training hospital in New Zealand.

Main Outcomes and Measures

The primary outcome was the level of meaningful autonomy by each New Zealand general surgery trainee (ie, trainee as primary operator without the surgeon mentor scrubbed for the case). Outcomes were compared using multivariable analysis.

Results

This study included 120 New Zealand general surgery trainees (42 women [35%] and 78 men [65%]) who were analyzed over 279.5 trainee-years (88.5 trainee-years for women and 191.0 trainee-years for men). Included were 119 380 general surgery procedures (17 465 endoscopic, 56 964 major, and 44 951 minor) in 18 hospitals. By the end of the 5-year training program, female trainees had a lower cumulative mean autonomous caseload than male trainees for endoscopic (284.0 [95% CI, 207.0-361.0] vs 352.2 [95% CI, 282.9-421.6], P = .03), major (139.9 [95% CI, 76.7-203.2] vs 198.1 [95% CI, 142.3-254.0], P = .02), and minor (456.3 [95% CI, 394.8-517.9] vs 519.9 [95% CI, 465.6-574.2], P = .007) procedures.

Conclusions and Relevance

After accounting for differences among trainees, hospital type, number of female and male surgeon mentors at each hospital, and trainee seniority, female trainees performed fewer cases with meaningful autonomy compared with male trainees. These findings support the need for pragmatic solutions to address this bias and further investigations on mechanisms contributing to discrepancies.

The unspoken reality of gender bias in surgery: A qualitative systematic review

OBJECTIVE

This study was conducted to better understand the pervasive gender barriers obstructing the progression of women in surgery by synthesising the perspectives of both female surgical trainees and surgeons.

METHODS

Five electronic databases, including Medline, Embase, PsycINFO, CINAHL and Web of Science Core Collection, were searched for relevant articles. Following a full-text review by three authors, qualitative data was synthesized thematically according to the Thomas and Harden methodology and quality assessment was conducted by two authors reaching a consensus.

RESULTS

Fourteen articles were included, with unfavorable work environments, male-dominated culture and societal pressures being major themes. Females in surgery lacked support, faced harassment, and had unequal opportunities, which were often exacerbated by sex-blindness by their male counterparts. Mothers were especially affected, struggling to achieve a work-life balance while facing strong criticism. However, with increasing recognition of the unique professional traits of female surgeons, there is progress towards gender quality which requires continued and sustained efforts.

CONCLUSION

This systematic review sheds light on the numerous gender barriers that continue to stand in the way of female surgeons despite progress towards gender equality over the years. As the global agenda towards equality progresses, this review serves as a call-to-action to increase collective effort towards gender inclusivity which will significantly improve future health outcomes.

Realities and challenges for female cardiothoracic surgeons: an African perspective

It is a fact that, despite the worldwide increasing intake of women in medical schools, women are still grossly underrepresented in all medical and surgical specialities, and definitely in cardiothoracic surgery in both developed and developing countries. This is counter-productive towards meeting the escalating need for cardiac surgical care in Africa. However, the natural evolution over time of increasing numbers of females entering medical school and specializing in the field of surgery, is expected to continue despite multiple challenges encountered on their way. The inequities of healthcare provision in Africa in particular needs the continual support of all professionals that are able to contribute to the wellbeing of those innocent individuals that need medical care particularly children born with congenital cardiac defects. In addition to factors on the African continent, realities and challenges for future female cardiothoracic surgeons include gender bias and gender-based discrimination by some male counterparts. The question must be asked: "Is it mere gender-based discrimination, or how much does deliberate 'bullying behaviour' mimic signs of superiority, arrogance and entitlement, bordering on psychological personality disorders?" Thorough investigation of the possible role of such behaviour disorders in gender bias and discrimination is long overdue. These disparities and challenges should be actively addressed on all levels by all role players by placing more emphasis on merit, competence and surgical outcomes than on the gender of the surgeon. Despite all these challenges, the benefits of a career in cardiothoracic surgery and tremendous job satisfaction far exceed the disadvantages.

The experiences of female surgeons around the world: a scoping review

INTRODUCTION

The Lancet Commission for Global Surgery identified an adequate surgical workforce as one indicator of surgical care accessibility. Many countries where women in surgery are underrepresented struggle to meet the recommended 20 surgeons per 100,000 population. We evaluated female surgeons' experiences globally to identify strategies to increase surgical capacity through women.

METHODS

Three database searches identified original studies examining female surgeon experiences. Countries were grouped using the World Bank income level and Global Gender Gap Index (GGGI).

RESULTS

Of 12,914 studies meeting search criteria, 139 studies were included and examined populations from 26 countries. Of the accepted studies, 132 (95%) included populations from high-income countries (HICs) and 125 (90%) exclusively examined populations from the upper 50% of GGGI ranked countries. Country income and GGGI ranking did not independently predict gender equity in surgery. Female surgeons in low GGGI HIC (Japan) were limited by familial support, while those in low income, but high GGGI countries (Rwanda) were constrained by cultural attitudes about female education. Across all populations, lack of mentorship was seen as a career barrier. HIC studies demonstrate that establishing a critical mass of women in surgery encourages female students to enter surgery. In HICs, trainee abilities are reported as equal between genders. Yet, HIC women experience discrimination from male co-workers, strain from pregnancy and childcare commitments, and may suffer more negative health consequences. Female surgeon abilities were seen as inferior in lower income countries, but more child rearing support led to fewer women delaying childbearing during training compared to North Americans and Europeans.

CONCLUSION

The relationship between country income and GGGI is complex and neither independently predict gender equity. Cultural norms between geographic regions influence the variability of female surgeons' experiences. More research is needed in lower income and low GGGI ranked countries to understand female surgeons' experiences and promote gender equity in increasing the number of surgical providers.

Gender Disparities in Authorships and Citations in Transplantation Research

Background.

Over the past decades, there has been a rapid change in the gender ratio of medical doctors, whereas gender differences in academia remain apparent. In transplantation research, a field already understaffed with female doctors and researchers, there is little published data on the development in proportion, citations, and funding of female researchers over the past years.

Methods.

To evaluate the academic impact of female doctors in transplantation research, we conducted a bibliometric analysis (01 January 1999 to 31 December 2018) of high-impact scientific publications, subsequent citations, and funding in this field. Web of Science data was used in combination with software R-Package “Gender,” to predict gender by first names.

Results.

For this study, 15 498 (36.2% female; 63.8% male) first and 13 345 (30.2% female; 69.8% male) last author gender matches were identified. An increase in the percentage of female first and last authors is seen in the period 1999–2018, with clear differences between countries (55.1% female authors in The Netherlands versus 13.1% in Japan, for example). When stratifying publications based on the number of citations, a decline was seen in the percentage of female authors, from 34.6%–30.7% in the first group (≤10 citations) to 20.8%–23.2% in the fifth group (>200 citations), for first (P < 0.001) and last (P = 0.014) authors, respectively. From all first author name-gender matches, 6574 (41.6% female; 58.4% male, P < 0.001) publications reported external funding, with 823 (35.5% female; 64.5% male, P = 0.701) reported funding by pharmaceutical companies and 1266 (36.6% female; 63.4% male, P < 0.001) reporting funding by the National Institutes of Health.

Conclusions.

This is the first analysis of gender bias in scientific publications, subsequent citations, and funding in transplantation research. We show ongoing differences between male and female authors in citation rates and rewarded funding in this field. This requires an active approach to increase female representation in research reporting and funding rewarding.

Markers of achievement for assessing and monitoring gender equity in a UK National Institute for Health Research Biomedical Research Centre: A two-factor model

BACKGROUND

The underrepresentation of women in academic medicine at senior level and in leadership positions is well documented. Biomedical Research Centres (BRC), partnerships between leading National Health Service (NHS) organisations and universities, conduct world class translational research funded by the National Institute for Health Research (NIHR) in the UK. Since 2011 BRCs are required to demonstrate significant progress in gender equity (GE) to be eligible to apply for funding. However, the evidence base for monitoring GE specifically in BRC settings is underdeveloped. This is the first survey tool designed to rank and identify new GE markers specific to the NIHR BRCs.

METHODS

An online survey distributed to senior leadership, clinical and non-clinical researchers, trainees, administrative and other professionals affiliated to the NIHR Oxford BRC (N = 683). Participants ranked 13 markers of GE on a five point Likert scale by importance. Data were summarised using frequencies and descriptive statistics. Interrelationships between markers and underlying latent dimensions (factors) were determined by exploratory and confirmatory factor analyses.

RESULTS

The response rate was 36% (243 respondents). Respondents were more frequently female (55%, n = 133), aged 41-50 years (33%, n = 81), investigators (33%, n = 81) affiliated to the BRC for 2-7 years (39.5%, n = 96). Overall participants ranked 'BRC senior leadership roles' and 'organisational policies on gender equity', to be the most important markers of GE. 58% (n = 141) and 57% (n = 139) respectively. Female participants ranked 'organisational policies' (64.7%, n = 86/133) and 'recruitment and retention' (60.9%, n = 81/133) most highly, whereas male participants ranked 'leadership development' (52.1%, n = 50/96) and 'BRC senior leadership roles' (50%, n = 48/96) as most important. Factor analyses identified two distinct latent dimensions: "organisational markers" and "individual markers" of GE in BRCs.

CONCLUSIONS

A two-factor model of markers of achievement for GE with "organisational" and "individual" dimensions was identified. Implementation and sustainability of gender equity requires commitment at senior leadership and organisational policy level.

Women Surgeons' Experiences of Interprofessional Workplace Conflict

IMPORTANCE

Gender differences in interprofessional conflict may exist and precipitate differential achievement, wellness, and attrition in medicine.

OBJECTIVE

Although substantial attention and research has been directed toward improving gender equity in surgery and addressing overall physician wellness, research on the role of interprofessional conflict has been limited. The objective of this study was to understand scenarios driving interprofessional conflict involving women surgeons, the implications of the conflict on personal, professional, and patient outcomes, and how women surgeons navigate conflict adjudication.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative approach was used to explore the nature, implications, and ways of navigating interprofessional workplace conflict experienced by women surgeons. The setting was a national sample of US women surgeons. Purposive and snowball sampling were used to recruit women surgeons in training or practice from annual surgical society meetings. Participants were eligible if they were currently in a surgical training program or surgical practice. Nearly all participants had experienced at least 1 workplace conflict with a nonphysician staff member resulting in a formal write-up.

EXPOSURES

A workplace conflict was defined as any conflict resulting in the nonphysician staff member taking action such as confronting the woman surgeon, reporting the event to supervisors, or filing a formal report.

MAIN OUTCOMES AND MEASURES

Interviews were conducted between February 19, 2019, and June 21, 2019. Recordings were transcribed and deidentified. Inductive thematic analysis was used to examine data in relation to the research questions.

RESULTS

Thirty US women surgeons (8 [27%] age 25-34 years, 16 [53%] age 35-44 years, 5 [17%] age 45-54 years, and 1 [3%] age 55-64 years) of varying surgical specialties were interviewed. Conflicts were often reported as due to a breakdown in communication or from performance-related disputes. Participants perceived personal and professional implications including self-doubt, depression, frustration, anxiety, loss of sleep, reputational harms, and delays to advancement. Participants also described potential patient safety implications primarily due to decreased communication resulting from some surgeons being hesitant to engage in subsequent interactions. Participants described a variety of navigation strategies including relationship management, rapport building, and social capital. The success of these processes tended to vary by individual circumstances, including the details of the conflict, practice setting, level of support of leadership, and individual personality of the surgeon.

CONCLUSIONS AND RELEVANCE

This qualitative study highlights women surgeons' experiences with interprofessional workplace conflict. Interprofessional culture building, broader dissemination of implicit bias training, and transparent and equitable adjudication systems are potential strategies for avoiding or mitigating the implications of these conflicts.

Behind the Mask: An Exploratory Assessment of Female Surgeons' Experiences of Gender Bias

Though overt sexism is decreasing, women now experience subtle, often unconscious, gender bias as microaggressions. The authors sought to explore the prevalence and impact of the sexist microaggressions female surgeons experience, using a sequential exploratory mixed methods approach (January 2018-April 2018), to identify opportunities for education and prevention. First, all resident, fellow, and attending female surgeons at the University of New Mexico Health Sciences Center (UNM HSC) were invited to participate in focus groups conducted by experienced moderators using a semistructured interview guide based on the 7 Sexist Microaggressions Experiences and Stress Scale (Sexist MESS) domains. Qualitative analysis was performed using line-by-line manual coding to identify themes aligned with the Sexist MESS domains as well as other gender bias experiences of female surgeons. Next, a survey was sent to all resident, fellow, and attending female surgeons at the UNM HSC, which included the Sexist MESS questionnaire and questions related to surgeon-specific experiences of gender bias that the authors developed based on major thematic categories from the focus groups.Four focus groups of 23 female surgeons were conducted, revealing 4 themes: exclusion, increased effort, adaptation, and resilience to workplace slights. The survey response rate was 64% (65/101 surgeons). Across Sexist MESS domains, the frequency and severity of microaggressions was higher for trainees than attendings. The variables of non-White race/ethnicity, having children under 18, and fellowship training generally did not demonstrate statistical significance. This exploratory study adds to the growing body of evidence that gender bias in surgery continues and frequently manifests as microaggressions. Trainees reported the highest rates and severity of microaggressions and bias experiences. Further research should investigate how to address microaggressions, the experiences of male surgeons, the perspectives of medical students and groups who were reported as often perpetuating gender bias, and the efficacy of possible interventions.

It's not you, It's me: The influence of patient and surgeon gender on patient satisfaction scores

BACKGROUND

Surgeons face the unique challenge of being responsible for both clinical encounters and surgical outcomes. We aim to explore how patient evaluations of surgeons may be influenced by patient and provider factors.

METHODS

Patient responses from the 2016 CGCAHPS survey at a single institution were identified. A Poisson regression model was used to identify patient/provider factors associated with ratings.

RESULTS

11,007 surveys of 134 surgeons were included. After adjustment, higher overall surgeon ratings were associated with older patient age (p < 0.001) and male patient gender (p = 0.001). Lower ratings were associated with higher patient education (p < 0.001) and lower patient self-health ratings (p < 0.001). Although female surgeons tended to have higher communication scores, overall scores did not differ based on any surgeon factors.

CONCLUSIONS

Patient satisfaction scores of surgeons are more closely correlated with patient variables than surgeon factors. This may have implications for physician performance evaluation in value-based care models.

Women anesthesiologists' journeys to academic leadership: a constructivist grounded theory-inspired study

BACKGROUND

Women continue to be underrepresented in academic anesthesiology, especially in leadership positions. Possible reasons for this gender disparity include family responsibilities, inadequate mentorship, lack of desire for leadership, the leaky pipeline effect (i.e., attrition of women physicians over the course of their career trajectories), and discrimination. Our objective was to understand the lived experiences of Canadian anesthesiologists in leadership positions.

METHODS

In this constructivist grounded theory-inspired study, we used purposeful sampling to identify women anesthesiologists in leadership positions at one Canadian institution. Each participant underwent a one-on-one semi-structured interview of 40-60 min in length, sampling until theoretical saturation was reached. We included questions about the participant's practice setting, influences on their career, and advice the participant would provide to other women in leadership. We used an iterative approach to theoretical sampling and data analysis. The audio-recorded semi-structured interviews were transcribed and coded. NVivo12 was used for open and axial coding, and cross-referencing.

RESULTS

Eight women anesthesiologists were recruited and interviewed. Our iterative process identified four interconnected themes: difficulty internalizing a leadership identity, identifying systemic barriers and biases, dissonance between agentic traits and communal social gender roles, and mentorship as shaping lived experiences. Participants consistently expressed experiencing discrimination, articulated barriers related to family responsibilities and ingrained societal expectations, and discussed how typical leadership traits are applied differently to women and men. Women perceived themselves as more compassionate and communicative than men. Despite these traits, these women have expressed barriers to obtaining mentorship.

CONCLUSION

We identified consistent interconnected themes among the experiences of our sample of women anesthesiologists in academic leadership and found that academic anesthesiology is a gendered profession as experienced by these women leaders. Further research should focus on strategies to remove barriers to participation in academic anesthesiology for women.

Gender differences in academic rank among faculty surgeons at US veterinary schools in 2019

OBJECTIVE

To describe academic rank, gender, surgical career length, and publication record of academic veterinary surgeons and to estimate the association between gender and higher academic rank.

STUDY DESIGN

Cross-sectional study.

SAMPLE

Residency-trained surgeons at US veterinary schools in 2019.

METHODS

Surgeons were identified via institutional websites. Data including surgeon gender, academic title, and year of board certification were collected from public resources. Publication record was measured by using author h-indices obtained from Scopus. Data were analyzed with descriptive and inferential statistics.

RESULTS

Three hundred eighteen surgeons were identified from 30 institutions, including 162 (51%) women and 156 (49%) men. Women represented 66% of instructors and assistant professors, and men represented 60% of associate and full professors. This distribution differed significantly (P < .001). Author h-index was associated with career length but not gender. Men were 2.5 times more likely than women to be associate or full professors (odds ratio 2.52, 95% CI 1.03-6.14, P = .042) after adjustment for career length and h-index.

CONCLUSION

Female surgery faculty at US veterinary schools in 2019 were concentrated in lower academic ranks and were less likely than male surgery faculty to be associate or full professors after adjustment for career length and publication record.

IMPACT

A gender gap exists in academic veterinary surgery in the United States. It is critical to recognize that women's increasing participation in veterinary medicine has not been matched by equal representation in all areas. Additional efforts are warranted to identify contributing factors and implement strategies to improve gender inclusion.

Women in surgery: a web-based survey on career strategies and career satisfaction

Women represent the majority of medical students in several countries. In any surgical specialty and above all in surgical leadership positions, women still remain disproportionally underrepresented. The objective of this study was to investigate female surgeons’ career advancement and satisfaction with training. A standardized questionnaire was devised and sent out via the web-based survey tool SurveyMonkey^® to female surgeons in the German federal state of North Rhine-Westphalia. A total of 125 completed questionnaires were analyzed (response rate 40.8%). Female surgeons are at least largely (76%) satisfied with their surgical training. Increased time (>5 h/week) as the principal surgeon in the operating room significantly stimulates the satisfaction with the surgical training (86% vs. 68%, p = 0.0384). At the participants’ current workplace, the heads of departments are predominantly male surgeons (91%). Respondents not satisfied with their surgical training prefer a female head of department more frequently (24% vs. 2%, p = 0.0085). The majority of the respondents themselves aspire to become a consultant surgeon (56%), while only 12% intend to become a head of a department. Female surgeons aiming at leadership positions work overtime (≥50 h/week) significantly more frequently (81% vs. 57%, p = 0.0041). Favoritism of male colleagues is perceived by 34%. Respondents who do not perceive any preferential treatment are significantly more satisfied with their surgical training (88% vs. 57%, p = 0.0004). In conclusion, female surgeons seem positive about their career choice, once in the surgical profession, and aptly fill upcoming positions. Women interested in surgery are likely to pursue a surgical career despite the alleged workload, demonstrating the importance of professional self-fulfillment among female surgeons.

Gender Disparity in Authorship of Peer-Reviewed Medical Publications

BACKGROUND

Women are underrepresented in medicine despite increases in the percentage of female physicians. It is unknown if academic productivity contributes to these differences. We sought to determine whether gender disparity exists in peer-reviewed literature authorship in the United States from 2000 to 2017.

METHODS

Medical and surgical peer-reviewed research articles from the United States were retrospectively reviewed using PubMed from 2000 to 2017. Manuscripts were randomly selected within 4 different time periods: 2000-2005, 2006-2010, 2011-2015 and 2016-2017. The gender of the first and last authors was determined and the journal's impact factor recorded. The Accreditation Council for Graduate Medical Education (ACGME) and Association of American Medical Colleges (AAMC) databases were used to determine the percent of female residents, attendings and academic leadership positions. Primary outcome was the prevalence of female authors in peer-reviewed literature. Secondary aims were differences in disparity in medical versus surgical specialties, differences in publications' impact factor among gender and the association between gender and mentoring.

RESULTS

Within 1,120 articles reviewed, 31.6% of first authors and 19.4% of last authors were women. Female first and last authors increased over time and authorship was proportional to the number of women in the studied specialties at that specific time period (P = 0.78). There was no difference in the journal's impact factors between gender (P = 0.64). On subgroup analysis of medical and surgical subspecialties, results remained unchanged.

CONCLUSIONS

Women publish research at a rate proportional to the number of academic female physicians. Disparities in leadership roles are unlikely explained by differences in publications. While gender disparities in medicine have improved, substantial disparities in leadership persist.

Sexual discrimination in neurosurgery: a questionnaire-based nationwide study amongst women neurosurgeons in Bulgaria

BACKGROUND

The aim of this qualitative, descriptive, cross-sectional study was to identify potential factors influencing the progression of female neurosurgeons in Bulgaria.

METHODS

The study was conducted nationally, by sending out an online (SurveyMonkey®) questionnaire with 30 questions over a 3-month period to 15 registered female neurosurgeons in practice including residents/trainees and specialists from state universities, private universities and regional hospitals in Bulgaria. The questionnaire covered basic demographics, level of academic achievement and aspects of personal and professional experience, along with questions on the perceived barriers that female neurosurgeons nationally encountered during their clinical and academic career. These results were compared with similar studies conducted in other countries following a literature search on PUBMED.

RESULTS

Eleven out of fifteen respondents returned the completed survey, covering 10 institutions which included 8 university clinics and 2 regional clinics, achieving a response rate of 73.3%. No questionnaires were excluded. The factors negatively influencing the clinical and academic professional development and progression in the field included lack of mentors and other female role models, perceived bias regarding remuneration and leave, as well as a lack of support with regards to work-life balance and difficulty progressing in the academic fields.

CONCLUSIONS

Although there is an ever increasing and growing awareness of the factors negatively impacting women progression in neurosurgery worldwide, there are still significant gaps and biases that hinder career progression amongst female neurosurgical communities and highlight a need for potential practices to be established in the workplace to counteract this.

"Yes, I'm the Doctor": One Department's Approach to Assessing and Addressing Gender-Based Discrimination in the Modern Medical Training Era

While gender-based bias and discrimination (GBD) is known to exist in medical training, there is limited guidance for training programs on how to understand and combat this issue locally. The Massachusetts General Hospital Department of Surgery established the Gender Equity Task Force (GETF) to address GBD in the local training environment. In 2017, members of the GETF surveyed residents in surgery, anesthesia, and internal medicine at 2 academic hospitals to better understand perceived sources, frequency, forms, and effects of GBD. Overall, 371 residents completed the survey (60% response rate, 197 women). Women trainees were more likely to endorse personal experience of GBD and sexual harassment than men (P < .0001), with no effect of specialty on rates of GBD or sexual harassment. Patients and nursing staff were the most frequently identified groups as sources of GBD. While an overwhelming majority of both men (86%) and women (96%) respondents either experienced or observed GBD in the training environment, less than 5% of respondents formally reported such experiences, most frequently citing a belief that nothing would happen. Survey results served as the basis for a variety of interventions addressing nursing staff and patients as sources of GBD, low confidence in formal reporting mechanisms, and the pervasiveness of GBD, including sexual harassment, across specialties. These results reproduce other studies' findings that GBD and sexual harassment disproportionately affect women trainees while demonstrating how individual training programs can incorporate local GBD data when planning interventions to address GBD.

Military Medicine and the Academic Surgery Gender Gap

Introduction

Gender disparity in academic medicine has been well described in the civilian sector. This has not yet been evaluated in the military health system where hundreds of female surgeons are practicing. Military service limits factors such as part time work and control over time spent away from family, which are often cited as contributors to the pay and promotion gap in civilian academic medicine. The military has explicit policies to limit discrimination based on gender. Pay between men and women is equal as it is based on rank and time in rank. One would expect to see less disparity in promotion through the academic ranks for military female surgeons given this otherwise equal treatment. This has not previously been objectively tracked or reported. It is beneficial to characterize the military academic medicine gender gap and benchmark against national data to define the academic gender gap and lay the groundwork for future work to identify factors contributing to the observed difference.

Material and Methods

This study was granted exemption from the Walter Reed National Military Medical Center (WRNMMC) Internal Review Board (IRB). The Uniformed Services University (USU) Department of Surgery academic appointment list was reviewed to assess female representation in the categories of Instructor, Assistant Professor, Associate Professor, Professor, and Other. Defense Manpower Data Center (DMDC) and the US Navy Bureau of Medicine and Surgery (BUMED) were assessed for total numbers of female surgeons on active duty, and numbers were compared with nationally published Association of American Medical Colleges (AAMC) data using a logistic regression model.

Results

There was a higher proportion of women in academic positions in the civilian cohort than in the military cohort (OR: 1.84; CI: 1.53–2.21, p &lt; .0001). This difference was observed at every level of academic achievement. A higher percentage of women were observed at lower levels of professorship than at higher levels; instructors were more likely to be women than assistant professor (OR: 1.44, CI:1.16–1.79), associate professor (OR: 2.24, CI: 1.77–2.84), or full professor (OR:4.61, CI: 3.57–5.94).

Conclusions

Fewer female surgeons in military medicine hold academic appointment when compared with their counterparts in civilian medicine. Similar to the civilian sector, military academic surgery also demonstrates less likelihood of female representation in higher academic stations. This discrepancy in representation follows a linear trend over the different ranks. This discrepancy has not been previously documented. The military offers a unique opportunity to study the issue of gender imbalance in academic promotion practices given its otherwise equal treatment of males and females. Additional studies will be necessary to understand uniformed female surgeons’ barriers to academic advancement.

Every doctor needs a wife: An old adage worth reexamining

Half of medical school graduates are women, but female doctors experience significant professional tensions. Low numbers of women in leadership roles, high burnout and attrition, and continued harassment suggest a culture that undermines the contributions of women. This manuscript explores research from sociology, business and medicine through a personal lens. Understanding the way gender influences the complex state of women in medicine suggests changes are needed in the architecture of the modern medical workforce. Individuals, mentors and organizations can make changes that would improve the way that the working environment cultivates a diverse workforce to reach its full potential.

Gender Diversity in General Surgery Residency Leadership

OBJECTIVE

This study aimed to evaluate the proportion and characteristics of women who serve in general surgery program director (PD) and associate program director (APD) positions in the United States.

DESIGN

General surgery programs (n = 276) and directors were identified using the Association for Program Directors in Surgery website; information was cross-referenced with American Medical Association FREIDA and Accreditation Council for Graduate Medical Education databases, current to July 1, 2017. Each program's website was accessed to determine the gender and academic ranking of faculty.

RESULTS

Results reveal a preponderance of men in PD and APD positions. Women accounted for 18.4% (n = 51) of the 276 PD positions, with more women in APD positions (29.6%). There was no correlation between gender of PD and the corresponding APD, (χ2 = 0.68, p = 0.41; Phi coefficient = -0.0695). Of those with academic appointments, men who were PDs were more likely to be full professors when compared to women PDs (38.5% vs 24.1%, respectively). The median number of days since appointment to PD was similar in both groups (1461 days for men vs 1377 for women, p = 0.18), although more men have held PD positions longer. Programs with a higher proportion of women faculty were more likely to have a woman PD (p = 0.0397), but not those with more women residents (p = 0.225) or a woman Department Chair (p = 0.56).

CONCLUSIONS

Among general surgery program directorship, men continue to hold more positions of educational leadership, although the trend appears to be shifting toward a more equal balance, particularly in those programs with proportionately more women faculty. This discrepancy may be due to academic rank or length of tenure. As more women hold academic positions in the field of general surgery, an increase in the representation of this group in leadership is anticipated. Although senior leadership (PD) positions remain disproportionately held by men, APD positions are filled by a greater percentage of women than academic surgical faculty, although the absolute percentage remains less than 50%. Educational leadership may be a viable path to academic leadership for both women and men.

The role of gender in patient preference for breast surgical care - a comment on equality

Gender preference among patients seeking medical care is an issue that is not well understood. It warrants exploration, particularly for patients undergoing sensitive physical exams. In a recent IJHPR article, Groutz et al. reported a survey study that explored patient preferences in selecting a breast surgeon. They found that a third of patients preferred a female surgeon for their breast examination. However, surgical ability was the primary factor in selecting a surgeon for their breast surgery. This commentary discusses these findings in the context of patient-centered care and issues of gender equality in medical education.Gender equality is considered an important societal movement in achieving human rights for everyone based on their ability, rather than their gender and opportunity. This commentary argues that the goal of gender equality is why women should be encouraged to enter surgical professions, recognizing that patient preferences will be shaped by societal norms. Gender preferences for the performance of sensitive physical examinations by some patients are likely multifactorial and they warrant more exploration to deliver ideal patient centered care.