Women in Neurosurgery Around the World: A Systematic Review and Discussion of Barriers, Training, Professional Development, and Solutions

Does gender disparity exist in neurosurgery training? Evidence from a nationwide survey from Pakistan

Gender disparities are prevalent in the neurosurgical field, particularly for female trainees, despite the growing demand for neurosurgeons. The situation is bleaker in low-and middle-income countries, where gender disparities among neurosurgical trainees have not been evaluated. We aimed to gauge the gender differences in opportunities and perceptions of neurosurgery training in Pakistan by comparing responses between males and females. A nationwide web-based survey was conducted in Pakistan, covering 22 College of Physicians and Surgeons of Pakistan (CPSP) accredited neurosurgery training programs. Convenience sampling was used with a pilot-tested questionnaire. Data analysis was performed using SPSS version 26. A total of 120 trainees participated in our survey. The mean age of the participants was 30.4 ± 4.1 years, with 29.2% females and 70.8% males. Concerns about gender equity were more among females (34.3%) than males (27.1%). Poor work-life balance was reported by more females (34.3%) than males (30.6%). Burnout due to working hours was strongly agreed by more females (54.3%) than males (35.3%). More females (40%) acknowledged sufficient mentorship opportunities versus males (25%). Female respondents (65.7%) worked 50-100 hours per week, less than males (69.4%). Satisfaction with surgical exposure was lower among females (2.9%) compared to males (18.8%). More females reported access to teaching courses (82.9% vs. 77.6% males) and neurosurgical conferences (85.7% vs. 80.0% males), cadaver workshops (17.1% vs. 12.9% males), morbidity and mortality meetings (88.6% vs. 82.4% males), case-based sessions (82.9% vs. 75.3% males), and radiology discussions (82.9% vs. 74.1% males). Our study highlights substantial gender gaps in neurosurgical training, concerns over working hours, burnout, mentorship, work-life balance, and gender equity. These findings underscore the necessity for interventions to rectify these disparities and foster gender equity in neurosurgical training.

Recent Trends in Successful Neurosurgery Resident Matriculation: A Retrospective and Bibliometric Analysis

BACKGROUND

Prior literature has demonstrated barriers to successful residency matching, including sex, medical school background, and international medical graduate status. Our aim is to characterize the recent trends in successfully-matched residents, with particular attention to geography and academic productivity.

METHODS

Resident information, including demographics and educational background, was gathered from program websites. Bibliometric analysis focused on PubMed publications from the top neurosurgery journals. A top 20 medical school was defined using the US News Rankings for research in 2022. Regression analyses were performed to explore the associations between total and first-author publications and other relevant factors, correcting for graduate studies.

RESULTS

A total of 114 institutions and 946 residents were included in the final analysis. Of the 845 with medical school information, 62 (7.3%) completed medical school internationally and 181 of 783 (23.1%) came from a top 20 medical school. Male residents had a higher proportion of residents with international undergraduate and international medical school degrees when compared to female residents [32 (7.5%) vs. 4 (2.4%), P = 0.021; 52 (8.6%) vs. 10 (4.2%), P = 0.026; respectively]. The multivariate regression analysis demonstrated a significant increase in publications for international medical school graduates (B = 8.3, P < 0.001), top tier medical school graduate (B = 1.3, P = 0.022), and male sex (B = 1.20, P = 0.019) for total number of publications.

CONCLUSIONS

Geographical factors, reported sex, and graduation status have influenced how resident candidates are perceived. Understanding these trends is vital for future resident matching. Addressing gender and educational diversity is essential to foster inclusivity and research-driven environments in neurosurgery residency programs.

Women in spine surgery: can we change the society?

BACKGROUND

Although the number of educated women and physicians, and especially neurosurgeons, is increasing worldwide, the educational opportunities, careers, and beliefs concerning female neurosurgeon's status and abilities are undermined. To date, reported studies have focused on the conditions of the work environment, work-life balance, and the academic career of female neurosurgeons. In this study, we aimed to report the patients' viewpoint and how they choose spine physicians.

METHODS

We conducted an international survey based on 19 questions in four languages (Bulgarian, Greek, English, and German). The responses of 413 individuals, unrelated to the medical field (sex, 315 female and 115 male individuals; one individual did not answer the question regarding the gender), were obtained. Except for the question regarding the patient's preference for the physician sex, the survey aimed to examine the factors that might be contributing to this choice, including education, age, heard/read recommendations/advertisements, knowledge regarding the work of the neurosurgeons/orthopedists, and their difference regarding spine surgery.

RESULTS

The majority of the participants responded that they prefer male surgeons to treat their spine. The results showed a significant correlation between the choice of a male spine surgeon and heard/read advertisements/recommendations and knowledge regarding the work of the neurosurgeon. Despite the fact that education was not related to physician selection, it was an indirect factor that led to the final choice.

CONCLUSION

Women in surgery, mainly in neurosurgery, are being treated by society in an unequal way. Female surgeons are still discriminated because of their gender. The most patients prefer female physicians to talk to, but still believe that they are incapable to perform spine surgery. We cannot stop this until we change our mindset and perception of reality.

Maxine Deborrah Hyde: First Female Graduate of Case Western Reserve University's Neurologic Surgery Residency Program and Second Black Female Neurosurgeon in the United States

BACKGROUND

The historical diversity gap in the neurosurgical workforce persists to this day. Women, despite constituting over half of the yearly total of medical school graduates, comprise only 6% of certified practicing neurosurgeons in the United States. Furthermore, Black Americans make up under 4% of U.S. neurosurgeons, despite making up around 14% of the national population. The purpose of this account is to highlight the life and career of Dr. Maxine Deborrah Hyde and illustrate the importance and necessity of diversity and inclusivity in advancing the field of neurosurgery. Through this paper, we aspire to encourage the development of new diversity initiatives.

METHODS

Original scientific and bibliographic materials of Hyde were examined, and an extensive analysis of her life was compiled.

RESULTS

Despite growing up during the era of Jim Crow, Dr. Hyde persevered and became the valedictorian of Oak Park High School. As a first-generation college student at Tougaloo College, she later earned her MS from Cleveland State University. Dr. Hyde graduated with honors from Case Western Reserve University School of Medicine in 1977. Thereafter, she became the first female and first Black graduate of Case Western's neurosurgery residency and the second Black woman to receive certification from the American Board of Neurological Surgery. Later in life, Dr. Hyde established the Beacon of Hope Scholarship Foundation to assist disadvantaged students in overcoming educational barriers.

CONCLUSIONS

Dr. Hyde was a trailblazer who overcame systematic barriers and paved the way for future generations of aspiring neurosurgeons.

Female Neurosurgery Residency Program Directors in the United States: A Cross-sectional Descriptive Analysis

BACKGROUND

The residency program director (PD) position is a valued leadership appointment in academic medicine. PDs are responsible for the success of their program and its residents. The objective of this study is to provide a cross-sectional analysis of baseline demographics and academic backgrounds of current neurosurgery program directors.

METHODS

Data was compiled on neurosurgery PDs and their residency programs, as of the end of May 2021, using publicly available resources including Doximity, FREIDA, and Healthgrades. The Mann-Whitney and Fisher exact tests were used for statistical analysis.

RESULTS

Of 113 PDs identified, 91.15% are male (P < 0.01). The majority of PDs (88.5%) received their medical degrees from U.S. medical schools. The average age of current PDs is 54 years, and the average age at appointment was 48 years. Compared to their male counterparts, female PDs are more likely to be younger at appointment (41 vs. 48 years; P = 0.001) and while holding the same position (45 vs. 55 years; P = 0.001). As a result, female PDs experience less time to appointment after residency (8.6 years vs. 14.7 years, P = 0.013). There are no significant differences regarding the gender of the PD and university affiliation, current appointment, completion of a fellowship, and resident gender ratios.

CONCLUSIONS

The position of neurosurgery residency PD is dominated by fellowship-trained men in their late 40s to 50s. The gender ratio of neurosurgery residents is consistent with the underrepresentation of women in this position. With increasing female representation in neurosurgery, more women may assume this leadership position and begin to hasten the gender balance.

Barriers Encountered Toward Pursuing a Neurosurgical Career: A Cross-Sectional Study Among Medical Students, Interns, and Junior Doctors in Africa

BACKGROUND

Africa has an increased burden of neurosurgical diseases with an estimate of 1,986,392 neurosurgical cases, 108,824 neurosurgical case capacity, and 1,877,568 case deficits yearly. Literature suggests that about 8420 neurosurgeons are needed to fill this vast gap. The main objective of this study is to elucidate barriers encountered in pursuing neurosurgery training in the African context.

METHODS

A cross-sectional electronic survey, developed in English and subsequently translated into French, was utilized. This was disseminated among medical students, medical interns, and junior doctors in all 5 African regions.

RESULTS

A total of 491 responses were received from the following 5 African regions: West Africa (30.5%), East Africa (30.3%), Central Africa (18.1%), North Africa (11.8%), and Southern Africa (9.2%). Of the participants, 55.2% were men and 44.8% were women. Seventy-six percent of respondents were aware of the neurosurgery deficit in Africa. Barriers to pursuing neurosurgery included discouragement from others over lack of an "ideal personality" trait, culture/cultural beliefs as related to gender roles, lack of mentorship, inadequate neurosurgical training opportunities, poor health infrastructure for neurosurgical practice in Africa, poor patient outcomes, and challenges with work/life balance were some of the barriers highlighted to pursuing neurosurgical career on the continent.

CONCLUSION

Even with its robust population growth, Africa is not producing enough neurosurgeons to meet the demands of the population due to several barriers. Delineating these challenges and barriers represents an important step in developing sustainable mechanisms for recruitment, training, mentorship, and support of burgeoning African neurosurgeons.

Women in Neurosurgery: Historical Path to Self-Segregation and Proposal for an Integrated Future

Despite the rising percentage of women accessing the medical profession over the last few decades, surgical specialties are still largely male-dominated; in particular, a remarkable gender disparity is evident in neurosurgery, where only 19% of practitioners are females. Although women may be reluctant to choose a challenging specialty like neurosurgery due to concerns around how to balance family and career, it must be admitted that prejudices against female neurosurgeons have been deeply rooted for long, prompting many to give up and switch track to less demanding subspecialties. Among those who have persisted, many, if not most, have experienced difficulties in career progression and received unequal treatment in comparison with their male counterparts. In 1989, a group of 8 female neurosurgeons founded Women in Neurosurgery (WINS), an organization that aimed to guarantee inclusivity in neurosurgery, encouraging a better and more egalitarian working environment. Thereafter, WINS sessions were regularly promoted at international conferences, offering female neurosurgeons a platform to report issues related to gender discrimination. Over recent years, the mission of WINS sessions in national and international conferences has taken an unexpected deviation; they have progressively become supplementary scientific sessions with only women neurosurgeons as speakers, thus paving the road to a form of self-segregation. This tendency has also resulted in the establishment of sections of only female neurosurgeons within some national societies. Although there remains a faction that fiercely supports the WINS mindset of reserved spaces for women, such segregation is an upsetting prospect for those who believe that science and professionalism have no gender; a growing part of the global neurosurgical community believes that the conception of a “female neurosurgery” and a “male neurosurgery” is misguided and counterproductive and consider the existence of the WINS as anachronistic and no longer necessary.

Early Barriers to Career Progression of Women in Surgery and Solutions to Improve Them: A Systematic Scoping Review

OBJECTIVE

This study aims to summarize the evidence concerning the barriers that exist to the career progression of women in surgery and to provide potential solutions to overcome these obstacles.

BACKGROUND

Visible and invisible impediments can hinder female doctors' pursuit of a surgical career, from choosing a surgical specialty to training opportunities and all the way through career progression.

METHODS

Database search of original studies about barriers for female surgeons during choice of surgical career, residency, and career progression. A query including possible solutions such as mentorship and network was included.

RESULTS

Of 4618 total articles; 4497 were excluded as duplicates, having incorrect study focus, or not being original studies; leaving 120 studies meeting the inclusion criteria. Of the articles included, 22 (18%) focused on factors affecting the pursuit of a surgical career, such as surgical work hours and limited time for outside interests, 55 (46%) analyzed the main barriers that exist during surgical residency and fellowship training, such as discrimination and sexual harassment, 27 (23%) focused on barriers to career advancement, heavy workloads, ineffective mentorship, unclear expectations for advancement, inequality in pay or work-home conflicts. Among studies reporting on possible solutions, 8 (6.5%) articles reported on the role of effective mentorship to support career advancement and to provide moral support and 8 (6.5%) on the emerging role of social media for networking. Our analysis showed how different impediments hinder surgical career progression for women, with notable consequences on burnout and attrition.

CONCLUSIONS

Identification and recognition of obstacles to career progression is the first step to addressing the gender gap in surgery. Active strategies should be improved to promote a culture of diversity and to create equal opportunity for women in surgery, while implementing structured mentoring programs and investing on an adequate communication on social media to engage the future generations.

Gender disparity in neurosurgery: A multinational survey on gender-related career satisfaction

Introduction

Women continue to be underrepresented in the majority of surgical specialties, including neurosurgery.

Research question

In this multinational survey, we aimed to assess current gender disparities in neurosurgery focusing on job satisfaction and inequity/discrimination at work.

Material and methods

Female and male members of the European Association of Neurosurgical Societies were asked to complete an electronic survey (Google Forms, Mountain View) containing demographic baseline data and questions on attitudes regarding gender disparity, personal experience with gender inequity and career satisfaction/work-life balance. Quantitative analyses were performed to analyse the responses, including summary and comparative statistics.

Results

We received 168 responses from 40 different countries. Survey responders had a mean age of 40.8 ​± ​11.5 years; 29.8% were female. There were significant more male than female residents and attending surgeons per department. Eighty-eight percent of female and 38.1% of male responders experienced gender inequity or discrimination at work (adjusted OR 10.8, 95%CI 4.2–27.8, p<0.001). Female neurosurgeons were more likely to be discriminated by colleagues (aOR 4.32, 95%CI 2.1–9.1, p<0.001) and by patients/relatives (aOR 3.65, 95%CI 1.77–7.54, p<0.001). There was a trend towards lower job satisfaction (p=0.012), less satisfaction with career goals (p=0.035) and worse work-life balance (p=0.0021) in female surgeons.

Discussion and conclusion

This survey underlines that a significant proportion of neurosurgeons – in particular females – continue to experience gender inequity & discrimination at work, which may translate into lower work-related satisfaction. A better understanding of the gender-related aspects of job satisfaction is an important step to improving gender equity in our profession.

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Women continue to be underrepresented in clinical and academic neurosurgery.

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The most common source of discrimination are patients/relatives and colleagues.

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Women generally report lower job satisfaction in neurosurgery.

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Progress towards gender equity has been made in the last decade.