We have cracked the ceiling, but how long must we walk on broken glass? Addressing the pitfalls confronting women in surgery

Abstract

The turn of the 20th century showed the ‘gentle sex’ taking a foothold in the medical profession in Europe and the United States, after centuries of prevailing biological determinism. With the persistent effort of women who would not take no for an answer, the number of practicing female doctors rose from 25 in 1881 to 495 in 1911 in the United Kingdom and Wales. The first woman to practice medicine in Australia was Constance Stone in 1890 and the Royal Australasian College of Surgeons (RACS) admitted its first female fellow, Lillian Cooper, in 1927. As recently as 1996, women comprised a quarter of medical practitioners, and only 3.1% of surgeons in Australia. The projection at that time was that women would make up 42% of the medical workforce in 2025. However, despite reaching that benchmark earlier than anticipated, with women now accounting for 55% of medical students and over half of medical practitioners, progression in surgery has been slower, with only 13% of practicing surgeons and 27% of SET trainees now being female. Notably in 2019, 29.6% of applicants to surgical training were femaleas were 29.5% of successful applicantsindicating proportional training programme acceptance. Women still hold a disproportionate minority of medical leadership positions. Of the 22 medical school deans in Australian and New Zealand currently, eight are female (36.4%), as are 12.5% of large hospital chief executive officers. Women make up 33% of Australian health department chief medical officers, 22% of AMA presidents and 32% of national health and medical research council funded project lead investigators.; women are also underrepresented at medical conferences, overall making up 30% of all speakers, and 36.6% of panels remaining all-male. RACS ASM conferences 2012–2014 had approximately 20% of female speakers, with median speaker time allocated being significantly longer for male speakers. However, female representation did exceed the proportion of women in the surgical workforce, unlike every other conference studied. It has been postulated there is a stubborn ‘glass ceiling’ affecting the female medical workforce. This term was first derived from George Sand’s Icarus-like female character who was rendered unable to fly due to une voûte de cristal impénétrable—an impenetrable crystal vault—in an 1839 play, but became mainstream terminology in the 1980s after publication in the Wall Street Journal to describe the lack of advancement opportunity for women in business. The metaphor became popular to describe the difficult to see (but tangible to those affected) point where women could not ascend the corporate ladder beyond middle management. It has also come to represent the same issue for many minority groups in different settings. Medicine with its natural emphasis on evidence-based practice prides itself on being a meritocracy, so having a discrimination-affected workforce is particularly abhorrent. Recognising that the surgical selection process accepts a proportionate gender distribution of applicants, this suggests barriers to surgery begin pre-vocationally. The second period of concern is attrition during training (not completing the programme for reasons including choosing to leave, dismissal or examination failure). Women are 2.5 times more likely to resign (choose to leave) than men. This has been demonstrated to be an international pattern, with women 1.4 times more likely to leave surgical training in a study conducted in the United States (in fact, this was the strongest independent risk factor). A range of contributing factors have been identified: firstly, issues relating to organisational culture— including workplace gender-based discrimination, career structure and inflexibility, male dominant culture and lack of equal opportunities for advancement in some casesand secondly, work and family/personal balance conflict. Gender has no correlation with leadership or intellectual competence, but males are still viewed more favourably than female candidates in many workplace settings; this is termed intrinsic gender bias. If there was any lingering leftover-from-the-1800s doubt as to the capability of the female surgeon, it has been expunged in the literature with the publication by Wallis et al. demonstrating that female surgeons in fact have better patient outcomes. This has also been the case for physician patient outcomes in multiple studies, and thought to be resulting from female doctors being more likely to use a patient-centred approach, a different communication style and following evidence-based guidelines. Nonetheless, an estimated 65%–91% of female surgeons experience genderrelated discrimination in the course of their work, from both male and female colleagues, patients and patients’ families. The Expert Advisory group leading research inquiry for RACS into bullying and harassment found that 71.9% of females reported experiencing gender-based discrimination. We know that implicit bias attitudes are a natural unconscious pattern-recognition method of filtering large amounts of data. However, if unrecognised, gender bias can be severely damaging for patients and medical practitioners. Surgery has been slow to relinquish its ‘survival of the fittest’ culture, which has allowed systematic bullying to thrive in the past, now being addressed with multiple initiatives. Furthermore, the perception of being excluded from the ‘boy’s club’ with less access to mentoring, informal networking and collaboration opportunities remains a very large impediment for women trying to navigate a male-dominated workplace. There are limited flexible training