Ann Arbor, Mich.—Last November, women surgeons from across the United States and from all stages of surgical careers met in Michigan to discuss the gender gap in surgery and find ways to close it. The year 2017 was an important one for women in surgery: the #ilooklikesurgeon movement on Twitter and the subsequent cover of The New Yorker (April 3 issue) made the sight of a woman in surgical scrubs a familiar one; an unprecedented 22 women became chairs of surgery in the United States; and women took on top leadership roles at the American College of Surgeons and the American Board of Surgery. Yet, a major gender gap persists in surgery. Despite holding a record number of spots as surgical chairs, women represent only about 10% of chairs of surgery in the United States. Differences remain with regard to salary and compensation, with a 2016 study showing that the largest gender gaps in salary were often in surgical specialties (JAMA Intern Med 2016;176:1294-1304). Women are underrepresented in senior positions of surgery, an imbalance that becomes more pronounced at each step up in professorial rank. The percentage of full professors in surgery who are women is increasing at a rate disproportionately slower than increases in female medical students and surgery residents (J Surg Educ 2012;69:84-90). In 2008, 48.8% of medical school graduates were women, and 32.3% of general surgery residents and 7.3% of full professors in surgery were women. In the past decade, the percentage of female full professors has risen to 9.8%, according to figures reported at the Michigan conference. By one analysis, surgery residents could have equal proportions of women and men by the year 2028, but an equal number of male and female full professors in surgery is unlikely to be achieved until 2096 without a change in trends. Of the 16% of women who hold positions as dean in medical schools, they are more likely to be in positions that focus on education and image making rather than general leadership, clinical roles and research roles. Conference organizer Dana Telem, MD, MPH, associate professor of surgery at the University of Michigan Medical School, in Ann Arbor, said the meeting was designed to bring women together to talk formally and informally about leadership and strategies to overcome the systemic barriers that impede female surgeons. In 2008, women made up 48.8% of medical school graduates, 32.3% of general surgery residents, and 7.3% of full professors in surgery. Since then, that number has grown to 9.8%. At that rate, it would take until 2028 for surgical residents and 2096 for full professors to reach equal gender porportions. “This was about leadership development, not adapting as a female, but providing tools on how to be a successful leader, ” she said. “It was to talk to each other and learn from one another, to find out what we can take home to make changes.” Over two days, the 125 attendees discussed issues such as contract negotiations, work-life balance, career challenges and cultural barriers. Janet Dombrowski, an executive coach and a consultant, led the women through a series of exercises designed to find their strengths in leadership and communication styles, and to exploit these skills. Organizers asked faculty to speak candidly about personal experiences rather than recite data. The women spoke openly about negotiations for jobs and their reliance on others to help manage busy schedules. They offered practical advice: Accept imperfection; share credit but don’t share blame; stop saying you were lucky to get this spot. Outside of formal presentations, women also talked frankly about sexual harassment they’d faced, insults they’d received because of their gender, and concerns about the repercussions of speaking out. Participants shared stories about struggles in and out of the operating room—lack of support, lack of equipment, and lack of action to proactively move to equality and equity in surgery. “I was actually surprised to hear acknowledgment of the struggles we have in the operating room and how universal those struggles are. I was amazed at how common and shared our experiences are even though we are all trained differently and at different institutions,” said Arghavan Salles, MD, PhD, assistant professor of surgery at Washington University School of Medicine in St. Louis. Dr. Salles said she hoped that raising awareness of gender bias and issues of gender equity will start conversations and bring about change. Many people are unaware of the data that show the ways in which women are disadvantaged in professional careers, which has been shown in studies from medicine and in nonmedical professions. “Women are systematically left out of networks and opportunities simply by virtue of their gender. Until that is widely recognized and acknowledged, we will have to keep fighting to get that data out into the world,” she said. A theme heard again and again over the two days was that equality and diversity will not happen without a concerted effort by women and men. Many speakers spoke of the need for intentional efforts in recruitment, retention, compensation, negotiations and mentorship to raise the position of women in surgery, as well as that of surgeons from ethnic minorities or who are LGBTQ. Jennifer Waljee, MD, MPH, associate professor at the University of Michigan, said institutions and organizations need strategies to overcome what’s known as “demographic inertia”—that even in the absence of discrimination, demographic constraints mean many decades will pass before the increases in the entry of women into a profession are fully reflected at each step of the academic ladder. Unless older faculty take early retirement or more faculty are hired, it would require the length of entire careers before changes in the gender composition of a profession overall are reflected in the composition of its leadership. This phenomenon has been studied throughout higher education, law, science and sociology. “In that vein, this really calls for active strategies to close these gaps and achieve parity,” Dr. Waljee said. But demographic inertia doesn’t tell the whole story, according to Dr. Waljee. Gender- and ethnicity-related differences also play a role. Leaky pipelines and glass ceilings result from a series of barriers rather than one giant stumbling block, she said. One of those barriers is bias. In the days after the conference, a working paper out of Harvard University showed that a surgeon’s gender greatly affects referrals (Sarsons H. Interpreting Signals in the Labor Market: Evidence from Medical Referrals [Job Market Paper]. Working Paper). Referring doctors judged female surgeons much more harshly than male surgeons; they increased referrals more to a male surgeon than a female one after a good patient outcome, and decreased their referrals more to a female surgeon than a male one after a poor outcome. In addition, poor performance by one female surgeon shaped how all female surgeons in the same specialty were viewed by referring physicians afterward. Dr. Waljee presented studies of gender differences in leadership and career choices, using examples from the corporate world and medicine to show how the process of parity is slowed. Women are less likely to negotiate salary and compensation. Across departments at the University of Michigan, they are less likely to choose tenure track. They are more likely to experience sexual harassment: In a sample of clinician researchers in the United States, 30% of women reported having experienced sexual harassment compared with 4% of men (JAMA 2016;315:2120-2121). Despite equal work hours between men and women, women surgeons are more likely to experience burnout and depression than their male counterparts. Women are not at a disadvantage for securing an R01 award, but compared with white women, Asian and black women PhDs and black women MDs were significantly less likely to receive funding. Women submit fewer applications and are more likely than men to drop out of the R01 applicant pool after a single unsuccessful application (Acad Med 2016;91:1098-1107). An example from the business world: Despite evidence that male and female leaders both are effective and that female leaders outperform their male counterparts when the role requires interpersonal skill and cooperation, gender role expectations often put women at a perceptual disadvantage. Amalia Cochran, MD, associate professor of surgery at the University of Utah Health, in Salt Lake City, said surgeons have fought some “interesting and complicated” battles to get more women into leadership positions, and it is important for senior surgeons to help mentor and sponsor younger surgeons to keep pushing change. “We have to keep our focus on identifying worthy women for leadership roles, be they academic or organizational. I personally keep a list of diversity candidates—not just gender here—who I know do great work and who are ready for a professional next step whose names I push forward when asked for my input. I would challenge other people in senior and leadership capacities to do the same.” She wrote, in an email interview, that she was surprised and disappointed to hear how many younger surgeons still experience sexual harassment in the workplace. “I’ve been witness to gender discrimination in terms of salary and academic rank, but I have not been at an institution where I have been aware of high levels of flagrant sexual harassment. I was dismayed to learn this is STILL a real thing at some places (and it made me grateful that it’s not been part of my experience). We collectively as a house of surgery need to stand up and take a zero tolerance stance for the bad actors. Unfortunately, power structures and fear of retribution, much less the question of he said-she said, make this an ongoing challenge. This is where I see the most urgency to moving the needle.” The conference grew out of a conversation in 2016, among five women on the faculty in the University of Michigan’s Department of Surgery. Dr. Telem, Dr. Waljee, surgical education scientist Gurjit Sandhu, PhD, pediatric surgeon Erika Newman, MD, and vascular surgeon Dawn Coleman, MD, found they were facing new challenges as they transitioned from the assistant to associate professor rank. So they formed the Michigan Surgical Women’s Collaborative to study the gender gap in surgery and implement strategies to address it. “Even though we are of different backgrounds, different interests, different specialties, we face similar challenges as we started to transition from the assistant to associate level. In facing these challenges, we realized we needed to do something about it,” Dr. Telem said. The members of the Michigan Women’s Surgical Collaborative organized the conference to share their strategies beyond their institution. The meeting opened with a presentation from Michael W. Mulholland, MD, PhD, chair of surgery at the University of Michigan, outlining some of the unusual steps taken at that institution to speed the process of parity and diversity. (He was one of two men who presented at the conference with its all-female attendance and more than a dozen female faculty.) “It’s not enough to have good intentions. Change requires something more,” Dr. Mulholland said. Between 2005 and 2015, women arrived at the University of Michigan as surgical residents in increasing numbers, now accounting for 50%. But over that time, representation of women among faculty remained steady at about one-third, which is the university average. And so over the past year, the surgical department set out new policies designed to bring about equality between the men and women on faculty. It is part of a larger effort at the university, called the Michigan Promise, to build a more diverse, equitable and inclusive university. In surgery, those efforts began with changing the way people think about women in surgery, according to Dr. Mulholland. For a year, every surgeon invited as a grand rounds speaker was a woman asked to speak on topics relevant to clinical surgery. The department invited women to give all keynote lectures. Dr. Mulholland asked women to replace him as moderator of the weekly death and complications conference. “For every week that this happened, a woman was in front of 100 people, giving a judgment, directing the conversation, being in judgment of men and women both. I personally think this is a gigantic cultural moment to change the way of thinking about women surgeons,” he said. The department’s annual retreat was focused on diversity, equity and inclusion. Organizers set up a leadership development program and an office of faculty life, and laid out strategies for improving diversity and excellence. The department includes house officers in recruitment and has a diverse committee that interviews job candidates. “We have an obligation to our future and to the next generation to do something different,” Dr. Mulholland said. It is believed to be the only surgical department taking such a proactive campaign to bring about diversity and equality. Source
