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Table of Contents
EDITORIAL
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 1-4

Why do we need more women in surgery?


Department of Surgical Oncology, New City and Mubarak Hospitals, Srinagar, Jammu and Kashmir, India

Date of Submission10-Mar-2022
Date of Acceptance01-May-2022
Date of Web Publication12-Sep-2022

Correspondence Address:
Shabnam Bashir
Department of Surgical Oncology, New City and Mubarak Hospitals, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcs.ijcs_3_22

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How to cite this article:
Bashir S. Why do we need more women in surgery?. Indian J Colo-Rectal Surg 2022;5:1-4

How to cite this URL:
Bashir S. Why do we need more women in surgery?. Indian J Colo-Rectal Surg [serial online] 2022 [cited 2022 Sep 26];5:1-4. Available from: https://www.ijcrsonweb.org/text.asp?2022/5/1/1/355940

Surgery has all along been a male-dominated specialty. Women's entrance, which is still inconspicuous, has been a recent phenomenon. Globally, only one-third of surgeons (including those in Obstectrics & Gynaecology (OBG)) are females.[1] Despite the fact that the US had its first female surgeon as early as 1855, women still form a mere 22% of the surgeons there.[2] In Canada, the proportion is even lower at 12%.[3] In South Africa, 20.7% of general surgeons were found to be females.[4] In developing countries, the situation is expectedly more pathetic. In India, with 31,200 general surgeons on record and 27,100 registered with the Association of Surgeons of India, only 2779 are women, suggesting a ratio of 1:10.[5] The scary situation was highlighted in a March 2016 story by the Times of India[6] reporting that only 10% of the surgeons in corporate hospitals of Hyderabad were women, and almost all of them were obstetricians and gynecologists. The hospital records had revealed that only a few women were in general surgery, and that finding a woman surgeon in a surgical super-specialty was “almost looking for a needle in a haystack.” The ominous conclusion was that women surgeons were a “vanishing tribe.”

The dearth of women surgeons globally is because of varied reasons, but we know that less women are entering and more are leaving surgical departments. The situation in the developed world is not very different. In the USA where women now form 50.5% of the total medical school enrollment, the majority opt for family medicine or pediatrics, and very few show inclination for surgery.[7] In 2019, women constituted only 15% of applicants to residency in surgical subspecialties.[8] India is no different; even in the prestigious Banaras Hindu University, Institute of Medical Sciences, there were just 3 female general surgery residents among a batch of 20 in 2019.[5] In the Kashmir Division of the Erstwhile Jammu and Kashmir State with a population of 3.5 million, we had a single woman general surgeon for almost 20 years!

To understand the situation certain pertinent questions need answers:

  1. First and foremost, why are there fewer women in surgery everywhere?
  2. Is there a need for increasing the number of women in general surgery and its sub-specialties?
  3. If more women surgeons are needed what needs to be done to increase their numbers in surgical specialties?



  Why are There Less Women in Surgical Fields? Top


Multiple reasons are cited by experts for acute shortage of women in general surgery and its subspecialties. Some factors are already inherent in the woman, her family or the society. These are what we may call “extra-professional” factors.

General disinterest of women in surgical specialties

Women, for a variety of reasons may be disinterested in general surgical fields and its subspecialties. Some of them are groomed and mentored from the outset to take up careers which are less demanding, easier, and without stress.

Family pressure

Women in middle class face pressure to maintain a family-work balance. That is quite challenging when the job is almost a 24 × 7 assignment especially because of emergencies. Nonsurgical fields leave enough energy and time for women to look after their home and fulfill social obligations. Studies in Nigeria found that the choice of specialty by females was mainly determined by the anticipated impact on their family lives and social engagements.[3] In multinational studies family support was found lacking even in some progressive countries like Japan.

Studies, however, suggest that the main factors discouraging women from taking up general surgery or its subspecialties may be primarily within the profession itself.

  1. The attitude of male colleagues towards the entry of women in the field can be gauged by the historical fact that the first woman surgeon of the USA (Dr. Mary Edwards Walker) was denied to do surgical practice simply because she was a woman. Ironically she was made to work as a nurse in the US army for 8 years before she was accepted as a female surgeon.[9] The first British female surgeon (Margaret Ann Bulkley) had to disguise as a male for 25 years to pursue her surgical career; she was officially buried as Dr. James Barry. Even after her death, they never acknowledged that there was a female surgeon in England.[10]


Various multinational studies conducted in high income countries demonstrate that women still experience intense discrimination from male workers.

There is a long-held assumption among the peers that women don't make ideal surgeons. There is an inherent bias from the existing male surgeon fraternity against women entrants. It is a common knowledge that male surgeons, with a few exceptions, try to discourage women from what Dr. Shristi Sharma, the founder of the “Association of Women Surgeons of India,” says “breaking in the all-boy's club.” Many of the male surgeons hold a view that the field is too challenging and, “the weaker sex,” can't do justice with its demands.

Similar reasons are operative behind the attrition of the female trainees or those pursuing surgical career. A meta-analysis of studies researching the reasons behind the attrition of women trainees in general surgery found that 25% of the female trainees did not complete their training because of work-place harassment.[11] Studies in both high-income and low-income countries have suggested that women surgeons leave the field because of different types of harassment by male colleagues particularly those in power.[12]

A large number of male surgeons may still hold the belief that women make inferior surgeons or that they don't venture into complicated procedures. This wrong perception may be persisting in spite of the evidence that women surgeons at work are at least as good as their male counter parts.

Since from the very beginning, the field is occupied primarily by males the existing mentors are predominantly males, and not surprisingly may be sharing similar assumptions that women surgeons imply a liability rather than an asset for the department or hospital. Women graduates who dare to enter the male bastion against all odds find very few women mentors and role models to encourage them. Existence of a female mentor or role model in the field has been found to impact choice of field for a female resident.[13] The Lancet Commission for Global Surgery analysing 139 studies[14] which evaluated female surgeons' experiences globally to identify strategies to increase surgical capacity through women, found that across all populations lack of mentorship was seen a career barrier by women. It was concluded from the studies from high income countries that establishing a “critical mass of women in surgery” encourages female students to enter surgery.

Gender inequity in remuneration is a known fact and plagues almost all occupations. Women surgeons despite being more hardworking and dedicated, and according to some studies more efficient, are paid less in comparison to their male counterparts, particularly in the private set up. A recent study showed that female surgeons earned 27% less than their male peers; in some specialties this could go to as high as 60%![15] Wage inequality is not restricted to developing countries; even in the USA payment disparity exists. According to the 2015 Open Payments Reports, surgeons in the USA received more in payment than other specialties, yet there was a higher likelihood of receipt and higher value of payments to men than to women.[16] Other studies also found that, although the annual income of white and black female general surgeons in the US was equal, in both cases it was lower than that of males. This showed a clear gender inequality.[17] Equal pay for equal work is definitely going to attract more females to surgical side and retain female surgeons in the specialty.

Studies have also shown that female surgeons are more sharply judged at the work place and less likely to be promoted in their place of work.

Then, there are various public perceptions and stereotyping of roles in the society. People generally equate a surgeon with a male. This is primarily because they have almost always seen a male surgeon and a female obstetrician. Acceptance of a female as a competent surgeon is generally difficult for them. Even in the USA, only 12% of women patients accept to be operated upon by a female surgeon.[18]

Whatever the reason we see that there are a few existing women surgeons and the new generation of women doctors is not enthusiastic or encouraged to take up surgery, not to speak of surgical super-specialties. The issue needs to be addressed urgently. Otherwise, as the Times of India March 2016 story fears the women surgeons may actually become “a shrinking tribe.” Attracting, inducting and retaining women in surgery are multidimensional tasks and need to be tackled at various levels.

  1. At the family level, parents should encourage girls taking up medical education to break the stereotypes and step out of their comfort zones. After marriage the in-laws have to be understanding, accommodative and supportive
  2. There should be effective encouragement in medical schools to make surgical fields more attractive to female interns and residents. Some medical universities in the US and UK have already taken such initiatives. In some institutions, medical students have come up with innovative programmes to this end. In 2014, a group of students at the University of Connecticut, School of Medicine (USA), formulated the “Women in Surgery Interest Group” to raise awareness among all medical students about careers in surgery, and especially to help “breakdown the barriers that have traditionally discouraged women from being surgeons.” The group has been working effectively at sharpening the interest of women graduates to opt for surgery.[19]


Being a miniscule minority, women surgeons have to assert themselves. They should know that they are swimming against the tide, and, to succeed, will require additional and harder effort than a male surgeon. Many female surgeons in the US, with the help of the New Yorker magazine, adapted a French cover design depicting four female surgeons in full surgical gear surrounding a patient in an operation theatre. It made the cover of April 23, 2017 edition of the New Yorker magazine. The idea was to send a message to the profession and to the public that female surgeons exist as male surgeons do. Women surgeons across the US, Mexico, Brazil, Turkey, and Saudi Arabia quickly stepped up to upload photos of their own recreations of the magazine cover. The challenge is now trending on Twitter as the #NYerOCoverChallenge. Thus a movement of awareness and assertiveness was born.[20]

Women in general surgery are not only fewer but also invisible. The women surgeons, whether in general surgery or pursuing super-specialty careers need to make themselves noticeable to the public as well as to the fraternity. It is primarily on them, but their mentors, seniors, well-wishers in fraternity, and opinion-makers in the society and media persons can all help them to be conspicuous in the society.

Change of public perception so that they trust in women surgeons as they do in male surgeons is a formidable hurdle. The wrong assumption that women surgeons are less talented or less competent needs attitudinal reformation. People should know that there is strong evidence that, with regard to patient outcomes, women surgeons may be better than their male counterparts.

A population-based, cohort-matched, retrospective study[21] conducted on more than 1 million patients operated upon by 3314 surgeons in Ontario, Canada, from 2007 to 2015, to examine the effect of surgeon sex on postoperative outcomes concluded that female surgeons were better than male surgeons. The researchers found that patients treated by female surgeons had a statistically significant decrease in 30-day mortality and other surgical outcomes (length of stay, complications, and readmission) compared with those treated by male surgeons.

Another recent population based, retrospective, cohort study conducted on 1.3 million patients operated by 2937 surgeons between 2007 and 2019[22] found worst outcomes among female patients treated by male surgeons. However, outcomes were better in patients of both sexes when operated by female surgeons. Again, female surgeons had proved better at reducing mortality, hospital stay, and readmission rates.

The researchers contend that there is irrefutable evidence that women surgeons are “better for a variety of reasons.” Many researchers have suggested further studies to find out these reasons. Some believe that women are better suited to be surgeons because they are more compassionate and patient, qualities which are very important when one is holding a scalpel or suturing. It is also held that women surgeons make the atmosphere of operating theatre “more congenial” which facilitates better communication and improved outcome. Wallis, the lead author of many such reports, believes that the better outcome is there because “women surgeons have been asked to jump more significant hurdles which in turn may have forced them to be smarter, more talented, hardworking and more dedicated.”[22]

Such superior outcomes with women doctors are seen in other specialties also.[23],[24] In many such comparative studies, women doctors have been shown to follow medical guidelines strictly and adopt a patient conducive approach to their care.


  Conclusion Top


In conclusion, surgery has been a tightly guarded male bastion where some openings need to be kept for women surgeons. A breed of women graduates has to be prepared by medical schools who enthusiastically opt for the difficult fields. More women mentors are required to motivate and enthuse newer entrants; that, in turn, needs timely promotions to senior women surgeons like their male counterparts. Remuneration disparities have to be removed. Families, before marriage and thereafter, have to be supportive on a broader front.

One vital consideration in India, and other developing countries of South-east Asia, is that the population is mainly rural and conservative. Women prefer women surgeons, at least for conditions affecting breast, perineum, colon, and rectum. The limiting factor is their unavailability particularly in towns and villages. Even though India's first women surgeon, Dr Muthulakshmi Reddi, established the Adhyar Cancer Institute in Tamil Nadu as early as 1954,[25] her dream of prompting women to break the glass ceiling and tread the path least travelled remained unfulfilled. There is hardly any woman surgeon with super-specialization at district level; where available they are concentrated in metros or capital districts.

It is a recognized fact that, as in other countries, male doctors in India are increasingly opting for nonsurgical super-specialties while women surgeons remain a miniscule. That is certain to decrease the population of super-specialist surgeons in near future. The government can help by providing eye-catching incentives for it. Reservation for women in surgery and surgical subspecialties could be an effective answer to tackle the acute dearth of women surgeons in India. The Lancet Commission for Global Surgery[14] believes that, in view of male surgeons showing reluctance to take up surgical subspecialties, the void can be filled by drawing more females in general surgery and subsequently to surgical subspecialties. There is a dire need to change the current trends.

 
  References Top

1.
Johnston J. Why ARE There so Few Female Surgeons? Doctors Reveal How the Challenges of Motherhood & Professions' “Alpha Male” Image Force Women to Abandon their Dreams. Daily Mail, July 2017.  Back to cited text no. 1
    
2.
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7.
AAMC. 2018 Physician Specialty Report. AAMC/Executive Report; 2018. p. 1-2.  Back to cited text no. 7
    
8.
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9.
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10.
The Royal College of Surgeons of England, London. History of Women in Surgery; 2022. Available from: https://www.rcsen.ac.uk>history. [Last accessed on 2022 Mar 01].  Back to cited text no. 10
    
11.
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12.
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13.
Rawan ATH, Almustafa R, Malibary N, Nammazi A, AlBaqami A, AlSaleh NM, et al. Role models as a factor influencing career choice among female surgical residents in Saudi Arabia: a cross-sectional study. BMC Medical Education 22, Article number: 109 (2022), Open Access (Published 19 Feb 2033). https://doi,org/10.1.1186/s12909-03181-5.  Back to cited text no. 13
    
14.
Xepoleas MD, Munabi NC, Auslander A, Magee WP, Yao CA. The experiences of female surgeons around the world: A scoping review. Hum Resour Health 2020;18:80.  Back to cited text no. 14
    
15.
de Costa J, Josephine BA, Jose CX, Zineb B, Dominique V. Women in surgery: Challenges and opportunities. Int J Surg Glob Health 2018;1:e02.  Back to cited text no. 15
    
16.
Kathryn R, Marshall D, Mackey TK. Types and distribution of payments from industry to physicians in 2015. JAMA 2017;317:1774-84.  Back to cited text no. 16
    
17.
Ly DP, Seabury SA, Jena AB. Differences in incomes of physicians in the United States by race and sex: Observational study. BMJ 2016;353:i2923.  Back to cited text no. 17
    
18.
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19.
Kirk N. Fostering More Women Surgeons. UCONN Health Centre, University Communications, University of Connecticut; February 14, 2014.  Back to cited text no. 19
    
20.
New Yorker Scroll Staff. Life Imitates Art: Women Surgeons Recreating the New Yorker Magazine [email protected]/Twitter; April 15, 2017.  Back to cited text no. 20
    
21.
Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: A population based matched cohort study. BMJ 2017;359:j4366.  Back to cited text no. 21
    
22.
Wallis CJ, Jerath A, Coburn N, Klaassen Z, Luckenbaugh AN, Magee DE, et al. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surg 2022;157:146-56.  Back to cited text no. 22
    
23.
Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A 2018;115:8569-74.  Back to cited text no. 23
    
24.
Tsugawa Y, Jena AB, Figuesa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for Medicare patients treated by male and female physicians. JAMA Intern Med 2017;177:206-13.  Back to cited text no. 24
    
25.
News 18. Not Just a Doctor: India's First Woman Surgeon Muthulakshmi Reddi was a Rebel at Heart. Available from: https://www.news. 18.com>buzz. [Last updated on 2019 Jul 30].  Back to cited text no. 25
    




 

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