Spotlight

Women in Surgery

From left to right: Jessica Donington, MD, MSCR and Jessica J. Kandel, MD

Taking on Gender Inequality

Women make up just over half of all medical students, and their numbers are increasing in some specialties traditionally dominated by men, such as urology. More women are rising in the academic ranks and being promoted to leadership positions. Still, gender inequity and disparities in pay and promotions persist:

• Female physicians earn 76 cents for every dollar earned by males, even after adjusting for age, rank and specialty, according to a recent Association of American Medical Colleges (AAMC) report.
• Women continue to be underrepresented in many specialties, including surgery—especially orthopaedic surgery—and radiology.
• In academic medicine, fewer than 20 percent of deans and department chairs are women, the AAMC reported.
• Female physicians report higher rates of burnout—48 percent compared to 38 percent for men—according to a recent National Academy of Medicine paper. Women are more likely than men to leave the profession.
• Half of women in medical school have experienced sexual harassment—most commonly, gender harassment—according to a 2018 National Academies of Sciences, Engineering, and Medicine study. In March 2020, the American Association of Hip and Knee Surgeons posted a video with real comments made to female surgeons and residents by their male colleagues. (An example: “You’re not the strongest resident, but gosh, you sure are pretty.”)

“Once the number of men and women enrolling in medical school reached 50-50, a lot of people thought these issues would go away,” said Vineet Arora, MD, AM’03, Herbert T. Abelson Professor of Medicine and Assistant Dean for Scholarship and Discovery at the University of Chicago Pritzker School of Medicine, and a national leader in medical education. “But clearly that hasn’t happened. We need to think about improving gender equity using a scientific lens, with a focus on structures, processes and measurable outcomes.”

In January 2020, the AAMC board of directors issued a call to action to address gender inequity in academic medicine. The organization also called for a special focus on women in underrepresented groups, who often are impacted disproportionately by gender inequity.

Changing attitudes

Implicit biases are thinking habits formed over many years that are unintentional, unconscious prejudices. These biases may be subtle, but pervasive, and hold women back from advancement. Arora and colleagues recently analyzed attending physicians’ comments about first-year and third-year emergency medical residents. The researchers found that during the third year of residency—when trainees are viewed more as colleagues than students—females received less supportive feedback and were more harshly criticized than their male counterparts for making similar medical errors. Both male and female attendings encouraged male trainees, but not females, to enter academic medicine.

“Performance evaluations in residency are linked to judgments,” Arora said. “Your residency program director writes your letters of recommendation for jobs, and, if you’re not perceived as performing well, your job prospects might not be as good and your starting salary could be lower.”

Even in nomination letters for awards or other recognitions, female physicians are more likely to be described using touch-feel words than are their male counterparts. “For example, men are described as ‘brilliant,’ whereas women are said to be ‘good team players,’” the AAMC noted in its gender inequity statement.

Caprice Greenberg, AB’94, MD’98, MPH, is a breast cancer surgeon who holds an endowed chair at the University of Wisconsin School of Medicine and Public Health, and the former president of the Association for Academic Surgery. “My goal when I give a talk on gender inequity in medicine is to really stick to the data, and try to get people to understand that this is a broad societal problem and that women are as much to blame for where we’re at as men, because we have the same biases,” Greenberg said.

The leadership gap

If current trends continue, it would take until 2096 for there to be an equal number of male and female full professors of surgery. Despite advances during the last several years, women are underrepresented at the highest academic ranks across the board.

“The exclusion of women from, and the concentration of men in, leadership positions creates extreme power differentials in academic medicine,” the AAMC said in its gender equity statement. More men are in key decision-making positions where they control resources and promotions.

But there are a number of reasons why fewer women hold medical leadership positions. “Without role models, it’s hard for women to see themselves in the field,” said Jessica Donington, MD, Section Chief of Thoracic Surgery at UChicago Medicine. “Just by being here, I’m a visible reminder to female medical students that, yes, you can be a thoracic surgeon.”

Women often are less likely to apply for positions if they don’t feel they hold 100 percent of the job qualifications. “If you post a position and there are five competencies that you want, men look at those competencies and say, ‘Oh well, I can do three of them. I’m going to apply,’” said Jessica Kandel, MD, Mary Campau Ryerson Professor of Surgery and Surgeon-in-Chief at UChicago Medicine Comer Children’s Hospital. “And women look at them and say, ‘I can only do four and a half. I’m not going to apply.’ So that is a little bit of a self-editing reflex there. And it is important to talk about those things with people who may be affected by them.”

Kandel mentors younger surgeons and encourages them to explore job opportunities wherever they may find them. “One of the young faculty members in my own group heard about a professional opportunity at a different university and didn’t want to apply for it because it was outside our institution. I told her, ‘You know, you might someday want to work there. You should practice interviewing and exploring so that you have that skill set when you need it. And no, it’s not disloyal.’”

Women who make it into the leadership ranks still face challenges related to gender. “Women leaders are put under the microscope,” said Melina Kibbe, AB’90, MD’94, Chair of Surgery at the University of North Carolina at Chapel Hill and Editor-in-Chief of JAMA Surgery. “Their decisions are questioned more. They have to defend their actions more. When they make certain decisions, especially unpopular or challenging decisions, they are referred to as the ‘B’ word, while men are viewed as authoritative.”

In meetings, it’s not unusual for a female leader’s suggestion to fail to gain traction, while a similar suggestion made by a male leader catches on, Kibbe said. “It is truly frustrating and this happens to all of us, even at very high levels,” she said.

Research repercussions

Just 7 percent of editors-in-chief at prestigious medical journals are women. Most editorial boards are predominantly male, and men receive more research funding. Historically, many clinical studies included only white men as subjects, and the results were assumed to apply to women and to people of color.

Kibbe successfully lobbied to get the National Institutes of Health (NIH) to institute a new rule in 2014 that requires all NIH-funded research to have a plan to use both male and female cells and male and female animals in research and preclinical trials. She advocated for the change after she discovered that the majority of research was being conducted only on male cells and animals—including her own work on nitric oxide therapy to prevent restenosis. “The therapy that I had been working on my whole career, which works fabulously in males (rats), didn’t work at all in the females,” she said. “I was shocked.”

Vascular surgeon Chelsea Dorsey, MD’10, Assistant Professor of Surgery at UChicago Medicine, recently co-authored a study that found the iliofemoral arterial anatomy in women to be smaller when compared to men, even after controlling for height, weight and other comorbidities. Her data could impact the future design of stents that are used in minimally invasive treatment strategies for aortic aneurysm repairs.

“It’s incredibly important to have women in surgery pursue academic careers,” Dorsey said, “because women often think of research questions that their male counterparts may not have on their radar.”

Work and family

Women in many professions struggle to balance work and family life. Female physicians are no different. A 2017 study published in JAMA Internal Medicine and conducted by University of California, San Francisco researchers found that 36 percent of female physicians surveyed (2,070 out of 5,782) experienced maternal discrimination.

Many female physicians point out that balancing family life and career is not just a woman’s issue. Many male physicians—especially those in the millennial generation—also want better work-life balance so they can spend more time with their children. Nevertheless, a 2017 JAMA Internal Medicine study found that among first-year medical residents, women experience higher rates of depression than men, mainly related to work-family conflict. “Despite the increased presence of women in the medical workforce,” the study authors noted, “female physicians take on significantly more household and child care duties than their male counterparts.”

Greenberg, who has three children, credits serendipity for how she and her husband, also a surgeon, ended up balancing parenting duties. “When our first daughter was born, I had to go back and finish my fellowship after just a month of maternity leave, but my husband had just finished doing a master’s degree, so he had six weeks off before he had to go back to residency. Because he was home alone with our daughter during that time, it set us up to be very equal in terms of a partnership around the child-rearing.”

Female colleagues often band together in informal support groups. “A number of younger female surgeons [at UChicago Medicine] are in a support group,” said urologist Sarah Faris, MD, Assistant Professor of Surgery, who has two small children. “We discuss how to navigate with babies—how do you pump, what to do before and after baby? What do you do about school for your kids, where do you live? How do we have work-life balance and still advance our careers?”

Trauma surgeon Priya Prakash, MD, Assistant Professor of Surgery, formed a friend group of diverse women surgeons during fellowship. They still text each other almost daily.

“We are in frequent communication about our lives and the challenges of the job,” Prakash said. “And we offer each other opportunities and support as well. One of my friends asked me if I could review and edit one of her manuscripts, and I’ve identified another who could write a book chapter.”

Linda Phillips, AB’74, MD’78, Chief of Plastic Surgery at the University of Texas Medical Branch at Galveston, and other female surgeons of her generation were in the vanguard of fighting for change. She recalls when a male colleague quipped, “Just don’t get pregnant,” while they interviewed a trainee.

“There are things—like pregnancy and having children—that I thought were no longer an issue because as female surgeons, we had fought so hard for them,” Phillips said. “Then, years later, to realize that women surgeons are still agonizing over that early in their careers or that for some women it was the reason to stay out of surgery altogether was an absolute shock. And that made me more assertive. I felt it was incumbent upon me to speak up for them.”

Moving toward parity

Mentorship—either from male physician leaders hoping to diversify their fields or from women physicians who have worked their way to the top—is vitally important to leveling the playing field.

“I lucked out that I had great mentors—particularly men in general surgery,” said Grace Mak, MD, Associate Professor of Surgery and program director of the pediatric surgery fellowship. “I never had anyone say I couldn’t do something because I was a woman.”

Kinga Skowron, AB’09, MD’12, stayed at the University of Chicago for medical school and residency, and is now doing a fellowship in colon and rectal surgery. “Both female and male attending surgeons here mentored me and encouraged me,” she said. “I never felt gender was an issue.”

Interventional breast radiologist Deepa Sheth, MD, Assistant Professor of Radiology, acknowledged that it was a difficult decision to enter a male-dominated field. “I decided to focus all my energy and just do it,” she said. “I tell other younger women to carve out their own pathway, and, with the help of mentors, do things that challenge you. Females can excel in this field.”

Women may benefit from having mentors for different aspects of their careers. One person might be good at advising in the clinical space, while another can help in research and yet another might assist with practical career skills such as salary negotiation—another area where men have an advantage. As a result, women are offered less in starting salary and other forms of compensation than men with equal rank, training and experience, the AAMC reported.

“Even when women do negotiate, there are negative perceptions of that,” Kibbe said. “You’re seen as difficult: ‘She’s asking for more.’ But when the men ask for more, that’s considered the norm.”

Kibbe and other female physician leaders said they have tried to do away with salary negotiation altogether when hiring a new faculty member. “I make it transparent and I take all the negotiation out of it,” Kibbe said. “When I make offers for all my faculty positions, the salary is straight from the pay tables. That way, there is parity between men and women, and the starting salary is not based on who negotiates better.”

More women physicians are taking steps to empower each other in academic settings.

In 2017, Julie Oyler, MD’01, Associate Professor of Medicine at UChicago Medicine and Chair of the Department of Medicine Women’s Committee, successfully lobbied the department chair to add images of women in their office hallways. Today, portraits of past chairs—all white men—have been joined by those of chief residents, section chiefs and other leaders (both past and present). Many women are represented. “The change has been well-received,” Oyler said. “Some of the residents and faculty say they feel more welcome.”

Surgical resident Ava Ferguson Bryan, AM’10, MD’18, has nothing but positive things to say about her experiences as a Pritzker medical student and UChicago Medicine resident. But she knows that “the world was much more hostile” to women trainees in the not-so-distant past.

“I recognize wholeheartedly the flag in the sand that was planted by women who trained in surgery and who have made my experience what it is today,” she said.

By Nancy Averett. Originally published in the Spring 2020 issue of Medicine on the Midway.