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To be or not to be…
  1. Fiona E Karet Frankl
  1. Correspondence to Professor Fiona E Karet Frankl, Cambridge Institute for Medical Research, Cambridge Biomedical Campus Box 139, Hills Road, Cambridge CB2 0XY, UK; fek1000{at}

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Last year, at their request, I ran a session with a group of medical students who wanted to discuss potential career choices including craft specialties and clinical academia. I was dismayed when a female student recounted how she had been advised by a senior male surgeon not to choose a career in surgery—“surely you will want to have a family?” he asked. I have since heard almost identical stories from colleagues in several other medical schools, even including a similar conversation reported by a first year preclinical student.

In PMJ, Hui-Ling Kerr and colleagues have added some new data to the well-accepted body of evidence that women are less likely to choose a career in surgery than are their male equivalents.1 The Royal College of Surgeons’ (RCS) most recent statistics indicate that in 2014, while 30% of surgical trainees were women, this figure translated into only 11% of consultants. That said, the figure has risen from just 3% in 2001.2 There is variability among subspecialties—for example fewer than 7% of neurosurgeons are women, compared with just over 26% in paediatric surgery.

The results from Kerr et al's questionnaire, while involving only a small subject set, add further colour to a much larger canvas: that of problems with recruitment and retention of women across all science, technology, engineering, mathematics and medicine (STEMM) subjects. Indeed, consideration of gender in the workplace is not confined either to academia or to the health professions. Dame Helena Morrissey's 30% club aims to see a minimum of 30% women on Financial Times Stock Exchange 100 company boards by 2020 (as I write this, the number is 26%, up from 12.5% in 2010).3

There cannot be a medical school or division across the country still unaware of the Athena SWAN Charter, to which higher education institutions have been able to sign up for over 10 years, and whose Bronze-level, Silver-level and Gold-level awards are widely sought as a measure of institutional support for women's careers. Indeed, SWAN awards are already a requirement for some forms of National Institute for Health Research funding; the Research Councils have talked about making similar rules. University arts and social sciences departments now have a similar scheme, and membership organisations are about to become eligible.

Analysis of the demographics within an organisation, and its internal culture, are essential first steps to trying to remedy any unwarranted imbalances. For example, the tipping point at which women ‘disappear’ from career ladders may be different in different disciplines. The RCS suggests that longer career trajectories for women, who for family reasons may train less than full-time, can explain their gender imbalance.

‘Time will cure the problem’, say some. But when I started medical school in 1980, 52% of my class was female, but some 35 years later, only 13% of my professorial cohort is. We speak of a ‘leaky pipeline’, but further discussion often focuses on the water rather than the pipe. From the simple perceptive of losing a significant proportion of talent in our future workforce, we cannot afford to maintain stereotypic attitudes and rigid regimens where they currently exist.

It is notable that the limitation of weekly working hours in the clinical world has done much less to change gender demographics in clinical specialties than many would have hoped. So what exactly are the factors that prevent women from achieving their full potential, whether in surgery or elsewhere, and in some cases not even be willing to engage with the ‘establishment’ that they encounter? It is undeniable that biology plays a part. Although the introduction of shared parental leave in the UK may well help, women's careers are likely to be interrupted for longer—though chronic sleeplessness in homes with small children will of course not just affect women!

The often unconscious (also termed ‘implicit’) biases that label women as somehow less able, committed or effective if they have a career break, or that affect other diversities, may be lessened following specific implicit bias training, but there is no good evidence yet to suggest that the effects of such training are long-lived.4

It would also be a mistake to assume that having children is the only barrier. Good role models may be few in number or insufficiently visible. A lack of inspiring role models can have a big effect, and this makes the first steps towards changing trainee and student minds more difficult to achieve. In my organisation, we work hard to try and put together appropriately balanced seminar speaker lists, but find that women invitees may be less free to travel and therefore less likely to accept invitations. At the very least, we can ensure that sessions are chaired by as diverse a team as possible.

One thing that is universal, however, is that there is no single factor that if fixed, would make gender imbalance disappear. A long-hours working culture may not be easy to change, but increasing flexibility and or job-sharing may help. So also may schemes to provide more support for anyone who has caring responsibilities (which increasingly may be for older relatives) and to welcome returners from career breaks. We and others also put much effort into support (including peer-support networks) and mentoring for those at the mid-career level—in clinical academia, the ‘leakiest’ stage. In addition outreach activities, particularly to schools, can be important to lessen stereotyping at a much earlier stage.

But above all, those I talk to who are working on Athena SWAN-related initiatives within STEMM and in related organisations such as the Academy of Medical Sciences and the Medical, Dental and Veterinary Schools' Councils, all agree that senior male engagement with trying to effect cultural change has been, and continues to be, very important. The attrition of women (or any other form of under-representation) is not a women's problem to be solved by women. It needs all of us to work together. The worst outcome for an organisation thinking about trying to address diversity issues, which of course extend far beyond gender, is the assumption that it's all someone else's responsibility and that tackling these problems is just a tick-box exercise.

Recognition of missed opportunity and a real desire to change the culture in an organisation are critical. After all, many of us spend more of our waking hours in the workplace than we do in our own homes. Embedding new practices, new values and collecting feedback and impact data may not be straightforward, but to realise the potential for the greatest number, the investment is surely worth it.


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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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