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Barriers to becoming a female surgeon and the influence of female surgical role models
  1. Hui-Ling Kerr1,
  2. Lesley Ann Armstrong2,
  3. Jennifer Ellen Cade3
  1. 1Department of Trauma and Orthopaedic, Bristol Royal Infirmary, Bristol, UK
  2. 2Department of Trauma and Orthopaedic, Cheltenham General Hospital, Cheltenham, UK
  3. 3Department of Anaesthetics, Royal Berkshire Hospital, Reading, UK
  1. Correspondence to Lesley Ann Armstrong, Department of Trauma and Orthopaedic, Cheltenham General Hospital, Flat 4 Douglas House, Parabola Road, Cheltenham, Gloucestershire GL50 3AH, UK; lesley.armstrong{at}doctors.org.uk

Abstract

Objectives We aim to investigate the reasons that medical students and junior doctors who are women are less likely to pursue a career in surgery compared with their male counterparts.

Methods An anonymous questionnaire was distributed to female final year medical students and female junior doctors in two UK hospitals between August and September 2012. Topics included career choice, attitudes to surgery, recognition of female surgical role models and perceived sexual discrimination.

Results 50 medical students and 50 junior doctors were given our survey. We received a 96% response rate; 46 medical students and 50 junior doctors. 6/50 (12%) junior doctors planned a career in surgery compared with 14/46 (30%) medical students. ‘Work-life balance’ was the main reason cited for not wishing to pursue surgery (29/46 (63%) medical students and 25/50 (50%) junior doctors). 28/46 (61%) medical students and 28/50 (56%) junior doctors had encountered a female surgical role model; only five students and two junior doctors felt that these were influential in their career decision. Of those who had not, approximately 40% in each group felt that if they had, they may have considered surgery. Approximately 30% in each group had encountered female surgeons that had dissuaded them from a surgical career.

Conclusions Work-life balance is still cited by female junior doctors as being the main deterrent to a surgical career. The paucity of female role models and some perceived sexual discrimination may cause female doctors to discount surgery as a career.

  • MEDICAL EDUCATION & TRAINING
  • SURGERY

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Introduction

Female medical students make up to 63% of the total medical student intake in some medical schools in the UK, and in 2012, 61% of doctors under the age of 30 on the medical register were women.1 Despite this, a much smaller proportion applies to become surgeons, and this diminishes with seniority.2 In view of improved working hours, adherence to the European Working Time Initiatives and improved equal opportunities, barriers to a surgical career for women should have subsided. However, surgery remains an unpopular choice for female doctors,3 ,4 with just 10% of consultants being women, compared with 29% in other medical specialties.5 Previous studies have identified that women cite ‘work-life balance’ and perceptions of a surgical lifestyle as their main reasons for not choosing a surgical career.6 ,7 It has also been suggested that a lack of female surgical role models,8 ,9 and in some places, a ‘boys club’ mentality, are negative influencing factors.6 In 2000, the government published the ‘Improving Working Lives Initiative’,10 which is supportive of flexible training. In 2009, the Royal College of Physicians published a paper ‘Women in Medicine: The Future’ which acknowledged that women would make up a greater share of the future medical workforce and was supportive of increasing the options for flexible training and part time working.11 Following a report published by the Department of Health in 19912 the Women in Surgical Training group was set up with the aim to reduce the gender gap in surgery. This became the ‘Women in Surgery’ group in 2007.12 Despite all these measures recent studies have shown that surgery remains an unpopular choice for female doctors.3 ,4

The main aim of this study was to determine which factors deter current UK female junior doctors and medical students from a surgical career. In addition, we assessed the significance of female surgeons as role models in the career decision-making process of these junior women, and also their experience of sexual discrimination during training or at work.

Methods

Participants

We conducted a cross-sectional study of two separate cohorts of participants; first a group of female medical students and second a group of female junior doctors. They were distributed across two separate UK hospitals; first a teaching hospital and second a district general hospital. Fifty medical students and 50 junior doctors in total, all women, were invited to complete the questionnaire. They were approached while attending scheduled weekly teaching sessions. Permission to recruit the participants was received from the educational administrators responsible for the individual groups. The doctors included in the study were in their first or second postgraduate year of training.

Questionnaire

An anonymous closed question paper survey entitled ‘Attitudes to a career in surgery and the importance of female surgical role models’ was distributed to the participants between August and September 2012. Participation was voluntary and no incentives were offered. The questionnaire was designed to seek subjective answers relating to career choice, attitudes to surgery, the presence or absence of female surgical role models, the importance of female surgical role models and opinion relating to perceived sexual discrimination in the surgical workplace. An open-ended section on experiences of gender discrimination was also included for comments from the respondents. The questionnaire was distributed as a hard copy to the participants in their teaching session as outlined above, and collected in at the end of the session.

Data analysis

Data analysis was carried out using SPSS V.17. Specifically, data were analysed using χ2 test and Fisher's exact test.

Ethical committee approval

We did not require ethical approval from the National Health Service Research Ethics Committee. We had individual consent from participants and educational administrators at each site.

Results

Participants

A total of 46 female final year medical students and 50 female junior doctors completed the survey, giving a response rate of 96%.

Planned careers in surgery

Only 6/50 (12%) of the junior doctors planned a career in surgery compared with 14/46 (30%) of the medical students (p<0.05). This is the only result in this study that reached statistical significance. Work-life balance was the main reason cited for rejecting the idea of a surgical career for 29/46 (63%) of medical students and 25/50 (50%) of junior doctors. Only 30% from both groups cited the nature of the work as a deterrent (14/46 medical students and 15/50 junior doctors). Only 10/46 (22%) of medical students and 8/50 (16%) of junior doctors were put off by perceived boys club mentality. Very few respondents were put off by fears of job security: 2/46 (4%) medical students and 4/50 (8%) of junior doctors). Only 6/46 (13%) of the medical students and 3/50 (6%) of the foundation doctors felt put off by perceived sexual discrimination in the workplace. These results are summarised in Table 1.

Table 1

Summary of results

Female surgical role models

28/46 (61%) of the medical students and 28/50 (56%) of the junior doctors had encountered a female surgical role model during their career but of this subgroup, only five of the students and two of the junior doctors felt that these were strongly influential in their career decision. Of the six junior doctors who said yes to a surgical career, five of these had encountered a female surgical role model and of the six that said maybe, three had encountered female surgical role models. Thirty-eight junior doctors were not considering surgery, and of these 20 had experienced a female surgical role model and 18 had not. Of those who had not encountered a female surgical role model, 9 students and 10 junior doctors felt that if they had, it may have persuaded them to consider a surgical career. On the other hand, approximately one-third in each group had encountered female surgeons that had dissuaded them from a career in surgery (15/46 students, 18/50 junior doctors). These results are summarised in Table 2.

Table 2

Impact of female surgical role models

Sexual discrimination

7/46 (15%) of medical students and 9/50 (18%) of foundation doctors felt that they had at some time been subject to sexual discrimination in the surgical workplace. Sixteen per cent of the respondents felt strongly enough that they wrote comments in the open-ended section with regard to perceived sexual discrimination in the surgical workplace. Some examples of the comments are given in box 1.

Box 1

Questionnaire comments relating to perceived sexual discrimination

▸ ‘We endured 8 weeks of sexist comments such as “6 girls?! That's at least 3 full time doctors between you…”’ (This was told to a female medical student by an orthopaedic surgeon.)

▸ ‘There are always sexist comments at some stage, especially in orthopaedics…’

▸ ‘Two male surgeons claimed women are no good as all they do is cry…’

▸ ‘Once you hit the menopause, your career is over!’ (This was told to a junior doctor by an orthopaedic surgeon.)

▸ ‘In theatre the males are chosen to assist and suture…’

▸ ‘I felt faint in theatre and the male surgeon asked me if I was pregnant’

▸ ‘Female surgeons are anti-female’

▸ ‘Flexible training is not as established as in medical specialties’

▸ ‘In surgery there is general favouritism towards male students…’

▸ ‘An old-school surgeon assumed that female students wouldn't be going into surgery and therefore we had fewer scrubbing up opportunities and were given less teaching’

▸ ‘I feel I have to be better than my male colleagues…’

Discussion

Surgery remains an unpopular career choice for women in their final year of medical school and, even more so, in first year of postgraduate training. A significantly smaller proportion of the foundation doctor respondents were considering a surgical career compared with the student respondents. The reasons for this are not clear. It could be due to a greater understanding of the reality of the surgical job and nature of the work, however, this is not reflected in the results of the study which suggest that fewer foundation doctors were put off by the non-content related career factors and an equal proportion of both groups were put off by the nature of the work. The exception to this was the fear of job security which was twice as great in the foundation doctor group, although this was not significantly different compared with the student group. It may be there are other non-content related career factors that have a significant impact on the junior doctors that we have not accounted for.

Many studies have shown that the recruitment of women into specialties is dependent on their need to work less than full time at some stage in their careers,13 ,14 and their ability to combine family life with their careers.15 ,16 Concerns regarding work-life balance have been well known to be the main deterrent to women with regards to a surgical career,6–8 ,16 ,17 which has also been confirmed in our study with 50% of the foundation doctors and 63% of the medical students citing work-life balance as the main reason for not choosing surgery. The European Working Time Directive has reduced the official working hours of trainee surgeons. However, in reality the European Working Time Directive is not strictly adhered to and working hours remain arduous. This may partly explain why a smaller proportion of foundation doctors, with more insight into actual working hours, are interested in pursuing a surgical career compared with their medical student counterparts.

Other common reasons found in other studies include ‘personal preference’,9 and perceptions of a negative attitude towards women with bias towards men and sexual discrimination.7 Compared with previous studies,7 few of our respondents felt that they had been exposed to sexual discrimination and fewer respondents in our study (13% medical students and 6% doctors) felt actually put off by this when considering a surgical career. However, for those who felt they had experienced sexual discrimination, 16% of our respondents felt strongly enough about it to write about their experiences in the open-ended comment box in our study. Along a similar vein is the perception of the boys club as being a barrier to a surgical career. Gargiulo et al,6 found that 23% of 150 female surgeons surveyed in their study perceived this, and similar results were found in our study.

Surgical role models have previously been shown to be important to both men and women,18–20 however, there is literature suggesting that women place more importance on role models.21 ,22 In previous studies, the proportion of female medical student and junior doctor respondents who felt that a lack of female surgical role models was a deterrent to choosing surgery as a career path ranged from 6% to 35%.6 ,8 Some studies have recommended that female students should work with or meet with female surgeons who may be able to show how family life can be combined with a surgical career.16 The mentoring of female medical students by female surgeons could disperse some of the misperceptions surrounding the satisfaction of these surgeons with regard to their careers and home lives.23 It has been suggested that the majority of female surgeons are satisfied with their careers,17 ,23 with no significant differences in the ‘tradeoffs’ of personal and family time for work compared with their male colleagues.23 Women are significantly less likely to encounter their own gender surgical role models compared with men,7 ,9 and it could be theorised that a cyclical relationship of few female surgical mentors results in few female surgical trainees. In our study, approximately 40% of our respondents who had not encountered a female surgical role model did feel that if they had, it might have changed their opinion of surgery as a career choice. Ravindra and Fitzgerald's study demonstrated that 63% of newly qualified doctors questioned as part of their work were able to identify a positive role model, and that they (irrespective of gender) were twice as likely to be interested in a surgical career if they were able to identify a positive role model (p=0.0006).20 This association was not found in our study, however, where up to 61% of the respondents had encountered a female surgical role model but only 4% of the junior doctors and 10% of the students felt that this was a positive influencing factor in their career choice. This suggests that the presence of a female surgical role model may not be as influencing as previously thought. However, because most of the six foundation doctors wanting to do surgery had actually encountered a female surgical role model, it stands to reason that increased exposure to female surgical role models may be an important factor that could influence these junior doctors and medical students to consider a career in surgery. Scott et al4 surveyed 2168 medical students and found that surgical female role models were not discerningly influential on those choosing surgery as a career. Another study by Smith et al24 surveyed 33 female surgeons and found that only three out of the 33 felt hampered by a lack of mentorship during their training. It is well known that mentoring is an important influencing factor in career choice for young female surgeons,19 but there is evidence to suggest that gender specific mentoring may not be as important as the quality of the mentoring.25 Approximately a third of students and foundation doctors stated that they had been dissuaded from a career in surgery by female surgeons. This could be due to either the female surgeons describing their own difficult experiences in ascending the surgical hierarchy which could have put the respondents off. Another possible explanation is alluded to in the comments of one of the respondents. She wrote ‘Female surgeons are anti-female’. This could be interpreted that in her experience the female surgeons she had encountered were unfriendly and did not give her the appropriate attention or support that she expected as a fellow female doctor or student. This is, however, just one opinion and cannot be assumed to be a true reflection of any individual female surgeon or female surgeons as a group.

Attracting students to a surgical career appears related to their experience during surgical placements, including participation in theatre.26 Berman et al27 found that students who were involved in theatre and given tasks such as suturing or holding the laparoscopic camera were 4.8–7.2 times more likely to be interested in a surgical career (p<0.005). Williams and Cantillon also found that preregistration house officers were more likely to have positive perceptions of surgery if they were actively involved in theatre rather than present observers.16

Medical students have less exposure to surgical specialties during their clinical training compared with medical specialties, and this has decreased further in recent years.26 There is some evidence that the majority of women who are put off surgery are put off at medical school.13 ,28 Ravindra and Fitzgerald observed in their aforementioned study, that newly qualified doctors who had received good surgical teaching during medical school were more likely to identify a role model.20 Encouragement and involvement at this stage may be essential to attract new graduates to the profession.

Although these findings were not significant, a consistently greater proportion of the student respondents were put off by three factors: the work life balance, the boys club mentality and the perceived sexual discrimination compared with the foundation doctors in our study. Both groups, however, had the same proportion of respondents put off by the nature of the work. This could suggest that the students have a worse perception of the non-content related career factors which is then reduced once they become exposed to the reality of a surgical job. Therefore, the potential to change a student's attitude to a surgical career exists, so long as they gain the appropriate exposure and involvement and are not put off by the nature of the work.

Limitations to the study include the low numbers of respondents in each group and the distribution of the questionnaire to only two hospitals. The authors recognise that there could be wide variability in respondent experience in different areas of the UK. Also opinions from male medical students and junior doctors were not sought which could have shed greater light on our female responses. Undergraduate and mature medical students were not differentiated; age and previous experience could have resulted in bias in terms of their responses. The number of months of exposure to surgery was also not asked of the respondents. If the respondents had little exposure to surgery in the past this could be a confounding factor and again could lead to bias in their responses.

Despite European Working Time Directives resulting in improved working hours and increased opportunities for flexible training, work-life balance is still cited by newly qualified female doctors as being the main deterrent to a career in surgery. Exposure to female surgical role models may not be as an important influencing factor for these doctors as previously thought, but the paucity of female surgical role models along with some perceived sexual discrimination in the surgical workplace may cause some female doctors to discount surgery as a career option. Addressing these issues by making changes to current surgical working culture and by engaging with female medical students and junior doctors in the surgical environment would make a career in surgery more attractive to these doctors.

Main messages

  • Surgery remains an unpopular career choice for women in their final year of medical school and first year of postgraduate training.

  • Concern regarding maintaining an acceptable work-life balance is cited as the primary deterrent to today's female doctors pursuing a career in surgery.

  • Increased exposure to female surgical role models may be an important factor in influencing female medical students and junior doctor’s decisions to pursue a career in surgery.

Current research questions

  • How can flexible training be further modified to enable female trainees to pursue a career in surgery?

  • Would active mentorship in the final years of medical school encourage more women to consider pursing surgical careers?

  • Are there any disadvantages, other than increasing the length of training, to training less than full time?

References

View Abstract

Footnotes

  • Contributors H-LK conceived of the study. Data collection by H-LK and JEC. All authors contributed to interpretation of data. Initial draft by H-LK. Revisions and final manuscript by LAA. All authors approve final manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Raw data available from LAA (corresponding author) if required.

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