Nevertheless, She Persisted: Women Face Unique Obstacles When Pursuing Surgery as a Specialty

Anya Romanowski, MS, RD


January 31, 2018

The Role of Gender and Perception in Surgical Specialty Choice

In the United States and abroad, there is a growing public reckoning over the routine discrimination and harassment that many women have faced in the workplace. The field of surgery has not been immune to these larger upheavals. Although surgery remains a male-dominated field, more women are choosing to enter this profession.[1]

Medscape spoke with Dr Aurora Pryor, professor of surgery and division chief of bariatrics, foregut, and advanced gastrointestinal surgery at Stony Brook Medicine (Stony Brook, New York), and Kristie Price, a medical student at Stony Brook University School of Medicine, about their research on gender-based perceptions of surgeons and subsequent influence on choosing a surgical subspecialty.

Medscape: A 2010 study in the Journal of the American College of Surgeons[2] found that the most influential factors in general surgery residents' specialty choice were type of procedures and techniques, exposure to positive role models, and ability to balance work and personal life. What did your survey find?[3]

Kristie Price

Kristie Price: While traditionally there aren't many women in surgery in general, we noticed that there are particular surgical specialties that appear to have less female representation. In seeking to figure out why, we observed that there are gender-based differences in how surgeons advise medical students.

In our survey, we asked surgeons what surgical specialties they would recommend to men versus to women. What we found was that the top five specialty lists were different for men and women.

The top five list of surgical specialties for women was breast, ob/gyn, plastic, ophthalmology, and general surgery, whereas for men it was orthopedics, general surgery, urology, vascular, and neurology.

Another interesting example we observed was in cardiovascular surgery: 50% of surgeons said that this specialty was open only to men.

We think that the influence of mentorship plays a large role. If you have a mentor who thinks that a particular specialty is open to one gender only, that would largely influence whether you choose to pursue that specialty.

Aurora D. Pryor, MD

Medscape: You also asked members of the American College of Surgeons whether they advise trainees to take time off to have kids. The majority of both male and female respondents said "no." Why do you think that is?

Aurora D. Pryor, MD: What was interesting to me is that we had some respondents from outside of the United States, and I think they are much more open to both men and women taking time off for kids. We're just a little more career-focused and not as family-oriented in the States.

Underrepresentation in Major Medical Societies

Medscape: Has there been any shift in the specialties that men have chosen over the past two decades?

Ms Price: We didn't look specifically into the specialties for men. What I can say is that of the [societies of the] top five specialties that are listed, the American Association of Orthopedic Surgeons as well as the American Urological Association, have yet to have a female president. Traditionally, it appears as though some of these specialties have been male dominated, and they continue to be.

Dr Pryor: And sometimes it is a lack of awareness that there is underrepresentation in those specialties, because people tend to promote people who are like them. If they are more open to promoting people who are not like them, then that helps to continue to grow underrepresented groups.

Some of the societies have acknowledged that and are making an effort to make the representation more diverse, while other societies are clearly not at that point right now.

A Need for Female Mentors and Leadership in Surgery

Medscape: You asked about role models and mentors in medical school. I was surprised to learn that so many men had mentors while the women did not. Why do you think that is?

Ms Price: Our study was geared mainly toward surgical residents and practicing attending physicians. I think their responses were quite interesting, with 31% [of all respondents] saying they didn't have a role model or a mentor. Of those who did, 61% had male role models and only 8% had female role models.

What's interesting is that if you look at the stratification among ages, only 2.5% of female respondents over the age of 60 had female role models, compared with 9.2% under the age of 30. So we're starting to see a bit of a shift toward more female role models, but we still have a long way to go.

Medscape: Do you think it's important to have a role model who is of the same gender?

Ms Price: I think that there is value in having role models from both genders. As a female, having a role model of the same gender just showed me that my dreams and aspirations are realistic and attainable, because I have someone to look up to and, essentially, emulate—hopefully—in my career.

On the other hand, it is still useful to have a role model who is male—maybe not because of that fact, but rather because he has another perspective or other experiences to add to my professional growth.

Medscape: Why do you think some specialties, such as orthopedics, have not been very successful at recruiting more female (and minority) surgeons?

Ms Price: It's a slow process. There are many papers that have come out recently that discuss this exact same issue, which showed me that there is awareness of the lack of representation of these groups. I think that over time it will improve as the efforts continue.

I read about a couple of initiatives, especially in orthopedic surgery, that seemed to be successful. One is the Perry Initiative Medical Student Outreach Program. They seem to have a lot of success in terms of increasing the match rate of their medical students. Other mentorship programs, like the Association of Women Surgeons, also seem to have a lot of success and seem to be popular. But I think it is a matter of making medical students aware of these opportunities that are there.

I'm a third-year medical student, and I found out about a lot of these programs only this past year. So if I hadn't been in a place that has a strong female presence in surgery, if I didn't have knowledge of these other programs and opportunities to connect with female surgeons, I may have been discouraged from surgery in my first year.

Medscape: Did you find any difference between female and male surgeons in bedside manner, procedural outcomes, and so forth?

Dr Pryor: Well, I do think that you are going to find men who can be compassionate and do an excellent job with their bedside manner. I think that, more traditionally, women fill that role and men are more aggressive and efficient. But we are also going to find women who are aggressive and efficient. I think our traditional roles are more supportive of women having a better bedside manner.

Ms Price: To speak to bedside manner, we do have, at least at Stony Brook School of Medicine, a course throughout our first year called "Instruction of Clinical Medicine." In this course, we work with simulated patients to deliver bad news, do physical exams, take medical histories, and work on communication. We can view the videos later. It is wonderful for anyone who doesn't have the best bedside manner or who doesn't realize that they rush through questions or perhaps cut patients off. There definitely is an effort in medical education to increase or enhance bedside manner with medical students.

Reflections on a Career in Progress, and One Just Beginning

Medscape: What personal challenges did you face in pursuing a career in surgery?

Dr Pryor: We both have very different perspectives. When I picked surgery, there were not a lot of women in the field, and I had been given advice that other things may be easier. But I have never chosen the easy road and instead picked what I really liked to do. I figured that if it was really bad, I could always change specialties later.

I ended up picking minimally invasive and bariatric surgery, partially for lifestyle reasons. I was married and was interested in having kids. I did not wind up taking a lot of time off for either of my kids. I think that prevented some people from being biased against me for having kids, but maybe it wasn't the best thing for my family in the long run.

[This specialty allows me] to do big procedures, but my patients go home shortly after, so I don't spend as much time in the hospital as do other surgeons who chose more hospital-intensive surgical specialties. It did have some effect in terms of family dynamics.

Medscape: What advice do you have for women pursuing a career in surgery?

Dr Pryor: My advice is that if they want to do something, they should do whatever that is, because we spend most of our waking hours in our adult life doing whatever we do for a career. It has to be doing something that you like.

But they need to go in realizing that if there are not a significant number of women already in that field, they will face more challenges. Looking at the leadership in particular disciplines can help them see if it has historically been okay. It is not wrong to be a trailblazer; it just means that it is going to be more of an uphill battle.

If they pick a discipline, a training program, and a practice location that historically has had more women, it will be easier. But that doesn't mean that they should exclude something if it is really where they want to be.

Medscape: Kristie, as a medical student, have you selected a surgical specialty yet?

Ms Price: Being in medical school, my goal right now is to match to a general surgery residence program. I am also interested in minimally invasive surgery and that's probably because my medical mentor, Dr Pryor, is also in that specialty. Previous research has also shown that medical students are very likely to go into the same surgical specialty as their mentor.

Regarding the challenges that I face in pursuing surgery, I have been very fortunate to have had a very strong female role model in medical school from the very beginning, so I have not had to face any challenges in regard to that.

Final Words of Advice and Useful Resources

Medscape: Any other final thoughts that you want to share?

Dr Pryor: I would like to point out that with increased awareness, we are seeing a shift across the United States, both in surgical societies and in leadership. More of our chair positions and society leadership roles are filled by women and minorities. That shift is going to open the door for more people to continue in those roles. The barriers, or perceived barriers, of the past are decreasing, which is a big positive.

Ms Price: For medical students—in particular, female medical students—who are interested in surgery and who don't have a large female presence in their surgical department, I would definitely recommend attending national meetings. Get involved in the Association of Women Surgeons and take opportunities to speak to female surgeons throughout the country. In my experience, everyone is very receptive to mentoring women who are interested in surgery. I think it gives you a better understanding of where we stand in surgery and all of the opportunities that really are available.

Medscape: Are there any other websites or organizations that you recommend to provide support for female surgeons so that we see their numbers increase?

Dr Pryor: I can recommend the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). We just had a leadership retreat that was about diversity and inclusion. I am actually the president-elect for 2019-2020, and we are having some shifts in the right direction.

The Association for Academic Surgery is another good one that has had some very excellent female representation in its leadership. They have a self-nominating process, so you can get in without somebody having to put your name in the hat. So it is positive that way.

Aurora D. Pryor, MD, has disclosed the following relevant financial relationships:
Serve(d) as a speaker or a member of a speakers bureau for: Stryker; W.L. Gore & Associates; Medtronic, Inc.; Ethicon, Inc.; Merck & Co.
Received research grant from: Baranova, Inc.; Obalon Therapeutics Inc.
Received income in an amount equal to or greater than $250 from: Stryker; W.L. Gore & Associates, Inc.; Medtronic, Inc.; Ethicon, Inc.; Merck & Co.

Kristie L. Price has disclosed no relevant financial relationships.

Follow Anya Romanowski, MS, RD, on Twitter @Anya13

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