'Glass Ceiling Shattered' by Female Breast Surgeons. How?

Nick Mulcahy

November 02, 2020

In the United States, the field of surgery is dominated by men, but women have broken through in one subspecialty ― breast surgery.

During the past 10 years, women surgeons have represented a majority of participants in committees, speakerships, and scientific presentations ― and thus leadership ― at annual meetings of the American Society of Breast Surgeons (ASBrS), new research indicates.

Dr Sharon Lum

"The glass ceiling [for women] in breast surgery has been shattered," conclude study senior author Sharon Lum, MD, of Loma Linda University School of Medicine, Loma Linda, California, and colleagues.

That breakthrough to prominence is contrary to all other surgical specialities and most other medical specialties, Lum tells Medscape Medical News.

"In medicine in general, women lag far behind in leadership positions, and in surgery in particular, women are even farther behind...but breast surgery is different," she said.

The study found that despite the fact that women account for only 20% of general surgeons in the United States, at the breast surgeon society, women on average constituted 44.8% of members of the board of directors, 41.7% of committee chairs, and 54.8% of committee members from 2009 to 2019. (In the United States, breast surgeons are certified in general surgery, which includes a wide range of operations.)

During the study period, there was also majority female participation on average in all ASBrS scientific presentations, such as posters and oral sessions.

The study was published in the Annals of Surgical Oncology.

Notably, women dominate ASBrS membership: in 2019, 62% were women and 38% were men. "There is overrepresentation of women in breast surgery," comments Lum.

Peter Beitsch, MD, former president of the ASBrS and a surgeon at the Dallas Surgical Group in Texas, says the organization has sought to include women in the annual meeting and related leadership. "It takes a concerted effort over years to achieve equality, but [it] seems to have worked," he told Medscape Medical News.

Dr Liz Ball

"It's fantastic that women are now applying for and being appointed to senior roles on committees, and the era of 'manels' is becoming a thing of the past," said Liz Ball, MD, a breast surgeon in Suffolk, United Kingdom, who was asked for comment. She is widely known by her married name and the name she uses on social media name, O'Riordan.

"This is a good start," said Lum about advances in ASBrS engagement.

"The shards falling from the glass ceiling at the ASBrS Annual Meeting may help to shatter the glass ceilings of other surgical conferences as well," Lum and colleagues comment.

However, in breast surgery, there is still disparity in income, with men being better paid. A 2018 compensation survey of the ASBrS found a $51,733 (8.3%) income difference between the sexes, after multivariate analysis.

Lifestyle Choice and Little Choice

The study investigators briefly consider how women came to prominence in breast surgery. It is often assumed that female breast patients prefer female surgeons and that patients have driven the trends documented by the new study.

But the data on such a preference are "mixed," and most women patients say gender is not highly important when choosing among a wide range of physician specialists, summarize the authors. "There's not a great literature on this," acknowledged Lum.

The authors also speculate that individual "surgeon initiative" has driven women's presence and accomplishments, but they cite no research.

The UK's O'Riordan says she entered the field largely because of predictable hours.

"I was drawn to breast surgery as a lifestyle choice," she told Medscape Medical News. "Most breast surgeons in the UK don't do any on-call work, so it's an 8:00 to 6:00, Monday to Friday job, which makes having a life outside of medicine easier. I wanted my weekends back after all those years on call."

Dr Susan Love

The influence of lifestyle is important with respect to the presence of women in breast surgery, agrees Susan Love, MD, who has founded breast centers at two academic institutions and has authored several bestsellers, including Dr. Susan Love's Breast Book.

"It's a better lifestyle if a woman is also running the household and taking care of the kids. Breast is easier than being, say, a trauma surgeon," she said, referring to the fact that emergencies occur around the clock.

Lifestyle and sexism have been the two principle factors driving women into breast surgery, claims Love, who is now chief visionary officer of the Dr. Susan Love Foundation for Breast Cancer Research.

"When I did media interviews early in my career, I would be asked, 'Why did you become a breast surgeon?,' and they wanted me to say, 'Well, I was at my mother's deathbed...' or something like that...but no, I said, 'Sexism!' "

She recalls there were negative attitudes toward women surgeons in the late 1970s, when she was starting out on her career.

In 1979, after being chief resident in general surgery at Boston's Beth Israel Hospital, Love hit the employment market. "Nobody offered me a job," she said, which was "unusual" because "most chief residents at Harvard-affiliated teaching hospitals get recruited.

"It was because I was a woman," she believes. She noted that US medical schools capped female admissions at 5% to 10% in the early 1970s.

Undeterred, Love "hung out a shingle" as a private practitioner and discovered that her referrals from other physicians were "all women with breast problems.

"It was an interesting time," she said, because practice started changing after the publication of the first randomized controlled trials showing that lumpectomy plus radiotherapy was as effective as mastectomy. Breast surgery started to change, and male general surgeons increasingly "didn't really like it," she said.

"It was more fun when they were doing nothing but big macho radical mastectomies. But then surgery got to be more fiddly and involved breast conservation and trying to do it cosmetically [and it was less fun]," Love commented.

"So the men decided, 'That's okay, we will let them [female general surgeons] do the breast, and we will do everything else in general surgery,' " Love told Medscape Medical News.

Some men avoid breast surgery because it is perceived as unmasculine or unsubstantial, says O'Riordan, partially echoing Love's comments.

"Many male surgeons don't think breast surgery is a proper career and that we just fiddle around with fat," added O'Riordan, who is the coauthor of The Complete Guide to Breast Cancer .

She argues that "breast surgery shouldn't be seen as the 'female' choice, though; it implies women are only cut out for simple surgery."

The future for women in general surgery in the United States is bright, says Lum, observing that 90% of breast surgery fellows, 40% of general surgery residents, and a majority of medical students are now women.

Lum, Love, and Ball have disclosed no relevant financial relationships.

Ann Surg Oncol. 2020;27:4662–4668. Abstract

Nick Mulcahy is an award-winning senior journalist for Medscape. He previously freelanced for HealthDay, MedPageToday and had bylines in WashingtonPost.com, MSNBC, and Yahoo. Email: nmulcahy@medscape.net and on Twitter: @MulcahyNick

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