A study examining gender imbalance among surgeons shows widespread cultural change is needed to stamp out bullying, harassment and lack of support for women entering the profession. By Sophia Auld.

Surgeons and gender

Gold Coast surgeon  Dr Rhea Liang.
Gold Coast surgeon Dr Rhea Liang.

Nadine Simmons* was 14 when she knew she had to be a surgeon. Having met a young girl whose facial deformities were corrected by plastic surgery, the Queenslander says, “The result was so incredible, I thought it would be very rewarding to help a person in such a way.”

Simmons, who is now in her mid-30s, began a traineeship in 2012 with the Royal Australasian College of Surgeons (RACS). But, despite her childhood ambitions, she chose to drop out before its completion.

Half of all medical students are women, but in 2018 female surgeons made up just over 13 per cent of the active surgical workforce, according to the RACS’s 2018 Activities Report. In the same year, just over 26 per cent of surgeons who achieved fellowship through the Surgical Education and Training pathway were women.

Moreover, a 2014 analysis by the RACS showed a higher proportion of women choose to leave surgical training than men. To explore why, a team led by Gold Coast surgeon Dr Rhea Liang interviewed 12 such women. Their research, published last year in The Lancet, found several factors – such as the rigours of training and a culture of sexism, bullying and discrimination – triggered the decision. Furthermore, initiatives to keep women in the profession seem to have exacerbated the problem.

Dr Liang, who almost left training herself, says she formulated the Lancet study so data about why women choose to leave surgical training could guide effective interventions. The most important finding was that well-intentioned efforts to support women trainees can backfire, she says. “It’s a bit like when someone new starts at a workplace – the way to make them feel welcomed is not to immediately put them on a special program, emphasise their differences and perpetuate stereotypes about what they should act like,” she explains. Programs for women in surgery were “reinforcing stereotypes, emphasising differences and cutting women off from the male support and networks they really needed”.

Also, the study found that issues stacked up like blocks that tumble at a certain height. This was true for Dr Simmons. “My decision was made when it became clear that the surgical college didn’t have any regard for us as individuals,” she says. “I turned up to work one Monday morning and someone else was doing my ward round… No one had bothered to inform my consultant or I … that my job no longer existed. The head of department was very blasé about it all and said something would be found for me.”

Simmons was told to move to another town within days, at her own expense, if she wanted to continue. Fortunately for her, another trainee was recalled for air force service, which freed up a position at her original training hospital. However, the RACS took a month to tell her whether this position would count towards her surgical time, she says.

Compounding this were senior surgeons’ comments that surgery must come first and that women must inform the college of any attempt to fall pregnant, as well as “notable differences” in the way some male surgeons “treated females as inferior compared to our male registrars”, Simmons says.

The Lancet study confirmed several known factors driving decisions to leave, including long working hours, fatigue and bullying, with one participant claiming the bullying culture was set by senior consultants and filtered down through the team.

Another was the impact of pregnancy and childbirth: “The chair of the board … said on our welcome meeting with her that if we got pregnant we couldn’t expect any support from her,” one participant said.

Others cited sexism, discrimination and sexual harassment, with one participant saying, “… sexist jokes are widely seen to be acceptable and you’re considered overly sensitive, and thus not well suited to the profession, if you think otherwise.” One participant’s male colleague waved “his chest in my face saying, ‘Come on [name]. Touch my nipples. Touch my nipples. You know you want to.’ ”

Another woman was denied time off to care for her child, while a male counterpart’s leave was approved. Researchers said that rather than being treated as a surgeon requesting leave, she was treated as a woman requesting leave.

Dr Liang’s team also discovered six previously undescribed factors, including unavailability of leave, poor mental health and fear of repercussions for speaking out. One participant said, “… most people I know won’t complain about bullying … because there is so much fear about talking about it, particularly on the program or [if] you’re wanting to get back on the program.”

Liang says uncovering the multifactorial nature of decisions to leave training has helped the RACS develop a “more nuanced, complex and responsive” approach that addresses several issues simultaneously.

The RACS vice-president Richard Perry says the college has focused on building a respectful culture and believes diversity in all its dimensions strengthens the profession. “We have engaged in a profession-wide campaign of education, including presentations at surgical meetings and courses specifically aimed at increasing awareness of the pernicious nature and the consequences of poor behaviour in the healthcare environment and on patient outcomes. Gender bias and disrespectful behaviour towards women in surgery are a particular focus.

“This includes addressing broader issues that discourage women from surgical training, such as age of entry into surgical training, access to part-time or interrupted training opportunities, and more flexible on-call rosters – all issues as relevant to making the profession of surgery more family-friendly for both men and women,” says Perry.

“The widespread cultural change required is championed by male as well as female surgeons. The RACS expects its fellows to have a heightened sensitivity to incidents of gender discrimination, bullying or harassment, and to call them out. Through a number of courses, including the Operating with Respect course (OWR), we are providing them with the skills to do that.”

Launched in 2015, OWR is an evidence-based course designed to help surgeons create a safe, respectful workplace culture that positively impacts trainee learning and ultimately improves surgical care. Liang says the online OWR module has been completed by more than 99 per cent of surgeons in Australasia. Surgeons involved in educating trainees and/or who sit on advisory boards or committees must complete a face-to-face course within six months of their appointment. An OWR course for surgical trainees is scheduled for 2020.

Liang says she has seen promising behavioural changes. “We are more likely to recognise and speak up about bullying, discrimination and harassment,” she says. “More consultants are aware of what to do when disrespectful behaviours are brought to their attention. There is less stereotyping and more recognition of diversity, not just for trainees but for consultants as well – it makes as little sense to lump ‘women in surgery’ into a homogeneous group as it does to think that all men in surgery are the same.”

Dr Christine Lai, the RACS councillor and chair of their Women in Surgery group, emphasises that change must also happen where surgeons are employed. As the professional body setting educational standards, “we don’t actually have control over working conditions”, she says. Perry says the RACS has partnered with more than 30 health services and employers of surgeons to collaborate on complaints management and cultural change.

Lai says the RACS is expanding its flexible training options, with 19 trainees across Australia and New Zealand currently doing flexible training. She says the college’s target for women entering training is 40 per cent, ideally with minimal attrition. To help achieve this, they are promoting the work of female surgeons in their magazine and social media campaigns, and encouraging mentoring and networking between medical students, young trainees and fully qualified female surgeons.

Meanwhile, Simmons, who now works as a surgical assistant, doesn’t believe much has changed. “Females are still discouraged from having children during training and the options for part-time return to training post-children is a very ugly situation that I have seen friends go through,” she says, adding that bullying and surgical culture are probably slightly improved.

Lai encourages young women considering a surgical career “not to be deterred by well-intentioned people saying it’s not a career for them”.

“I had a lot of people say, ‘Maybe you shouldn’t do surgery – you don’t fulfil the stereotypical college white male in the surgical training program,’ ” she says. “Fortunately, I was naive enough not to realise there were gender inequities at the time and didn’t pay heed. There will be challenges no matter what training program you do, but I think everyone should follow their dreams and do something they truly enjoy.”

This article was first published in the print edition of The Saturday Paper on March 14, 2020 as "Operating systems".

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Sophia Auld is a freelance writer and editor based on the Sunshine Coast.

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