Being a Surgeon: It’s (Still) Not the Same for Men and Women

December 12, 2017 | Lindsay Morgan

Imagine this.

It’s the day of your surgery residency interview. You walk up to the building on the school of medicine campus. It’s named after the department founder—a woman. You take the elevator to the third floor to meet the program director—a woman—and are asked, courteously by the office assistant, a man, to please wait here and would you like some coffee. You put your bag down and look at the wall of framed photographs of the current and previous department chairs and you notice that only one of them is a man. It’s not surprising though—it’s been like that in every surgery department where you’ve interviewed.

You’re familiar with the data on gender inequities in surgery—women dominate, especially in leadership positions. And then there are the issues of pay gaps, voice, even harassment. But as the figure below shows, things are getting better. And you are proud, as a man, to be part of the changing social norms in medicine.

Figure 1 From the Association of Women Surgeons. The actual ratio between men and women in surgery is reverse.

The Real World

The world is not like this, of course. In the United States and Canada, only 8% of full surgery professors are women; 18 out of 190 chairs of surgery departments are women; and female surgeons earn 8% less annually than male surgeons after controlling for specialty, age, faculty rank, and metrics of clinical and research productivity (Association of Women Surgeons).

Women surgeons are also underrepresented in research. In a new study in Nature Human Behaviour, Stanford-trained sociologist Mathias Nielsen and his team surveyed a million and a half papers from around the world published between 2008 and 2015 and sorted them by authorship, with a special focus whether a woman was listed as first or last author. Women accounted for 35 percent of all surveyed authors and only 27 percent of last authors. (Read more about this in the New Yorker article by Rena Xu.)

At UC San Diego, the first woman resident joined the Department of Surgery in 1973. Today, female residents represent 43% of the Department’s trainee population, and women faculty in health sciences has risen—from 23% in 1997, to 41% in 2017.

Dr. Sarah Blair

“Things are a lot different now,” says Dr. Sarah Blair, Vice Chair, Academic Affairs and Professor of Surgery in the Division of Surgical Oncology at UC San Diego. “When I started out in 1992, our medical school had about 20% women. And that was considered good. Back then, as a woman, it felt like you had to work doubly hard, be doubly good. Patients assumed you were the nurse. Ancillary people in the hospital assumed you were the nurse.”

Today, she says, “We have a lot more women leaders. Almost half of our trainees our women. In terms of hospital and departmental leadership, that has lagged behind, although it’s improved in the last few years—we now have a couple women division heads.”

The Department also supports Women in Surgery (WIS), an initiative created to connect, inspire and support the professional development of women surgeons through periodic networking events; an annual lectureship; and helping women surgeons navigate issues of work-life balance; negotiating in the workplace; and leadership.

Dr. Sonia Ramamoorthy

WIS began informally in the mid-2000s as a support group for women. Dr. Sonia Ramamoorthy, chief of the Division of Colon and Rectal Surgery, spearheaded the effort. “We were new faculty, just having our first kids, trying to manage all of this stuff,” she says. The initiative was not formally recognized by the Department: “It was just sort of like our little thing.”

That changed in 2008, when the Department was confronted with a sexual harassment scandal. In a now-familiar narrative, a longtime, senior male faculty member who had trained at UC San Diego and was widely admired was discovered to have been sexually harassing residents and nurses. Then-chair, Dr. Mark Talamini, decided to invest resources in WIS and elevate it to an annual lectureship.

Says Blair: "He wanted to raise morale and bring some of the issues women face out into the open."

Since then, WIS has hosted nine women leaders in surgery, including this year’s speaker, Dr. Mary Hawn, chair of the Department of Surgery at Stanford University.

Persistent Disparities—Pay and Career Advancement
Despite progress, the experiences of men and women surgeons continue to differ, in some cases dramatically. Women physicians earn less than their male counterparts, even after accounting for age, experience, specialty, faculty rank, and measures of research productivity and clinical revenue. The 2015 Report of the UC San Diego Vice Chancellor Health Sciences Task Force on Gender Equity found similar results.After adjustment for relevant cofactors, women … faculty are paid significantly less than male faculty. The magnitude of the difference is approximately 12%.”

There are a number of drivers of disparities in compensation. Although women surgeons are paid the same dollar value per RVU, “there’s these little carve outs that they create for certain people to keep them happy, and nobody knows where the funding for that comes from,” says Ramamoorthy. “That’s not transparent. It really should be.”

Ramamoorthy also sees special appointments—which go overwhelmingly to men—as a contributing factor. “The way it impacts salary is that you can pay a man and woman 200K for the same job with the same productivity expectations. But if you give one of them a leadership position with a stipend, then that person’s salary is offset by that amount. Now the two people—same level, same experience—are benefitting differently from the system. That’s the stuff that needs to be turned over, and asked is this a justified promotion, was everyone given an opportunity to compete fairly for that leadership position, and what makes one person more qualified than another?”

Women surgeons are also less likely to advance to full professorships — even after controlling for productivity. At UC San Diego, 2016-17 data from the Office of Health Sciences Faculty Affairs shows that women’s representation dwindles at the higher ranks of full professor and FTE (see Figures), with implications for compensation.

Click charts for larger display

As part of her role as Vice Chair for Academic Affairs, Dr. Blair oversees the faculty promotion process and says that, overall, “UC San Diego actually has a pretty transparent process for promotion as opposed to some other places. The issue is more: are the women staying and sticking it out or are they going to private practice because academics is too challenging? Across the departments there are less women who stay to become full professors.”

One reason for the lack of progression to the upper ranks of professorships may be that female physicians are more likely to cut back professionally to accommodate household responsibilities. A recent New York Times article notes that, “Among young academic physicians with children, women spend nine more hours per week on domestic activities than their male counterparts, and are more likely to take time off when a child is sick or a school is closed. Women in dual-physician households with young children work 11 fewer hours per week (outside the home) compared with women without children. There’s no difference in hours worked by men, and this disparity hasn’t narrowed in the past two decades.”

Other Forms of Gender Bias

Gender differences aren’t all about pay. They are also about how women surgeons are treated and viewed—by colleagues and patients. While social norms may be slowly changing across industry, gender stereotypes still manifest, sometimes deeply, in medicine.

Many women surgeons have stories about colleagues and patients who respond differently to them when they engage in behaviors similar to their male counterparts. As Ramamoorthy recalls: “The first time I bumped into gender issues was with nurses during residency. I remember being part of a code with my chief resident running it, and watching how he managed it that. Then my day came when I was running the code, and I got written up for talking in a heated way to people to get them to do what I wanted them to do. I didn’t see it as anything different from what he or any of the other males I was working with were doing. I was really surprised to get complaints.”

Dr. Simone Langness

Simone Langness, a Chief General Surgery resident and member of the Graduate Medical Education Committee, says “It’s challenging—figuring out how to have confidence and authority as a surgeon while also being yourself. There’s a lot of bias towards women with other providers and ancillary staff. When I started, the examples I’d had from older female residents was to be pretty aggressive. I thought that’s what I needed to do. It took a few months for me to realize that that’s not me and it wasn’t working.”

Dr. Jeanne Lee

“What hasn’t changed is the notion that women aren’t doctors,” says Dr. Jeanne Lee, Director of the UC San Diego Burn Center and Associate Professor of Surgery in the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery. “That they’re always nurses whenever you see them. That happens all the time. You go around to see patients, you’re the woman in the room. There’s a guy in the room—he’s a student. They still think the guy is their physician.”

Women also face unique issues when it comes to starting a family. While men can have biological children into their 70s and beyond, women can’t.

Says one resident: “I’ve been stressed out about when to have a family, and jealous of male colleagues who have wives who aren’t in the profession.” After numerous years in training, and the potential for more in fellowship, she is interested in freezing her eggs. But “trying to do it as a surgical resident is comical,” she says. “It’s one of those important life goals and the field of surgery could adapt better. If I had to do chemo, no one would think twice about ensuring I had the flexibility in my schedule to do that. But when I try to do something proactive—to ensure I can reproduce—it’s perceived in a different way.”

Critiques of Initiatives like WIS

Do initiatives like WIS succeed in narrowing gaps between men and women or do they unintentionally exacerbate them? Says Lee: “I don’t necessarily like to separate myself from the guys who are in surgery. Then what happens is that people look at women in this field as being different and I don’t think that should be the case. I think everyone should be evaluated the same. When you start separating people out because of their gender I feel like the expectation is different.”

“Points shouldn’t be awarded just because you’re female,” says Langness. “You’re awarded because you bring value to the field. Because of your intellect and the difference you make. We don’t highlight women because they’re different, we highlight them because of their accomplishments. The problem is there are biases that prevent us from seeing women’s accomplishments.”

Looking Ahead

Huge progress has been made in narrowing the gap between men and women in surgery, and, importantly, a stronger constituency of women is leading the charge for equity.

But work must continue.

As Dhruv Khullar, MD, MPP, of New York-Presbyterian Hospital writes:Disparities don’t close on their own. They close because we close them.”