Is Surgical Culture Changing?

As a new generation enters surgery and as the number of women in the field is (slowly) increasing, one could hope that this also changes surgical culture. But does it? Judith Belle Brown and colleagues asked themselves exactly this question and conducted an interview study with academic surgeons.

Despite the fact that women still reported more struggles to achieve a good work-life-balance, participants overall noted that surgical culture was indeed changing and that surgeons were no longer expected to devote every waking hour to their jobs. For example, one participant noted: “I think things have changed over the years…I mean surgery in the past has been you just work hard, this is your life, and I think it’s changing a little bit … you are allowed to have a life outside. I think that’s good.”

Moreover, participants stated that this change did not only affect attitudes towards work-life-balance in general, but also attitudes towards childcaring responsibilities. One surgeon said: “I think the younger male colleagues, like my generation, it’s a bit different. We’re seeing more and more male surgeons who are doing more stuff at home … and they’re also having to leave early to pick up their kids because their wife is working too… So it’s changing. It’s not like how it used to be, 20 or 30 years ago.”

So let’s hope that these changes prevail!

Why Do Women Leave Male-dominated Professions?

Concerns about childcare are an often cited reason for women to leave (or never enter) male-dominated fields such as surgery – and these concerns need to be addressed. However, a recent study by Nadya Fouad suggests that childcare concerns might not be the main culprit that drives women away.

In her survey with women who held engineering degrees the author found that most women who had left engineering had not done so in order to stay at home and raise a family but had rather left the industry to work someplace else. Moreover, the reason these women cited were very similar to those that men usually cite for leaving their jobs – inhospitable work climate and a lack of opportunities for career advancement (although caregiving responsibilities were also an often cited reason).

This demonstrates once again that leaving certain occupations is not due to some inherent lack of interest among women. On the contrary, women and men are looking for quite similar things in their careers – but men might just have an easier time achieving these goals in male-dominated fields.

The Effects of Perceived Gender Discrimination

Gender discrimination has obvious negative effects such as keeping women from rising to leadership positions or achieving equal pay. That alone should be enough reason to address these issues but there is also evidence that demonstrates the negative impact of perceived gender discrimination on women’s motivation – one of the key ingredients to high quality work.

Sharon Foley and colleagues investigated these issues in a sample of solicitors. Not surprisingly, they found that women perceived higher levels of gender bias against women and more personal gender discrimination compared to their male counterparts. This perceived personal gender discrimination was directly linked to two important motivational outcomes. First, it predicted solicitors’ organisational committment, and second, higher perceived gender discrimination was associated with higher intentions to leave the organisation.

This study shows how important gender equality is not just for its own sake but also for keeping women motivated and committed and ultimately ensuring that their talent and expertise is not lost.

Patients May Not Be All That Biased

There is a lot of research on how women in male-dominated areas (e.g. management or politics) are in a somewhat “damned if you do, damned if you don’t” situation. When they present themselves in a warm and feminine way their demeanor is at odds with what the field requires (e.g. they’re not perceived as “real leaders”), but if they present themselves in a masculine, assertive way, they’re not perceived as “real women” and thus disliked. So is that also the case in surgery? A recent study by Marie Dusch and colleagues suggests that this may not necessarily be the case, at least not from the patients’ perspective.

They presented patients in a general hospital with short scenarios describing either a male or a female surgeon who presented themselves in either a feminine or masculine way. Moreover, they were described as either performing breast cancer surgery or lung cancer surgery. Somewhat surprisingly (at least to me) patients did in general not prefer male surgeons over female surgeons or masculine surgeons over feminine ones. Neither did they prefer masculine male surgeons to feminine male surgeons or feminine female surgeons to masculine female surgeons – nor the opposite. In fact, the only significant result they found was that for lung cancer surgery, masculine surgeons were seen as more competent regardless of gender.

While it is important to replicate these results before drawing strong conclusions, this study nevertheless shows that gender stereotypes in surgery may be slowly changing or at least not be as pervasive among patients as we might assume.

Stereotype Threat in Medical Education

Stereotype threat is a psychological phenomenon in which people feel at risk of confirming a negative stereotype about their group, even if they don’t believe the stereotype to be true. For example, a woman might be confident in her math abilities and the math abilities of other women, but still be aware of the stereotype that women aren’t good at math. This feeling of anxiousness is then associated with lower performance.

An interesting study by Katherine Woolf and colleagues suggests that in medical education, students of Asian origin might experience a different kind of stereoype threat. While they are perceived as smart and studious, they are also seen as too quiet and not good at interacting with patients. Moreover, they are often seen as being forced into medicine by their parents, all of which can lead to stereotype threat among them. For example, one teacher notes “Students that are of South Asian or Indian origin, tend to be, or come across as being far more academically knowledgeable and they can justify what they’re doing and they’re very very bright, but actually putting that into practice and both with communication and practical skills doesn’t seem to gel that well”. The study further suggests that Asian medical students are aware of these negative stereoypes and that this does influence their behavior. The auhors illlustrate this with the example of one of the Asian students in their study: “she recalled hearing clinical teachers talking about the number of students from ethnic minorities at medical school and how she believed that teachers presumed that as an Asian student with medical parents she had been forced into medicine (the stereotype). She perceived they purposely made life harder for her, resulting in her feeling under psychological pressure (stereotype threat) and forced to prove that she was worthy of being at medical school. To prevent people making stereotypical assumptions about her she avoided telling people about herself.”

The Belief in Meritocracy as an Obstacle for Minorities in STEM/M

The fields of science, technology, engineering, mathematics and medicine are often constructed as fields in which scientific ability is all that matters for success. Topics such as gender and race are often not discussed despite the fact that the majority of members of those fields are still white men. An interesting interview study by Angela Johnson illustrates how this construction of science as a meritocracy can negatively impact minorities, namely female science students of colour in the US.

The author acknowledges the good intentions of constructing science as a race and gender neutral field – because none of these variables should matter, but she also highlights that this can have negative, unintended consequences as it makes gender and race topics that cannot be openly discussed. She notes: “Belief in the meritocracy of science made the way that some laboratories were divided by race and ethnicity seem like a matter of personal choice (which, in a sense, it probably was). When students felt otherwise (…) there was no room for these suspicions within the race-neutral culture of science.”

This unintended, but also unaddressed, segregation of minority students is especially important in the light of findings that suggest that a lack of fit and belonging in a field has severe negative consequences for motivation and career intentions.

How Do Role Models Work?

We’ve highlighted the importance of role models in general and female role models in particular in a number of quite a few of our past posts. Research suggests that role models serve different functions and lead to different outcomes and that gender is not necessarily important for all of them. However, other studies suggest that gender does matter, especialy in domains in women are under-represented, and one reason why that might be the case is that they can change stereotypes.

STEM/M fields in general and surgery in particular are stereotypically associated with men and maleness. The first person one might imagine when thinking about a surgeon is likely to be a man and when asked to describe a surgeon, stereotypically masculine traits such as “cold” might be used. The so called Stereotype Inoculation Model developed by Nilanjala Dasgupta argues that role models might act as a “social vaccine” and inoculate against these stereotypes which prevent women from entering or staying in STEM/M fields.

She proposes that when exposed to other minority members in one’s domain (e.g. other women in surgery), minority members can identify with this person, which then leads to changes in stereotypes and a stronger identification with the field (e.g. with surgery), but also a more positive attitude towards the field, social belonging in the field, perceived threat and one’s perceptions of one’s own abilities.

Thus, while male role models might be just as effective in some regards (e.g. for learning by emulation), visible female role models in surgery are important – not just for those women already on their path to becoming surgeons, but also for those who might not have made their career choices yet.

Harassment and Career Satisfaction of Female Physicians

Sex-based harassment at work has been a problem since women started entering the workplace. But how much of a problem is it in the medical profession and how detrimental is it for job satisfaction? In a survey with a large and representative sample of female US physicians, Erica Frank and colleagues give an answer to this question.

Quite shockingly – and we sincerely hope that this fact has changed in the 15 years since this study was conducted – almost half of the over 4000 participants report a history of sex-based harassment in a medical setting. Younger physicians were especially likely to report a history of sex-based harassment. Moreover, this was predictive of all three measures of career satisfaction: whether they felt satisfied, whether they would choose to become a physician again and whether they would like to change their specialty.

This shows that sex-based harassment is indeed a problem in the medical profession and the fact that especially younger women reported experiences of sex-based harassment in the workplace suggests that there is not necessarily a decline in sex-based harassment in medicine. The topic therefore needs to be addressed.



Male and Female Role Models in Academic Medicine

The lack of female role models is often cited as one reason of the under-representation of women in various fields – surgery among them – and psychological research shows that role models can indeed be very beneficial. They can teach us how to reach our goals, demonstrate that goals are attainable and inspire us to adopt new goals. However, some women in surgery argue that role models don’t necessarily need to be female and that male role models can be just as effective.

A study by Lori Bakken suggests that it depends. Women and men in different career stages were asked about their own ability beliefs with regards to a number of skills such as scientific writing. They were further asked about who they envisioned as an expert role model while making those assessments as well as a number of questions about this role model. For example, they were asked which important qualities the expert had. Results showed that male and female participants who described a male role model did not differ in what skills they based their role model selection on. “Multiple publications”, “supportiveness” and “scientific knowledge” were most widely reported both by male and female participants. Female participants who had chosen a female expert, however, reported “problem solving abilities” and “communication skills” more frequently in comparison to men who had chosen men.

Thus, it seems that men make just as good role models for women who are looking for similar qualities in a role model as their male counterparts do. However, for those who value other qualities such as problem solving ability or communication skills, female role models might be more important.

What matters to female and male medical students?

In order to address the under-representation of women in surgery it is important to understand what female medical students deem important in their future careers. Do they value the same things as their male counterparts and just don’t think that they can achieve those goals in a surgical career or are they actually looking for different things in their careers? A study by Nancy Baxter and colleagues suggests that the latter is the case.

They sent out a questionnaire to Canadian medical students and found that men and women named different factors as important for choosing their specialty. Women placed more importance on the availability of part-time work and parental leave as well as residency conditions, while men valued technical challenge, prestige and earning potential. As both male and female students agreed that surgeons earn a lot of money but do not have high quality family lives, it is not surprising that of the participants, men were more likely to choose surgery as the specialty they were pursuing or considering to pursue.

This study once again highlights two facts: First, it is important to make surgery a career in which family related goals can be achieved by both men and women, and second, the fact that a family and a career in surgery can be combined needs to be communicated effectively to medical students.