The Impact of Work Hour Restrictions in Surgery

Surgery is a time demanding job and that is indeed one of the reasons cited by female and male medical students alike of why they are not interested in going into surgery. While many people argue that long work hours are necessary to avoid frequent handoffs of care and loss of information, others point out that long work hours are detrimental for both physical and mental health and can lead to additional errors.

A study speaking to this issue comes from the US, where Matthew Hutter and colleagues investigated the effects of mandated restrictions in the work hours of surgical residents. Notably, we are not talking about restrictions that would make their work hours “normal” by any regular-work-person standards. Their work was restricted to 80 hours a week. But even so, they found effects after the changes were implemented including decreased burnout and increased quality of life. However, participants also voiced concerns about reduced quality of care.

These issues are of course also important for part-time work, which seems to be an option that many women in surgery would like to opt for. So how can the same benefits be achieved while maintaining a high quality of care for patients?

Working Part-Time?

Last week we reported some interesting findings on the effects of different arrangement aimed at helping women in the workplace on female physician’s career motivation. Today, we would like to focus on other effects of those measures, working part-time. This measure aims to give women, especially those with kids, the opportunity to spend more time at home without abandoning their careers. However, a study by Rosemary Crompton and Clare Lyonette shows how problematic part-time work can be. In their qualitative study with accountants and physicians they find that working part-time is perceived as quite detrimental to women’s careers and the type of work they can do, especially for physicians working in hospitals. One participant notes:

“a lot of the time the part-time posts are just waiting list initiatives, you know, they need somebody to see this number of back pains or this number of people with such and such, whereas a full-time post, you’re part of a team, you’re setting up a service or doing something a bit more meaningful. So it would be difficult to get the equivalent post as a part-time person, I think.”

The authors also note that women in medicine try to avoid specialties in which part-time work might be detrimental (such as surgery) and prefer going into General Practice, which is perceived as more family friendly. On the bright side – at least for all you women in medicine – , the authors find that women in medicine fare considerably better than those in accountancy. However, whether that holds true for women in surgery, is another question.

The Conflicting Roles of Female Doctors

Working women with children in general and those in masculine domains in particular are confronted with a dilemma: Based on traditional gender roles, the ideal of a good mother requires them to focus most of their attention on their children and make sure they spend enough time at home, while the ideal of a good worker involves being committed to their job and able to focus most of their time and attention on work related issues. Men don’t face this issue as the ideal father is mostly characterised by being able to provide for their family, which is not in conflict with the ideal worker. So how do women deal with this conflict and how does it relate to their career motivation? Moreover, how can organisations alleviate this conflict?

A study by Berber Pas and colleagues from the Netherlands distinguishes between four different groups of women: Those who identified with the role of the ideal mother but not the role of the ideal worker (the authors call this the care goal frame), those who identify highly with the role of the ideal worker but not the role of the ideal mother (career goal frame), those who identify highly with both (switching goal frames) and those who don’t identify highly with either (non-traditional goal frames).

They further distinguish between three different types of policies which organisations implement in order to help working mothers. One set of arrangements aims at providing working mothers with the opportunity to fulfill their role as an ideal mother and spend more time with their children (ideal mother arrangements), for example part-time work arrangements. Another set of measures (ideal worker arrangements) aims at helping women to fulfill their roles as ideal workers, for example by providing coaching and mentoring. The last set of arrangements (revising work-culture arrangements) includes measures such as flexible work hours and is generally presented in a non-gendered way.

They investigated the relationship between these variables and career motivation in a large sample of female physicians and found that those women with switching goal frames were just as motivated as those with career goal frames and more motivated than the other two groups. Not surprisingly, the effectiveness of measures to increase women’s motivation depended on their goal frames. Women with career goal frames benefited from ideal worker arrangements whereas those with care goal frames benefited from ideal mother arrangements. Revising work-culture arrangements were overall the most motivating regardless of goal frames.

For more details, please check out the original paper, which is a very fascinating read.

Guest Blog: Take it Like a Man

Oooh, exciting! This week we have a guest blog! The awesome Tiffany from Surgery at Tiffany’s (a blog which I can highly recommend) has kindly agreed to share her response to out post about whether or not women in surgery are less confident than their male counterparts.

If you are interested in guest blogging on this site some time, please get in touch. It would be great to make guest blogs a somewhat regular thing! But now, without further ado, here is what Tiffany has to say:

When I was accepted into plastic surgery training back in my mid-20’s, I was the only female plastic surgery trainee in the state. There was only one female plastic surgeon working in town, but she was trained overseas and imported into our hospital. She was my mentor and ally. She told me stories of her training and gave me valuable insight into the minds of my male colleagues.

When I first started training, I used to get upset about every little thing. She used to shake her head at me and said that I should toughen up, use my stiff upper lip, and basically grow a tough hide. But it wasn’t until she said to me ‘Take it like a Man’ that I realised to succeed and survive my training, I needed to be like my male colleagues. I needed to be one of them.

Behaviour

Short of wearing pants and ties, I started to observe my colleagues. They don’t cry when they get upset (well, maybe only when they were very very drunk), and they tell you as it is when they are. However, when I started to behave like one of the boys, people’s response to me was completely different. When one of my male colleagues started to rant and rave about something that had not been done for his patients, deathly silence ensued, and the nurses scrambled to do his bidding. When I mention that a certain instruction was not followed, nurses shrugged their shoulders at me and I was called a bitch behind my back.

Once, I watched one of my colleagues brush off a female patient’s concern as if it didn’t really matter. The patient reacted by shrugging her shoulders and put it down to ‘he’s a man, he doesn’t understand.’ Yet when I inferred a similar response to her complaint, she carried on about how that I was an unsympathetic doctor and should have been more understanding of her feelings.

So I learnt my lesson. I had to be tough like a male, but I needed to behave like a female, because my co-workers and my patients expected me, as a woman, to be more perceptive to their feeling, to be gentler, thoughtful, considerate and compassionate. All the qualities of their mothers.

Competency

And yet what did people expect of my abilities as a female?

There are several facets to this issue. Firstly, people make assumptions that you understand certain aspects of their lives, or have specific skills because you are female. Patients often tell me that they have specifically chosen me as their surgeon because I am female. That they know I will pay more attention to detail, that my work would be more delicate and that I have gentler hands. I have found these ideas vocalised more from female patients, although the back-handed sexist compliment makes an appearance now and then from the male patients: ‘Female hands are made to do fine embroidery, your sewing would be better.’ This is all inference without evidence. Some of the best microsurgeons I have had the privilege of learning from, are male surgeons with big clumsy-looking hands who couldn’t sew a hem to save their lives.

Some tell me that I would better understand what results they are after because I am female. One of my specialties is cosmetic and reconstructive breast surgery. Even my colleagues have presumptions and send their wives to me as a preference because I would know what beautiful breasts are supposed look like. I have my suspicious that it was more because they hesitate to have one of their male colleagues handling their wives’ bosoms. I often joked with them that beauty is in the eye of the beholder, and unless their wives are lesbians, what I thought would not really matter. Not to mention, as far as I was concerned, you are too big if you are bigger than me. Without fail, their gaze would lower to the A cup push-ups I wore hidden under my dress. The disappointment in their eyes when they come back up to my face is almost comical.

An interesting social survey that was done locally in my state by the Plastic Surgeons’ Society showed that majority of women preferred a male plastic surgeon for cosmetic procedures, but female plastic surgeons for reconstructive procedures (e.g. after cancer surgery, or for treatment of congenital deformities). I guess this may just be a reflection of the underlying reasons for these procedures. Most of the patients who have cosmetic procedures book in because they want to look attractive for the opposite sex, whilst those who have reconstructive procedures proceed for their own self-esteem.

But realistically, are male surgeons better than female surgeons? My personal experience is that overall, the common public perception is that male surgeons are more competent. It is not that unusual for my patients to ask for a second opinion specified to be from a male surgeon. It is also not uncommon that patient find it easier to accept an opinion (especially one that they do not agree with) from a male surgeon. Sometimes I would argue patients until I am blue in the face about my decision, and yet when my male colleague comes to the same conclusion, the answer is a meek ‘Yes, whatever you think is best, doctor.’ It is also not uncommon that when I am doing ward rounds with my junior male residents, the patients look to them to reassurance, assuming that they are the doctors in charge.

This perception is not just restricted to patients. I have had male colleagues who have volunteered to take difficult cases from me because they felt that it was stress I didn’t need or the procedure would be too long for me. I have had to stop myself being a ‘hypersensitive girl’ and ask them if they were questioning my competency; instead, I would often smile sweetly and tell them that ‘you are so thoughtful, but I really enjoy the challenge’. There is also no doubt that my male colleagues are particularly protective of me at times. Once I was bullied by a male colleague from another specialty, because he was not willing to accept that he made a mistake with my patient, an incident which I unfortunately had to bring up at the morbidity and mortality (M&M) meeting. The next thing I knew, two male surgeons from my department cornered the poor man in the tea room two days later. Ever since the incident, that particular surgeon seemed to be awfully fond of stairs when we bump into each other at the hospital lifts. The male protectiveness didn’t just come from senior staff either. When I have had to visit the secure unit (prison hospital) to see some patients with my junior residents, I have had male residents trying to protect me from seeing obnoxious abusive patients. Sweet, but totally unnecessary. I was more effective in getting the prisoners to comply with their therapy than any other surgeon. Apparently a pissed off female surgeon is a lot more terrifying than a male one.

Confidence & Self-Esteem

So with such behaviour surrounding female surgeons, you would think we have no confidence or self-esteem in ourselves. Yes and No. I believe these are two very different things.

Confidence is a projection, or a façade as I’d like to think. This is something a lot of female surgeon learn very quickly early on in their career, because a show of weakness or doubt, especially in front of our male colleagues or senior staff, was a sign we didn’t have what it took to be a good surgeon. Being decisive and making good clinical judgement is the crux of a good surgeon. Several times throughout my career it was emphasised to me that you could teach a monkey to operate, but you could never teach it to choose the right operation. Personally, I don’t think it is hard to project the illusion of confidence, because you see it around you constantly from all your colleagues. I don’t need to puff up my chest or spit at my feet, but when I announce my decision to the team, it is clear to all and sundry that it was my way or the highway.

Self-esteem, however, is another matter. It is no secret that females are more introspective than males. Looking at the gender difference in the psychology of cause and reason – females tend to blame themselves, and males tend to blame external factors. This is no different in surgery. How many times during an M&M have I had to listen to my male colleagues go on and on about how the surgical instruments they were using were old and unreliable, about how the patients were non-compliant, about how the disease was so advanced or that the patient’s anatomy was abnormal. Whereas I hear female surgeons lament about how they should have done this, thought about that, or even not have taken on the challenge in the first place. Whenever an unexpected problem occurs, the female will look inside themselves for reasons rather than recognise that sometimes the patient’s pathology defeats even the best surgeons.

This is something I constantly remind my female trainees (and myself from time to time). I tell them that there has never been any evidence that female surgeons are less competent than male surgeons. Yet, we have an innate inferior complex about ourselves. We tend to beat ourselves up when things go wrong. Then we are tempted to fall in a heap of self-pitying mess. I often tell them that we can’t ignore this female psyche we possess, if anything, it makes us a better surgeon because we are constantly evaluating ourselves. But we have to have the insight to understand that too much of it can be debilitating. Good surgeons should be able to move on from their complications, ‘failures’, and mistakes – to learn from it, and start the next case as a completely fresh problem. We shouldn’t be accumulating ‘baggage’ which erode our self-esteem, because our patients rely on us making the right decisions for them at every crucial moment – and the right decisions are never made when self-doubt takes over the decision making process.

Confidence and self-esteem does go hand in hand. The more self-esteem one possesses, the easier it is to project confidence. However, the biggest trick in the trade is to be able to take criticisms, scrutinies, mistakes and failures on the chin, and yet still project the same confidence so that both your colleagues and your patients will continue to have faith in your abilities. If being a female means you are more critical of yourself, this is not necessarily a bad thing, it just need to be moderated. Having good support from a sympathetic colleagues (male or female) can also go a long way.

Even though surgery is slowly being ‘infiltrated’(as one of my male colleagues like to put it), by females, it is still very much a male-dominant area of medicine; partly due to diminishing remnants of the ‘Old-boys’club’ attitude, but mostly due to its unrelenting hours and commitment. A career in surgery is unconducive for the stereotypical role of women – one of bearing babies, spending time with family, home making and baking cookies. Honestly, the only babies I see are those in the hospital, and the only baking I do is with a diathermy.

So until we have more female surgeons, and society start to see us as the norm, my belief is that we should Take it like a Man, but Give it like a Woman.

Obstacles for Women in Pediatric Surgery

Just as any are within surgery, pediatric surgery struggles to recruit women. But what might be some of the barriers women in this field face and how do they influence job satisfaction? In order to investigate this issue, Donna Caniano and colleagues sent out a questionnaire to 95 female pediatric surgeons in the US.

They found that, in line with what female medical students might fear, women in pediatric surgery did express a desire to spend more time with their families and more room for personal interests in their lives. This is obviously an important issue which needs to be addressed. Offering part-time work may be an option and about half of participants showed interest in reduced hours. Moreover, about a third of female pediatric surgeons expressed interest in fixed-time schedules. However, women working in academic surgery were concerned that this would interfere with their career.

On a more positive note, regardless of these issues most women reported high career satisfaction, perceived their career to be rewarding and would make the same career choice again. Nevertheless, the issues raised above need to be addressed in pediatric surgery, but also in surgery in general.

Are Women in Surgery Less Confident Than Their Male Counterparts?

Research in achievement domains such as the workplace and education shows that while men over-estimate their performance, women under-estimate how well they are doing. This is especially true in areas that are stereotyped as being “masculine”. It could thus reasonably be expected that this would also be the case in surgery.

However, Rebecca Minter and colleagues investigated this issue in a study and found that this wasn’t the case. While they did find a trend such that female general and plastic surgery residents under-estimated their performance to a greater extent than their male counterparts, this difference did not reach significance. There were also no gender differences with regards to actual performance.

Together with the study we reported on last week, this is promising. It seems that the perception of women in surgery as less competent is changing not only in the general public, but also in the eyes of those women who are involved in surgery themselves.

Stereoypes, They Are a-Changin’

While women are generally seen as more warm and caring, men are perceived to be more competent. Unfortunately, these stereotypes are especially pronounced in male dominated fields such as surgery. However, a study by Kamyar Noori and Allyson Weseley gives hope that these stereotypes are slowly changing.

In their experimental study they presented men and women with the profile of either a male or a female physician who was either a surgeon (and thus a member of a male dominated field) or a dermatologist (a member of a female dominated field) and then asked them about their perceptions of warmth, competence and willingness to see the physician. Surprisingly, neither specialty nor gender influenced the perception of competence. Women, even those in a male dominated field, were perceived as just as competent as their male counterparts. Interestingly, the stereotypes around how caring the physicians were perceived to be depended on who was asked: While men rated female physicians as more caring regardless of specialty, women tended to rate those in counter-stereotypical fields (i.e. the female surgeon and the male dermatologist) as more caring.

Overall, this study gives hope that gender stereotypes in medicine may indeed be changing. Go humanity!

Are Female Doctors With Young Children Less Motivated?

No. No they aren’t. Although it is often claimed that career motivation suffers from having children – at least for women – a study by Berber Pas and colleagues from the Netherlands finds that this is not necessarily the case. Neither being a mother nor the age of the youngest child significantly predicted career motivation.

What did matter, however, was one’s view on motherhood. Those who had more traditional views on what a mother ought to be (e.g. spending most of their time with their children) were less motivated than those who had more modern views on this issue. Moreover, a supportive work environment – especially supervisor’s support for one’s career goals – was beneficial for career motivation of female doctors.

This clearly shows that the negative attitude of some employers towards working mothers – or those who might one day become mothers – is quite unwarranted. Instead, it is important to focus on supporting female doctor’s career goals and changing unrealistic expectations of what a “good mother” is.

Career Satisfaction of Female and Male Surgeons

Despite the low number of women in surgery, those who do decide to become surgeons generally report high job satisfaction that does often not differ very much from that of their male counterparts. However, do they achieve their satisfaction in different ways? A study by Nasim Ahmadiyeh and colleagues investigates this issue.

They interviewed a sample of male and female surgeons who were all married and had children using semi-structured interviews and found, among other things, that men and women in surgery did indeed report similar levels of career satisfaction. In addition to that they also did not differ in the degree to which they had made trade-offs between their careers for their personal lives or vice versa. However, when talking about the reasons for their satisfaction and dissatisfaction, men and women differed. While male surgeons mostly named internal job characteristics as reasons for dissatisfaction, female surgeons spoke much more often about a lack of support and lack of credit. Furthermore, women also seem to rely on different strategies for success. They stressed the importance of social networks – professional as well as personal – far more than men did. This, of course, makes sense if they experience a lack of support.

These findings indicate that networking opportunities such as Women in Surgery are indeed very important and beneficial for female surgeons as they address the lack of support experienced by them.

Changing the Perceptions of Surgery

Surgery is not just struggling to recruit women – there has been a decline in the popularity of surgery among medical students in general. Luckily it seems that even brief and easy to organise interventions can make a difference. Rosemary Kozar and colleagues report on such an intervention in a short and interesting paper.

In their intervention, first year medical students listened to a panel of surgeons speak about their career satisfaction and lifestyle. The authors found that this did indeed change the perception of surgery. For example, the length of training was seen as less deterring after the intervention.

This study indicates that interest in different sub-disciplines of medicine might often be based on stereotypes and prejudices and that it is important for surgeons to be proactive and share their experiences with the next generation of doctors.