By Victoria Cook
Victoria attended the 2016 UN Commission on the Status of Women in New York.
Since 2001, the majority of students graduating from Australian medical schools have been female. Yet in 2015, only 9.2% of surgeons were female, a figure that declines further in sub-specialties such as orthopaedics. Female students accurately perceive significant gender-based barriers to building a successful career in surgery. These negative perceptions are compounded and exaggerated by experiences of medical education. Increasing the numbers of women in surgery requires a comprehensive approach across all stages of medical education, as well as surgical training and practice. This paper will focus on the role that universities can play in encouraging a more gender-neutral pattern of specialisation in medical graduates, in particular by increasing the number of female graduates choosing surgery.
This report recommends that university medical programs develop comprehensive gender equity policies and commit to fostering a more gender-neutral pattern of specialisation in their graduating students.
1. Gender discrimination and unconscious bias training
1.1 Collaborate with clinical attachments to train surgical educators in avoiding gender discrimination and identifying and rectifying patterns of unconscious bias
1.2 Incorporate gender equity requirements in performance assessments and teaching feedback
1.3 Develop reliable mechanisms for students to report instances of gender discrimination in surgical rotations
2. Mentorship programs and exposure to female surgical role models
2.1 Aim to expose the majority of medical students to female role models in surgery
2.2 Monitor gender composition of surgical educators and administrators
2.3 Collaborate with surgical professional bodies to implement a ‘mentorship’ or ‘surgical-experience’ program to increase positive exposure to female students interested in surgery
3. Fostering female surgical leadership and participation in research at the university level
3.1 Consider gender equity policies for academic promotions and progression in surgical departments.
3.2 Develop formalised pathways for students to gain surgical research experience
4. Monitoring and reporting of measurable gender equality objectives
4.1 Develop sampling mechanisms to monitor the evolution of career preferences during and after medical school
4.2 Report on gender-splits in surgical education and research positions
4.3 Monitor instances of reported gender based discrimination in surgical rotations
5. Encourage visible leadership and accountability in implementation of the gender equity interventions
5.1 Develop a consensus statement on the importance of gender equity and reducing gender based barriers in medical school
5.2 Incorporate gender equity expectations into the code of conducts for students and faculty
5.3 Appoint a gender equity officer to oversee the implementation of gender equity policy and monitor progress
Female students have been graduating medical school in significant numbers for over 30 years. Yet in 2015, only 9.2% of surgeons were female, a figure that declines further for other surgical sub-specialties such as orthopaedics (3%) . Research in Australia and abroad consistently identifies high rates of gender discrimination in the surgical profession. In particular, research describes a paucity of female leadership, unequal progression of female surgical careers compared to male peers and higher rates of attrition for female surgeons. Barriers to female participation in surgery occur at many levels and interventions to correct the under-representation of women in surgery will need to be multifaceted and coordinated with a variety of stakeholders including universities, health departments and professional bodies.
Historically, female absence from procedural specialties was considered a reflection of differing professional and personal priorities including a lack of interest in ‘technical skill’, a preference for ‘patient contact’, and a desire for a career with more family friendly hours  . Others argued that the disparity would simply correct itself with time. Given the enduring nature of the problem, and the predominance of women in highly procedural and unpredictable specialties such as obstetrics and gynaecology, these hypothesizes have been discarded for a more nuanced view of a structural barriers deterring women from selecting or succeeding in a career surgery  . This approach returns the onus for increasing gender diversity from individuals to the professional and educational institutions they belong to.
Surgery in Australia remains a popular and competitive choice. Each year applications for positions on Surgical Education and Training (SET) programs exceed available places, and surgery retains is aura of competitiveness and prestige . However, patterns in the US, UK and Canada show a declining interest in the surgical profession  . Yet, the profession has been largely resistant to the influx of female graduates, and is effectively excluding a proportion of the best and brightest graduates because they do not fit its traditional demographic.
This paper will focus on the role that universities, as the facilitators of the first formal contact of medical students with the surgical profession, can play in encouraging a more gender-neutral pattern of specialisation in medical graduates, in particular by increasing the number of female graduates choosing surgery.
Evidently, increasing recruitment of female trainees to the surgical profession is meaningless without a simultaneous commitment to retaining and nurturing women within the profession. This paper endorses the recently released Royal Australian College of Surgeons’ Action Plan for combatting DSBH ‘Building Respect, Improving Patients Safety’ in the surgical profession, in particular its commitments to increasing gender diversity, fostering female leadership and eliminating gender-based discrimination and sexual harassment .
This paper also acknowledges that measures to increase gender diversity in surgery are futile without a simultaneous commitment to increasing flexibility of training programs and work schedules for young surgeons. This includes, but is not limited to, increasing access to parental leave schemes and job-share options. No strategy to increase the participation and progression of female surgeons will be successful as long as female trainees are required to choose between delaying or foregoing children in order to pursue an ambitious surgical career.
Countering the gendered messages around surgery in medical school:
The proportion of female SET trainees is rising, but at a slower rate that other specialty training programs and variably between subspecialties . In 2014 56.7% of pediatric surgery trainees were female, yet women made up only 9.7% of orthopaedic trainees. In comparison over 80% of trainees in obstetrics and gynecology are female. Female applicants to SET programs are accepted at a proportionate rate to male applicants, therefore lower female trainee numbers are a result of less female graduates choosing to apply to surgery, and high rates of attrition of female trainees.
Students form some perceptions of specialties even prior to beginning at medical school, yet research shows career aspirations change markedly during medical school . The most significant factor influencing career choice in medical graduates is gender . Medical schools have a role in shaping career aspirations of their students . Strategies to minimize the influence of gender-based factors on students at medical schools are central to achieving an equal pattern of specialization in students post-graduation.
One of the key mechanisms implicated in the development of medical school perceptions of specialties is the concept of a ‘hidden curricula’. The ‘hidden curricula’ refers to the cultural knowledge, beliefs and behaviors acquired at medical school through informal routes. In medical school the ‘hidden curricula’ is described as ‘powerful, visible, gendered and discriminatory’ . At medical school students develop distinctly masculine stereotypes of ‘typical surgeons’ and learn to anticipate barriers based on gender . Strikingly, both female and male medical students gain a general understanding that surgery is not a career welcoming women .
Female medicals students interested in surgery cite the same reasons for their choice as male candidates . However, compared to male students, female students disinterested in surgery cite different reasons for this preference. Commonly cited factors include negative experiences on surgical rotations, a perception of surgery, as a male dominatedspecialty, an ‘old boys club’ mentality, difficulty maintaining family life, limited flexible training options, few female role models, long hours, and poor attitudes in surgical teams .
Therefore, increasing participation of women in surgery requires addressing negative perceptions of surgical careers in female medical students and affording a broader characterisation of a ‘typical surgeon’. Medical schools must actively engage and counter this damaging ‘hidden curricula’ to dispel negative stereotypes that are damaging recruitment into surgery. This may be achieved by the broad policy measures outlined below.
Gender discrimination and unconscious bias training:
Fnais et al. (2014) found that, in a cohort of third year medical students, inappropriate gendered behaviour was ubiquitous in medical training . Women experienced higher rates of gender discrimination on surgical rotations. Overt discriminatory or sexist comments are the most common predictor of a negative perception of surgery. In the US, a study found that 87% of women observed or experienced gender-based discrimination surgical training at medical school.
Additionally, unconscious gender bias contributes to students’ perceptions of specialties, confidence levels and career choice  . Training in unconscious bias raises awareness of thought or behavioral patterns that inadvertently disadvantage a particular group. For example, male medical students receive more exposure and hands on experience in surgical training rotations than their female peers 
Acknowledging the powerful influence of supervisors on learning outcomes for trainees is crucial. In addition to excellent knowledge in their disciplines, clinical supervisors need to have knowledge and skills in the areas of teaching methods, different learning styles, ethics, patient safety and sexual stereotyping. Being a senior doctor is not a qualification for teaching in itself…
Clinical tutors, examiners and lecturers should be trained in avoiding gender discrimination and unconscious bias, and actively encouraged to combat harmful gendered messages at medical school. These include equally encouraging female and male medicals students to consider their future family commitments, and avoiding sexist or disparaging comments to female students interested in a
typically male-dominated specialty. On surgical rotations this includes ensuring that female and male students receive equal exposure to hands on practice . For examiners, steps must be taken to ensure that gender bias is not unfairly affecting female scores in oral or practical examinations where marking cannot be standardized. This may include the inclusion of ‘implicit bias statements’ in marking guidelines, and modifying marking criteria that may include inherent bias against female students (See Box 1.).
[Text Box: Box 1: Example of an implicit bias statement As an institution, The New York Stem Cell Foundation seeks to pro- mote gender equality and increase diversity, in all of its forms, throughout its programs. Studies have demonstrated that often subtle, unconscious, and implicit biases exist in academic science, which have the potential to negatively impact outcomes in review processes. To that end, please be aware of potential implicit biases when reviewing, scoring and discussing candidates and applications throughout the review process so that we can work together to combat their potential negative impact. Source: Smith, Kristin A, et al. (2015), 'Seven Actionable Strategies for Advancing Women in Science, Engineering, and Medicine', Cell Stem Cell, 16 (3), 221-24.]
Teaching feedback exercises should include student, and faculty evaluation of an educator’s commitment to gender equity policies. Critically, medical students must have access to transparent, reliable mechanisms for reporting sexual discrimination or harassment at medical school or clinical placements. Anonymity and transparency is key to ensuring students will not be deterred from reporting bad behavior by fear of reprisal . Medical schools should develop considered guidelines to respond to complaints in a timely and transparent manner and commit to re-training, or replacing teachers who perpetuate gender discrimination.
Mentorship opportunities and exposure to female role models:
Lack of female role models is a significant factor deterring women from selecting surgery as a future career. Female students are more likely to choose a surgical career when exposed to higher of female surgeons at medical school. Interactions with female mentors and exposure to positive experiences of surgery allow female students to conceptualize a ‘successful-self’ in regards to a future in surgery.
Additionally research shows that perceptions medical students hold about female opportunities in surgery are discordant with the experiences reported by surgeons in the profession. Female surgeons report high levels of self-efficacy and career satisfaction. They feel well prepared for and enjoy their careers in contrast to female medical students perceptions that surgery is not a good career choice for women. . Medical students who have the opportunity to interact with female surgeons will develop more accurate perceptions of a surgical career.
Medical schools should aim to expose students to a diverse range of surgical role models, as clinical tutors, lecturers or, student mentors. Particular attention should be paid to disparities between the gender teachers in non-clinical, pastoral or administrative roles, compared to consultants and academics.
It is realistic, given the small pool of female surgeons available as mentors, that exposure to women in surgery may not be possible at all schools, or for all students. Formal mentorship programs are a strategy to bridge this gap . Medical Schools should collaborate with professional societies to coordinate a ‘women in surgery program’ in the form of an extra-curricular mentorship system, or exposure-based surgical experience program, to minimize disparity in access to mentoring opportunities for female students.
Fostering female surgical leadership and participation in research at the university level:
The limited availability of female role models in academic surgery settings is linked to barriers to female progression in academia more broadly. Female academic surgeons progress to the rank of professor less often, and at a slower rate than their male peers . Additionally, they have a lower rate of publication than their male peers, and are less often published as lead or senior author , despite findings that the quality of their published scholarship is often higher  . Studies shows that research productivity in American academic surgeons initially lags behind male peers but later will equal or surpass their male counterparts. This phenomenon, referred to as the ‘sticky floor’, is recognized by female surgeons who cite lack of time, lack of funding and lack of opportunities for collaboration as the impediments to publishing in their early careers.
Although the discussion of policies relating to increasing the progression of women in academia goes beyond the scope of this paper (see Smith et al.’s paper ‘Seven Actionable Strategies for Advancing Women in Science, Engineering, and Medicine’ for further discussion on this topic ), it is important to consider the likelihood that gendered patterns of research opportunity and publication are already occurring at the undergraduate student level, aggravated by the dearth of female academic mentors in surgical departments.
Surgical traineeships are highly competitive and increasingly students require substantial research experience to be considered for a limited number of places.
Student’s lacking in research experience or publications may feel underprepared or unable to pursue a career in a highly competitive surgical specialty. This disparity of opportunity could be corrected by implementing a formalised research pathway for students desiring exposure to surgical research, including providing surgical research opportunities within honours and MD tracks or in an additional program. Actively supporting student-run surgical interest societies as opportunities for networking and research collaboration is also advisable.
Monitoring and reporting progress:
Implementing strategies to increase gender equity should be assessed and monitored for efficacy. Transparent reporting of gender data will encourage increased accountability and awareness of ongoing inequalities in surgical education.
Medical school programs should commit to implementing several standardized surveys, at specific points in medical school (on admission, post surgical rotation, on graduation) to create an accurate picture of student’s perceptions of surgery and how it evolves during medical school. This longitudinal data can be used to monitor the effectiveness of gender equity interventions and allow adaption and improvement of policies. Similarly medical school’s should have a comprehensive data regarding the career paths of their graduating students- such research may help reveal specialties that are particularly poorly perceived during medical school and in particular, if these perceptions are gendered on not.
Similarly medical schools should track incidents of gender-based discrimination, and monitor student experience of surgical rotations, as well as participation in surgical research and promotional patterns for faculty.
Cultural change from the top-down:
The surgical profession is traditionally resistant to change, and its deeply hierarchical structure precludes cultural change from the bottom up. As a result, individuals may be reluctant or unable to confront perpetrators of discriminatory behavior due to fear of detrimental consequences to their future career, unless support from top-level faculty is visible and dependable.
(…) the chief barrier to medical professionalism education is unprofessional conduct by medical educators, which is protected by an established hierarchy of academic authority. Students feel no such protection, and the current structure of professionalism education and evaluation does more to harm students' virtue, confidence, and ethics than is generally acknowledged.
It is imperative that the development and implementation of a comprehensive gender equity plan includes a strategy for leadership - outlining a top down approach to cultural change. Schools should collaborate closely with clinical attachments to develop and implement the plan.
Medical school programs should develop a consensus statement outlining their commitment to pursuing improvements in gender equity and reducing gender-based barriers in medical school. Schools should appoint an officer for gender equity responsible for overseeing and reporting on the implementation of the plan. Additionally, programs should incorporate gender equity goals into their institutional code of conduct and statement of expectations for students and faculty.
Medical school leadership should be visible advocates of the program, actively engaging lower management and managing backlash, to ensure that the message is consistent– ‘we have a responsibility to ensure all students, regardless of gender, have equal opportunity to succeed in all aspects of medicine.’
This paper concludes that gendered perceptions of surgery are created and perpetuated in medical school and contribute to the rejection of surgical career options by graduating female medical students.
Medical schools have a responsibility to contribute to efforts to improve gender equity in the medical profession, especially in surgery, by fostering a more gender-neutral pattern of specialization in their graduating students. This paper recommends that medical schools develop comprehensive gender equity policies to combat gendered stereotypes, eliminate gender discrimination and minimize the patterns of unconscious bias encountered in surgical education in medical school.
It must be reiterated that the success of the above policies is dependent on a simultaneous commitment by the surgical profession to address additional barriers faced by female students during and post surgical training. Collaboration and coordination with surgical leadership will be pivotal for increasing opportunities for females interested in surgery. Without substantive action from the surgical profession endeavors to combat negative perceptions of surgery will be in vain. Visible action, in support of verbal commitments, is required to convince female students that the surgical profession is invested in the future of female surgeons.