It is not enough to encourage women to enter surgery if the workplace then discriminates against them, write Roisin Finn and colleagues

Women make up more than half of medical graduates and have done for decades, yet worldwide, surgery remains extraordinarily male dominated. Women are less likely to enter and complete surgical training (one US study found a 25% vs 15% attrition prevalence), and their abilities are judged far more harshly by colleagues. Gender based discrimination is widely experienced and goes vastly under-reported. Experiences of sexism have changed little since 1980 when the president of the Royal College of Surgeons questioned “whether surgery is particularly suitable for women.” Studies have reported that female surgeons earn 27% less than their male peers (in some specialties it’s been estimated to be as high as 60%) and are less likely to be promoted.

Right from the beginning of medical school, we noticed that women were actively discouraged from pursuing a career in surgery from senior doctors because “it just isn’t for nice girls like you.” During foundation training, one of us was told, “There are two types of female surgeons. One who shouldn’t be a surgeon and the other who shouldn’t be female. Which one are you?” This is echoed by a recent study of Harvard medical students, which found that women are more likely to report discouragement towards surgical careers based on their gender.

A lot of commentators have focused on what can be done to encourage more women into the specialty, however we think that instead we should be asking what we can do to make the workplace a more equal, hospitable place where women would want to work. It is not enough to just encourage women to enter surgery if the workplace actively excludes or discriminates against them. 

Firstly, we think that hospitals need to take a tougher stance on misogynistic attitudes and behaviour. Discrimination towards women in surgery comes from many directions in our experience, but is frequently ignored. We agree with Mello and colleagues, who proposed that sexual discrimination should be recognised as an important ethical issue, which doctors have a moral obligation to recognise and object to. 

Throughout our training, we have noticed countless patients make inappropriate comments about female surgeon’s appearances. It is intensely demeaning to reduce a professional woman to nothing more than her appearance, yet our objections to this have been brushed off as being “touchy” and that the patient made the comment “innocently.” If we make sexual discrimination an ethical issue, however, it would push sexism to the forefront, and empower staff to speak up when this happens. 

Patients and colleagues who make inappropriate comments relating to a doctor’s gender should be pulled up on it and given a formal warning. A zero tolerance policy needs to be upheld. In extreme cases where a doctor is sexually assaulted at work, the patient should be held criminally responsible in the same way they would be if they had assaulted someone outside the hospital. 

In the corporate world, many organisations have taken active steps to improve awareness about sexist language and behaviour towards women, and to encourage the reporting of harassment. In our experience, the healthcare sector languishes decades behind this and needs to follow suit. We’ve had senior colleagues tell us that they also feel helpless to protect their colleagues and juniors from sexist behaviour. Too often, reports of gender based discrimination are ignored or inadequately investigated, and there appears to be little faith in the disciplinary systems in place. 

Internationally, there should be reviews into the processes by which hospitals are managing reports of sexual discrimination. This drive for change needs to come from the top and include senior hospital leaders, patient representatives, and the staff who bear the brunt of this behaviour. Hospitals need to not just give lip service to “zero tolerance” and actively empower our senior surgeons and managers to deal with reports of discrimination in an appropriate fashion. 

Secondly, the surgical workplace would be more appealing as a long term prospect if there was more flexibility within the career pathway. There’s good evidence to suggest that women are put off becoming surgeons due to the long and unsociable hours, rigid training structure, and poor life-work balance. While in the UK, for example, there are opportunities to apply for less than full time training, it has been the experience of our colleagues that the rules governing this vary in how they’re applied between various deaneries and hospitals. Of the 11% of UK consultant surgeons who are women, few are part time and the opportunities for a trainee to get appointed to a less than full time consultant position are very limited. 

More support for women who are pregnant and on maternity leave would also help. It’s common for female colleagues to fear they’ll be perceived as weak if they ask to amend any of their duties during pregnancy. We know of one surgeon who completed a minor operating list while in the early stages of labour. A culture of machismo still prevails within surgery, which needs to be kicked back into the last century.

Support for pregnant women should include flexible working patterns and conditions. Covid-19 has shown us how working remotely and virtual clinical activities can be integrated into clinical practice, and this could be used for the benefit of pregnant women. Hospitals should also have as standard a programme of support and enhanced supervision for women returning to work after maternity leave. This would ease the concerns women may have about feeling out of practice and help them refresh their clinical skills in a supportive environment.

Several organisations in the UK and North America have set up engagement programmes to counter the misconceptions around women surgeons, but dismantling the institutional barriers that deter women from working in surgery will require broad organisational and cultural change and senior buy-in. 

Doctors and surgeons need to recognise that they have an ethical obligation to object to and speak up about sexual discrimination. Hospitals and training organisations need to actively change attitudes towards reports of discrimination and proactively deal with them. The inflexible organisational structure and working patterns in surgery need to be modernised. The surgical workforce has demonstrated its ability to change rapidly in order to continue services during the covid-19 pandemic. We should harness this appetite for change and use it to overhaul the current state of affairs for the benefit of the workforce, including the introduction of more flexible working patterns and a less rigid career pathway. 

Our healthcare systems are under unprecedented strain and we cannot afford to shut out or neglect any part of our workforce. We need to strive for an inclusive, diverse workforce and provide equitable access to success for all if we want our healthcare systems to survive and thrive. 

Roisin Finn is a neurosurgical ST7 at Oxford University Hospital NHS Foundation Trust, United Kingdom.

Mario Ganau is a consultant neurosurgeon and deputy training programme director for neurosurgery at Oxford University Hospital NHS Foundation Trust, United Kingdom. 

Gianni Lorello is chief diversity officer and assistant professor at the Department of Anesthesiology and Pain Medicine at the University of Toronto, Canada. 

Competing interests: None declared.