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Gender Equity in Surgery Is Much More Than Numbers

— Bias and discrimination persist in the field

MedpageToday
A close up photo of two female surgeons in the operating room.

More women entering general surgery careers is a harbinger of the medical workforce. The number of women in general surgery residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) is rapidly approaching parity with the number of men. While this is an encouraging trend, gender equity is much more than numbers.

Our Study

To investigate the number of women in general surgery residencies, we gathered 24 years of data from the national graduate medical education census, administered by the Association of American Medical Colleges (AAMC) and American Medical Association. We separated residents by gender and documented their numbers in three major cohorts: U.S. allopathic graduates (USMDs), U.S. osteopathic graduates (DOs), and international medical graduates (IMGs). Our findings were presented at the AAMC Workforce meeting and American Medical Women's Association annual meeting.

The total number of women in general surgery residencies has increased from 1,612 in 1997 (20.5% of total general surgery residents) to 4,317 in 2020 (44.8% of total). The trend toward numerical parity is being driven by the largest cohort, USMDs, rising from 21.8% to 47.5%. The proportion of women DOs in general surgery residencies also grew dramatically, from 13.4% to 44% in 2020. The proportion of IMGs who are women (including both U.S. and non-U.S. citizens) was comparable to the DO cohort before 2000, remaining between 17% and 20% for 9 years, then rising less dramatically than the rate of USMDs and DOs, to 31.6% in 2020.

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Putting the Numbers in Context

General surgery in the U.S. has long been a male-dominated specialty, and despite the growth of women in this field, gender-related issues abound. For blunt biopics of this bias, women surgeons described their tortuous training and professional paths in a in 2020. They described sexual harassment, bullying and intimidation, lack of mentors, job discrimination, and equipment and facilities that were designed for and dedicated to men. To make matters worse, they reported that there were almost no institutional means for reporting abuse. Related problems have been documented elsewhere. As Yue-Yung Hu, MD, MPH, et al., female general surgery residents report more emotional exhaustion, depression, and burnout than their male colleagues.

As the numbers of women entering medical school and careers in surgery continue to increase, such high rates of burnout and depression among female residents must be specifically addressed, both for their wellbeing in residency, as well as for their ability to become productive and capable surgeons in practice.

Could the fact that general surgery residency programs in the U.S. continue to be competitive pyramids (more interns start than finish the 5 years) contribute to abusive behaviors? Despite this possibility, women appear to advance in general surgery residencies at the same rate as men. Based upon the demographic data in Hu's survey, of all 7,409 general surgery residents at all levels in 2018, for every woman at a PGY 4 or 5 level, there were 1.75 female PGY1s, and for every man at the PGY 4 or 5 level, there were 1.74 male PGY1s.

To move toward true equity, academic and clinical surgery programs must have more women leaders as chairs, program directors, and hospital executives. Leadership must also provide supportive environments for parents, including reasonable parental leave and breastfeeding accommodations. Preoperative facilities and operating rooms must be updated to provide equitable amenities for both genders. On-site child-care facilities would also improve the efficiency and productivity of both men and women surgeons.

We have highlighted these problematic reports and trends in general surgery to illustrate a more pervasive point: all residency programs and their sponsoring institutions need to provide psychologically safe, fair, and effective environments free from harassment for learners to thrive. That any residents are currently subjected to discrimination, abuse, and harassment (women more frequently) must cease immediately for both genders. Surgery training programs, along with all residency programs, must also provide more flexibility in training and career progression to accommodate childbearing and family building for people of all genders.

Paul H. Rockey, MD, MPH, is a professor emeritus in internal medicine and medical humanities at the Southern Illinois University School of Medicine. Sarah E. Brotherton, PhD, is director of data acquisition services at the American Medical Association.