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While progress has been made on gender diversity in surgery, to make a substantial cultural change, much more work needs to be done, researchers suggested.

In a large national survey, surgeons across two organizations confirmed what many previous studies have showed -- that female surgeons were less likely to be involved in surgical/hospital administration compared with their male counterparts (16.8% vs 20.5%, P=0.01), less likely to be involved in education (8.4% vs 10.9%, P=0.02), and more likely to be involved in nonacademic/private practice (45.8% vs 35.9%, P<0.001), reported Cheryl Zogg, PhD, MSPH, MHS, of the Yale School of Medicine in New Haven, Connecticut, and colleagues.

However, the survey showed that female surgeons were more interested than male surgeons in pursuing medical school administration and education at some point during their careers (P<0.001 for both), they noted .

Notably, female surgeons were also less likely to have gender-concordant mentors (57.5% vs 92.3%, P<0.001), the researchers said.

But more important were the qualitative results that got at the heart of perceptions from both female and male surgeons, Zogg told MedPage Today.

For instance, male surgeons were less likely to perceive that gender disparities exist in their personal practice, and they believed that differences can be resolved by "treating everyone the same," Zogg said. As for recommendations for change, male surgeons said their female colleagues should "be more available with your time" and "do not expect special treatment or use children as an excuse."

Female surgeons, on the other hand, said male surgeons should acknowledge gender bias and admit their role. They also urged women surgeons to support each other more and stop creating competition.

Zogg noted that some of the most interesting trends in perceived barriers included explicit discriminatory remarks for female surgeons -- "I was told not to unpack my bags at the beginning of an away plastic surgery residency because: 'Girls shouldn't be surgeons, and it's my job to make you quit!'" one respondent said.

For male surgeons, it was the fear of being misunderstood, Zogg said. One respondent wrote, "As a white male, I no longer feel that I can talk openly or candidly about many issues, including gender, because of the possibility that I might be misunderstood."

"While progress has been made, there's still a long way to go, both in terms of increasing representation and increasing acceptance," Zogg noted. "There is this recognition of a need for an ongoing conversation that includes all of these voices if we're going to institute meaningful cultural change."

'Queen Bee Phenomenon'

Zogg said the phenomenon in which female surgeons don't support other female surgeons was particularly fascinating. The social science literature suggests that in male-dominated workplaces, some women feel the need to compete to compensate for increased scrutiny and limited opportunities.

Zogg, who is an MD/PhD candidate in her final year and will apply for surgical residency next year, said she has experienced both support and resistance.

"On one hand, I've had phenomenal female mentors who have opened doors and supported me and gone out of their way," she said. "I've also had the opposite experience, with senior female residents, or the occasional attending, where they had been through it, they were tired and exhausted, and were perhaps additionally critical. They weren't meaning to shut us [female trainees] down, but it's, 'I'm going to treat you the way I was treated,' or, 'I'm going to teach you to be tough because that's what I had to do to survive.'"

In an , surgeons Kelly Herremans, MD, and Amalia Cochran, MD, of the University of Florida in Gainesville, acknowledged the "so-called queen bee phenomenon," which describes how women "may perpetuate gender disparities by discriminating against and competing with other women."

"This problematic behavior undermines the success of women, further potentiates the gender hierarchy, and reinforces a noninclusive workplace," they wrote.

"New models should explicitly emphasize that success is not a zero-sum game," they added. "Treating success as if it is infinite, rather than a scarce resource, has the potential to disrupt biased structures, facilitate diverse mentorship, and subsequently increase opportunities for all underrepresented groups in surgery."

'A Bit of a Cop Out'

Zogg said the perception among male surgeons that they're afraid of being misunderstood was a particularly unique finding, and can be a barrier to moving conversations forward. A fear to take on important issues head-first can lead to worsening disengagement or a "culture of fear," she and colleagues wrote.

In a , Keith Lillemoe, MD, of Massachusetts General Hospital in Boston, opened with his disclosures: that he's an older white male surgeon who "grew up in surgery in a traditional male-dominated program that was late to adapt to the changing culture of gender inclusiveness."

Lillemoe is also the father of a young female surgeon who will soon take her first faculty position in academic surgery.

He said the recommendations for change from male surgeons are "disappointing and somewhat defensive."

"Calls for gender neutrality, for decisions to be made solely on merit, to focus less on gender as the only determinant for treatment, suggestions that childcare needs constitute special treatment, and intimations that female surgeons are less available are a bit of a cop out," he wrote.

The value of paper, he said, is "to create an awareness that biases will never be resolved until male and female surgeons can see the issues through the lens of the other and are willing to acknowledge and work together to eliminate biases of both groups."

Study Details

For their study, Zogg and colleagues surveyed 7,500 male and 2,500 female fellows of the American College of Surgery (ACS) from January to June 2020. They also surveyed female members of the Association of Women Surgeons (AWS), which is focused on mentorship among female surgeons, in May 2020.

They noted that they oversampled the male surgeon population expecting a higher response rate from female surgeons.

Their aim was to investigate practicing male and female surgeons' experiences with gender across five qualitative/quantitative domains: career aspirations (quantitative), gender-based discrimination (quantitative), mentor-mentee relationships (quantitative), perceived barriers (qualitative), and recommendations for change (qualitative).

Overall, 2,860 male surgeons (38%) and 1,070 female surgeons (43%) from ACS responded, and an additional 536 female AWS members responded as well.

Of note, women in surgery were less likely to be married than their male counterparts (67.3% vs 89.5%, P<0.001), and less likely to have kids (61.7% vs 90.9%, P<0.001).

The study was limited by its reliance on subjective data and an incomplete response rate. It's possible that the results were influenced by disproportionately higher or lower responses from respondents who feel more or less strongly about the issue, Zogg and colleagues acknowledged.

Nonetheless, Zogg said there's a need to "bridge the gap," and go from "a group of passionate women advocating for each other, to a true change in what the culture of being a surgeon means."

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