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A PATIENT contacted me last year after she read about Dr Yumiko Kadota’s experiences of relentless bullying and harassment as a female surgical trainee.
Outraged, she said: “I knew it (surgical training) was bad, but I never thought it was this bad!” This patient was referring to the misogyny, lack of support, and callous labelling of a female trainee as an “emotional female”.
This patient is an architect, a profession which is arguably as equally male dominated as surgery. Even to an outsider who is no stranger to the issues of working in a male dominated field, the behaviour outlined by Dr Kadota was clearly unacceptable.
Sadly, the experiences of Yumiko Kadota are not unique. Just a few years earlier in 2015, the Royal Australasian College of Surgeons (RACS) conducted a survey of its membership to investigate the prevalence of discrimination, bullying and harassment. The findings were staggering.
Almost half the respondents (49.2%) had experienced discrimination, bullying or harassment, with women much more likely than men to have had these experiences.
The findings were staggering not because they were vastly different from what had been reported elsewhere but because formally reporting it made it real – it was no longer a matter of debate or opinion. It was there, visible to all those who seek the information. It validated how wrong the experience is and encouraged victims to speak up.
In response, the RACS implemented a number of measures, including educational programs, improved complaints handling mechanisms, and improved support provided to victims who come forth (here, here, here).
You could question the effectiveness of these measures given Dr Kadota’s experience came to light just a few years after the 2015 RACS study. It is heartening to know that the RACS Expert Advisory Group has reconvened this year to review the progress that has been made and advise on future directions.
Changing behaviour of individuals takes time, effort and commitment. It takes more than drafting policies or being able to recite them without putting words into action. To fully address the issue of discrimination, bullying and harassment in the workplace, a multipronged approach is needed. It needs to address individual, organisational and structural issues.
It is well known that over-representation of particular trait within an organisation (such as gender and race) tends to promote group-think and marginalise those who look and think differently, thereby inadvertently promoting discrimination. Having a genuinely inclusive approach to workplace hiring, perhaps through the use of quotas until a culturally and gender diverse workforce can be sustained, will help foster meaningful change.
In surgery, the lack of gender diversity has been in the limelight for some time and the chasm in the numbers between male and female surgeons has continued despite gender parity at medical school enrolment for the past two if not three decades. Even taking into consideration the time taken to complete surgical training and possible career interruption, the number of practising female surgeons simply does not reflect the number of female students at medical school entrance.
A workforce report published by the RACS in 2021 showed that just 14% of active Fellows, including non-consultant Fellows, are women. While this has improved compared with the 4% in 2002 and 12% in 2019, progress is slow (here, here). With such meagre improvement rates, it has been previously demonstrated that it will take more than 200 years to achieve gender parity in orthopaedic surgery.
Gender parity, however, is different from gender equality, and it is important to distinguish between the two. Gender parity simply refers to having comparable numbers of female and male surgeons and in many ways, is a much simpler metric against which we can measure progress, but gender equality is undoubtedly more important as it refers to the fundamental way women are viewed and treated within the profession.
Studies have shown that female doctors contemplating career choices are less likely to consider a surgical career, have higher attrition rates than their male counterparts and upon completion of training, and are less likely to secure a consultant position in a teaching hospital (here, here, here).
Even for consultant surgeons, gender equity issues persist. Research shows preferential referral between male doctors, poorer renumeration and reduced opportunity to embark on leadership roles, all despite equal if not better surgical outcomes of female surgeons.
The natural question therefore is how can we support our women doctors and, in particular, help nurture the next generation of female surgeons?
Surveys of female doctors and medical students attempting to understand barriers in a surgical career have repeatedly identified the same themes, including concerns about toxic working environments, possible stymied career pathways, harassment, and the lack of role models. Combined with inadequate support to help raise a family, it is not surprising that many of our young and bright women doctors are turned away from surgery.
As I recently wrote in an editorial in The BMJ, to bring about change, there must be change at all levels. Respect and attitudinal change among colleagues will make the female surgeon feel appreciated and valued at work. Respect and attitudinal change from partners at home by sharing childcare and home duties will help lighten the burden on women for what is really a shared responsibility rather than the sole responsibility of the mother. Organisational change at a local level supported by government, medical boards and college policies will help improve workplace flexibility, innovative hospital-based childcare arrangements, and a genuine inclusive approach to ensure equal opportunity for career progression (here, here).
All of these are well within the realm of what is achievable. But change is never easy. There may be financial outlay and there may be resentment. Nonetheless, for the sake of our patients, for a healthier diversified workplace that is more productive, the gender inequity in surgery needs to change and it needs to change at a quicker pace than is happening now.
The lack of progress is inexcusable, the continued discrimination that affects half the population is unacceptable.
Associate Professor Cherry Koh is a colorectal surgeon who underwent subspecialty training at the Royal Prince Alfred Hospital in Sydney and John Radcliffe Hospital in Oxford. She is currently affiliated with the Surgical Outcomes Research Centre at the RPA, and the Discipline of Surgery in the Faculty of Medicine and Health at the University of Sydney.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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RACS reported the 5 year results of their “operate with respect” intervention last year:
Overall prevalence of unprofessional behaviour had not changed _ 48% in 2015 and 50% in 2021 but they reported that the nature of behaviours had changed.
There was a significant increase in reports of sexual harrassment (7% to 21%)
with reports by men increasing from 2% in 2015 to 16% in 2021; by women 30% to 36% and by trainees 12% to 45%.
There was a slight decrease in reports of yelling shouting aggression or physical abuse but reports of belittling behaviour, career constraints, humiliating comments and being undermined have increased.
It is time for the “black box” in theatre so that the behaviours can be observed objectively.
can we please be given clear verbal behavioural examples of the complaints and not assume that
we know exactly what has been said and done and how and what was the purpose on the part of the accused.
Do we have evidence that women do obstetrics because of the training scheme and not in spite of it?
What does the author propose for Eye surgery, where the majority of trainees are female? Or for obstetrics, where some training programmes have 90% female trainees?
It’s disappointing to see that the first few comments here appear to have missed the point of the article.
It is not logical to say that “women just don’t want to do surgery” if the training scheme is not conducive to attracting them.
In contrast, Obstetrics and Gyne, also a surgical specialty and once almost exclusively male, now has a very diverse workforce. Clearly, female obstetricians are quite capable of rigorous training conditions, hard work andfrequent on-call. They even manage to work within the rarified environment of labour wards and operating theatres.
Those who dismiss the points in the article should ponder the reason for the differences.
We seem to see regular articles in “Insight’ on gender inequities, this time in surgery. It has become a bit tiresome to read them and feel the need to balance out very one-sided portrayals. The RACS has had, for some time a major focus on women in surgery. Numbers are increasing all the time, and innovations such as part time training have been brought in specifically for women trainees wanting to have children etc. The issues of harassment and bullying have been carefully and rigorously addressed by the RACS, but can never be stamped out completely in any workplace. What is frequently ignored is that some of this behaviour comes from women themselves, towards their colleagues or female trainees, as a result of personality issues or professional jealousies. This is also seen in the female-dominated profession of Nursing. Let’s please try to get past this stuff, or at least make it a workplace rather than a gender issue.
Gender equality? Is it possible that women (slightly larger numbers than men) don’t want to become surgeons ? That some character traits of surgeons are better suited to males? Or is it possible that having children and being the prime person in a family that provides child care/ nurturing could interfere with career paths that surgeons undertake?-
My college trains more women than men (AFRM). Will there be a similar article demanding change (with targets) to encourage men to join and complete training and get consultant posts?
Or is it possible that people can choose career paths that suit them and that we accept that sex differences are real and not just a product of the patriarchy
This year i have heard of two cases of trainee surgeons being belittled in a MDM meeting and in an operating theatre. In both cases this was a female consultant behaving badly. The RACS needs a site for reporting, naming names and addressing the issue with the accused. Inactivity and broad statements do not change this culture.
‘…workplace that is more productive’.
Part of the crisis in medical workforce supply comes from the investment in a full training position not translating into a full time member of the workforce. It affects all specialities – most obviously GPs – but also Surgery.
Whatever the benefits of gender equality in medicine, increased productivity cannot be assumed to be one of them.