When I departed Scotland in 1985 to travel to America for my surgical oncology fellowship (breast surgery fellowships had not been invented by then), I left a country where I had experienced no female consultant (attending) surgeons during my training. I’m told there were ten female attending surgeons in England at the time, but none that I knew of north of the border. A year of my surgical training I spent in Edinburgh as a Senior House Officer at the Royal Infirmary of Edinburgh. A grand building with a gothic clocktower, the Infirmary presented an imposing façade to Lauriston Place. There were times my team operated in Sir Joseph Lister’s former operating theatre. A vitrine against the wall displayed the instruments he used. Wooden benches ascended from the OR table level to allow viewing by, in Lister’s day, an audience of students and trainees.
The infirmary exuded history. What should have been history, but was not, sadly, was that every time I needed to dictate an operative note, I had to enter the men’s locker room to use the only dictaphone in the operating suite. After all, why would there be a dictaphone for women to use? Women weren’t surgeons. Apparently. I certainly had no female role models. No female surgeons lecturing to my class, teaching in the OR, or rounding with the residents at the bedside. Near the end of my surgery rotation at the Western Infirmary in Glasgow, I requested a meeting with Sir Andrew Watt Kay, the Regius Professor of Surgery. I asked him about whether I should pursue a career in surgery, given the lack of women in the field. “Go for it,” was his answer. If alive today, I’m sure he would commit to #HeForShe, and “stand in solidarity with women to create a bold, visible and united force for a gender equal world.”1
My dictaphone example is one of blatant, overt inequity and discrimination. Inequities can be much more subtle however—microinequities.2 We see them in medicine every day. Women are still not regarded as equal to men in the medical profession, not just by peers, but sometimes by patients too. I recall when I was an assistant professor at Washington University in St. Louis in the early 1990s, I made rounds one day on post-op patients at Barnes Hospital. I entered the patient’s room, introduced myself as Dr. Radford, the surgeon who had operated on him the night before. The young man, maybe early 20s, looked at me dismissively, waved his hand at the food tray in front of him, and asked “Did you cook this chicken?” Obviously, he was confused between “surgeon” and “chef.” His assumption was either that I served in both roles or I couldn’t possibly be a surgeon. After proceeding to tell me the chicken was not adequately seasoned, he continued, “And I want different socks. I don’t like this color. I want burgundy.” He pointed this time to his no-skid hospital bootees, light blue in hue with white non-slip stripes. I was his dresser too, it seemed, or his fashion advisor. Not having a response to this, I headed to the nurses station. “Mr. **** does not like the color of his socks. He wants burgundy.” The head nurse looked at me and sighed, putting her hands on her hips. Shaking her head, she said, “You can’t be serious. What’s wrong with light blue now? He’s already had a scarlet pair, and he tried the yellow. He’ll have to stick with what he’s got, we don’t have burgundy bootees.”
My authority was not recognized. The inequities that I describe happened many years ago in the UK, however such conduct is still happening today in the USA. We see examples of this behavior frequently, albeit more muted: a male medical student and a female doctor enter a patient’s room and the patient asks questions of the medical student, assuming he is the senior party; at a surgical meeting you attend you see the panel of experts on stage comprises all men, a “manel;” you pay dues to a society of which you are a member only to find that the proportion of invited female named lectureships is not proportionate to the female representation among the society’s members. The list of inequities goes on: the gender pay gap, the lack of transparency thereof, gender discrimination, sexual harassment, representation of women in the leadership of societies, representation of women as recipients of awards etc.3
The time has come to put an end to gender inequity in medicine and surgery, and it will take effort from both men and women to end it. The campaign on Twitter initiated by Heather Logghe, MD in 2015, #ILookLikeASurgeon, raised awareness about women in surgery—the campaign went viral. 4 The now-iconic New Yorker cover by Malika Favre (Operating Theatre) that appeared on April 3, 2017, depicting four female surgeons in scrubs looking down on an operating table, struck a chord. Susan Pitt MD, an endocrine surgeon at the University of Wisconsin, challenged her fellow female surgeons around the world to reproduce the image in their own settings and share those images on social media. The #NYerORCoverChallenge was born. Hundreds of women surgeons responded globally. Dr. Pitt commented, “Women surgeons are saying to other women surgeons, ‘I see you,’ and to the world, ‘See us.’ ”5
Some organizations are seeing the women and making strides for change. The American Surgical Association (ASA) white paper—Ensuring, Diversity, and Inclusion in Academic Surgery—written by twenty-two male and female leaders in surgery, comments that women and underrepresented minorities have fewer opportunities to enter academic surgery, a situation magnified in more senior positions.6 In 2014, 31.4% of male general surgery faculty were full professors, compared to only 12.7% of women. Regarding compensation, the inequity is even more pronounced: an $83,000 pay gap exists between male and female general surgeons. The American Association of Women Surgeons, in their Statement on Gender Salary Equity, notes that the gender salary gap that appears early in a woman’s career is likely to widen over time.7 The ASA white paper states, “These inequities in advancement and compensation have been clearly documented, and must be addressed in order to advance a culturally competent surgical workforce.”6 As Keith Lillimoe MD pointed out in his 2017 presidential address to the ASA, “The number of outstanding qualified female candidates is more than adequate to fill very open surgical leadership position in America today. The problem is not the pipeline—it is the process.”8
The #BeEthical campaign described in the white paper9 by Julie Silver MD, and the initiative of the Harvard Medical School meeting she created, Career Advancement and Leadership Skills for Women in Healthcare,10 outlines how the status quo can be changed. In her white paper, Silver refers to the four gatekeepers in healthcare: medical schools, hospitals, and healthcare organizations; medical societies; medical journals; and funding sources. It is the responsibility of these gatekeepers to make gender equity an ethical imperative (italics mine); prioritize and properly fund initiatives to close gender equity gaps; avoid critical thinking errors; use a systematic process and specific metrics to evaluate disparities; and implement strategic interventions. But the #BeEthical campaign is not only the responsibility of the aforementioned gatekeepers. It is the responsibility of each one of us, especially those of us who trained when the inequities were even more pronounced.
Examples such as the dictaphone experience should be a thing of the past, of historical interest only (like the Royal Infirmary of Edinburgh on Lauriston Place which is now a block of flats). The past should remain in the past. So, what did I do about the dictaphone? I knocked, moved forward, and entered the locker room. We must move forward…to gender equity.
- Micro-inequities in Medicine. Silver JK (guest editor) PM R 2018; 10(10):1106-1114
- Female Physicians are Underrepresented in Recognition Awards from the American Academy of Physical Medicine and Rehabilitation. Silver JK, Bhatnagar S, Blauwet CA et al PM R 2017; 9(10):976-984
- #ILookLikeASurgeon goes viral: How it happened. Hughes KA, Bull Am Coll Surg, 2015; Nov 100(11):10-6.
- The New Yorker Cover That’s Being Replicated by Women Surgeons Across the World. Françoise Mouly and Genevieve Bormes, The New Yorker, April 11, 2017
- Ensuring Equity, Diversity, and Inclusion in Academic Surgery. Task Force, on Equity, Diversity, and Inclusion, American Surgical Association, 2018. http://americansurgical.org/files/2018/Equity.pdf
- Association of Women Surgeons Statement on Gender Salary Equity, 2017 https://www.womensurgeons.org/page/SalaryStatement
- Keith Lillimoe MD, Presidential address to the ASA, 2017. https://bit.ly/2DqItfW
- #BeEthical A Call to Healthcare Leaders: Ending Gender Workforce Disparities is an Ethical Imperative, Silver JK 2018 http://sheleadshealthcare.com/wp-content/uploads/2018/10/Be_Ethical_Campaign_101418.pdf