Behind the Mask: An Exploratory Assessment of Female Surgeons’ Experiences of Gender Bias : Academic Medicine

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Behind the Mask: An Exploratory Assessment of Female Surgeons’ Experiences of Gender Bias

Barnes, K. Lauren MD; Dunivan, Gena MD; Sussman, Andrew L. PhD, MCRP; McGuire, Lauren MD; McKee, Rohini MD, MPH

Author Information
Academic Medicine 95(10):p 1529-1538, October 2020. | DOI: 10.1097/ACM.0000000000003569

Abstract

Surgeons are idealized as strong, logical, in control, and decisive—adjectives that are often considered to be masculine qualities.1 Although medical school student populations are now almost evenly divided between male and female students, proportionally fewer women enter surgical fields.2,3 In 2018, 45.6% of medical graduates entering residency were female; however, after excluding obstetrics and gynecology (OB/GYN), all surgical specialties were notably male majority, with female resident representation ranging from 14.8% of orthopedic surgeons to 40.1% of general surgeons.3 This lack of representation becomes even more notable in leadership roles within academia as females compromise only 25% of assistant professors, 17% of associate professors, 9% of full professors, and 5% of chairs of surgery nationally as of 2013.4 Despite the impression that more women are entering leadership positions in recent years, the Association of American Medical Colleges reported that only 5.3% of surgery chairs were female in 2018.5 Earlier studies had theorized that the disparity was due to a lack of desire, inadequate role models, and family duties culminating in a leaky pipeline and the underrepresentation of women in leadership positions.6–9 More recently, investigators have identified ongoing gender bias as a factor that discourages women from pursuing surgical specialties, delays promotions and tenure, and ultimately deters many rising female leaders.10–13

A Transformation in Gender Bias

Historically, discrimination based on gender openly occurred as sexual and verbal harassment, workplace marginalization, and bias in hiring.14 Derthick noted in 2015 that “most scholars agree that blatant, overt, and easily identifiable expressions of discrimination have become less prevalent since the Civil Rights Movement […], perhaps due to normative pressures against endorsing blatant prejudice.”14 Despite the decrease in overt acts, a majority of women still report discrimination in the workplace.15,16 Prior qualitative work examining academic female surgeons indicated that overt sexism has declined, but covert forms of discrimination continue and many women are unaware of how this subtle bias negatively affects their lives.17 Female surgeons continue to report discrimination, earn less money, lag in academic promotion, and experience higher rates of burnout.18–20 This shift toward “subtle” or “modern” sexism has led to fewer overt acts of discrimination but continued bias in the form of discriminatory acts known as microaggressions.14

Microaggressions are subtle, often unconscious, discriminatory, or insulting actions that communicate demeaning or hostile messages aimed at marginalized groups and were originally studied in relation to racism.21 Similar subtle, discriminatory actions are used to perpetuate sexism; these microaggressions may contribute to continued gender disparities in medicine.16,17,22 Although subtle, microaggressions inflict psychological harm on individuals who chronically experience them. For example, studies demonstrate higher rates of depression, anxiety, sexual dysfunction, somatic symptoms, decreased well-being, and increased binge drinking in those experiencing microaggressions.23–27 Career and academic performance also suffer from the daily invalidation of one’s ability and identity perpetuated by microaggressions.7,28–30 Unfortunately, many perpetrators are not aware that their actions and words are harmful, and the lack of overt aggression can make microaggressions difficult to confront.

Given the negative psychological effects of microaggressions and the difficulties in identifying and confronting them, Derthick developed and validated the Sexist Microaggressions Experiences and Stress Scale (Sexist MESS) to assess the frequency and severity of gender-based microaggressions.14 This scale uses 7 domains including: (1) leaving gender at the door (which captures the downplaying of femininity to succeed), (2) sexual objectification, (3) environmental invalidations (which describes discrimination in the physical environment or systemic policies), (4) invalidation of the reality of women (or denying that gender bias exists), (5) assumptions of traditional gender roles, (6) expectations of physical appearance, and (7) inferiority (which identifies ways women are assumed to be inferior to men).14

We hypothesized that the subtle sexism of microaggressions may play a role in the issues plaguing modern female surgeons, including burnout, earlier retirement, and delayed promotion.8,13,20,22 Although many authors have identified that gender bias is a problem in medicine, there is little in the literature detailing the types of microaggressions female surgeons experience, which is important as this may help to reveal the specific ways in which gender bias is perpetuated under the radar. We sought to explore the prevalence and impact of the sexist microaggressions female surgeons experience to identify opportunities for education and prevention.

Exploratory Assessment

In January 2018 to April 2018, we conducted a sequential exploratory mixed methods study using focus groups followed by a survey questionnaire to assess female surgeons’ gender bias experiences.31 In the absence of prior studies on this specific topic, we used an inductive and hypothesis-generating approach to accurately and comprehensively characterize the experience of female surgeons.

The University of New Mexico Human Research Review Committee approved this study.

Qualitative assessment

In January 2018, we invited all resident, fellow, and attending female surgeons in every surgical discipline (i.e., general surgery, OB/GYN, orthopedic surgery, neurosurgery, otorhinolaryngology, and ophthalmology) at the University of New Mexico Health Sciences Center to participate in focus groups. Each focus group was 2 hours in length and included between 3 and 8 participants. We divided the focus groups into trainee groups (residents and fellows) and attending groups (faculty surgeons) to ensure that participants felt they could speak freely. Each focus group was moderated by the same experienced research coordinators who have extensive experience in conducting qualitative work and was digitally audiorecorded. None of the study authors were present for focus groups. Moderators used a semistructured interview guide based on the 7 domains of sexist microaggressions on the Sexist MESS (see above). The full interview guide is included as Supplemental Digital Appendix 1 (at https://links.lww.com/ACADMED/A989).

A professional transcriptionist deidentified and transcribed the digital audio files. Qualitative analysis was conducted by the research team analysts, all experienced in qualitative research methods (A.L.S., G.D., R.M., K.L.B.). We used a multiphase thematic analysis methodology to structure all data collection, analytic or interpretive, and report-generating activities. Research team members first became immersed in the data through a collective review of all transcripts.32 To develop a coding template, we then conducted line-by-line manual coding independently to identify themes aligned with the domains of sexist microaggressions outlined above as well as other gender bias experiences of female surgeons.33 We used a group process to reach consensus on the coding scheme and associated themes. This process involved scrutiny of coded passages and thematic summaries to more deeply review initial interpretations and assess contextual influences on the data to further refine the proposed thematic categories. Data analysis proceeded in an iterative fashion, enabling additional topics to be included. We conducted focus groups until we reached thematic saturation and subsequently summarized the data into major thematic categories.34 Based on these categories, we created questions related to 15 surgeon-specific experiences of gender bias for use in our quantitative survey to detail specific microaggressions that female surgeons face.

Quantitative analysis

Following completion of the focus groups, we used SurveyMonkey (SurveyMonkey Inc., San Mateo, California) to send a survey that included the validated 44-question Sexist MESS questionnaire, our surgeon-specific questions, and demographics questions to all resident, fellow, and attending female surgeons in every surgical discipline (see above) at the University of New Mexico Health Sciences Center in April 2018. Participants in the focus groups were included in the survey sampling frame given that the survey questions assessed personal experiences of bias, which are unlikely to change due to prior group discussion. A consent form was included with the survey. All survey responses were anonymous. The full survey is included as Supplemental Digital Appendix 2 (at https://links.lww.com/ACADMED/A990).

We divided the Sexist MESS questions into domains as determined by Derthick and totaled the scores for each domain.14 We then performed a bivariate analysis using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina) to assess for differences among domains and surgeon demographics using t test. We compared responses between surgeon demographic variables that were postulated to make a difference in personal experiences of gender bias based on qualitative focus group findings and a literature review. These demographics included being a trainee versus an attending surgeon, fellowship- versus non-fellowship-trained physicians, women who have children under 18 versus those who do not, those of White versus those of non-White ethnicity, and majority male versus majority female specialty surgeons. We assessed the equal variance assumption of the t test using the folded F test.

The Surgeons’ Experiences

Focus groups

We completed 4 focus groups, with a total of 23 female surgeons. This included 2 trainee focus groups with 15 participants and 2 attending focus groups with 8 participants. General, colorectal, vascular, neurosurgery, urology, OB/GYN, urogynecology, gynecologic oncology, and orthopedic surgery were represented. No additional or differing themes were identified in the attending groups, with these groups reporting that the same negative experiences continue after the completion of training. Four overarching thematic categories emerged from the focus groups: exclusion, increased effort, adaptation, and resilience to workplace slights. See Table 1 for exemplary quotes organized by themes. Using an iterative process, we also explored ways to combat microaggressions and bias experienced at work with the final 2 focus groups.

Table 1 - Exemplary Quotes From Focus Groups by Themesa
Theme Exemplary quotes
Exclusion • Attending: They tried to push out a female faculty member “because women didn’t belong in surgery.”
• Trainee: I was told multiple times that I could really only be a breast surgeon…. I don’t think it was malicious, but it was clear.
• Trainee: I overheard a resident say, “Why would we ever hire a female resident…? She would just be taking a spot from a man who’s going to work his whole life.”
• Attending: Gender really isn’t the qualification to be a good surgeon or to be a good physician, and yet somehow we’ve let patients maybe use that as a way to pick a doctor.
Increased effort • Attending: I just want to show up to work and have people respect what I do…. I want [my] work to be good enough at face value because it’s being done and being done correctly.
• Attending: I get the comment at least 2 or 3 times a week that I’m too young to be doing what I’m doing. “You don’t look old enough.” “Are you sure?” “How many of these have you done?” “How long have you been doing this?”
• Trainee: I think that women [in surgery] in general are held to a much higher standard.
• Trainee: I think, “Oh, well. I’m a woman, and that’s just the way it’s going to be. It’s always going to be harder.” And I wonder, how do we disrupt that? How do we question that for our own medical students who are going through the same experience, and how do we stand up for them?
• Trainee: What I don’t understand is why I have to spend so much more energy being nice.
Adaptation • Attending: I learned a lesson earlier that if you can stuff all your hair underneath one of the like, guy scrub caps, you’re a lot more legitimate in the OR. You know that is one of the first surgical lessons I ever learned and so I still wear it like that.
• Trainee: I was constantly talked to about how I looked and how I should look and different ways to change my appearance.
• Trainee: I think there’s also the built-in apology. I’m always like, “I know you’ve been running around doing a bunch of things, but could you get me this?” I pre-apologize.
• Trainee: I did feel pressure to play up confidence, decisiveness, and those traits that are like, we’re socialized to believe that are male…. So, gender expectations—definitely present.
• Attending: You morph into this person to be able to achieve what your goals are and be competitive in this environment.
• Trainee: You adapt to survive and be accepted and included for so long and that shapes who you become, which is so far away from what you were before medicine.
Resilience to workplace slights • Attending: I heard someone say “it’s not useful to let women do this work. Because they’re only going to stay for 5 years. There’re going to stop taking call by 42.” It was like “We gave you a shot and you blew it as a group.”
• Trainee: I was asked at every single interview [for] my residency if I was going to get pregnant and when.
• Trainee: I don’t go home and cry about it [having judgment questioned] or anything.
• Attending: Most [microaggressions] I think are perpetrated by men. But it does come from women as well.
• Trainee: I think gender discrimination does not always happen with a male being the aggressor. I do think women also discriminate and insult other women.
Future directions • Attending: I think I like implicit bias training because it’s usually very eye-opening to what may be your biases. I think doing it in a way that’s not criminalizing someone who maybe truly is very ignorant.
• Attending: My attitude is teach women to be assertive, advocate for themselves, and not take everything too personally, but choose their battles wisely and let the others fall away.
• Attending: There aren’t enough women who have been able to get into power to advocate and take up those spots on the panels to counteract all the damage that’s been done for 50 years—the culture just hasn’t changed.
• Trainee: I think the problem is a lot of it needs to come from modeling from leadership. I don’t think I’ve ever seen a microaggression been stood up for…. Our attendings aren’t giving a lecture to them about, “You should really be kind,” when they happen to us.
Abbreviation: OR, operating room.
aFrom a January 2018–April 2018 sequential exploratory mixed methods study exploring the prevalence and impact of the sexist microaggressions female surgeons experience.

Exclusion.

From finding mentorship; attending national conferences; and working in clinics, hospitals, and operating rooms, most participants felt they had experienced exclusion in the workplace. Attending physicians reported that overt exclusion improved over time and with increased clinical experience.

The advice of mentors heavily influenced participants’ career choices; thus, negative comments during critical times when trainees choose a career direction were mentioned as something that may push women away from surgery. One trainee noted, “He told us that the ladies in the room might want to think about something like [pediatrics] or family medicine, so that we can be at home and see our children grow up.” If a trainee was determined to pursue a surgical specialty, they would often be encouraged to “choose a lifestyle-comfortable surgical specialty,” such as breast surgery or OB/GYN.

Increased effort.

Participants noted a constant need to prove their ability and intellect, while male colleagues were assumed to be competent. They also worked hard to ensure their physical appearance did not affect their work life, with many noting having to spend effort on choosing clothing that was not too revealing or feminine so that they would not have to endure comments about their appearance instead of their work. Many participants reported needing to work harder than their male colleagues, avoid stigma during the hiring process (by mentioning if they were not planning on having children, dressing in a more masculine manner, or lowering the pitch of their voices), and maintain a work–home balance.

Participants reported frequently being asked about their fertility goals while applying for jobs and noted being pressured to delay childbearing or to not have children to enjoy a successful career. Furthermore, conflicting, paternalistic messages about fertility from nursing staff, colleagues, and patients were common, requiring participants to repeatedly address and defend personal choices. Decisions pertaining to number of children, timing of pregnancies, taking time off after delivery, and deciding not to have children were all openly questioned at work, with none appearing to be accepted as correct. This pressure to explain one’s family goals, change family planning timing, and discuss childbearing plans during the hiring process was reported to demand increased effort from our cohort compared with male colleagues.

Adaptation.

To avoid exclusion, our participants often changed their appearance, voice, and interests. Attendings reported less pressure to adapt as compared with trainees. Although overt discrimination was rare, participants reported that nurses, male superiors, and patients regularly perpetrate microaggressions. To mitigate this, many participants become deferential, “pre-apologize” when asking for anything, or act overtly cheerful.

The impact of these adaptations on the women’s perception of self was significant. One attending described the dehumanizing affect by noting, “I keep thinking—when I retire and become a real person again….” Trainees held the hope that this would improve once training was completed.

Resilience to workplace slights.

Participants reported that negative work experiences caused them to become more resilient and develop coping mechanisms. A barrage of negative verbal language toward female surgeons was mentioned by participants as being ubiquitous; for example, being called “bitch,” “bossy,” “sweetie,” “honey,” “little girl,” and “sensitive” or addressed as “hey beautiful” were common. All focus groups mentioned rolling eyes, ignoring requests, and using sarcasm as mechanisms that were used to undermine a woman’s position (e.g., saying “yes, doctor” or “of course, doctor” in a sarcastic tone or while rolling eyes). Trainees mentioned this behavior more often than attendings, but both groups noted that such negative behavior undermined status and emphasized gender to disparage female surgeons. Overt sexual harassment also occurred. Many participants insisted that they did not want to be portrayed as victims despite this treatment.

Participants reported such workplace slights caused them to become “tough” and have “thick skin,” with many adopting coping strategies such as humor or ignoring negative comments. Participants also reported variable responses to these comments, with some women finding the comments insulting while others were not bothered.

Responding to microaggressions.

We also asked participants to discuss how they responded or had observed coworkers responding to microaggressions. Most participants reported never seeing colleagues defend another person against a microaggression. If they did confront the problem, participants often felt excluded afterward. If personally insulted, strategies to cope included not engaging, avoiding the room, making jokes, or ignoring the person or comments.

When asked for ideas for how to combat bias, one attending recommended “teach[ing] women to be assertive, advocate for themselves, and not take everything too personally, but choose their battles wisely and let the others fall away.” Other advice was for leaders to model respect, implement implicit bias training, and encourage attending surgeons to stand up for trainees. No participants could recall an episode of reverse discrimination against male surgical colleagues.

Survey results

The survey response rate was 64% (65/101 surgeons). The items on the survey included demographics (Table 2), the validated Sexist MESS questionnaire (Table 3), and questions related to surgeon-specific experiences of gender bias based on the themes from the focus groups (Table 4).

Table 2 - Demographics of Survey Respondents (N = 65)a
Characteristic No. (%)
Years of age (n = 63)
 26–35 32 (51)
 36–50 24 (38)
 51–70 7 (11)
Race/ethnicity (n = 62)
 American Indian 1 (2)
 Asian 8 (13)
 Hispanic 10 (16)
 Pacific Islander 1 (2)
 Non-Hispanic White 42 (68)
 Middle Eastern 1 (2)
 Indian 1 (2)
Have children < 18 (n = 62)
 Yes 32 (52)
 No 30 (48)
Fellowship trained (n = 63)
 Yes 25 (40)
 No 38 (60)
Department/division (n = 61)
 General surgery 10 (16)
 Neurosurgery 2 (3)
 Obstetrics and gynecology 31 (51)
 Ophthalmology 1 (2)
 Orthopedic surgery 4 (7)
 Otolaryngology 7 (12)
 Surgical oncology 2 (3)
 Urology 3 (5)
 Vascular surgery 1 (2)
Title (n = 63)
 Resident 29 (46)
 Fellow 3 (5)
 Assistant professor 17 (27)
 Associate professor 9 (14)
 Professor 5 (8)
aFrom a January 2018–April 2018 sequential exploratory mixed methods study exploring the prevalence and impact of the sexist microaggressions female surgeons experience.

Table 3 - Sexist MESS Questionnaire14 Results by Domain and by Trainee Versus Attending Scoresa,b
Domain (no. of questions) Frequency scores, mean Severity scores, mean
Attending Trainee P value Attending Trainee P value
Leaving gender at the door (4) 5.6 7.2 .01 5.2 6.1 .14
Sexual objectification (8) 7.2 10.5 < .01 7.4 11.2 .01
Environmental invalidations (4) 6.0 7.3 .01 4.5 6.4 .02
Invalidation of the reality of women (10) 8.5 11.4 .04 11.5 16.7 .02
Assumptions of traditional gender roles (6) 4.5 8.4 < .01 4.1 6.7 .07
Expectations of physical appearance (3) 2.2 3.3 .04 3.3 4.8 .08
Inferiority (9) 9.7 11.8 .17 12.3 15.4 .12
Abbreviation: Sexist MESS, Sexist Microaggressions Experiences and Stress Scale.
aFrequency scores indicate how often a microaggression occurred, and severity scores denote the level of bother due to the microaggression. Each domain has a different potential score based on the number of question items. The frequency and severity are rated on a Likert scale from 0 to 3, and this is multiplied by the number of question items in the domain. For example, inferiority has 9 questions, so it has a possible range from 0 to 27 points for both frequency and severity. From a January 2018–April 2018 sequential exploratory mixed methods study exploring the prevalence and impact of the sexist microaggressions female surgeons experience.
bBolded values denote a significant P value of less than .05.

Table 4 - Surgeon-Specific Experiences of Gender Bias Results by Trainee Versus Attendinga,b
Have you experienced any of the following: Overall (n = 61), no. (%) Trainee (n = 33), no. (%) Attending (n = 28), no. (%) P value
Been mistaken for a nurse, OT, PT, or receptionist or asked when the doctor is coming in 58 (95) 32 (97) 26 (93) .47
Been told you look too young to be a doctor 56 (92) 32 (97) 24 (86) .11
Pre-apologized before asking for something from another health care provider (i.e., scrub tech or nurse) 49 (80) 30 (91) 19 (68) .02
Noticed that nurses treat you in a different and more negative manner than your male colleagues 47 (77) 26 (79) 21 (75) .73
Needed to ask circulating nurse or anesthesiologist many times to get surgical supplies or bed height changes 40 (65) 28 (85) 12 (43) < .001
Been referred to as a “girl” or “little girl” at work 36 (59) 23 (70) 13 (46) .07
Received unsolicited advice on when to have children or the size of your intended family 36 (59) 24 (73) 12 (43) .02
Hidden personal life or changed personality to adapt to work environment 33 (54) 19 (58) 14 (50) .56
Had difficulty with scrubs being too revealing (i.e., gaping V-neck top) 32 (52) 18 (55) 14 (50) .73
Someone being surprised you are as good or better than a male physician 29 (48) 18 (55) 11 (39) .24
Had difficulty finding a female mentor 26 (43) 11 (33) 15 (54) .11
Felt excluded from networking opportunities due to gender 23 (38) 10 (30) 13 (46) .20
Been unable to obtain correctly sized gloves, shoe covers, scrubs, or medical device handles while male colleagues did not have these issues 23 (38) 12 (36) 11 (39) .82
Pretended to be interested in a sport or activity (i.e., drinking whiskey) to be included in conversation or event outside of work 22 (36) 15 (45) 7 (25) .10
Been told to wear glasses or pants or change hair color to be taken seriously 10 (16) 5 (15) 5 (18) .78
Abbreviations: OT, occupational therapist; PT, physical therapist.
aQuestions related to surgeon-specific experiences of gender bias were developed by the authors based on major thematic categories from focus groups to detail specific microaggressions female surgeons face. From a January 2018–April 2018 sequential exploratory mixed methods study exploring the prevalence and impact of the sexist microaggressions female surgeons experience.
bBolded values denote a significant P value of less than .05.

Overall trends.

Sexist MESS questionnaire results. Over half of respondents reported the following experiences at work many times or most of the time and also noted the experiences to be moderately or extremely stressful: attempting to “overcompensate” for being female (leaving gender at the door), attempting to appear assertive to avoid being dismissed by colleagues (leaving gender at the door), hiding emotions to not appear emotional (leaving gender at the door), working in a setting where a male was automatically allowed to dictate the agenda (inferiority), and having someone assume a male was responsible for their work (inferiority).

Surgeon-specific results. The majority of respondents had experienced gender bias in the workplace. Major sources of microaggressions were patients, physicians in positions of authority, nurses, and operating room staff (Figure 1). Responses to gender bias varied, with most surgeons blowing it off, feeling offended, or making a joke. The most common surgeon-specific experiences of gender bias were being mistaken for a nonphysician (e.g., nurse, medical assistant), being informed they were “too young” to be a doctor, and feeling the need to pre-apologize before asking for something from another health care provider. Almost all (57/62 [92%]) respondents felt gender bias was a national problem (not isolated to one region) and most (42/64 [66%]) were optimistic that gender bias will improve in the future. Over a third of respondents (25/64 [39%]) noted that gender bias is a moderate or severe problem in their current role, and the majority (37/62 [60%]) identified the perpetrators of gender-based microaggressions as “both men and women equally.”

F1
Figure 1:
Percentage of all survey respondents (N = 65) who indicated that a certain group of people were a source of microaggressions. From a January 2018–April 2018 sequential exploratory mixed methods study exploring the prevalence and impact of the sexist microaggressions female surgeons experience. Abbreviation: OR, operating room.

Trainee versus attending surgeons.

Compared with attending surgeons, trainee surgeons noted significantly more frequent microaggressions in 6/7 Sexist MESS domains: leaving gender at the door, sexual objectification, environmental invalidations, invalidation of the reality of women, assumptions of traditional gender roles, and expectations of physical appearance (Table 3). The frequency of inferiority microaggressions was higher for trainees than attendings but was not significant. While microaggressions in all Sexist MESS domains were more severe for trainees than attendings, microaggressions in the domains of environmental invalidations, invalidation of the reality of women, and sexual objectification were significantly more severe for trainees. When asked about surgeon-specific experiences, trainees noted needing to ask nurses or anesthesiology staff to perform a task multiple times (28/33 [85%] vs 12/28 [43%], P < .001), pre-apologizing before asking for something from another health care provider (30/33 [91%] vs 19/28 [68%], P = .02), and receiving unsolicited family planning advice (24/33 [73%] vs 12/28 [43%], P = .02) more frequently than attendings (Table 4). Trainees were more likely to identify the clinical role of those perpetuating bias as patients (31/33 [94%] vs 18/28 [64%], P = .003), circulating operating room nurses (25/32 [78%] vs 14/26 [54%], P = .04), floor nurses (24/32 [75%] vs 10/28 [36%], P = .002), scrub techs (25/33 [76%] vs 11/28 [39%], P = .003), and trainees at lower levels (24/32 [75%] vs 6/28 [21%], P < .01) than attendings. In responding to microaggressions, trainees were more likely to feel offended (22/33 [67%] vs 9/30 [30%], P = .003) or blow it off (22/33 [67%] vs 10/30 [33%], P = .008) than attendings.

Male- versus female-majority specialties.

Aside from OB/GYN, all surgical specialties have more than 50% male practitioners nationally,35 so we grouped these specialties as male-majority and OB/GYN as female-majority to assess if having a higher proportion of male or female surgeons in a field influences experiences of gender bias. Of the Sexist MESS domains, only leaving gender at the door demonstrated higher rates of frequency and severity of microaggressions in male-majority surgical specialties, possibly reflecting a pressure to downplay femininity to succeed. Additionally, respondents in male-majority fields were significantly more likely to be bothered by scrubs being too revealing (20/30 [67%] vs 12/31 [39%], P = .03), feel excluded from networking opportunities (16/30 [53%] vs 6/31 [19%], P = .005), and note bias from physician peers of the same rank (20/29 [69%] vs 11/31 [36%], P = .009) than those in female-majority fields. Although not statistically significant, respondents in male-majority specialties noted more difficulty finding a female mentor (16/30 [53%] vs 6/31 [19%], P = .06) and were less likely to recommend their specialty to trainees or family members (7/30 [23%] vs 2/32 [6%], P = .06) than those in female-majority specialties.

Other variables.

Non-White (i.e., any race/ethnicity besides non-Hispanic White) surgeons were more likely to have children under the age of 18 than White surgeons (16/22 [73%] vs 15/40 [38%], P < .01), but no other significant differences were found between these groups. We also evaluated other variables, including having children under the age of 18 and fellowship training, but there were no statistically significant differences.

The Current State and Moving Forward

This exploratory study adds to the growing body of evidence that gender bias in surgery continues and frequently manifests as microaggressions. Prior studies of gender bias in medicine have addressed open forms of discrimination,6–9 but microaggressions are more difficult to quantify. This current work includes female surgeons’ responses to the Sexist MESS, a validated questionnaire, which assesses the frequency and severity of gender-based microaggressions. We also used focus groups, which allowed us to identify themes and add questions that were specifically about the unique experience of being a female surgeon to identify surgeon-specific bias experiences. This may improve our ability to identify and respond to microaggressions when they occur. Women with lower hierarchical status (i.e., trainees) reported the highest rates and severity of microaggressions and bias experiences. Additionally, female surgeons working in an environment with few other women reported more surgeon-specific bias experiences. Although we hypothesized that the intersectionality of race and gender would result in more gender bias experiences, we did not find this, though we may not have had a sufficiently large sample size to evaluate this intersection.36

Training

Attending surgeons in our study noted that gender bias has become less overt and has improved over time. However, trainees in our exploratory study report continued systemic bias, gender discrimination, sexual harassment, unequal treatment compared with male colleagues, and a lack of female surgeon role models, which is consistent with prior work.12,16,37,38 One concern is that the resulting pressure may lead some aspiring female surgeons to self-select a nonsurgical specialty or an “appropriate” surgical field, such as OB/GYN or breast surgery; this should be investigated in future work. A 2019 study asked female surgeons to list specialties that have a sexist culture, and the majority reported trauma and orthopedic surgery, followed by cardiothoracic surgery, as having such cultures—not surprisingly, these surgical fields have the lowest numbers of women in their ranks.39 This information provides potential areas on which to focus efforts to decrease microaggressions and suggests possible ways (e.g., implicit bias training for anyone conducting interviews, the creation of interest groups for female trainees interested in surgical disciplines) to help promote the recruitment of women into these male-dominated surgical specialties.

Career trajectory

Beliefs that women are not as surgically skilled, focused, or able to complete physical tasks are pervasive biases that our participants and respondents faced, despite evidence suggesting female surgeons have lower mortality, readmission, or complication rates than their male counterparts.40 Although this study is exploratory and only included participants and respondents at a single institution, they reported that child-rearing, exclusion from networking opportunities, and gender bias negatively affect career advancement, which is consistent with prior studies.18–20,41 These findings are similar to studies that demonstrate other high-powered women, such as female PhD candidates in physics and astronomy as well as women in business, experience discrimination and gender bias that could slow advancement and promotion.42,43

Not a victim

Our focus group participants demonstrated the belief that success in surgical fields is merit based and felt strongly that they were not victims; paradoxically, many identified barriers to advancement in the field due to gender (e.g., discrimination in hiring or being pushed out of a position due to gender) and shared many instances of gender bias. Prior work examining academic female surgeons and gender discrimination noted a trend of wanting to avoid being seen as a victim; pride that personal merit was the reason for their success; and feeling that personal qualities, rather than systematic gender bias, were the reason for female peers’ failures.17,44 Belief in a meritocratic system in which personal choices, rather than systematic prejudice, determine a woman’s success or failure may be easier to internalize.17 As gender-based discrimination serves to take power from women, we hypothesize that our cohort may not have wanted to identify with being a victim as they felt this might further play into the belief that women are less able, less powerful, and less capable.

Combating bias

We found that the majority of the participants and respondents in this exploratory study experienced gender-based microaggressions at work, which is consistent with previous studies. For example, a prior study reported 87% of medical students, 88% of residents, and 91% of practicing female surgeons reported gender-based discrimination in their careers that negatively impacted job satisfaction, perceptions of self-efficacy, their respect for coworkers or colleagues, and career advancement.44 Education about microaggressions and the harm they cause is paramount to combat gender-based discrimination, as subtle assaults are difficult to counteract. Trainees in this study primarily responded to bias by blowing it off or getting offended, which may indicate that trainees feel unable to address bias given their lower hierarchical status.

When we asked focus group participants to think of options for how to address microaggressions, most felt that “criminalizing someone who may be truly very ignorant” was not the right approach. They recommended implicit bias training, recruiting more women into traditionally male-majority arenas, and empowering all personnel to call out microaggressions when witnessed to help educate people unintentionally perpetrating bias. To improve job satisfaction, our respondents suggested that we should actively recruit female trainees into surgical fields, retain and promote women, and address gender bias in the workplace at a systems level. Universal bystander and implicit bias training for all hospital employees might help other members of the care team address these events. We also recommend anonymous institutional mechanisms for reporting unprofessional behavior. The majority of our participants (37/62 [60%]) identified that men and women commit gender-based microaggressions equally; this finding was also stated consistently in the focus groups. Based on this finding, interventions for change may need to include all levels of the medical hierarchy regardless of gender, since patients, nurses, physicians in positions of authority, and operating room staff were all cited as common sources of microaggressions.

Future work, strengths, and limitations

In the future, we would like to explore the perspectives of other groups, including men in surgery. Some of the experiences our participants and respondents had may be explained by the general treatment of all surgeons in the high-pressure surgical environment, so exploring the experiences of male surgeons will be vital. Additionally, the perspectives of the groups who were reported as often perpetuating gender bias, including patients, nurses, and physicians in positions of authority, would be interesting to elicit to understand the underpinnings of this behavior. Future work should also investigate how to address microaggressions, the efficacy of possible interventions, and the perspectives of medical students.

Limitations of this study include the exploratory nature of the study and the lack of prior robust quantitative data, which precluded a power analysis. Response bias is a risk of qualitative work exploring attitudes and experiences, and female surgeons more affected by gender bias may have been more likely to respond than female surgeons who were less affected by gender bias. As the survey was anonymous (to allow participants to share openly), we were not able to compare respondents with nonrespondents. In addition, this study included only a single academic institution; therefore, the results may not be generalizable. Focus group participants were also allowed to complete the survey as both the focus group and survey focused on personal experiences and discussing past experiences should not change the reporting of experiences on a subsequent survey. There may also be some effect of self-selection on the attending surgeons, as those who continued to practice surgery in the face of chronic adversity may intentionally or unintentionally ignore microaggressions. This could account for part of the difference in the reported frequency and severity of microaggressions between attending and trainee surgeons. Finally, we acknowledge the difference between sex and gender. All of our participants self-identified as female; our study does not evaluate the experiences of transgender or nonbinary surgeons.

Notable strengths include participation of surgeons in multiple surgical disciplines, levels of training, and years in practice (data not shown). The mixed methods approach demonstrated consistency between the focus group findings and survey responses, both of which provide unique data on this topic and areas for future study.

Conclusions

These findings support prior work indicating that gender bias is pervasive in surgical specialties.9,12,13,16,17 We identified exclusion, increased effort, adaptation, and resilience to workplace slights as common themes for female surgeons’ experience of gender bias. Trainees in our study had significantly worse experiences than attending surgeons for 3 Sexist MESS domains, but gender bias and microaggressions were cited as a problem for the majority of female surgeons. We recommend further research investigating how to address microaggressions, the experiences of male surgeons, the perspectives of medical students and groups who were reported as often perpetuating gender bias, and the efficacy of possible interventions (e.g., universal bystander and implicit bias training, the active recruitment of women into traditionally male-majority specialties).

Acknowledgments:

The authors wish to thank their research staff—Cassandra Darley, Cynthia Wenzl, and Julissa Zambrano—for assistance in conducting the focus groups for this study.

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