“Jonasson becoming chair showed us all that it could be you being chair”
—Dr Julie A. Freischlag
There is a respectful hush and a certain gravitas when surgeons and trainees sit side by side at surgical meetings paying rapt attention to the presidential speeches that define the vision of the society's leadership. What the trainees may have overlooked, but amazes and encourages those with a few more gray hairs, is the sudden spike in the number of women surgeons at the podium. The past 5 years have seen a marked and persistent tide of women rising into surgical leadership positions among our major surgical societies, with some even having several women presidents, such as the Association of Academic Surgery and the Society of University Surgeons. This momentum is also reflected at the American Board of Surgery and at academic institutions in the rising number of women serving as department chairs and in other senior leadership positions. The momentum and energy that this breakthrough has brought to our profession is nothing short of a watershed moment. Hopefully these advances of the past 5 years are just the beginning of things to come. One example of this transformational progress is a page on the Association of Women Surgeons (AWS) website set up to keep track of the number of women chairs of US Departments of Surgery, because it was finally approaching 10; now the AWS has a hard time keeping up, having to update the website constantly to make sure to include all the new women chairs, now over 20 and growing!
For many years, women have made major contributions to surgical societies and the Boards of the surgical specialties, yet they remained markedly under-represented in leadership circles.1 There are now clear signs that senior leadership in American Surgery is starting to better reflect the membership of these societies and demonstrate to our future surgical workforce that women surgeons are a well-respected and integral part of the profession.
The importance of diversity (race, sex, sexual orientation, etc.) has been well-documented across a variety of disciplines. Businesses with more women and under-represented minorities on their staffs and in their boardrooms have better financial performance.2 This may reflect a broader perspective and innovative approach to work that has been associated with groups embracing greater diversity. Similarly, in surgery, these new women leaders are catalysts for positive change in all areas of surgery, including the promotion of diversity and inclusion of more broadly, championing pay equity, and addressing issues such as well-being and burnout.
While there is still considerable distance to go to achieve full parity and equity for women and especially under-represented minority women, the pipeline is now more robust, with a steady stream of qualified individuals representing diverse demographics. As Dr Keith Lillemoe pointed out in his presidential speech at the 2017 American Surgical Association—“We as surgical leaders must recognize the importance that we can play in advancing the careers of our women faculty.”3 We recognize that we are making inroads because women in nonsurgical societies, from anesthesia to gastroenterology, have taken notice of our progress, and are asking for guidance. What follows is a brief overview of some of the pioneers who paved the way to a remarkable year when the new Executive Director and Chair of the American Board of Surgery, the President, the Chair of the Board of Regents, and the Chair of the Board of Governors of the American College of Surgeons are all women.
HISTORICAL PERSPECTIVE ON WOMEN IN LEADERSHIP
When the American College of Surgeons published a comprehensive history of the organization in 2012 entitled “A Century of Surgeons and Surgery: The American College of Surgeons 1913–2012,” the entirety of the history of women in surgery to that point was summarized in 1 chapter, representing only 7 of the 389 pages.4 Although the influence of women surgeons was almost a footnote in the first hundred years of the ACS, this is now poised to change dramatically.
Elizabeth Blackwell, MD, the first woman physician in the United States, graduated with honors from Geneva Medical College in upstate New York, in 1849.5 Although she hoped to be a surgeon, she lost an eye to infection and was not able to realize this dream. Not long afterward, Mary Edwards Walker, MD, graduated from Syracuse Medical College, NY, in 1855 and went on to become the first woman surgeon in the United States.5 Dr Walker volunteered to serve with the Union Army at the outbreak of the American Civil War and was held as a prisoner of war for 4 months in 1864 after being captured when crossing enemy lines to treat wounded civilians. Dr Walker is the only woman to ever have received the Congressional Medal of Honor—the highest United States Armed Forces decoration for bravery.
Of note, Rebecca Crumpler, MD, was the first African American woman in the United States to earn a medical degree in 1864. Dr Crumpler is known for publishing a book of medical advice for women and children—Book of Medical Discourses—in 1883, one of the first medical publications by an African American physician.6 Matilda Arabella Evans, MD, who graduated from medical school in 1897, was one of the first African American women to practice surgery.7 A champion of public health, Evans believed that health care was a right of citizenship and just as important as public education.
Florence West Duckering, MD, a surgeon at the New England Hospital for Women and Children, Boston, MA, and Alice Gertrude Bryant, MD, were among the first women surgeons admitted to the American College of Surgeons in 1913.8 Almost 40 years later, in 1950, Helen Octavia Dickens, MD, was the first African American woman to become a Fellow of the College.9
The first woman certified by the American Board of Surgery was Barbara Bartlett Stimson, MD, in 1940.10,11 An accomplished orthopedic surgeon, she served with distinction and honor in the Royal Army Medical Corps during World War II, choosing this path due to the US Army Medical Corp's prohibition against woman physicians serving as commissioned officers at the time. The first African American woman to be certified by the American Board of Surgery was Dr Hughenna L. Gauntlett in 1968.6
Progress for women in medicine and surgery remained slow until recently. It was over 100 years before all medical schools in the United States were open to women. Harvard Medical School did not admit women until 1945. Jefferson Medical College in Philadelphia, PA, was the last holdout and started to accept women in 1960. Title IX of the Education Amendments of 1972, which required the end of sexual discrimination for any educational program receiving federal financial support, opened the door for considerable progress. Due in part to the Surgeon General's call for training more physicians in 1960 and the changing attitudes about women's professional careers, the number of women in medicine and surgery has grown significantly.1 Women now compose half of all medical school graduates, a remarkable increase when compared to the 1960s when women comprised 5% to 6% of American physicians and 10% of medical students. The number of women in leadership positions has lagged behind what would be expected from the proportion in the “pipeline.”12 Data from the Association of American Medical Colleges (AAMC) demonstrate that 38% of full time academic faculty in the United States are female; however, only 21% of full professors and 15% of department chairs and deans are women. Less than 10% of full professors of surgery were women as of 2015.13,14 Only 5.7% of surgical chairs were women as of 2013.15
Women Who are Under-represented Minorities Face Even Greater Challenges
Progress for women in medicine who are under-represented minorities has been even more difficult (Table 1). It is well-recognized that the numbers of under-represented minorities (URMs) including African American, Hispanic, and Native Americans on US faculty is unacceptably low. Women URMs are doubly under-represented, especially when promotion to the higher ranks of academic faculty is considered.16
The US population is increasingly diverse. Census data from 2016 found that 13.3% of the US population identified as black or African American, 17.8% as Hispanic or Latino, and 5.7% as Asian. Unfortunately, this diversity is not represented in medical school faculty, let alone Departments of Surgery. AAMC data from 2008 showed that while African American people comprised 12.2% of the US population, African American women represented only 1.5% of the medical school faculty and well below 1% of full professors.16
More recent data from the AAMC for 2017 shows a very slight improvement in diversity.17 There are now a total of 173,166 medical school faculty members (including all specialties) in the United States. Of these, there are 3036 African American women faculty (1.7%), of whom 223 are full professors; 1979 Hispanic women faculty, of whom 172 are full professors; and 102 Native American women faculty, of whom 3 are full professors. This slow progress led Yu et al18 to estimate that at the current rate, it would take nearly 1000 years for the proportion of black physicians to catch up to the percentage of African Americans in the general population.
For surgical faculty, specifically in 2017, AAMC data show a total of 15,667 women surgical faculty.17 Of these, 12.8% are tenured. There are 550 Asian women surgical faculty, 34 are tenured; 124 African American women surgical faculty, 11 are tenured; 82 Hispanic women surgical faculty, 5 are tenured; 7 Native American women surgical faculty, none are tenured.
Collaboration, Mentorship, and Sponsorship
As pioneering women in surgery entered into surgical careers across the United States, they recognized the need for collaboration, mentorship, and sponsorship. In many cases, male colleagues stepped up as crucial sponsors of women surgeons. The support of men is essential because sponsorship is necessary to advance in academic medicine and surgical societies. In addition, women surgeons have formed organizations dedicated to the advancement of the careers of women in surgery. Although some may have doubted the need for these organizations, there is no doubt that the Association of Women Surgeons and similar subspecialty organizations for women in surgery have served as training grounds for leadership in American surgery.
Association of Women Surgeons
The AWS was founded in 1981 when Dr Patricia Numann posted a sign inviting any woman surgeon to a breakfast at the October meeting of the American College of Surgeons (ACS) in the San Francisco Hilton Hotel.19 By 1988, there were almost 1000 members and AWS earned a seat on the ACS Board of Governors in 1995. The AWS has afforded many women surgeons support, community, and mentorship, and also leadership experience not available to them elsewhere.20 The AWS has advocated for better maternity/family leave policies and pay equity.21 The organization has also published 2 immensely helpful “self-help” guides for women in surgery: The Pocket Mentor, which provides guidance for medical students and residents in surgery; and Navigating Your Surgical Career: the AWS Guide to Success, which provides practical career advice for junior faculty.20,22,23
ACS Women in Surgery Committee
The ACS established a Committee on Women's Issues in 1998 in response to a proposal from Dr. Olga Jonasson.4 A transplant surgeon and Chair of the department of surgery at The Ohio State University, Dr. Jonasson was the first woman to chair a surgery department in the United States. She also was the first woman to be selected as a member of the American Surgical Association, the first woman to hold an executive position with the ACS, and the first woman to serve as director of the American Board of Surgery. The Committee on Women's Issues was later renamed as the Women in Surgery Committee (WiSC). The 4 original areas of focus included College membership recruitment and retention, professional development, society membership, and leadership roles. WiSC subcommittees run a successful formal mentoring program, write letters of support for women candidates for leadership positions and awards, and create presentations designed to address issues of importance to women in surgery for the yearly ACS Clinical Congress The committee also established the annual Olga Jonasson Lecture, which provides a platform for prominent women in surgery to share their insights and provide inspiration.
Efforts by the AWS and WiSC have contributed greatly to the success of women in assuming leadership positions. Tables 1–7 show the progress of URM women and the incorporation of women surgeons into leadership positions in major surgical organizations around the country to the best of our knowledge.
The field of surgery has been changed forever by the contributions of remarkable women who have pushed through sexual barriers at local and national levels. Sexual equity and inclusion of URMs in surgery is critical to the survival of our specialty, particularly now that more than half of all American medical students are female. We cannot forget that diversification and inclusion of women and especially URM women in American Surgery is ultimately what is best for patients and for our profession as a whole.12 A number of pioneering women surgeons have fought personal and professional barriers to be able to stand alongside men at the pinnacles of surgical leadership, we must now all stand on the shoulders of these giants to move our specialty forward. We need to embrace key policy changes in our departments and medical societies to allow women surgeons and in particular underrepresented minority women achieve equity at the highest positions in surgery. Chairs and Division Chiefs should be encouraged to allocate resources to closing sex-related gaps in academic promotion, compensation, departmental resources, and research funding.
The Council on Graduate Medical Education (COGME) published a report on Minorities in Medicine in 2005 reflecting on progress made and making recommendations for the future.24 The COGME was authorized by Congress in 1986 to provide ongoing assessments of physician workforce trends and recommend Federal and private sector efforts to address identified needs. Reports addressing URMs in medicine were published in 1990, 1998, and again in 2005. Although some progress has been made, as noted above, there are still opportunities for improvement. In fact, in 1997, Libby et al25 estimated that reaching racial and ethnic population parity would require a doubling of Hispanic and African American physicians. It is of utmost importance that we continue to increase the number of URM women in surgery so that culturally competent surgical care can be provided to our increasingly diverse population. The efforts to this regard have to start early in the educational process. To this end, the yearly Women in Surgery conference led by Dr Sharona Ross and co-sponsored by the American College of Surgeons and industry support now includes a special session for high school students interested in surgery.26 Women medical students, and especially URM women, need encouragement and affirmation about surgical careers.27,28 Women surgical residents need exposure to a diverse faculty, equal treatment, ongoing flexibility, support, and mentoring to complete rigorous training.29,30 Also, young faculty need mentoring and sponsorship to not only juggle clinical responsibilities but also start their families, and/or research careers, and also preparing to assume leadership positions locally and nationally. Other issues that will need ongoing attention to increase the number of URM women in the pipeline to surgical leadership include lessening the enormous debt accumulated by undergraduate and medical students, better support and preparation for academics and standardized testing including the USMLE and board examinations, and addressing systemic and institutional barriers faced by URM women in surgery.
How can we change the status quo? We need to educate young women, and men, as to the importance of inclusion and what this does to improve the surgical workforce. In addition, we need to acknowledge the concept of “second-generation sexual bias,” which can be subtle assumptions or organizational barriers limiting women from assuming leadership roles. For instance, gendered career paths which seem to fit males more than females, and women's lack of access to sponsors within hospitals can be examples of this bias.31 Mentorship is often cited as a need especially for young surgeons. Being a mentee carries a responsibility; to seek advice from seasoned surgeons as to career and family. Mentors who want to help promote inclusion can reach out to trainees or young surgeons whom they identify as having an aptitude for leadership. There are data to suggest that many young women are not told they can be leaders, and shy away from leadership roles for myriad reasons including family responsibilities or confidence concerns.32 In addition, department leaders and mentors need to help women navigate unprofessional behavior, sexual bias, and exclusion from informal activities that create networking activities.33 Reinforcing to our young surgical trainees, especially our young women and particularly URM women, that they can, and should be, leaders will help build their “leadership identity.”
Every surgical society should look at increasing equity by examining the data on women in leadership positions such as committees, task forces, officers, and governing boards. Research on diversity and inclusion within all specialty societies in surgery should be a priority for our shared mission of training surgeons and providing excellent care.
Program committees in charge of meetings need to strive for equity when choosing speakers for symposia and sessions, panelists, moderators, and plenary/keynote speakers. Award/nominations committees should be tasked with finding worthy recipients for recognition and leadership that includes a broader perspective and avoids looking through a narrow lens to define accomplishments or only choosing from the inner “power circles.”34 Courses in leadership development programs, clear paths to leadership, mentoring programs, career coaching, and sponsorship are all additional ways to keep moving the needle on equity in surgery. Data showing the successes and failures of these endeavors should be tracked and shared publicly.
Finally, it is important to recognize the need for flexibility, accommodation, and support for all surgeons to meet their responsibilities outside of work. Surgeons have traditionally represented the sole breadwinners for their families and extended, inflexible work hours were possible as there was most often someone at home to manage all aspects of childcare, eldercare, and household duties. As women have increasingly entered the workforce, both men and women face increasing challenges in this area. The current data on burnout suggest that we are not meeting the needs of our changing workforce in this area. It is critical to recognize that both men and women need this support and will benefit from increased flexibility.
So, let us be the first to stand up in appreciation of the progress we have made in the American surgical community for advancing the goal of sexual equity in leadership. And let us keep the momentum going!
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