Her gaze was piercing. She had weighed her options and made the decision to proceed with segmental resection of the bile duct. In that moment, every movement was focused, precise, and intentional. She was all in. As I watched the fine balance of surgical skills, teaching, and patient care, I recognized the intensity of her look. I was transfixed. As a direct observer of these intraoperative events, I had repeatedly seen this look before. It had been recorded in my field notes along with descriptions of sharpened attention and “being in the zone.” Once more, I was reminded of bicycle face. A story this ordinary, yet simultaneously old and carrying currency today, is worth retelling.
Bicycle face was an unsubstantiated health concern in the 1800s.1,2 It was thought that a woman could be inflicted if she chose to ride her bicycle with too much intensity. The strain and effort from riding—complete with clenched jaw, furrowed brow, and dark circles under her eyes—would remain chronically as bicycle face. The permanence of the condition was debatable as some doctors expressed hope that by distancing herself from the machine, a woman's bicycle face may ease. For those who chose not to heed caution, rules were put in place to reduce the onset of exhaustion and elevated heart rates. Among those rules were:
- Don’t race. Leave that to the scorchers.
- Don’t overdo things. Let cycling be a recreation, not a labor.
- Don’t use bicycle slang. Leave that for the boys.
- Don’t appear to be up on “records” and “record smashing.” That is sporty.
The myth of bicycle face was eventually debunked in favor of the health benefits associated with the activity. While we read and shake our heads at the absurdity of regulating women's performance as it relates to bicycling, I am hard pressed to find explicit dogma limiting women from riding. Rather the restrictions present themselves through the subtle stories that get told and retold—stitching seamlessly into the values, attitudes and beliefs of the culture. Who looks like a rider? Who has the skills and stamina to be a cyclist? The response almost becomes self-evident.
Judith Butler has advanced that gender is not performed as an innate act; rather gender is a convention that is constructed through socially reinforced behaviors.3 In other words, behaviors that are lauded will likely be repeated, rehearsed, and reinforced. Whereas performances of gender that are antithetical to social norms are more challenging to sustain. Thus, some configurations of behaving come to be seen as “natural” gender roles, while others are deemed objectionable expressions. For example, when women started to ride bikes, their behaviors were described as more disgusting than smoking because these individuals were not adhering to social norms of how women's gender ought to be performed. When women surgeons lead with decisiveness, within and outside of the operating room, they are labelled as aggressive and bossy similarly because their position contests normalized constructions of who performs the surgeon role. Thinking about gender as performance and interrupting binary expectations of masculine and feminine roles creates opportunities for more equitable experiences.
SPEAKING OF WOMEN SURGEONS
Who looks like a surgeon? Who has the skills and stamina to be a surgeon? Most recently, this discussion of gaps, trends, and myths has occupied social media internationally, leaned into discussions in surgical departments and residency programs, and found its way front and center into podium keynote addresses. What was once implicit, is becoming more explicit. However, there continues to be a cognitive and cultural disconnect that pits a woman's identity in contrast to a surgeon's identity.4 We expect a surgeon to lead a team, make high-stakes decisions, and demonstrate persistence with problem-solving. However, women surgeons who show decisiveness, drive, and ambition are negatively described as difficult, whereas men surgeons are positively described as assertive. While we are largely able to agree on qualities core to a surgeon's identity, how they align with women and men surgeons is made more complex by gender.
According to social role theory, women are perceived and expected to be more communal, thereby exhibiting characteristics of being pleasant, warm, and helpful.5 Men, on the other hand, are perceived and expected to be more agentic shown through being independent, confident, and analytical. Thus, agentic traits are closely associated with qualities describing a surgeon's identity making it easy to cognitively confirm men as surgeons. In contrast, communal traits are not well aligned with a surgeon's identity making it difficult to reconcile women as surgeons. When women surgeons are perceived as not performing their gender role, the incongruity can create challenges for them in the workplace.
STORIES AS TRANSFORMATIONAL TOOLS
Many will bristle at the described division of genders, contending that it does not fit her or him. We agree. All the while, communal and agentic stereotypes are implicitly reinforced through social interactions, exposure to media, and affirmation when behaving in accordance with gender norms. Addressing implicit bias,6 amplifying work from the diversity of surgeons, and sharing practices that are incompatible with gender stereotypes serve to enhance equity in surgery. Using stories to transform culture, increase access, and enrich engagement is an intentional act. It requires seeking out, listening to, and then disseminating stories of struggle and success. We must deconstruct and address the bicycle face myths we find in surgery.
To give breath to transformative narratives, we must be willing to ask questions and even more willing to hear the myriad of responses. We find transformative narratives as ethnography exploring the everyday work realities of women surgeons,7 memoir recounting discrimination faced by a pioneering neurosurgeon,8 anthology of individual experiences of being a woman surgeon,9 and lectures reflecting on invisibility and resilience.10 Including scientific investigations of gender, the collective story provides a hinge between what was and what is to what could be.11Unless inequitable experiences are recognized; unless behaviors are interrupted; unless we are willing to question the way things have always been, the story will be slow to change.12 Purposefully establishing surgical environments that are equitable requires a new performance and new stories.
The call for transformation in surgery is heard on many platforms—from private conversations to conference audiences. The rules for gendered performance by surgeons are being questioned. It is time to account for our collective capacity as scorchers, as individuals and communities, to be remarkable with advancing equity and inclusion in the field of surgery. Three strategies that lend themselves to this transformation include scholarship, visibility, and narratives.
The rigorous investigation of diversity—in business, education, and psychology, for example—has illuminated the value of this dynamic. Social scientists are applying well-established designs as well as developing novel methodologies to better understand the influence and effect of individuals and group characteristics. Surgery is ripe to promote the scholarship of diversity, equity, and identity. Research funding, departmental support, and critical research questions exploring diversity from multiple perspectives would serve to enhance equity in surgery.
There is much to be said about mentoring in surgery, and for good reason. What we are also coming to appreciate is the equally important role of sponsors. Sponsors promote and advocate for colleagues and residents who benefit from increased visibility. Sponsors intentionally create connections and recommendations for further promotion. Amplification is another approach that has been adopted among peers to help leverage the ideas of one another. For example, when a woman colleague makes a verbal contribution during a meeting, another colleague would repeat the statement and credit the initial speaker. It ensures “authorship” for the idea and endorses her contribution. Mentorship, sponsorship, and amplification are practical means by which to bring visibility to the diverse strengths of surgeons.
By attending to the micro-stories—everyday moments that position women surgeons—the foundation begins to shift and new ways of interacting are required. Micro-stories, such as #ILookLikeASurgeon and #HeForShe social media campaigns, set the stage for meso-level discussions empowering medical students, residents, and faculty to raise consciousness and intentionally address gender inequities. This has resulted in cultural and structural transformation of surgical departments, for example, through purposeful mentoring and leadership development. Finally, high-impact macro-level stories in the form of presidential addresses at national conferences, make transformational narratives inescapable. Greenberg13 presents the scientific evidence reflecting disparity in professorial rank, NIH grants, and the effect of gender schemas.
With micro-stories and macro-stories in hand, we are well positioned for a new discourse that speaks of leadership, adaptability, community, and grit. It is a discourse that calls for new rules or rewrites old ones. We offer four:
- Be scorchers.
- Find your flow.
- Speak your truth.
- Smash records.
The authors acknowledge the other members of the Michigan Women's Surgical Collaborative (MWSC) at the University of Michigan: Jennifer Waljee, MD, MPH, Dawn Coleman, MD, Erika Newman, MD, Janet Dombrowski, BSN, MHSA and Hadley Stoll, BA for their support.
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