I have always admired Dr James Barry, one of the unsung heroes hidden within the history of surgery. Dr Barry, more affectionately known as the “beardless lad,” graduated from the Edinburg Medical School in 1812, joined the army as a surgeon during the Napoleonic wars and performed one of the first cesarean sections in 1820. At the time of his death in 1865, autopsy findings confirmed evidence of a previous pregnancy. Dr James Barry was actually Dr Miranda Stewart—a woman who spent her entire life hiding her identity so she could practice surgery. As described by a close friend of hers, “she chose to be a military doctor. Not to fight for the right of a woman to become one, but simply to be one.”1 Dr. Barry transformed herself and assumed a different gender to fit in.
Today, it remains a question of fit. Although I have not had to transform myself to practice surgery like Dr Barry did, I have had to accommodate myself to surgical instruments designed with another sex in mind. This technology manufactured for everyone is not one-size-fits-all, which raises the question—even though I do not have to be a man to be a surgeon, do I still need to operate like one?
As a medical student on the first day of Surgery, I learned that it's all about your hands. The nurse who did my scrub orientation and sized our gloves proclaimed, “such cute little hands! You’ll be a size 6.” It was meant as a compliment, but as a surgical resident I’ve learned that although my hands might be “cute,” “cute” does not help me fit in. This became evident when I started using a laparoscope. It was paradoxical; an instrument that was designed to extend the reach of surgeons limited mine. Instead of being strengthened and empowered by this technology, I often struggled to simply hold the scope properly. It was big, bulky, and the light cord (critical for adequate visualization) was out of my reach.
I’m not the first female surgeon to find manipulating laparoscopic instruments difficult. A 2004 survey study of 726 surgeons found that respondents with a glove size 6.5 or lesser reported significantly more difficulty using laparoscopic instruments, such as the staplers and scissors. Based on sex and glove size distribution, the authors predicted that 87% of female surgeons and 22% of male surgeons would be expected to experience significant difficulty with laparoscopic instruments.2 A survey of surgery residents done by Adams et al3 found that smaller-handed surgeons were more likely to manipulate laparoscopic instruments with 2 hands, a move that confers an operative disadvantage, disrupts surgical workflow, decreases efficiency, and makes the operator more dependent on their assistants. In addition, female surgeons are shorter,2–4 and studies have indicated that short stature increases the risk of occupational injury.5 Notably, grip span, grip strength, and hand anthropometry are also significantly different between men and women.6 These disparities have health consequences for female surgeons, as evidenced by report that female operators are more likely to experience discomfort as compared to their male colleagues with the same glove size and more likely to receive treatment for injuries sustained during laparoscopic surgery.4
In addition to the risk of occupational injury, surgical ergonomics and the misfit of laparoscopic instruments may place female surgeons at a competitive disadvantage. Although somewhat controversial, certain studies have shown that female medical students take longer to perform laparoscopic simulations than males.7,8 Notably, differences in learning curves are not entirely explained by gaming experience,9 operator accuracy is no different,10 and time discrepancies appear modifiable with instruction.8 A recent study by Flyckt et al11 demonstrated that women consistently underestimate their laparoscopic skills as compared to their male colleagues despite no difference in performance. One could speculate that low feelings of self-confidence might be linked to the difficulties women experience with laparoscopic instruments; all because of variables that are literally out of their hands. In an era of “sticky floors” and “glass ceilings” for women in academic surgery,12 diminished confidence and perceived surgical skill could make otherwise strong female surgeons appear less qualified than their male peers, perpetuating gender stereotypes which already disadvantage women in surgery. This is all despite evidence that suggests patients of female surgeons have better postoperative outcomes.13
It's ironic that so many of the gender issues that remain unaddressed in surgery can be revealed through the instruments that we use, and I suppose that's fitting because, after all, surgery is the work of our hands. I should not be surprised. Toward the end of my surgical clerkship, 3 of us were standing in an open elevator. A young woman began jogging toward us as the elevator doors were closing and I, very politely and instinctually, stuck out my hand to hold the door for her. Concurrently, I heard my senior resident laugh. When I looked around at him, I noticed his hands resting safely in his pockets and his right foot outstretched and positioned in the open door. Grinning, he said, “you can always tell what kind of doctor someone is by how they choose to hold the elevator. I do not need my feet to operate.”
Beyond the anecdote, this is clearly larger than just the instruments we use. It's about fairness and a level playing field. If this were a sport, we would all compete with equipment that fits us.14 To be clear, this is not an argument about patriarchy or misogyny in surgery. No, it's about solidarity. All of my surgical colleagues, both men and women, are making unnatural emotional and physical adjustments to fit into our surgical culture. To be a surgeon is, historically, to be unbreakable, commanding, and full of grit. We prevail despite the arduous work hours and lengthy operations where we stand in awkward positions without food or water retracting the weight of the body wall with steel. Important life events are missed. We hear the disappointment in our significant other's voice when we tell them we’ll be home late again. But through all the pain, we still love it, and we all have this in common. Our job hurts and our training teaches us that sometimes it's supposed to. As an avid runner and an aspiring triathlete, I believe that pain is good for me—it makes me stronger. I just think if we suffer, we should suffer and thrive equally. This is not happening.
The surgical community should consider the information presented here and appreciate how surgical ergonomics may precipitate discrimination, perpetuate sex disparities, and risk the wellbeing of surgeons at every level of training. I would implore surgical instrument manufacturers to address the apparent misfit of laparoscopic surgical technology. Designing an adjustable handle or lines of instruments for hands of various sizes and dominance is entirely within our capabilities. Understandably, manufacturers catered to their demographic at the time of the laparoscopic revolution—when ergonomic design criteria suggested “A good compromise is to design a handle that is suitable for 95% of the user group … the population of laparoscopic surgeons consists of ±90% male and ±10% female.15” Clearly, the demographics of surgery have changed and will continue to change. We need to get a handle on this.
The author would like to acknowledge Joseph J. Fins, MD and thank him for his support and guidance in writing this manuscript.
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