INTRODUCTION
Although the presence of women has been increasing both in general surgery and surgical subspecialties in the last few years, the advancement of women surgeons in leadership roles and in apical academic positions is still limited. This is a multifactorial phenomenon influenced by educational and psychosocial factors that involves traditional gender roles and discrimination trends.[1–3-]
Only recently, some papers concerning the specialty of otolaryngology–head and neck surgery (OHNS) have been conducted but, to the authors’ knowledge, none of these analysed an Italian sample.[4–14-]
The field of OHNS has undergone enormous changes in the last decades. Once limited to minor ear, nose and throat (ENT) procedures, it has now evolved into a complex surgical specialty including several subspecialties requiring additional fellowship training. However, a contextual gender-based evolution does not seem to have occurred, with studies in the current literature demonstrating a particularly low rate of women involved in OHNS with leadership positions in American and European series.[15,16]
Herein, we describe the results of a multidisciplinary large scale national cohort study promoted by Women in Surgery Italia (WIS Italia), an association dedicated to encouraging women in their surgical career.[17] The aim of this study was to investigate possible differences in the professional and personal life and the perception of gender bias, among Italian women surgeons, comparing those working into the field of OHNS to an overall group (OG) of surgeons.
MATERIALS AND METHODS
Survey
Between November and December 2020, an online survey investigating several aspects of the professional career and personal life was proposed to Italian women surgeons with various backgrounds (such as OHNS, General Surgery, Thoracic Surgery, Gynaecology and Obstetrics, Ophthalmology, Maxillofacial Surgery, Neurosurgery, Plastic Surgery and Orthopaedics) by WIS Italia.[17,18] The survey was administered through the RedCap platform and data were collected by 18 women surgeons from several Italian Hospitals, among which two were Otolaryngologists (D.L., E.M.C.T.). The research was compliant with the Checklist for Reporting Results of Internet E-Surveys.[19]
The items included in the survey derived from pre-test interviews conducted among the authors of the study. Feedbacks regarding the survey coherence and clarity were acquired, allowing an iterative revision and re-test process. The participants were reached by two methods: (1) through e-mail, using a contacts’ database previously created for the purposes of WIS Italia and constituted only by female surgeons; (2) invitation through the WIS Italia social media pages (Instagram, Facebook, Twitter and LinkedIn). Since the WIS Italia database was used, it was not possible to extend the survey to male responders, to obtain a male control cohort. Included participants were female medical doctors working in all the surgical fields mentioned above, as residents, attendings and faculty members in Italian academic and non-academic hospitals. Medical students, men and retired surgeons were excluded. Only responders who entered at least 70% of the answers were included in the analysis. All participants gave their informed consent prior to answering the survey, through a dedicated informative page.
Although the original survey was composed of 83 multiple choice questions, in the present study we preferred to focus on 27 items exploring work setting, education, family status, practice pattern and surgical activity, presence of professional role models and gender bias [see: Survey on Female surgeons, as Supplementary Table 1]. Surgical activities were classified by complexity in high, moderate and low complexity cases and according to the role of the interviewer in leading surgeon versus assistant surgeon.
;)
Supplementary Table 1: Survey on female surgeons
The analysis of results was conducted on the entire cohort, which was classified in two categories: otolaryngologists and non-otolaryngologists, including all the women surgeons working in other surgical fields different from ENT.
The ethics committees of the participating institutions waived the need for ethics approval and the need to obtain consent for the collection, analysis and publication of the anonymised data for this study. All procedures performed in the study were conducted in accordance with the ethics standards given in 1964 Declaration of Helsinki, as revised in 2013.
Statistical analysis
The statistical analysis was performed using SPSS for Windows (IBM SPSS Statistics, Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation. Student’s t-test was used for continuous variables with normal distribution, while Mann–Whitney U-test was adopted for continuous variables without a normal distribution. Comparisons between groups were performed by Pearson’s Chi-square or Fischer exact test for discrete variables, as appropriate. The results were considered as significant for P < 0.05 with a confidence interval of 95%. The statistical model was analogous to that used in the two previous papers describing the overall results of the survey[17,18] and performed by the statistics department.
RESULTS
Overall, 3225 participants responded to the survey and 1963 (60.8%) were included in the final analysis, while the remaining 1262 were excluded because they entered <70% of the answers. Of the responders, 153 (7.8%) were otolaryngologists and included in the OHNG group (OHNSG), whereas the remaining 1810 (92.3%) were intended as the OG and included all non-otolaryngologists. Table 1 summarises data based on specific responses, number of evaluable responders and statistical comparisons between OG and OHNSG. The OG was mainly made up of general surgeons (1810, 92.2%).
Table 1: Detailed survey responses including statistical comparisons between the overall group and the otolaryngology-head and neck surgery group
As shown in Table 2, there were no statistically significant differences between the two groups according to age (38.1 years ± 9.5 in OG vs. 38 years ± 12.7 in OHNS; P > 0.05) and number of trainees (33.5% in OG vs. 23.6% in OHNS; P > 0.05). In both cohorts, female surgeons represented approximately one-third (31%) of the staff at their institutions. Also, homogeneous results were found when comparing years of experience (11.8 years ± 9.7 in OG vs. 11.9 years ± 12.7 in OHNS; P > 0.05) and number of surgeons who completed training experiences abroad (25.8% of OG vs. 25.6% of OHNS; P > 0.05). Although the difference was not statistically significant (P > 0.05), a lower percentage of women surgeons in the OG (34.9%) compared to the OHNS (40.5%) presented additional qualifications such as PhD and masters degree. Conversely, a statistically significant difference (P < 0.05) regarding the number of working hours per week emerged between the two groups (OHNS: 44.9 ± 2.12 h vs. OG: 48.8 ± 11 h).
Table 2: Multivariate analysis on the role of the different variables associated with overall monthly performed surgeries
Regarding the family status, about 60% of women surgeons were married/had a cohabiting partner and 36% had at least one child (P > 0.05 for both comparisons).
Interestingly, concerning the surgical activities, our results evidenced that at least one female surgeon in the staff does not regularly attend the operating room (OR), especially in the OHNSG (45.7% of OHNSG vs. 36.5% of OG; P < 0.05). A further analysis was performed by dividing the results on percentage of women in the staff and access to the OR, according to the different fields. The results are displayed in Figure 1.
Figure 1: Women distribution of the responders in different surgical fields
Fifty percent of OHNS responders versus 35% of the OG reported that they had to abandon the surgical activities to some extent in favour of outpatient services (P < 0.05). Even though >70% in both groups are willing to spend more time in surgical activities, most responders (51.8% in OG vs. 67.1% in OHNS, P < 0.05) usually spend more than 50% of working hours in non-surgical activities. Conversely, OHNS responders spent significantly less hours in surgical activities compared to the OG (P > 0.05).
Responders in both groups were involved as team surgeons in approximately less than one-third of the monthly planned surgeries (26.1% in OG vs. 22.7% in OHNSG; P > 0.05). Surgeons in both groups were involved as leading surgeons in about 8% of high complexity cases, 11% of moderate complexity cases and <20% of low complexity cases. All comparisons among groups did not evidence statistically significant differences (P > 0.05). However, the percentage of surgeries of moderate complexity performed monthly as assistant surgeons by the OHNS responders (17.4%) was significantly lower (P < 0.05) than those of the OG (22.7%).
A significantly higher proportion of OHNSG surgeons encountered critical difficulties in the OR versus OG (79.1% vs. 56.4%; P < 0.05), as detailed in Table 1.
Most responders had role models in their career, mainly males in both groups; however, the percentage of female role models in the OHNSG (12.7%) was significantly lower (P < 0.05) compared to the OG (22.3%).
When asked about the most common patterns of gender-based different treatment, OHNS responders (57.4%) reported “less training, advice and support compared to their male counterpart” in a significantly higher percentage (P < 0.05) compared to the OG (44.1%). Both groups reported that the most critical issues were “more unrewarding tasks,” “less acknowledgement” and “worse chance of being promoted,” and no statistical difference was detected in the comparison between groups (P > 0.05).
DISCUSSION
The survey investigated the professional and personal life of Italian women surgeons, comparing global results from all surgical specialties with the OHNS field. Some interesting disparities emerged: first, OHNS responders reported more qualifications (i.e., masters, PhD, masterclasses) than OG. The greater proportion of research-related qualifications could be explained by the existence of many clinical sub-fields in otolaryngology (such as audiology, vestibulology and rhino-allergology), more often associated with basic research. However, this finding is in contrast with the low number of responders entitled with academic roles: only 2.2% of the OHNS responders are associate professors (AP) versus the 2.5% in OG. This data reflects the national scenario of OHNS in Italy, where only 12% of AP are women according to the Italian Ministry of University, Education and Research.[20] Moreover, neither full professors (FP), nor department chairs in OHNS in the whole country are women. Garstka et al. reported that in the American Head and Neck Society, 60.2% of FP and AP were men, while at the junior level the proportion of female researchers was much higher (54.1% female vs. 36.3% male).[15] Recent studies showed that the number of female AP is overcoming the male counterpart.[21] These data suggest that female involvement in academic positions is slowly increasing in the USA and in the future a higher number of women will be covering leadership academic positions.
Despite both groups having an average of 31% female staff, suggesting a progressive “mathematical” equity, a significant disparity in the work tasks between men and women emerged. This has largely been reported in the literature since residency and across many surgical fields.[22–27-] In our study, OHNS responders spent significantly less hours in surgical activities and more in outpatient services, ward and administrative activities, compared to the OG. This trend is supported by the fact that 50% of the responders declared that they abandoned the OR to some extent in favour of clinical activities, and similarly, that almost half of the OHNS participants reported having a female colleague in the staff who does not attend the OR regularly. This may be due to some women being more involved in exclusively clinical subspecialties. However, the necessity to abandon surgical activity in favour of the clinical one seems more a “forced” choice than a personal one, since most women (74.4%) in the OHNSG would like to spend more time in the OR and would prefer to reduce their non-surgical activity (62.7%). Concerning case volume and management of complex cases, no statistical differences were detected between groups, but a substantial surgical “underemployment” was appreciated in the overall responses. On the one hand, the interviewed declared to participate to a high percentage of surgeries (22.7% in OHNS vs. 26.1% in OG). On the other hand, case volume as team leader in high complexity cases corresponded to only 8% of the overall commitment in both groups. The most frequent surgical activity was described as assistant surgeon in high-moderate complexity cases or leading surgeon in low complexity cases. These results led us to reflect on the women’s practice trajectories. On one hand, female surgeons are allowed to participate in surgical procedures as the same percentage as their male colleagues. On the other hand, they seemed less allowed to develop autonomy in the more complex, experience-building cases.
The third difference is the prevalence of male role models among Italian Otolaryngologists compared to the OG (87.3% vs. 77.7%). The paucity of senior female examples could have a negative impact on the appeal of a surgical career on female medical students and it is a direct effect of the underrepresentation of women.[28] Finally, it was shown that a significantly higher percentage of responders in the OG did not encounter any difficulties in the OR, compared to the OHNSG and poor training was significantly more reported by the OHNSG than the OG. The mechanisms underlying this scenario of dissatisfaction are complex and could be partially due to psychosocial attitudes on traditional gender roles and discrimination in the medical field.[29] Finally, although the surgical career does not seem to impede with the creation of a family in both groups, an impact on female reproduction was found, with more than 40% of responders willing to have a child and only <20% having more than one child. Unfortunately, this finding does not seem to receive much attention by the Italian institutions, who have not provided yet sufficient economic and social resources for working women during pregnancy and maternity leave.
This paper has limitations. The most important is the absence of a male control cohort, which impedes a full comparison between genders. As it is conceived, this study focuses on the point of view from women in surgery only, comparing those involved in the field of otorhinolaryngology to those in other surgical fields, and showing that the former perceives a worse professional situation than the latter in many areas. The main implication of this comparison is that work task distribution, involvement in surgical activities, perception of training quality and presence of female mentorship all deserve further attention for the future generations of female Italian otolaryngologists-head and neck surgeons.
The definitive presence of gender bias in the working environment could not be assessed according to the feedback from female responders only. However, it should be emphasised that the structure of several questions from the survey, together with the investigation of specific gender-related issues, allowed to explore the perception of possible gender disparities among the participants. The questions were designed to investigate the surgical case volume among female surgeons in relation to the entire surgical team and an objective approach with measuring the operative involvement was provided.
Specifically in the Italian scenario, it could be hypothesised that the level of dissatisfaction regarding involvement in surgical activities and academic career is equally high also in the male counterpart, mostly due to the maintaining of age-related habits in the Italian environment, that may contribute to prevent young surgeons to easily pursue their career, independently from gender. Indeed, when interpreting the results, one must consider that they are from an exclusive Italian cohort and thus could be variably influenced by the national psychosocial conditions. A prospective study on populations from different nations could help in clarifying the possible differences.
Eventually, the disparity in the number of OHNS responders significantly lower to OG responders, should be acknowledged.
CONCLUSION
According to the first survey addressed to Italian female surgeons, the otolaryngologists showed several disparities as compared to the overall surgeons group, regarding work tasks, involvement in surgical activities, perception of training quality and gender-based inequalities and female mentorship. All those aspects need deep reflection, as they may be linked to many critical issues, starting from the choice of a surgical career, to the paucity of female leaders in the otolaryngology field.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Brown JB, Fluit M, Lent B, Herbert C Surgical culture in transition: Gender matters and generation counts. Can J Surg 2013;56:153–8.
2. Basky G Study reveals “old boys'club” in surgical referrals. CMAJ 2021;193:E1847.
3. Lillemoe KD, Ahrendt GM, Yeo CJ, Herlong HF, Cameron JL Surgery-still an “old boys'club”?. Surgery 1994;116:255–9.
4. Parini S, Lucidi D, Azzolina D, Verdi D, Frigerio I, Gumbs AA, et al. Women in surgery Italia: National survey assessing gender-related challenges. J Am Coll Surg 2021;233:583–92.e2.
5. Barnes KL, McGuire L, Dunivan G, Sussman AL, McKee R Gender bias experiences of female surgical trainees. J Surg Educ 2019;76:e1–14.
6. Bernardi K, Shah P, Lyons NB, Olavarria OA, Alawadi ZM, Leal IM, et al. Perceptions on gender disparity in surgery and surgical leadership: A multicenter mixed methods study. Surgery 2020;167:743–50.
7. Bowe SN, Villwock JA Does gender impact personality traits in female versus male otolaryngology residents and faculty?. Am J Surg 2020;220:1213–8.
8. Chandrasekhar SS Tackling gender and racial discrimination in otolaryngology, head (and Neck) on. Otolaryngol Clin North Am 2021;54:23–27.
9. Kriegsman B, Harrison S, Sobin L Women and minorities in otolaryngology: A historical perspective and analysis of current representation. Otolaryngol Clin North Am 2021;54:233–8.
10. Okafor S, Tibbetts K, Shah G, Tillman B, Agan A, Halderman AA Is the gender gap closing in otolaryngology subspecialties? An analysis of research productivity. Laryngoscope 2020;130:1144–50.
11. Meyer TK, Bergmark R, Zatz M, Sardesai MG, Litvack JR, Starks Acosta A Barriers pushed aside: Insights on career and family success from women leaders in academic otolaryngology. Otolaryngol Head Neck Surg 2019;161:257–64.
12. Zambare WV, Sobin L, Messner A, Levi JR, Tracy JC, Tracy LF Gender representation in otolaryngology-head and neck surgery recognition awards. Otolaryngol Head Neck Surg 2021;164:1200–7.
13. Fu T, Wu V, Campisi P, Witterick IJ, Chan Y Academic benchmarks for leaders in Otolaryngology – Head & Neck Surgery: A Canadian perspective. J Otolaryngol Head Neck Surg 2020;49:27.
14. Landeen KC, Xie Y, Moran ML, Yang SF Female representation and academic leadership in facial plastic and reconstructive surgery. Laryngoscope 2022;132:781–5.
15. Garstka ME, Randolph GW, Haddad AB, Nathan CO, Ibraheem K, Farag M, et al. Gender disparities are present in academic rank and leadership positions despite overall equivalence in research productivity indices among senior members of American Head and Neck Society (AHNS) Fellowship Faculty. Head Neck 2019;41:3818–25.
16. Epperson M, Gouveia CJ, Tabangin ME, Takiar V, Howell R, Altaye M, et al. Female representation in otolaryngology leadership roles. Laryngoscope 2020;130:1664–9.
17. Available from:
https://womeninsurgeryitalia.it [Last accessed on 2023 Feb 28].
18. Lucidi D, Parini S, Reale M, Azzolina D, Verdi D, Spolverato G Women in Surgery Italia: What are the opportunities in the operatory room?Results from a nationwide interdisciplinary survey. Updates Surg 2022;74:803–16.
19. Eysenbach G Improving the quality of Web surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004;6:e34.
20. Available from:
https://www.miur.gov.it [Last accessed on 2023 Feb 28].
21. Tulunay-Ugur OE, Sinclair CF, Chen AY Assessment of gender differences in perceptions of work-life integration among head and neck surgeons. JAMA Otolaryngol Head Neck Surg 2019;145:453–8.
22. Dahlke AR, Johnson JK, Greenberg CC, Love R, Kreutzer L, Hewitt DB, et al. Gender differences in utilization of duty-hour regulations, aspects of burnout, and psychological well-being among general surgery residents in the United States. Ann Surg 2018;268:204–11.
23. Gil JA, Daniels AH, Weiss AP Variability in surgical case volume of orthopaedic surgery residents: 2007 to 2013. J Am Acad Orthop Surg 2016;24:207–12.
24. Lin TR, Kocher NJ, Klausner AP, Raman JD Longitudinal gender disparity in female urology resident primary authorship at an American Urological Association sectional meeting. Urology 2017;110:40–4.
25. Gupta N, Dragovic K, Trester R, Blankstein J The changing scenario of obstetrics and gynecology residency training. J Grad Med Educ 2015;7:401–6.
26. Talutis S, McAneny D, Chen C, Doherty G, Sachs T Trends in pediatric surgery operative volume among residents and fellows: Improving the experience for all. J Am Coll Surg 2016;222:1082–8.
27. Lynch G, Nieto K, Puthenveettil S, Reyes M, Jureller M, Huang JH, et al. Attrition rates in neurosurgery residency: Analysis of 1361 consecutive residents matched from 1990 to 1999. J Neurosurg 2015;122:240–9.
28. Baxter N, Cohen R, McLeod R The impact of gender on the choice of surgery as a career. Am J Surg 1996;172:373–6.
29. Zhuge Y, Kaufman J, Simeone DM, Chen H, Velazquez OC Is there still a glass ceiling for women in academic surgery?. Ann Surg 2011;253:637–43.
