General and Medical Healthcare

The female surgical career by Helen Fernandes (Opportunities in Surgery Committee) and Michelle Ryan, Mette Hersby, and Cate Atkins (University of Exeter)

Helen Fernandes is a Consultant Neurosurgeon and member of General & Medical’s Medical Advisory Panel

The problem

Despite the increasing number of female medical students, women continue to be underrepresented in more senior grades in the medical profession. In 1987 this was formally studied by Frances Lefford who examined the hospital careers of women in England and Wales. Lefford’s assessment acknowledged that the number of women in medicine had risen, but noted that there had been little improvement in women’s career prospects and that the number of women reaching subspecialities (such as surgery) was disproportionately low. Lefford concluded that being female was a handicap to achieving consultant status, particularly in the popular specialities (surgery, medicine and obstetrics). Lefford’s findings are mirrored in similar studies carried out in the UK (Elston, 1993; FirthCozens, 1994; Parkhouse, 1991) and the US (Bickel, 1988, 2001) including Isobel Allen’s influential Doctors and their careers, (Allen, 1988, 1994).

In a number of areas the statistics for women are encouraging. Allen (2005) found that over time, there had been an increase in the proportion of women in all grades of hospital medicine: 23% in 1983, rising to 35% in 2003. The proportion of women consultants over this time period had further doubled from 12% to 24%. Similarly, a UK study of qualifying doctors showed that women accounted for 50% of senior house officers and 44% of specialist registrars. The specialties with the largest proportions of women consultants in 1983 were psychiatry, pathology, and paediatrics; in 2003, paediatrics had continued to grow, and was the leading specialty for women in that it had 40% of female consultants. The number of women consultants had also increased greatly in acute specialties like obstetrics and gynaecology and accident and emergency. Surgery, however, remains a male preserve, with women constituting only 7% of consultants. Comparable findings are also reported by McManus (2000). Research reveals that in specialties such as surgery, anaesthetics, and obstetrics and gynaecology fewer women progress beyond the senior house officer (SHO) grade than would be expected.

The reviewed studies suggest that equal opportunity has not yet been achieved in all subspecialties. Particularly in surgery there seems to be a “glass ceiling” for women in their education or in their career choice seemingly blocking their move into certain fields of medical practice. “The glass ceiling” is a common metaphor for the largely invisible barrier that women face as they attempt to reach the upper echelons in male-dominated fields. Although 20 years have passed since the Wall Street Journal coined the phrase, it is clear that the glass ceiling still exists, with women continuing to be under-represented in leadership roles (Allen, 2005; Singh & Vinnicombe, 2006).

This large discrepancy between male and female medical professionals progressing beyond the SHO grade has led researchers to suggest that harassment and gender discrimination - whether direct or indirect – may have an impact on female health professionals’ education and opportunities (Bickel, 2001; Zeldow, 1991).

Explanations we can rule out

Considering previous research allows us to rule out a number of potential explanations for the current status of women in surgery. First, the obvious justification for the low number of women in subspecialties such as surgery could be explained as a “pipeline problem” – the suggestion that there simply are not enough female medical professionals to become surgeons later on in their careers. However, an examination of the trends in professional career progression of women doctors revealed that – in stark contrast to the pipeline problem - the increase of women in hospital posts is largely explained by the rapidly increasing proportion of women entering medical school (McManus, 2000). Further, statistics show that in the early 1990s, female medical school intake exceeded the 50% mark, reaching 61% in 2004 and continues to rise (HEFCS, 2004).

Similarly, the lack of female surgeons cannot be explained by differing ambitions among up and coming male and female health professionals. An analysis of career preferences and intentions from medical school applicants, students, and house officers suggest that male dominated specialties are popular career intentions for women (Zeldow, 1991).

Further, women’s underrepresentation at the top of the career ladder is often explained by elements external to their working environment such as their own inability to cope with the pressure or because they wish to stay at home with their children. However, Allen (2005) argues that such an argument is not the case in paediatrics, where despite its on-call demands and out of hours commitment (the very things that women are supposed to shun), it is the leading female specialty.

Men, Women and Stereotypes

Other explanations for the disproportionate number of women in surgery include the notion of a ‘surgical personality’. Findings have suggested that personality profiles for surgeons were remarkable in their consistency (Zelkow, 1991). A British study found that surgeons were significantly more extroverted and less neurotic than physicians, and significantly more intolerant of uncertainty (McCulloch, 2005). In addition, a small study reported that surgeons formed a distinct and homogeneous group based on temperament and personality traits (Schwartz, 1994).

Research suggests that there may be differences between a male and female surgical personality. A longitudinal comparative study of applicants for surgical and geriatric SHO posts reported personality differences between the specialities, but also between the male and female surgical applicants. This study concluded that although there were no differences in ability between surgeons and geriatricians at the start of their careers, there were differences in personality (Gilligan, 1999). Thus, the lack of female surgeons may be due to a mismatch between the personality of the typical surgeon and women with their more feminine characteristics.

Indeed, a similar line of reasoning has been offered for gender-based differentiation within the management hierarchy of other professional sectors. The tendency to associate being a manager with being male (the ‘think manager–think male’ association) has been thought to underlie many gender inequalities in the workplace. This has led social psychologists to investigate the perceived incompatibility between beliefs about what it means to be a good leader and what it means to be female (e.g., Eagly & Karau, 2002; Schein, 1973). One of the most important conclusions from this work is that the managerial and gender stereotypes do not simply describe people’s characteristics and behaviour, they are also strongly prescriptive in the sense that they dictate expectations of the way that people should act (Heilman, 2001; Rudman & Glick, 2001). As a result, these stereotypes impact upon a number of facets of gender differentiation in the workplace. For example, Eagly and Karau (2002) argue that the mismatch between the perceptions of women and managers can produce two forms of prejudice: (a) less favourable evaluation of the potential for women to take on leadership roles compared to men, and (b) less favourable evaluations of the actual behaviour of female leaders.

The importance of looking at experience

While research has looked at stereotypes of the general practitioner and the surgeon (e.g., Bellodi, 2004) no direct comparisons have been made with male and female stereotypes. However, evidence suggests that there may be a ‘think surgeon – think male’ association. Cassell (1998) explored the female surgical personality, observing 33 women surgeons in five areas of North America practising a range of surgical specialties. Cassell found that female surgeons had very different experiences from their male colleagues. Women surgeons, she found, encountered hostility and conflicts with mentors, nursing staff, male colleagues, and even patients due to embodied and socially constructed expectations based on gender. Simply put, women were not considered to fit the stereotypical picture of what it means to be a surgeon; the people they meet on a day to day basis expected them to be male. As a result of this Cassell argues that - consciously or not - women surgeons negotiate “feminine” gender expectations held by colleagues, nurses, and patients into their practice. Their training experience, surgical manner, and patient care management reflect this negotiation of being a woman and a surgeon. To elicit greater co-operation from male subordinates and especially female nurses, many women surgeons are more egalitarian, less authoritarian, and less hierarchical in their behaviour. Whereas certain behaviours by male surgeons are often tolerated, it is not so for women surgeons.

The importance of examining differential experiences between men and women is also suggested by the research of academic psychologists Ryan and Haslam (2005, 2007) who, over the past three years, have examined the nature of the positions that women attain, and the circumstances surrounding their appointment to leadership roles. Using a combination of archival and experimental studies, as well as in-depth interviews with senior women, their research suggests that the experience of women in leadership roles tends to be distinctly different from that of men. Ryan and colleagues have particularly focused on the incompatibility between gender and managerial stereotypes and the consequences that this has for women. Further, they have conducted large-scale surveys into the career trajectories of professionals from a range of occupational sectors in order to understand the impact that perceptions of self and professional role, career aspirations, workplace barriers and benefits, has on career choice, commitment and satisfaction.

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