Women in Surgery: A perspective from India
Sushma Sagar MBBS, MS, FACS
Two roads diverged in a wood and I…
I took the one less travelled by
And that has made all the difference
The lines keep echoing in my mind as I sit down to pen down my thoughts on a topic so tender and close to me. Mine is a country where cultural diversity runs in blood. Today, we see India as an emerging nation, riding on varied cultural beliefs and traditions. Technical advancement, digitalization and globalization has enabled many Indians to flourish contributing immensely in the field of Medicine and Information Technology.
The impact of this globalization, digitalization has greatly influenced the patriarchal society and the role of women that existed in India since the rise of civilization. Women, though often worshipped in various form of Goddesses, still face female foeticide and sexual abuse. This has often influenced women to remain indoors to work and support male members of the family and not adding a penny to their name. In a male dominated Indian society, it requires courage and confidence to break the barrier to come out in open and work shoulder to shoulder with men.
When we talk of medical field, especially Surgery, the impact is more visible. Nursing and midwifery was the domain where women found their place and later in Obst and Gynecology. Recently in an Annual meeting of Associations of Surgeons it was projected that for 25,000 surgeons there are only 700 women surgeons and of 12,700 members only 300 women are members of this society, a number too small to be reckoned at any forum.
In India, the social milieu is such that with its orthodox beliefs women are discouraged to take up jobs where most of the time one is surrounded by male colleagues and the working hours sees no night and day. A woman professional has to contribute significantly to household cooking/ home & school management of her kids & elderly parents. The joint family system allows her only balanced independence to pursue her demanding career. Unlike west, most religious festivals & social rituals in India mandate presence of women at the home front. Surgery as elsewhere in the world is equally demanding here also, principally all working days at times amounting to more than 80 hours a week. The male mindset when given a choice to select a candidate for pursuing a surgical specialty often discourages women.
Only now that I am in the field for more than 20 yrs do I realize that only a hard core women who is passionate about opting for surgery can face these challenges bravely by gulping the tears rather rolling them over cheeks. Attire, manor, language, built and height of women surgeon are often more discussed than her surgical skills, hard work and punctuality. “Sister please,” is a word which identifies you soon after your first clinical posting . The atmosphere in the OR and Duty rooms is often not very pleasant and audible and pushes you to stay focused and unwary of the surroundings. Conservative thinking does not allow women to be in the male bastion till they take the charge to boss around.
The path where I am today had torch bearers like Dr.T.S. Kanaka, Asia’s first female neurosurgeon who opted for a career in neurosurgery way back in the 1960s, and struggled hard to get the feel of scalpel.
But the scenario is changing fast with more women reaching at higher positions and mentoring the young ones to join the specialty.
Dr. Sushma Sagar MBBS, MS, FACS, Additional Professor, Division of Trauma Surgery and Critical Care at All India Institute of Medical Sciences, New Delhi, India. A course Director and a course faculty for ATLS India program, faculty for National Institute of Disaster Management. With more than 50 Research publications in National and International Journals, she is currently working as Investigator in major trauma related projects as Capacity Building for Advanced Trauma Life Support in India (NDMA ,Reducing the Burden of Injury in India and Australia through Development and Piloting of Improved Systems of Care( DST-AISRF), Capacity building and strengthening of Hospital Infection Control to detect and prevent antimicrobial resistance in India (CDC). She is member of various editorial board, wrote chapters in book, and a manual on School Safety Program in India. Being a founder executive member of Indian Society for Trauma and Acute Care (ISTAC) she is involved with other Teaching and Training program as RTTDC (ACS-COT), PHTLS, BLS and BECC all over the country and the region.
WOMAN SURGEONS IN ITALY
Dr Serena Bertozzi, MD
In Italy between the 1950s and the 1990s the incidence of women graduates in medicine increased considerably and the numerical imbalance between male and female doctors tended to disappear . Moreover, during 2000s the imbalance in the medicine degree was in favor of women . However, analyzing the current state of women surgeons in Italy, it is still impossible not to disclose an important percentage of gender discrimination. In fact, data collected by the Italian Association of Hospital Surgeons (ACOI) demonstrated that about 50% of women surgeons have been victim of mobbing or dissuasion during their lives .
Considering the registered surgeons in the two main Italian surgery societies (SIC – Italian Society of Surgery; and ACOI – Italian Association of Hospital Surgeons), the active female members are around 10 to 20% among specialists and up to 42.4% among trainees suggesting, as for other specialties, a women shift in the next generations (Figure 1A).
Probably also due to their evident numeric majority in comparison to men, during the study of medicine in the 2000s, women usually receive the same opportunities and evaluations of their men colleagues. Despite a progressive inversion of the gender prevalence even in the surgical resident school, during their surgery learning and their whole career, women surgeons often report episodes of discrimination .
In particular, it is still common to remark that women need to work harder than men to reach the same recognition, and mean women surgeons salary results lower than that of their men colleagues. Moreover, although women represent an increasing proportion of Italian surgeons (up to 60% of Trainees in 2004), only 0.5-1% of them cover relevant roles within the Italian National Health System  (Figures 1B and 1C).
For what concerns their private life, many women surgeons still chose to sacrifice the family for the work. Taking into consideration that the resident school for a woman surgeon ends when she is more than 30 years old, and than it usually takes her some more years to find a stable workplace and to further develop crucial skills for a successful carrier, she usually spends the most of her fertile years in a precarious condition, that surely does not help her in becoming married nor having children [3, 4]. Although in Italy pregnancy is protected, the pregnant surgeon woman as a professional is not yet protected during crucial years of its professional development .
Finally, it is not forgettable a sort of gender discrimination even from patients or parents, which is expression of some cultural prejudgments, so that it is not infrequent for women surgeons to be called “mrs” instead of “doctor”.
 Vicarelli G. Identità e percorsi professionali delle donne medico in Italia. Polis. 2003;17:93–124.
 Noè C. Genere e scelte formative. AlmaLaurea Working Papers n° 54 – ISSN 2239-9453. 2012.
 Uff St adnkronos comunicazioni. ACOI (2) Donne in Chirurgia. il Nuovo Medico d’Italia online (XXV Congresso Nazionale Associazione chirurghi ospedalieri italiani). 2006; Acessed on 24/03/2016.
 Piccoli M. Donne e Chirurgia – Debuttanti? Non si direbbe! ACOInews. 2006;2006(3):9.
Figure 1– Plot showing data (up to March 2016) of the two major Italian surgical societies. Panel A) Prevalence of women among members of the two Societies. Panel B) Job position of women in ACOI active members. Panel C) Job position of women in ACOI (all database).
We kindly tank for the following data Dr Micaela Piccoli (National Advisor ACOI) and the national secretariat of the SIC.
ACOI: Associazione Chirurghi Ospedalieri Italiani (Italian Association of Hospital Surgeons); SIC: Società Italiana di Chirurgia (Italian Society of Surgery). (*) Active members: members who have paid (up to three years in arrears).
Serena Bertozzi, MD received her MD from the University of Udine in 2008 and completed her studies in Germany and Italy. She has performed over 100 HIPEC treatments for peritoneal metastasis and received a grant for the prevention of female urinary incontinence. She is working in the Surgical department of the IRCCS CRO in Aviamo (PN) Italy.
PROGRESSING ONE STEP FURTHER: ENTICING WOMEN TO GO INTO SURGERY IN HONG KONG
Ava Kwong, M.B.B.S., BSc., PhD, F.R.C.S., F.R.C.S. (Edin), FCSHK, FHKAM (Surgery)
Over half of the medical students admitted to medical schools are women in Hong Kong but women surgeons still constitute a minority of the surgery community. In 2011, 8% of all surgeons in Hong Kong were women breast surgical specialists and 30% of surgical trainees were women. However, there is a trend over the past 5 years; in 2016 the percentage of women specialists have increased to 13% and the number of female trainees have raised to 37%. To date there is only one female who has attained the title of Associate Professor or above in Hong Kong.
The College of Surgeons of Hong Kong recognized the need to address the increased flux of women entering medicine as a career and the importance of attracting the most elite in either gender into the field of surgery. Due to the long duration of training and working hours, surgery was previously perceived to be a male career choice and may not be the most popular choice amongst females in this part of the world. More was needed to be done to address female specific needs so that a surgical career can become more appealing to all. The College of Surgeons has taken an active role to improve the numbers of women in surgery.
With support from the College and its members, the Women’s Chapter was formed on 22 November 2008. I was honored to be elected as the Chairlady at the time and help establish this important Chapter.
The mission of the chapter is to promote surgery as a career for women and enhance professional advancement amongst female surgeons. The Chapter also aims to facilitate social, clinical and academic interactions amongst women surgeons and to encourage a balanced lifestyle so that women will be able to excel in a surgical career and yet can still enjoy a good family life. Social activities were organized such as learn to be beautiful, dinner gatherings and participation to charity events such as walk for a cause became regular activities of the group. In addition, a mentorship programme was established to encourage medical students to learn more about Women in Surgery.
There is still more to do to encourage women to consider Surgery as a career but we are certainly progressing in this part of the world.
Dr Ava Kwong M.B.B.S., BSc., PhD, F.R.C.S., F.R.C.S. (Edin), FCSHK, FHKAM (Surgery)
Dr. Ava Kwong is the Chief of Breast Surgery Division, Clinical Associate Professor at the University of Hong Kong Medical Centre and Director of Breast Center of University of Hong Kong – Shenzhen Hospital. She is the Assistant Dean (Faculty Advancement and Knowledge Exchange) of Faculty of Medicine, The University of Hong Kong.
In 2007, she founded the Hong Kong Hereditary Breast Cancer Family Registry, where she currently serves as the Chairman. In 2009, she founded the Women’s Surgical Chapter at the College of Surgeons of Hong Kong and was elected to be the first Chairlady. In 2011 she was also elected to become a council member of the College of Surgeons of Hong Kong, being the first woman to attain such a position and she is the first women who has attained Associate Professor position in Surgery in Hong Kong where she served on the council until 2014.
AN ALMOST INSURMOUNTABLE BARRIER
To understand what in means to be a woman surgeon in Pakistan, one has to understand certain truths. In 1947, as the British Empire lost its hold on the Indian subcontinent, Pakistan came into being, becoming one of only two nations (the other being Israel) in the world created with the intention of protecting a religious minority. As it is with many nascent nations, there was infinite hope bolstered by a reasonable degree of potential. Pakistan’s strength was its geographic, ethnic, and cultural diversity. Despite the different languages, traditions, customs, and narratives, the one thing besides religion that these groups had in common was a rigidly patriarchal social structure. That was, and will remain, an almost insurmountable barrier to progress.According to the UNDP report from 2010, Pakistan ranked 92 out of 94 on the Gender Empowerment Index. It is estimated that < 3% of girls in the 17-23 year age group have access to higher education. As if that isn’t a big enough challenge, enter the Taliban with their violent delusions. Bombing girls’ schools is actually part of their policy.
Of the < 3% of young women who have access to higher education, a fair number will make their way to medical school. Till 1986, there were strict quotas for the number of women who could be enrolled in a public sector medical school. Not surprisingly, the quota system was challenged in court leading to a contrary imbalance. Now almost 70% students in public sector medical schools are women. Of these women, only 50% will go on to practice medicine. The other half will conform to the patriarchal social structure and willingly or not, become homemakers. Despite the large number of women graduating with medical degrees, females make up only 23% of registered doctors.
For those women who chose to continue in the profession, at this particular stage in their careers there are similarities with developed countries. The vast majority will opt for post-graduate training in disciplines that are perceived to have a better work-life balance. Of those that succumb to the thrill of the operating room, the majority will choose Obstetrics and Gynecology. The patriarchal society that they have to battle every step of the way, ironically, ensures that they will make a good living – it would be unthinkable for a man to deliver a baby, or even talk about a menstrual period.
At the very end, there is a tiny group of formidable young women who will choose General Surgery and subsequent sub-specialization. Those who have financial means and family support will probably head west to the UK or the USA for training. Those who choose to stay in Pakistan will attempt to secure training positions in the local programs. If I were to compare these women to their US counterparts until 5 – 8 years ago, they would be akin to the trailblazing women in residencies during the 70’s and 80’s. They would have to deal with chauvinism, sexism, and misogyny. There would be very little tolerance for issues related to child bearing or child rearing. A pregnancy would easily mean a termination from the program. Thankfully, in keeping with the natural history of these attitudes, the landscape is changing. In our program of 18, there are 6 women. The change in culture is enabled by the professionalism of the women and by the inherent or acquired enlightenment of their male colleagues and teachers.
Until now, the journey was straightforward. The real challenge is going out into practice. The only institutions where women general surgeons can practice with some degree of ease are the large tertiary care centers in the major cities. Very few brave women can venture into practice outside these boundaries. There are concerns for personal safety and security, as well as resistance by family members to allowing them to work in less than ideal environments. This doesn’t even account for patient’s reluctance to be treated by a woman and undermining by male ‘colleagues’.
So there must be a silver lining? The same patriarchal society that will try to confine its womenfolk will also insist that only women provide medical care to their female kin, especially any disease process below the neck and above the knees. In fact, I have had women balk at the operating room door if they see a male scrub tech in the room. My answer to them is ‘when you send your daughter to school and let her become a scrub nurse, then I can ask him to leave!’ Many women I see in clinic have suffered from simple surgical issues for decades rather than be seen by a man. Some have helplessly let cancers flourish for the same reason. As more and more competent women surgeons enter the workforce, these women will find respite.
So, when I said that the rigidly patriarchal social structure is an almost insurmountable barrier to progress, the young Pakistani women aspiring to be surgeons prefer the emphasis on ‘almost’.
Sadaf Khan obtained her medical degree from The Aga Khan University, Karachi, Pakistan. She completed her General Surgery residency and Colon and Rectal surgery fellowship at Henry Ford Hospital, Detroit. She is currently Associate Professor of Surgery at the Aga Khan University. Her interests include anorectal pathology and medical education.
A PROFILE FROM BOLIVIA
The Plurinational State of Bolivia, a lower-middle income country in the heart of South America, has a population of 10.6 million distributed over more than 400,000 square miles, nearly three times the size of Montana. Its citizens include 36 recognized indigenous and ethnic groups, creating a melting pot of languages, traditions, and cultures. Within this population gender is evenly split. According to the 2014 Social Institutions and Gender Index, out of 108 scored countries, Bolivia received a low rating for gender discrimination in social institutions. This means that Bolivia has strong laws promoting equal rights and opportunities between genders in family code, resource access, civil liberties, and land-making decisions. Laws mandate gender parity in the candidate selection process at all government levels, and others label sexual harassment a civil offense. However, enforcement is questionable. Despite a minimum-wage law that treats both genders equally, the most recent statistics from 2013 show women make only 70% of the average male salary, with even more pronounced differences in rural areas of the country.
Of matriculated students at the 10 medical schools within Bolivia, approximately 60% are women. Upon graduating, due to limited residency positions, of which surgery is one of the most competitive, the numbers plummet. The pervasive mindset is that a fulfilling personal life is an “either or” with career advancement in surgery. Although no formal statistics exist on the number of practicing female surgeons in Bolivia, anecdotally there are much fewer women than men. There are no Bolivian surgical societies, nor general medical societies for that matter, specifically targeted towards female physicians. But there are role models….
Dr. Mónica Vera Zalles is a general and bariatric surgeon, who was born, raised, and currently practices medicine in Santa Cruz de la Sierra, a city located in the easternmost part of Bolivia. She completed her training abroad in both Argentina and Israel, before returning to manage a busy surgical practice, while also balancing leadership roles in local surgical societies and family responsibilities.
When Dr. Vera began her surgical residency in Bolivia in 1990, the operating room nurses and scrub techs were completely unaccustomed to seeing a women operating. As in many places across the globe, Dr. Vera felt the need to work harder than men of similar training levels to adequately prove herself. This included working a full schedule while pregnant, and returning to residency three short weeks after delivering, jumping into 56-hour calls. She always aimed to be one-step ahead of her male counterparts, such as through a familiarity of available technology and new procedural skills. This desire propelled her to pursue further training in Bariatric and Metabolic Surgery in 1995, a specialty that previously was unknown in Bolivia.
Dr. Vera’s efforts and abilities were rewarded with significant mentorship and operative opportunities from early on in her training, motivating her to maintain a sharp focus on further honing her surgical capabilities and knowledge. However, it took this level of dedication and persistence for mentors, residents, and colleagues alike to eventually view and treat her as their equal. With a passion for detail and protocols to improve patient care, Dr. Vera served as President of the Bolivian Bariatric Committee for two terms, and currently serves on the Executive Committee of the Bolivian Surgical Society. All of the above exemplifies that skills, knowledge, and perseverance can trump gender stereotypes.
As seen from Dr. Vera’s experiences, no matter where one trains or operates as a surgeon across the globe, common themes persist throughout. While, the number of female students, trainees, and full-fledged surgeons is on the rise, leadership positions show a persistent gender disparity that is slow to close. Issues surrounding the integration of work and personal life are universal, with intolerance for discrimination based on these factors becoming more widespread across genders. Times are changing – as shown by the enthusiasm for a Women in Surgery panel in Bolivia during the 28th Panamerican Trauma Congress in November 2015, and the widespread international success of the #ILookLikeASurgeon social media movement.
Becoming a female surgeon in a Latino society such as Bolivia has not been easy; however the path forged by Dr. Vera and other female surgeons has cleared the way for females to more easily pursue careers in surgery, with increasing acceptance by both colleagues and the general population. There truly exists a worldwide desire to break the outdated surgeon stereotype and allow anyone with adequate knowledge and training to realize their full potential of being a surgeon, without limitations of unfounded biases. One such place is Bolivia, and its local champion is Dr. Vera.
Marissa Boeck is a general surgery resident at New York Presbyterian Hospital – Columbia. She is currently on her research years living in Santa Cruz de la Sierra, Bolivia working on furthering the development of the city’s trauma and emergency response system, and implementing hospital-based trauma registries.
(RE)PAINTING THE SURGICAL LANDSCAPE:
THE SITUATION OF WOMEN SURGEONS IN ZIMBABWE
Zimbabwe, is a Sub-Saharan African country with a population of 13 million. There are only 184 registered surgeons in the entire nation meaning that there is <1 surgeon per 100,000 population. There is also significant under representation of women in the surgical field. Currently women make up 5.6% of registered surgeons and 7.8% of surgery trainees. These numbers are in spite of a significant increase in the enrollment of women into medical school which currently stands at an all time high of 40% in 2015. There is not only a need to increase the number of surgeons that are trained and retained, but also the surgical specialties into which they go to meet the demands of a growing surgical burden of disease, and additional women surgeons could help with this significant deficit.
The representation of women in surgery is very specialty dependent. Currently there are no female Orthopedic, Urology, or General Surgeon attendings in the country. ENT represents the specialty where great strides have occurred. Currently there are two women attending surgeons and 3 women in residency. In this specialty women enjoy good working relations with male colleagues, and work-life balance is easier because of the largely non-emergency cases, flexibility in scheduling clinics and a low patient volume. All of these women had to get their training outside of Zimbabwe, primarily South Africa, until this year when the first ENT training program started. This new program is showing much potential and may help increase women specialists in this area.
A curtain of uncertainty hangs over the rest of the traditionally male-dominated specialties like General Surgery (where we are looking to graduate our first Zimbabwean trained woman in a few months), Neurosurgery, Plastic Surgery, Pediatric Surgery and Orthopedic surgery. The lack of women in these areas means that for a woman surgeon-in-training many questions remain unanswered… Will she have to defer child-bearing in fear of being labeled “not serious”? And what happens on the day she has to make the “womanly excuse” with a troublesome pregnancy, to take care of a sick child, or to attend her child’s graduation from pre-school? Will they not be asking behind her back “why didn’t she just do ENT?”
One truth remains; there is room for a woman in surgery in Zimbabwe and recruiting and training them would help alleviate the significant health burden of the population due to lack of access to care. Great changes have to be made in societal and male colleague expectations of women in the profession. The women medical students are very interested and hope that when they seek training the old adage of a surgeon being “male and older” will be replaced by a willingness to commit to “woman and younger”, even if it is for that one woman who will be relieved to find a woman surgeon to examine her at the Breast clinic. More importantly though, women can come up and model balance and excellence with no excuse, expand the face of a surgeon to include an empathetic listener, in heels and a skirt, because being true to her nature is part of the package.
In 2013 a small group of female medical students, tired of being silent, decided to establish the first-ever surgery-interest group; DREAM, whose objective is to reach, empower and mentor women medical students into surgery. It was formalized in 2014, and has since increased its membership to about 36 women including 3rd, 4th and 5th year medical students, and 2 interns. The organization is not only a mentorship and information-sharing platform, but has also pioneered basic surgical skills training for medical students at the College, something that has not been done in the past. It is important for this pipeline of young women students and surgeons that women like Dr. Maraire, a Zimbabwean who received neurosurgical training at Harvard and then returned to practice locally, serve as the much needed role models and trailblazers, providing mentorship and the networks we need as we paint a new landscape in surgical care in Zimbabwe alongside our male colleagues.
Annete Moyo is a final year medical student (graduating in January 2016) at the University of Zimbabwe College of Health Sciences. She hopes to be accepted into a General surgery training program after my internship, and one day be a role model, mentor and open doors for more women in surgery in Zimbabwe.She has served as President of DREAM since its official establishment in 2014 until the end of this year.
WOMEN IN SURGERY IN JAPAN
Yasuko Tomizawa MD, PhD
Japan ranks the 104th out of 142 counties in the global gender gap index (World Economic Forum 2014). It is still not easy for women to hold jobs with responsibility in Japan. OECD data shows that the wage disparity between men and women among full-time workers marked second only to South Korea. We live in such a country.
In Japan, women physicians’ leaky pipeline is markedly evident in academic medicine, and it is difficult for women to be promoted to higher positions. Japan is still male dominant.
Women doctors often leave job when they become pregnant. Because, 70% of women physicians’ husbands are physician and work long hours. And, if so, no cooperation of from the husband is expected. And, family responsibility by women is important. Japanese phrases “hurdle of first grade of elementary school”, and “entrance examination to prestigious high school or university” are still important.
Japan Surgical Society (JSS) has 3247 (8.2% of total member-ship) female members as of March 2015 and new female members of JSS was 20% in 2014. There is still only one female councilor in JSS. For medical students, surgery is not so attractive because of long working hours and hard labor. The situation is similar to other countries.
To increase diversity by increasing the number of female councilors, the conventional rules mainly determined by male members in the past should be reviewed and updated. The fact that there are so few women in decision-making positions in the Japanese Association of Medical Science (JAMS) makes it challenging for women to fight for equality.
With the participation of women doctors in all the committees, there will be opportunities to establish career development for female physicians and surgeons, to make rules that suit the unique lifestyle of women doctors in academic medicine, and to improve their work-life balance.
There are many issues facing women in terms of leadership, advancement and work life balance in Japan. Japanese women surgeons are willing to learn the leadership in surgery at the annual meeting of AWS and Women in Surgery Career Symposiumby Dr. Sharona Ross.
Japan Association of Women Surgeons (JAWS) was founded in 2009. The members are 240 including 80 male members as of February 2015. What we are doing to make people aware of the problems in Japan with gender equality in Surgery and other fields. It will take a long time to fix, but we cannot give up on this important topic.
Yasuko Tomizawa MD, PhD is the President of the Japanese Association of Women Surgeons, and an Assistant Professor of Surgery in the Department of Cardiovascular Surgery at the Tokyo Women’s Medical University in Tokyo, Japan. She has been a tireless advocate for the advancement of women surgeons frequently sponsoring junior faculty to accompany her to the American College of Surgeons Clinical Congress and has written extensively on issues of gender gap in Japanese academic medicine.