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A Profile From Bolivia

Marissa Boeck, MD MPHBolivia-Flag

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.

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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.

 

 


December issue of eConnections

December 2015: (Re)Painting the surgical landscape:
The Situation of women surgeons in Zimbabwe

Women in Surgery…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.

Annette

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.

 


November issue of eConnections.

November 2015: Women in Surgery in Japan, Yasuko Tomizawa 

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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 Symposium by 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.