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#ILookLikeASurgeon and the Push for Gender Equity in Surgery

Clockwise from top left: Kinnari Patel, MD, Carla Fisher, MD, Lisa Lin (medical student), and Victoria Gershuni, MD.

“In the OR, you’re not a man, and you’re not a woman — you’re a surgeon.” Victoria Gershuni, MD, a third-year resident in General Surgery at the Hospital of the University of Pennsylvania, has heard several of her male attendings make pronouncements like this. She appreciates the intent — she knows they mean it as an affirmation of equal support for male and female trainees, even as a statement of solidarity with women and against gender-based discrimination. But it’s also frustrating. Refusing to see a difference can render real issues invisible.

“When you don’t experience something, you often don’t realize it exists,” Gershuni said.

And what women experience when working as surgeons is different from what male surgeons experience — not necessarily in the specific acts of wielding a scalpel and other instruments, but in virtually every other area of their working lives. Over the past year, female surgeons across the country and world have reinvigorated a push toward visibility and toward changes to empower equitable success for women in a persistently male-dominated field.

One visible emblem of that push might have shown up in your social media feeds this spring, in the form of photos inspired by the cover of the New Yorker’s annual Health, Medicine & the Body issue, which featured a patient’s-eye-view illustration of four female members of a surgical team in gowns, masks, and gloves. Endocrine surgeon Susan Pitt, MD, at the University of Wisconsin, encouraged other female surgeons to pose for the photos — and responses flooded in from across the country and around the world.

Clockwise from top: Plastic surgeons Lin Lin Gao, MD, Liza Wu, MD, Olatomide Familusi, MD,  Cassandra Ligh, MD, Ines Lin, MD, and Catherine Chang, MD.

Gershuni, a personal friend of Pitt since the two crossed paths earlier in their training, was among the first at Penn to take up this #NYerORCoverChallenge. Several other groups of surgeons from across Penn Medicine followed suit. Many posts used the hashtag #ILookLikeASurgeon, continuing an earlier social media campaign for visibility of women in surgery. “It was inspiring and very timely, with everything going on in the world,” Gershuni said, “and in the world of surgery.”

“At our national meetings, women in surgery is the hot topic,” Stacy Ugras, MD, an assistant professor of Endocrine and Oncologic Surgery at Penn Medicine, confirmed. “There is evidence that despite equivalent matriculation, there is less retention of female residents. It’s important to address issues early on to prevent women from quitting.”

An influential speech by Caprice Greenberg, MD, MPH, president of the Association of Academic Surgeons and Pitt’s colleague in Wisconsin, has catalyzed such conversations about addressing gender equity in surgery over the past year, Gershuni said. Pitt, too, commenting in the Washington Post, cited the speech as a factor that primed female surgeons to respond to the New Yorker cover challenge.

“We’re all surgeons, and we like evidence,” Gershuni said. Greenberg “brings in data to make this an evidence-driven talk that describes how inherently there are issues that are different between men and women working in surgery — and it’s nobody’s fault.” Greenberg’s speech includes data about physician burnout in general and in surgery in particular — noting that women residents were approximately  twice as likely as male residents to feel dissatisfied with their overall well-being in one survey, and half of women reported thinking about dropping out of their residency in another. The studies Greenberg cites make clear that the influence of life outside of work is different for women in surgery than for men. Female surgeons who are married or in a committed partnership experience higher levels of emotional exhaustion in comparison to female surgeons who are single. But male surgeons who are married or in a committed relationship experience less emotional exhaustion than single male surgeons. The same pattern holds true for having children.

Unconscious gender expectations, sort of like stereotypes, are a key underlying issue to these challenges and others facing women in surgery, Greenberg pointed out. “When people act outside their gender schema and other people’s expectations, it raises bristles,” Gershuni explained. “When a woman has attributes that make her a great surgeon, people can unconsciously respond as if that’s negative” because the characteristics people associate with surgery — assertiveness, decisiveness, etc. — overlap substantially with the characteristics they associate with men.

In addition to affecting things like women’s selection for NIH grants and awards, those schemas affect female surgeons in numerous ways on a day-to-day basis, too. In her talk, Greenberg received a roaring laugh and applause of evident recognition among the audience of women and men at the Academic Surgical Congress when she highlighted examples from her own experiences: “More socialization is expected [for female surgeons]. When you walk on the floor, you’ve got to spend a little time talking, gossip, and then kinda slip in, ‘Oh, by the way, do you think you could take that NG tube out for me when you have a chance?’ We clean up after our own procedures. I don’t think I’ve ever seen a male resident or attending clean up after their own procedures… We pitch in with room turnover, we bring gifts and baked goods, and we’re expected to participate in potlucks and baby showers. I don’t think there are a lot of men in this room who are asked to bring in a dish for potlucks, yet they always participate” by eating.

Another day-to-day reality for some women in surgery based on gender schemas: Gershuni said that she is routinely mistaken for a nurse, and although she respects and appreciates nurses for the important job they do, it’s a different job than her own. When these mistakes happen, she has to spend extra time and energy explaining to a patient or family member — sometimes even insisting repeatedly when they disbelieve her — that, actually, she’s there to discuss their surgical plan and is qualified to do so.

Najjia Mahmoud, MD, chief of Colon and Rectal Surgery at Penn Medicine, delivered a talk to Penn women in surgery about preventing burnout.

While these individual experiences are often benign, even sometimes optional, they nevertheless drain women’s time and energy through numerous small cuts that male surgeons virtually never experience in the workplace. (Adding to the sense of draining energy, women on average also tend to have more extra cleaning and caregiving responsibilities outside of work.) And that can contribute to women’s decreased sense of well-being seen in surveys. That makes it all the more important for women to recognize there are reasons for these challenges and to know what it takes to avoid burnout. This was the focus of a talk delivered at Penn May 17 by Najjia Mahmoud, MD, a professor and chief of Colon and Rectal Surgery at Penn Medicine.

“There’s this idea that if you admit you’re struggling there’s something wrong with you,” Gershuni said, reflecting on what she learned. “That leads you to carry it inside so you don’t realize that you’re not actually struggling; you’re having a normal reaction to having very little time for self-care, working constantly for the sake of others, in a specialty notorious for long hours and little time for eating and going to the bathroom, let alone anything else.” Staying silent about these challenges leads to believing they reflect a personal weakness — but knowing that peers experience the same thing and discussing the issues openly can help prevent burnout.

Mahmoud’s talk was the second invited event in the last few months for women in surgery at Penn. (Women in surgery at Penn had a regular series of events about a decade ago, organized by Rachel Kelz, MD, MSCE and Kim Olthoff, MD, and this renewed effort was organized by Ugras with Carla Fisher, MD.)

“The purpose is to bring together women in the department of Surgery to discuss unique issues and challenges of women in surgery, including work/life balance, progressing in academia, contract negotiation, things like that,” Ugras said. “It’s also to foster mentorship relationships between residents, fellows, young faculty and senior female faculty.” She is working on formalizing a curriculum for an official Penn Women in Surgery Group and planning for regular meetings two to four times per year. 

“It’s nice to be reminded that you’re around these powerful successful women,” Gershuni said, “and to understand that we’re all facing similar challenges.”

This is what surgeons look like.


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