Academic surgery has long been considered among the most difficult career environments for women,1 and there is growing urgency to address sex equity and create environments that are more inclusive. The article by Thompson-Burdine et al2 provides nuanced and valuable insights into barriers and facilitators for success in advancing women in surgery. Through in-depth interviews with 26 female surgeons with almost 2 decades of experience in a single academic department, the study describes the complex issues that must be understood and addressed for progress to be made, such as organizational culture, institutional policies, and relational interactions. The authors also identify how the individual characteristics of female surgeons may mediate their perceptions of these issues and of career success.
There are several national efforts underway to address challenges faced by women in medicine and health care.3 Research examining differences in patient experiences and outcomes when treated by male and female physicians, sex bias in grant-making, sex differences in specialty choice and pay, and other similar topics appear almost weekly in the peer-reviewed and gray medical literature. The study by Thompson-Burdine and colleagues2 conducted at Michigan Medicine—an organization that many consider a pioneer—provides useful information for other organizations that are designing and implementing programs. It indicates that the intentional cultivation and strategic inclusion of diverse leaders, the explicit recognition of the intersection of sex and race, and the direct support of leadership development for women, financially and with protected time, are facilitators to career advancement of female surgeons.
The study’s use of qualitative methods provides a rich perspective on the facilitating role of peers, specifically male colleagues. This is useful evidence that aligns with recent national efforts—including by the Association of American Medical Colleges—to encourage and train men to support female colleagues as advocates, allies, peer mentors, and sponsors.4 The study time frame provides evidence for how intentionally focusing on addressing sex disparities over several years, educating an entire team, and including team-based leadership development can change the organization’s culture in meaningful ways.5
The study highlights that it is important for surgeons to think beyond their own influence to the entire system of care. The context within which surgeons work includes a myriad of professionals: nurses, physician assistants, research staff, other clinicians, and support staff. For female academic surgeons to advance, the entire academic medicine microsystem must be included in efforts to address sex biases, remove stereotypes about women’s roles, and develop and sustain an inclusive and supportive environment. Going beyond the academic surgical hierarchy will require surgeons to include other organizational stakeholders in their efforts. Breaking down these organizational silos will not be easy, but it is not impossible.
While the study’s conclusions about how female surgeons’ individual characteristics may influence their perceptions of the work environment and of career success may not be surprising, they are important. There is evidence from other industries about the complex behavioral and psychological reactions to the appointment of a female or racial minority leader.6 There is often a perceived (and reinforced) expectation for women in male-dominated fields to “tough it out” alone. The qualitative nature of the study by Thompson-Burdine et al2 tells the stories of female academic surgeons who experienced a single department through 26 different and very personal perspectives. It reveals how each faculty member is a collection of identities: researcher, clinician, woman, teacher, parent, spouse, division head, and so on. While there are interventions that are associated with the individual development of surgeons (for example, coaching and leadership development), for lasting progress to be made, these individual-focused interventions must be part of a comprehensive approach.
In fact, this may be at the heart of the movement underway to address academic medicine’s sex equity challenges: a recognition that structural, institutional, and cultural change is necessary. This includes changing decades-old policies, modifying facilities, changing compensation approaches, and intentionally creating and supporting opportunities for women in surgery to share their lived experiences with each other and with their male colleagues. If organizations are committed to inclusive excellence and sex equity, there is a way forward—intentional, transparent, and clear commitment to supporting all faculty, not asking a subset to toughen up and “deal with it.”
In recognizing these findings, it is up to all of us to do what we can within our own environment. It starts by examining your own process and then implementing fair and transparent practices. For example, the University of Alabama at Birmingham Department of Surgery created a new compensation plan because the legacy plan was opaque and unstructured. By instituting a fair and transparent plan and retrospectively analyzing its effort, leaders discovered that a sex inequity in salary existed (women were paid less on average). The new compensation plan, however, significantly narrowed the pay gap within 1 year.7 The university’s experience highlighted 2 key points: (1) you do not know if there is inequity unless you examine your system and (2) instituting fair plans based on transparent benchmarks can lessen these disparities.
A decade ago, few people publicly admitted awareness of the challenges faced by women in academic surgery. Today, the field has named the challenge, and some organizations are committed to solutions. It is no longer enough to know better; it is time to do better. The evidence base is growing quickly for what doing better looks like. We need more qualitative studies like that of Thompson-Burdine et al2 to delve more deeply into what works and share it widely. We also need mechanisms for identifying and sharing successful, innovative practices that reduce barriers and enhance career success. In the meantime, however, there is evidence to inform organizational, relational, and personal improvements that support the advancement of women in academic surgery.
Published: August 30, 2019. doi:10.1001/jamanetworkopen.2019.10211
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Lemak CH. JAMA Network Open.
Corresponding Author: Christy Harris Lemak, PhD, Department of Health Services Administration, University of Alabama at Birmingham, SHPB 530E, 1716 Ninth Ave S, Birmingham, AL 35294-1212 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Lemak CH. Knowing Better and Doing Better to Advance Women in Academic Surgery. JAMA Netw Open. 2019;2(8):e1910211. doi:10.1001/jamanetworkopen.2019.10211
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