Somewhere near the end of my eight years of surgical training, I was operating with an older female attending surgeon. We were exchanging stories about the traumatic yet awesome experiences of residency.
"Surgery made a man out of me," she chuckled.
We finished the operation and I headed home later that day.
I thought about the magnitude of that statement. She didn't need to explain the masculinization that had occurred through her surgical residency -- I totally got it. As a female surgeon 25 years my senior, hers had certainly been a more grueling experience, with no work hours regulations and a significantly more cutthroat environment than the current, more closely monitored world of surgical training today.
Since the Bell Commission implementation in New York in 1989 and the Institute of Medicine report in 1999 "To Err is Human," restrictions have been placed on resident work hours, sleep requirements and patient hand-offs. But don't get me wrong -- surgical residency today is still grueling. Anyone who has watched Grey's Anatomy would agree with that, however exaggerated or inaccurate Hollywood portrayals may be. And despite roughly one-third of women accounting for surgery residency positions these days, it is still very much a man's field.
I was the only woman in my graduating class of six from a highly competitive general surgery training program just a few years ago. But that was my decision. I had chosen to be smack in the middle of an aggressive, male-dominated field for those eight years.
Was I, too, somehow more masculine now that I'd been through surgical training? Did I lose my femininity through training, or perhaps was I always less feminine because I had chosen surgery as a career?
Indeed, the overwhelming majority of surgeons are men. A woman in scrubs walking through the hospital hallways rarely gets recognized as a doctor, and almost never as a surgeon. I am most often confused for a nurse, amongst other professions.
As a third year resident, having helped complete a colon operation with my attending surgeon, I went to check on our patient post-operatively. He was on the phone, but when I entered the room, he said, "Hang on, the aide just came in to give me my newspaper."
I stifled my frustration and politely corrected him. And to be clear, I was not carrying a newspaper.
On the other hand, male medical students need only don scrubs, and -- BAM -- they look like surgeons. During rounds, some patients would preferentially direct their gaze and answers to the male medical students, even though I was the chief resident leading the group, asking questions and directing care (and nearly a decade older than the students). Even when we are introduced as doctors, some older patients still refer to us as "lady doctors," whereas men are just "doctors."
I am a woman in a man's profession, and it's certainly time that the prevalence of societal sex-stereotyping is publicly addressed.
I, for one, am greatly encouraged by the social media #ILookLike...(fill-in-the-male-dominated-profession-here) movement. It's inspiring to see smart, capable women in fields such as engineering and physics take charge of this issue. In surgery, too, women have long struggled to gain a foothold, and have been fighting to overcome a perception of inability for years.
However, there is another side to the problem that must be openly discussed.
A woman in a male-dominated profession shouldn't need to assimilate herself into an established culture that isn't welcoming to women. The culture needs to change from within to become a truly gender-neutral meritocracy.
Although recognition that women are successfully participating in surgery is paramount, there are emotional barriers, including both subtle and overt misogyny, and a sense that we don't belong unless we are as "hardcore" as the men.
Another difficulty is that the lifestyle is not very conducive for having a family -- a reason frequently cited by women medical students when deciding not to pursue a surgical field. Dr. Julie Frieschlag, former surgeon-in-chief at Johns Hopkins, once wrote "the environment must be made more amenable to women" when discussing the lack of women in surgery.
During training, it was expected that surgery took precedence over all else. Being allowed the incredible privilege of operating on a patient and understanding all the complexities of smooth recovery, as well as the treacherous road of complications, requires significant dedication. But as residents, we were also subtly praised for being more masculine, more tough. For being able to tolerate the brutally long hours and lack of sleep; able to perform a 12-hour operation without succumbing to the physical needs of your body; able to hold back tears when realizing the patient you're operating on is dying in front of your eyes and there is nothing you can do to stop it.
The overall attitude is one of condoning brotherly camaraderie through an incredibly difficult personal experience, but with suppressed emotions, and where bonded commitment to training supersedes all else. It is a place where display of emotion is taken as a sign that maybe you aren't tough enough to be there, and actual admittance of having trouble with surgical life means you definitely shouldn't be there. A place where you put your head down, don't let feelings get in the way, and do your job.
It is also a place where there is muted acceptance of time spent away from your family, and underhanded remarks are made about women and pregnancy. According to a survey conducted by Cliff Straehley, M.D. and Patrizia Longo, Ph.D. for the American Journal of Surgery, over 75 percent of women surgeons experienced gender discrimination in their careers. I've spoken to many women surgeons about these topics.
There are subtle issues, like surgical instruments and sterile gloves being made to fit a man's hand. And there are more obvious transgressions. One surgeon told me that when her co-resident became pregnant, her program director said, "This is why we didn't want to match two girls in the same year. Oh well, we're stuck with you."
Another was told by a transplant surgeon that women surgeons are only useful in the operating room as organ donors. Yet another told me about her three weeks of maternity leave, considered adequate by her all-male faculty, and the only question they asked of her after delivery is whether or not it was a cesarean section birth, because that could mean longer leave. She was told that she belonged at home with her uterus, not in the OR.
We begrudgingly accept this level of misogyny and anti-family sentiment when it's subtle, constitutive and mixed with praise for being tough. After all, this is surgery. And surgeons are tough.
Women surgeons appear to take three distinct approaches to manage this internal conflict to prove their worthiness. She can become "one of the guys," essentially denying that there is any difference between herself and the male surgeons -- hence, she gets treated as gender-neutral. Alternatively, women surgeons can adopt almost a caricature of the traditional female role, seductive and helpless, and the men will consider her a sex object. Lastly, she may feel compelled to prove herself as unquestionably competent at both family and home, which begets praise from others for "having it all."
Many discussed an overall sense that for a woman to be considered as competent as the men, she must show that she's actually more capable than them. I saw many women, myself included, utilize all three of the above approaches.
For me, I struggled the most with the last of these angles. The cost of being in this environment came to a peak when I chose to start my family in the middle of my residency. As a woman in my early 30s, I felt it was a reasonable time to start a family. But I suffered a great deal to balance all of this -- to be a good surgeon, wife and mother.
When I had children, I felt tremendous guilt about being what I considered tantamount to an absentee mom -- and I didn't feel very tough. I had difficulty reconciling being fully committed to the two things I loved most: surgery and my family.
I loved being fully immersed in surgery. Understanding the nature of the ways in which the human body can be altered by infection, inflammation, tumors and trauma is completely engrossing. Being able to reverse those processes in a single day is even more so. It can be all-consuming. And for many surgeons, it is the pursuit of these experiences that gives meaning to their lives.
However, the time away from my family was painful, and there was little support or guidance through this process. I rarely saw my children during the last years of residency. I spent far more hours with my patients and my colleagues than I spent with my husband and kids. I left the house before my children woke up and arrived home after they were asleep, which left me feeling empty and depressed -- emotions that I stifled at work.
During the short months that I breastfed, I used a breast pump in the on-call rooms; most days I did not nurse my children even once. I wasn't there for my son's first steps or first words. I missed all of their doctor's appointments, school events, major milestones. My children would cry when our nanny left for the day, but not for me.
My phone was on 24/7, and anything relating to patient care took precedence over everything else, regardless of time, location or company. I dealt with frustration and resentment from my family and friends as surgery became a major priority in my life. I encountered bitter jealousy and spite from a friend, disappointed with her own choices in life, who took her anger out on me.
I had internal conflict about talking openly to my peers about the difficulties of balancing work and home, for fear of being accused of having anything less than total commitment to surgery, or being "weak." Nothing prepared me for these personal challenges, though now I know that I'm not the first to experience them.
My struggle was to find guidance and understanding through this process, not to somehow be a simultaneous stay-at-home parent and surgeon. Indeed, there is very little guidance during training, and the misogyny doesn't help matters. Surgery is a patriarchal field which, by the nature of its demanding schedules and those who pursue it, is neither female- nor family-friendly.
In addition, there is a severe paucity of female mentors.
There are wage discrepancies, as well as a lack of career advancement and leadership opportunities. According to the Bureau of Labor Statistics, in 2014 women physicians and surgeons earned only 62 percent of what their male counterparts were paid.
Only a handful of women currently hold leadership positions -- you can count on two hands the number of female Department Chairs of Surgery in the country. And although research has shown that the overall general surgery attrition rate of about 20 percent is not higher for women, more women are unhappy and consider quitting due to struggles with work-life balance.
It is not sufficient to simply find more women willing to survive in the male-driven world of surgery. Until we recognize that the culture of the surgical institution needs to strive for a more cohesive and balanced environment, women will continue to avoid surgical training, and we will lose competent, intelligent women to other fields. Recognition of stereotyping won't be enough.
Ultimately, my choice to become a surgeon has led me to a fantastic practice and a peaceful life beyond residency, and for that, I am grateful. My growing family has weathered the storm of surgical training, and I'm much more aware of the difficulties facing women surgeons today.
I would argue that these challenges did not masculinize me, but rather bolstered my femininity.
Still, recognition of these issues and mentorship through them would have helped provide a framework for a better experience. I now try to provide that for women medical students and surgery residents, as they traverse the long and challenging road of life in surgery.
The current social media campaign highlighting women scientists and doctors is both exciting and necessary. Now the next steps are to ensure that we provide these women with the opportunities to be sanguine, successful leaders in their fields without sacrificing their needs.