Female surgical residents face discrimination that can mean burnout, suicidal thoughts, study finds

When Ilene Wong was a urology resident at Stanford Hospitals and Clinics, she found herself sidelined in favor of her fellow resident — a white man — on at least one occasion when it came to major surgeries, like kidney or bladder removals.

“I remember a specific incident when my attending asked for someone with ‘more muscle,’ " said Wong, a urologist in private practice in Chester County. “It was very discouraging.”

For many female surgeons, her story is familiar. They describe being passed over in favor of men who are no more competent. They introduce themselves to a patient, only to be told, “I was expecting a man.” They are asked about their plans for a family during residency interviews, while men are not. They are often paid less than men — female surgeons have an average salary of $183,829, over $80,000 less than the average salary of a male surgeon. They feel they have to work harder to prove to patients that they are just as capable, if not more, than male surgeons.

Far more than annoying, these kinds of slights may mean serious and even lasting harm.

A recent study in the New England Journal of Medicine reveals that mistreatment — categorized as discrimination, verbal or physical abuse and sexual harassment — may contribute to burnout and suicidal thoughts in surgical residents. A national survey of 7,409 surgical residents from 262 programs found that nearly one in three overall have experienced gender discrimination. The numbers were higher for women — one in five reported sexual harassment, and 65% reported gender discrimination.

Gender bias in medicine is not new. Other studies have shown that female physicians and medical students tend to have more anxiety and less confidence than their male counterparts, despite performing at the same, and even higher, levels. Indeed, a 2017 study in JAMA Internal Medicine found lower odds of death and hospital readmission for patients cared for by women physicians.

Yet some 30% of women on medical faculties of all kinds report experiencing sexual harassment. And women find themselves most outnumbered in surgery, where as of 2015, only 19% of practitioners were women, according to the Association of Women Surgeons.

“Surgery still has a masculine feel,” said Jo Buyske, the president of the American Board of Surgery and a surgeon at the University of Pennsylvania School of Medicine. She is a coauthor of the New England Journal study. “It’s a team sport, like playing football. The surgeon dictates the conversation, the tone, and the music, so there’s a lot of jocularity in what is traditionally a kind of guy-ish way.”

Wong described surgery culture as “militaristic,” citing its emphasis on rigidity and adherence to routines. She said that the surgeon is often viewed as the quarterback of a team, and that in those situations, people tend to look for guidance from men.

In a survey of active medical residents in 2017 and 2018 by the Association of American Medical Colleges, men outnumbered women in every surgical specialty except for obstetrics and gynecology. (The University of Pennsylvania, where Buyske works, said it could not provide exact numbers on how many women are in its surgical residencies.)

The study also found that most of the discrimination came from patients, not other surgeons, which makes it a particularly tricky issue to tackle. It’s common to see a patient address the man in the room during an exam, even if the woman is more senior, said Buyske. She said that the patient should be the last person to be held accountable in that moment, but research shows that this behavior is really damaging to physicians’ confidence levels.

“All of us have had patients who say, ‘I don’t want a female doctor. I want a white male American doctor,’ ” Buyske said. “And a lot of hospitals will say that it’s their mission for the patients to come first, period.”

She said that in recent years, some institutions have started preparing residents to deal with those situations by including discussions about how to respond without shaming the patient. For instance, if the senior physician in an exam is a woman, but a patient directs comments to a man who is her trainee, the younger doctor could say, “I defer to my chief resident." Those prepared replies are important, Buyske said, because they can reset the tone of the conversation — without criticizing the patient.

“Anyone at any stage of their career can have serious insecurity and self-doubt,” said Neha Vapiwala, a radiation oncologist at the University of Pennsylvania Perelman School of Medicine who specializes in prostate cancer. As a female physician treating a “male problem,” Vapiwala said that she knows there are men who won’t come to see her, but she tries to allay their concerns through her professionalism, not to mention her notable credentials as clinician and researcher.

Vapiwala, who also is associate dean of admissions at Perelman, says any kind of stereotyping can be damaging to a doctor in training.

“To have a patient make the slightest offhand comment can feel so demoralizing," she said. "It can feel like, ‘Even if I learn this, I will never be received as this type of specialist because of these stereotypes.’ ”

Plus, patients who cling to stereotypes might miss out on getting excellent care.

“At the end of the day, if you are a patient, you want to work with your physician as an ally, and build a therapeutic relationship based on the person in front of you and their professionalism and talent, not their gender or color,” Vapiwala said.

Expecting patients to instantly change their deeply held ideas, however, won’t make for the kind of wholesale reform that’s needed.

Change needs to come from the top down, said Elizabeth Dauer, an associate professor of clinical surgery at the Lewis Katz School of Medicine and associate program director of Temple University’s general surgery residency program.

“The first thing is that people have to recognize that these problems exist,” Dauer said. “Then you can figure out how to change the culture. The faculty and leadership of the department have to lead by example by creating an inclusive environment where everyone is treated equally, no matter your gender, race, anything.”

She said that even though she’s been in the operating room for over a decade, patients still tell her, “I was expecting a male surgeon,” or “I would prefer a man.”

The New England Journal of Medicine study suggested that levels of mistreatment and discrimination varied across hospitals, which means that some are doing a better job than others, said Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at Northwestern Medicine and lead author of the paper. He plans to return survey results to each residency program that participated to give them an opportunity to improve.

“Culture is local,” Bilimoria said. “What will work to address sexual harassment at one program will not work at another program. But we’re hoping that the high-performing programs can share information with the lower-performing ones.”

Seventeen percent of residents surveyed also reported racial discrimination. That means most nonwhite surgeons have experienced discrimination, as nearly 70% of surgeons were white in 2017. And women of color in surgery programs often get both kinds of discrimination. Wong said that there have been multiple instances where male patients would try to flirt with her in Mandarin or Vietnamese.

“It definitely makes you wonder if it’s worth it at times," she said. "It’s demoralizing to realize that you are of less value to someone and that they prioritize things other than your skill.”

Though the statistics for mistreatment were disappointingly high, most female surgeons agreed that things have gotten better in the last few decades. Dauer said that the current generation of trainees are much more willing to stand up for themselves, albeit in a respectful manner. But better isn’t good enough for physicians or their patients.

“We do still tolerate it as a culture,” Buyske said. “It’s always been that way. It’s not funny, and it’s not OK. We have to develop a zero-tolerance policy for this stuff.”