Is the culture of surgery still a gender issue?

We read Brown and colleagues’ recent article1 on culture transition in surgery with interest. We agree with the accompanying editorial by Harvey,2 that this is an important addition to the literature and that open, frank discussion is needed from the profession. We feel that some of their points merit further exploration.

The authors highlight 2 key factors influencing the culture and future of our profession: the (slow) movement toward gender balance and a generationally driven attitudinal shift. They study how “new” recruits perceive these changes by interviewing 17 surgeons (9 women, 8 men),1 all of whom are assistant professor level or higher; have a mean age of 38 years; and are in heterosexual relationships. The ethnic profile of the sample was not reported.

We would suggest that interviewing this sample, though of interest, might in fact miss the point; the authors have sought the views of the “new establishment.” All of the participants of the study have become established academic surgeons, some against well-defined, albeit diminishing, barriers. They have opted to stay in the profession, in some cases alongside the added commitments of motherhood. In the UK, 90% of those in surgical training decide on this path during their first year postqualification with a similar gender ratio, yet far fewer women ultimately achieve their goal.3 Women initially attracted to surgery move away from this career option during their postgraduate education; this attrition was previously attributed to lifestyle considerations.4,5 We would postulate that the same may be true of some black and minority ethnic groups, and possibly also lesbian, gay, bisexual and transgendered surgical trainees. Interviewing a cohort from these groups — those who chose not to enter the profession they were initially drawn to — may cast further light on gender and cultural issues within surgery and undercover why it has been perceived for so long as an “old boys’ club” with ongoing discrimination.

Brown and colleagues1 cite a lack of mentoring as 1 potential reason for our profession’s loss of talent. We would support this claim. In our experience6 and the experience of others, access to mentors is limited not only for women but also for other minorities in this professional arena. Formalized mentoring programs that seek to pair candidates with suitably matched (but not necessarily demographically similar) mentors, and the use of mentoring frameworks, may help people to achieve successful mentoring relationships.7 Raising awareness for mentoring and mentor acquisition as early as possible in surgical careers (i.e., medical school) may also benefit potential surgeons.

Positive role models have been shown to significantly impact career choices.8 From our personal experience (H.M., T.B.), role models are limited for Generation Y female potential surgeons. We agree with the study, that increasingly this is not a gender issue; men, too, want a better work–life balance9 to pursue portfolio careers while having flexibility for more time at home and the opportunity to travel. Certain aspects of surgery as a career (e.g., emergency work, management of complications, unpredictability of surgical pathology, competition for attaining training posts) inherently clash with these aspirations; however, we believe that broad-minded individuals with ambition within and outside of medicine are assets to any workforce.

Surgical trainees with the Generation Y value set should be encouraged into, not dissuaded from, surgical specialties. This will not happen passively; it requires a strategic approach involving enhanced child care options, job sharing and flexible contracts, and signposting of role models and mentoring opportunities. It requires a culture change within our profession.