A solution to gender inequity in surgery? Better caregiving policies
====================================================================

* Anita Acai
* Chris Steyn
* Susan E. Reid
* Ranil R. Sonnadara

## Summary

Attitudes toward women in surgery appear to be shifting in a positive direction. Why, then, do women still represent only 27% of surgeons in Canada? The answer may, at least in part, lie in the field’s inability to adequately accommodate caregiving duties, which are still disproportionately “women’s responsibilities” in our society. Although most Canadian academic centres now have paid maternity leave policies for trainees and faculty, these do not necessarily apply to surgeons working in the community, nor do they always reflect what occurs in practice. The perceived inability of the field to accommodate both personal and professional duties is often a significant deterrent to young women considering a career in surgery. In this commentary, we explore the need to address the “caregiver problem” as an important step toward achieving gender equity in surgery.

We have been talking about gender inequity in surgery for decades. Countless studies, opinion pieces and news articles later, we are still talking about it.

Attitudes toward women in surgery appear to have shifted in a positive direction, at least in recent years.1 In fact, many of today’s trainees do not view their gender as a barrier to their professional success at all. For example, in a recent interview study, a trainee told us, “I (…) don’t consider [gender] to be a barrier in my life. Even though I think [gender] issues are for sure present, I don’t see [them] affecting me on a day-to-day basis.” Others agreed, and even seemed surprised that anyone would think a woman was not capable of being a good surgeon: “I’ve just always been taught that we can do the exact same things that boys can and (…) it’s not really something I ever think about.”2

However, if attitudes really have changed, then why do women still represent only 27% of all surgeons in Canada?3 Perhaps part of the answer can be found outside of the hospital: “Gender doesn’t become a challenge until you actually become a mother. That’s where it becomes much more challenging.”2 Around the world, women are still the predominant caregivers of children and of other family members.4,5 Balancing these caregiving duties with a demanding career is no doubt immensely challenging, and for many women, the perceived costs of doing so may simply be too high.

Canadian policies for parental leave might be considered reasonable compared with those of other countries, but they are still far from optimal — notably, for surgeons. Although most Canadian academic centres now have paid parental leave policies for trainees and faculty, surgeons in the community function as self-employed individuals and hence do not qualify for government assistance for parental leave.6 Compounding this, the spirit of policies may not always be reflected in practice. Studies of medical and surgical faculty in Ontario have found that both paid and unpaid leave are generally shorter than that allowed by law or identified as ideal.1,7 Moreover, those who take parental leave often perceive a negative impact on their careers.7,8 The reality of many surgical specialties, and especially subspecialties in which there are few qualified personnel, is that it can be extremely challenging for surgeons to be absent for extended periods of time. Providing clinical coverage when someone chooses to take time off for an extended period puts a substantial strain on programs that are already short-staffed. Coverage often falls to the remaining staff, many of whom are already working over capacity, and can create challenges for those who choose to take time off for parental leave.

For women in particular, parental leave may pose additional challenges. Following childbirth, there is a certain period of recovery time necessary, and choosing to breastfeed poses additional demands at the beginning of an infant’s life. Thus, women often have less freedom with regard to the timing of their parental leave, making it harder for their absence to be accommodated. Men, on the other hand, have fewer restrictions and are more easily able to adjust their time off to accommodate clinical needs. This may make finding coverage less challenging. Skills may also deteriorate after extended periods of time off,9 leading to longer training times for some trainees. For example, a study of American specialty boards found that in some programs, 6 weeks of parental leave resulted in up to a year of additional training time.10 This depends on specific board policies, many of which have defined limits on absences from training. The exact rationale behind these policies is unclear, but might have included factors such as “ensuring sufficient clinical and procedural experience [and] attempting to promote fairness and consistency” among residents.10

If we really want to challenge inequity in surgery, bolder steps need to be taken to address the “caregiver problem.” This will no doubt take some time and force us to ask some difficult questions. For example, surgical training tends to be most demanding during the years when many people might consider starting a family. So, are we starting to train surgeons too late, and are we taking too long to train them? We must also consider how to integrate caregiving into the profession more effectively. This means encouraging parents to actively share caregiving duties by advocating for better parental leave policies and practices for men and developing ways for women to more easily reintegrate into training or practice. Another solution is improved access to childcare for health care staff (e.g., providing daycare services on hospital premises), as Canada is currently ranked one of the worst in the developed world in terms of both funding of and access to childcare.11

Perhaps gender inequity continues to be an issue in surgery not because we think women cannot be successful surgeons, but because many women would rather not be successful surgeons if it means having to give up other aspects of their lives that they consider important. Although we in no way wish to undermine the efforts of women currently in the field who are both surgeons and parents and whose efforts have allowed us to have this conversation, we will not achieve the critical mass of women we need in the profession until we consider gender equity as a broader, system-level problem. It will not be easy, but other demanding professions, such as law, business and politics, are already paving the way in reconsidering what it means to be a professional and a caregiver.12

Although women still disproportionately take on caregiving duties in our society, it is an issue that will ultimately affect us all as we begin to care for the aging baby boomer generation. Shifting our focus to developing more equitable solutions for caregiving will allow us to make major strides not only toward addressing the gender gap in surgery, but also a healthier and more just society.

## Acknowledgements

The authors thank Victoria McKinnon, Portia Kalun, Jacqueline Wilcox, Sabahat Balaban and Cindy Tran for their editorial feedback on this work.

## Footnotes

*   See the related review paper by Peel and colleagues on [p. 58](http://canjsurg.ca/lookup/volpage/61/58)

*   **Competing interests:** None declared.

*   **Contributors:** All authors contributed substantially to the conception, writing and revision of this article and approved the final version for publication.

*   Accepted October 20, 2017.

## References

1.  Brown JB, Fluit M, Lent B, et al.Surgical culture in transition: gender matters and generation counts.Can J Surg 2013;56:153–8.
    
    

2.  Acai A, Kalun P, Wilcox J, et al.Breaking through the glass ceiling: an interactive discussion about challenges and opportunities related to gender issues in surgery [workshop]Annual Meeting of the Association for Surgical Education2017 April 18–22San Diego
    
    

3.  Canadian Institute for Health Information (2016) Supply, distribution and migration of physicians in Canada, 2015 (CIHI, Ottawa (ON)).
    
    

4.  Grigoryeva A (2014) When gender trumps everything: the division of parent care among siblings (Center for the Study of Social Organization, Princeton (NJ)).
    
    

5.  Sharma N, Chakrabarti S, Grover S.Gender differences in caregiving among family — caregivers of people with mental illnesses.World J Psychiatry 2016;6:7–17.
    
    

6.  Lent B, Phillips SP, Richardson B, et al.Promoting parental leave for female and male physicians. Gender Issues Committee of the Council of Ontario Faculties of Medicine.Can Med Assoc J 2000;162:1575–6.
    
    [FREE Full Text](http://canjsurg.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTYyLzExLzE1NzUiO3M6NDoiYXRvbSI7czoxNjoiL2Nqcy82MS8xLzYuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

7.  Phillips SP, Richardson B, Lent B.Medical faculty’s views and experiences of parental leave: a collaborative study by the Gender Issues Committee, Council of Ontario Faculties of Medicine.J Am Med Womens Assoc 2000;55:23–6.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=10680403&link_type=MED&atom=%2Fcjs%2F61%2F1%2F6.atom) 

8.  Humphries LS, Lyon S, Garza R, et al.Parental leave policies in graduate medical education: a systematic review.Am J Surg 2017;214:634–9.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fcjs%2F61%2F1%2F6.atom) 

9.  General Medical Council (2014) Skills fade: a review of the evidence that clinical and professional skills fade during time out of practice, and of how skills fade may be measured or remediated (General Medical Council, London (UK)).
    
    

10. Rose SH, Burkle CM, Elliott BA, et al.The impact of parental leave on extending training and entering the board certification examination process: a speciality-based comparison.Mayo Clin Proc 2006;81:1449–53.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.4065/81.11.1449&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=17120400&link_type=MED&atom=%2Fcjs%2F61%2F1%2F6.atom) 

11. Johnson T.The need to improve Canadian child care.Canadian Family 2007Available: [https://canadianfamily.ca/kids/need-improve-canadianchild-care/](https://canadianfamily.ca/kids/need-improve-canadianchild-care/)accessed 2017 Oct 2
    
    

12. Slaughter AM (2015) Unfinished business (Vintage Canada, Toronto (ON)).