Surgically Removing Gender Bias

When Dr. Pearl Lal joined her training in General Surgery in 2015 at Christian Medical College Vellore, she was one of the two women in her batch of ten residents. That changed considerably in the following years with the 2020 batch having more women than men. "Though we do not have the exact data, this seems to be the trend across all the medical colleges in India", says Dr. Pearl. "These days, we see more and more women choosing surgical fields such as Orthopaedics and Neurosurgery in India, which is amazing."

"But this trend was long-awaited", points out Dr. Eknoor, an orthopedic surgeon currently receiving super specialty training in hand surgery. Considering that Dr. Eknoor was only the second woman orthopedic surgeon in all of Rajasthan when she took up her course in 2017, what she mentioned bears weight. “Women have always been surgeons," she adds, "Haven't we seen women do very well in Obstetrics and Gynecology, which is predominantly a surgical specialty? Both the numbers as well as the performance of women surgeons in the fields of ObGyn, ENT, Ophthalmology, and even Dermatosurgery, reveal that women have always had the aptitude to be good surgeons. So, it is amusing to note that there are biases extended to them in other surgical fields such as General Surgery or Orthopaedics", she says.

"I'd been told multiple times as an undergraduate that women cannot make good surgeons", said Dr. M, who has recently completed her General Surgery residency. "When I was a student in MBBS, I remember a practical class in Surgery, where I was supposed to sew two ends of an animal intestine together. I had done a pretty decent job, but the supervising doctor congratulated me by saying, you will be a great obstetrician someday. I was taken aback, at first, because the potential I showed was quickly boxed into the surgical specialty that he considered appropriate for women, but then I allowed it to fuel me into pursuing General Surgery with a passion."

Dr. M was able to take that biased comment and turn it on its head. Many other MBBS students, however, give in to the biased remarks and subtle intimidation. "Many times, people tell us that women cannot manage the job with their family commitments. They also scare impressionable students by creating self-doubt about their aptitude for the subject. These things may have played a large role in keeping the number of women undergraduates choosing surgical specialties on the lower side."

Regardless of the bias, the current trend depicts that women are rightfully claiming their place in the operating rooms. But are their coworkers, seniors, and departments prepared for this change?

"It's not the entire department, but a few people in the department who carry on the bias toward women trainees”, says Dr. Eknoor. The Orthopedics department head she trained under in Rajasthan was very supportive and encouraged her to pursue the Hand Surgery course. "He had trained under Dr. Poornima Patni, the only other woman orthopedic surgeon in Rajasthan at the time. Having a woman role model in his field greatly influenced the way he approached and educated me," she says. Her experience drives home a crucial point about why the representation of women in the surgical field matters. Having women role models helps educators unlearn their biases, in turn making them better mentors for their women trainees.

“There are also a few other people who think that women lack the commitment to pursue surgery as a subject”, says Dr. M, "The reason for that could be that everyone views women as the glue that holds a family together. With such a view, everyone would automatically assume that a woman's priority will not be patient care.” However, time and again, studies have shown that across the board, women as surgeons perform equally well as men. 

"People hold women to higher standards compared to their male counterparts”, adds Dr. M. "I keep hearing from many senior women surgeons that we must always be the best versions of ourselves because otherwise, we will make all women surgeons look bad." The pressure to overperform is because of the phenomenon where one person's failure reflects on the entire group, especially for marginalized groups. For example, a man driving poorly is just a bad driver, but a bad woman driver is an example of why women are bad at driving. (Of note,  there are more bad men drivers compared to women drivers). 

The occurrence of this phenomenon is quantified in the surgical specialties by economist Dan Zeltzer. In a 2020 study quantifying the role of gender in inter-physician referrals, he found that when a physician refers a patient to a male surgeon and the patient suffers a bad outcome, the physician continues referring patients to other male surgeons than that one surgeon. However, when a physician refers a patient to a woman surgeon and the patient suffers a bad outcome, the physician stops referring patients to women surgeons altogether. Hence,  any and every woman surgeon, at all times, has to be at her best as all women surgeons are being judged by their behavior and performance. When this study was mentioned to Dr. M, she laughed and admitted that it did seem like a lot of pressure when put that way.

Another issue is that women opting for surgical training have to suffer from denial of their gender-specific needs. "The department gets annoyed at the fact that women are not men. The fact that they have gender-specific needs that may require accommodations from the system inconveniences them", says Dr. Silvia, who went through a bad time during her maternity period while in Surgery. "There are no accommodations because women are afraid to ask for them", she adds. "They feel that being allowed a place at the table itself is too big a privilege to spoil by asking for their needs to be addressed. They do not want to be seen as a separate group with separate needs." This is called camouflaging - women pretend to not have needs to avoid retaliation. This allows them to defer the discomfort for a short period but consequently blocks important conversations that may translate into fruitful accommodations for women. "Sometimes even senior women surgeons may not offer accommodations because they were not offered the same. My colleague worked herself almost into a pregnancy complication and people praised her for being very dedicated. It felt disturbing to see that" she concludes.

“I altered the way I carried myself so that people do not see me as a woman”, says Dr. Madhuri Evangeline, a consultant urologist. “In my outfits, my accessories, and even the way I look, I feel I have removed every trace of femininity.” As she says this, I wonder if it was some instinctual understanding she felt that more traditionally masculine traits would be valued and appreciated in the department as compared to traditionally feminine ones.

Workplace hazards affect men and women differently in surgical specialties and there is little information about the same currently - A study was conducted in 2021 to assess the awareness of breast cancer risk due to radiation among women orthopedic surgeons after noticing that they were 2.9 times more at risk for the same than the general population in a US-based study. This study revealed that most orthopaedicians were unaware of the risk and did not have a dosimeter to calculate their cumulative exposure.

"Both partners need work-life balance, not just women", says  Dr. Pearl. Her husband, a surgeon, is also a present parent to their two children. "We took turns taking breaks from our respective careers to take care of our responsibilities at home and him being an equal partner allowed me to focus on my career well", she adds. It is the oft-ignored reality. Most surgeons who are men have families and children, but in the popular narrative, they appear to have been absolved of all responsibilities towards them in their pursuit of "surgical excellence", which is unfair to everyone involved.  Familial commitments need to be viewed as common to surgeons of both genders.

Dr. Asha Bakshi, a renowned neurosurgeon working in Moolchand Hospital, Delhi currently points out that whenever she felt guilt about not having time for her child, she reminded herself that it was the quality of time that was important and not the quantity. “I was a present parent in whatever time I could spend with my daughter. I used the time to ensure she knew she was on the top of my priority list.” She feels that her daughter appreciates that now and has turned out to be a wonderful person.

Dr. Asha also recounts the sexual harassment she underwent during the time she attended conferences. “This is something that isn’t talked about much, but neurosurgery was a very male-dominated field when I began my training in 1992. When I went to conferences, I sometimes found myself being the lone woman in the room. I used to get catcalled and had to fend off unwanted advances at an alarming rate and eventually decided not to go to conferences at all. It’s been 12 years since I last attended one. I feel like I had to give up a chance at academic excellence in order to keep my dignity”, she says. Closer to work, Dr. Asha has also been subjected to harassment by a colleague she was posted with. When she brought up the issue with a senior, she found herself being displaced to a different hospital while the situation was being dealt with. “I almost regretted opening my mouth but then I saw that other women were also being victimized by him. That made me realize that speaking out was the right thing to do, even though it felt like I was being punished alongside him for complaining,” she said. “Having more women entering the field and the academic spaces will make them safer for every woman surgeon.” is her opinion on this matter. 

And there is the problem of remuneration - women surgeons are offered lower starting salaries than their male counterparts in private hospitals in India, government ones having a fixed compensation for both genders. “The  problem is also the lack of opportunity,” Dr. Asha points out, “When you are a private doctor, most of your cases come by referrals from a primary contact and if that primary contact for the patient is a male physician then he will almost never refer to a female surgeon, much less a neurosurgeon.” And as bleak as that sounds, this too has been quantified by a study published in the JAMA Surgery where they note that a physician who is a man is 32% more likely to refer a patient to a male surgeon while a woman physician refers to both men as well as women surgeons. This gives the opportunity to perform more interesting and complex surgeries heavily towards male surgeons. This leads to a large gender-based pay gap in surgical specialties.

Having women surgeons is important for women patients who may feel uncomfortable discussing certain aspects of their care with men doctors. These preferences for women surgeons increase when the area affected in question is the breast or the pelvic region. “I did not notice this much as a general surgeon, but as a urologist, I see the preference women patients have towards being treated by me as opposed to my male counterparts”, says Dr. Madhuri, who is now seriously considering pursuing a subspecialty of urology that focuses on female urogenital tract after seeing the difference her presence made to them. “Many women walk up to me almost every day to say how grateful they are that a woman doctor is available in my department.”   This impact on healthcare access is very important. In fact, the World Health Organization recognizes improving health worker gender parity as a critical component of improving the acceptability of the health workforce. Patients from certain populations may also have cultural barriers to accessing help for their conditions in such cases and a woman surgeon is the answer to their problems. Women patients also tend to do better under women surgeons according to various studies which indicates how the representation of women in surgery is vital from the patient's perspective. New evidence from Canada based on 1 million patients suggests that not just women but all patients regardless of their age and gender across different specialties and procedures seem to have better outcomes in the short and the long run when treated by women surgeons.   

Gender equity in surgical specialties is not as commonly discussed as it should be, at least in South Asia. There are unique barriers to professional growth and at times denial of gender-specific accommodations.  These can profoundly impact the quality of life of women choosing to train in the field. It is important to initiate and continue the conversation to ensure a better workplace for every woman surgeon and surgical trainee. The bottom line is that women are as capable, if not more capable than men to be surgeons. Yet, centuries-long societal bias against women has also seeped into surgery. The bias has to go away. 

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This article was originally published in August 2023.

Edited by Parth Sharma.

Image by Janvi Bokoliya.

About the authors:

Dr. Christianez Ratna Kiruba is a general medicine physician with a passion for medical ethics and patient rights advocacy.

Siddhesh Zadey is a co-founder of the non-profit think-and-do tank Association for Socially Applicable Research (ASAR) India and the Chair of the G4 Alliance Working Group for SOTA Care in South Asia.