Machismo in surgery is harming the specialty

Medical students in the United Kingdom seem to be less interested than their predecessors in pursuing a career in surgery, replicating a situation already seen in the United States.1 Although entry into surgical training has traditionally been highly competitive, in recent years there has been a decline in applications for core surgical training posts. In 2012, for each core surgical training post available there were on average 3.8 applications, but in 2014 this number fell to 2.2. In 2013 the NHS failed to fill all its available core surgical training posts.

The factors responsible for this drop in interest in surgical careers are not well understood, but making surgery a more appealing career option for women is likely to be the most effective way of dealing with future surgical skill shortages. Women present a large, and largely untapped, resource in surgery. They make up the majority of medical students but are substantially under-represented among applicants to surgical training, with male doctors in training being twice as likely to apply for core surgical training posts as equivalent female doctors.

Some doctors have suggested that the nature of surgical jobs would have to change to increase the likelihood of women choosing to become surgeons,2 and debates around working hours and the availability of less than full time training for surgeons are heated and ongoing.3

Surgeons’ jobs are undoubtedly demanding, requiring high levels of commitment, frequent on-call duties, and extended working hours, with 90 hour working weeks being common.4 Clearly, in a society where women still shoulder most of the domestic responsibilities of family life and are more likely to have a working spouse,5 pursuing a career in surgery is, generally, likely to be harder for women than men.

However, men, as well as women, are likely to benefit from changes in the structure of surgeons’ jobs. Research has shown that male surgeons are as likely as female surgeons to find conflict between their working lives and their personal lives,6 and that many male surgical consultants want to work part time at some point in their career.7 In addition, when women are asked to account for their lack of interest in surgical training, they are more likely to point to their belief that gender plays an important part in career success89 than to the lifestyle implications of a surgical career.1011

It may be that sex stereotypes in surgery are discouraging women from pursuing surgical careers. This possibility has some support from the fact that women have the highest levels of representation in paediatric surgery and the lowest levels of representation in orthopaedic surgery. Paediatric surgery, with its focus on children, is arguably the most stereotypically feminine surgical specialty, and orthopaedic surgery, with its traditional emphasis on the physical strength of the surgeon, is arguably the most stereotypically masculine specialty. Importantly, it is not possible to account for this simply by pointing to working hours and on-call demand, since women are much more likely to apply to general surgery than orthopaedics, even though the hours and on-call requirements are similar.12

Few people would challenge the notion that many in the medical profession and the general public hold gender stereotypes of surgeons (see box). Our experience, from delivering talks about our research to audiences of female medical students and surgical trainees, suggests that strong gender stereotypes of surgeons exist in the United Kingdom. Specifically, after first asking these women to bring a picture of the typical surgical consultant to mind, we then ask them to raise their hands if they had imagined a man. Most of the audience will raise their hands, even as they acknowledge the irony of doing so in a room full of aspiring women surgeons. At one level this is hardly surprising. Since women make up less than 10% of surgical consultants, statistically the typical surgeon is a man. However, the fact that this view of surgeons as men is understandable does not mean that it is not problematic.

People base their understanding of what it takes to do well in a particular occupation on the individuals that they see working in that field.13 They assume that success in male dominated occupations requires stereotypically masculine attributes, such as physical strength and competitiveness. These beliefs have negative consequences for women in male dominated occupations, since observers assume that women lack the attributes that are required for doing a job well. Women are then less likely to be given the opportunity to prove themselves in a masculine occupation and have to work harder to show that they have what it takes.1415

The negative consequences of these sex stereotypes can account for the difficulties that women face in rising to the top of most occupations. However, they are less able to account for the fact that, while women remain under-represented in surgery, in the past 50 years women have made dramatic inroads into other medical specialties, such as anaesthetics and psychiatry. The nature of specific masculine stereotypes therefore needs to be examined more closely to understand why some occupations may disadvantage women to a greater extent than others.

Some occupations have stereotypes that map on to understandings of men as independent, strong willed, technical, rational, or adventurous. However, the stereotype of surgeons maps on to an understanding of men as macho, tough, and aggressive.8 Katherine Kellogg, a researcher in business administration, has studied the behaviour of surgeons in the United States. She reported, “Their demeanour was macho: short haircuts, tucked-in scrubs worn low on the hips, green surgical caps and masks around necks long after leaving the operating room, fast striding movements during morning rounds and cocky swaggers in the evenings, and well-toned, muscular bodies.”16

We have found that both male and female trainees believe being macho is characteristic of surgical consultants but less characteristic of their own behaviour.17 However, female trainees experience more conflict than male trainees between how they see themselves and how they see surgeons. They also express lower levels of identification with surgery and a higher desire to opt out of surgery, and we have found that these differences can be accounted for by their perception that they do not measure up to the macho stereotype of the surgeon.

More recently, we have shown that these sex differences emerge over time (Peters et al, unpublished data, 2014). We found that in their first year of training both female and male trainees feel equally similar to surgeons and express equal levels of identification with their career. However, sex differences become increasingly pronounced as trainees progress through training. This is important, because it suggests that there are no pre-existing differences between men’s and women’s commitment to surgery but that there is something about the surgical context that undermines women’s commitment.

It is interesting to note that men are not insensitive to the impact of being in a macho surgical context. In particular, in an analysis done this year (Peters et al, unpublished data, 2014) we found that almost half of the male surgeons who participated in a longitudinal study believed that they did not measure up to the macho surgeon stereotype. Among those men who saw themselves as less macho, a lack of perceived similarity predicted higher career disengagement and an enhanced desire to leave a career in surgery one year later.

Together, these studies provide evidence that the nature of the masculine stereotypes associated with surgeons discourages women and a considerable number of men from pursuing careers in the specialty.

If surgery wishes to increase its appeal to female medical students, it is important that these stereotypes are actively countered. The dominance of men in surgery will continue to reinforce beliefs that stereotypically masculine characteristics are necessary for success. This is also likely to inform trainees’ interpretation of the difficulties that they encounter during training. In particular, these stereotypes will influence whether the normal challenges associated with occupational training are interpreted by a trainee as a challenge to be overcome or as a sign that she does not have what it takes to be a surgeon.

The profession needs to counter these stereotypes in word and in the creation of a context that encourages and supports women.