As the only woman resident throughout most of her surgical residency program, Joanne Favuzza, DO, still remembers the attending physician who asked her, "isn't there a makeup counter where you could be working?" Other attending surgeons regularly made it clear that they did not expect her to complete the surgical residency program.
Now nine years into her career and a colorectal surgeon at Boston Medical Center (BMC), Favuzza’s experience isn’t unique — though she notes that since joining BMC, she has worked with more women surgical residents and women in leadership positions than prior. According to a recent survey, women surgeons reported significantly worse experiences and less institutional support during their transition from residency into practice. And those disparities persist beyond residency, with significantly more women surgeons leaving their first job than their male counterparts.
Gender disparities in surgical residency: by the numbers
The survey results were published in the American Journal of Surgery in a paper that’s also a “call to arms” to address gender disparities and provide more institutional support to surgical residents broadly, says author Priyanka Chugh, MD, a second-year surgical resident at BMC.
Chugh says the paper grew out of a larger study that looked broadly at the experiences of physicians transitioning out of residency and into surgical practice. The study was done with surgeons at the Veterans Affairs Boston Healthcare System, where senior author, Gentian Kristo, MD, practices. The authors sent a survey to general, colorectal, vascular, and cardiothoracic surgeons who had joined the American College of Surgeons within the past five years.
“Originally we didn’t plan to look at this by gender, but as we collected the data, we came to realize there were some pretty significant gender differences,” Chugh says. “Women were reporting more issues in that transition — feeling supported was a main one, and feeling they didn’t have as much mentorship before and after transition.”
Women were also more likely than men to say they wanted more mentorship, including mentorship from retired physicians. Mentorship correlates with job attrition, according to the findings. Almost twice as many non-mentored young surgeons, across genders, ended up leaving their first job, 64.3%, compared to those who received mentoring (36.3%).
That transition is also a key moment with major disparities in experience between men and women: 38% of women surveyed reported an inadequate overall transitioning experience, compared to 21.7% of men. More than half, 51%, of women reported receiving inadequate institutional support during their transition into surgical practice, versus 41.6% of men. After transitioning into practice, the survey found higher rates of attrition among women: 48.2% of women surgeons versus 41.8% of their male counterparts leave their first job.
Disparities persist for women in surgery
The survey results prompted Chugh and her colleagues to do a “deep literature dive” to further illustrate the gender imbalance and provide additional context for their findings.
They noted that a 2017 study found women surgeons had patient outcomes that were as good or better than their male counterparts. In spite of this, women in surgery are still more likely than men to have their skills questioned and more likely to be perceived as incompetent by both patients and colleagues.
Other research documents some of the ways men entering surgery receive more support. One study found male surgical residents receive more positive comments during evaluations than similarly qualified women residents, who are more likely to be evaluated using terms expressing uncertainty. Another study found that women residents are given less autonomy in the operating room than their male counterparts.
Those inequalities persist after residency. Female surgeons receive lower salaries and fewer professional advancement opportunities than men, and are underrepresented in leadership positions, notes Chugh’s paper. At home, they are given more domestic and childrearing responsibilities than male surgeons, and they experience increased work-family conflicts leading to higher rates of divorce, depression, and burnout. They are also hampered by sexual harassment and gender discrimination in the workplace.
Survey findings resonate with women surgeons
Favuzza said the findings were all too familiar and resonated with her own experience.
“When I was a resident, I certainly felt like I had to work much harder and longer hours, had to take more weekend calls than my male co-residents. I constantly felt like I had to prove myself and that most of the male co-residents did not think I was going to make it through residency,” she recalls.
"At that time, my residency program offered no preparation to residents for their transition into surgical practice," she says. "I lacked critical information about things like job searching, salary, and contract negotiation."
Without transparency around salary, Favuzza had no idea how much to ask for or how much room she had to negotiate. She ended up being paid significantly less than male surgeons at the same level — something she didn’t find out until several years into her first job.
Another surprise: Favuzza expected that once she was out of residency she would have proved herself and would be treated the same as her male colleagues. That didn’t happen at her first attending job.
“My male counterparts were getting paid more, offered more leadership positions, and even promoted in academic rank far quicker that I was," Favuzza says. "I often did not receive the credit I deserved for work that I accomplished."
Addressing gender disparities improves patient care
Addressing inequality is about more than advancing the careers of women in surgery. Chugh notes that it also improves patient care. In addition to studies showing that women surgeons often have better patient outcomes, healthcare systems benefit from having providers with a variety of backgrounds, she says.
She points to the example of a breast cancer surgeon who herself has gone through treatment for breast cancer — bringing a personal understanding of what her patient is going through and how to help.
“Having people who look like you take care of you is hugely important,” she says. “It doesn’t mean your surgeon has to be a woman if you’re a woman, but it’s about having a diversity of thought and ideas.”
Acknowledging that implicit bias exists and committing to making a change are needed first steps to breaking the glass ceiling, Favuzza says. Other actions that hospitals and healthcare systems can take to address inequity include salary transparency, setting clear paths for promotion, recognizing the accomplishments of both male and female surgeons, and making sure that the workload of uncompensated, “invisible” tasks like teaching and service are distributed equally between women and men. Favuzza notes that BMC is a great example of a hospital system constantly striving to eliminate gender inequity, specifically calling out the leadership of its woman chair of surgery Jennifer Tseng, MD, MPH.
Chugh agrees with the importance of women in leadership. When discussing her decision to do her residency at BMC, she says, "I was wondering, would I be the only woman in the room, and when it came to picking chief resident would it always be a man chosen over a woman? I’m so grateful and lucky that our program is not like that."