Women represent just over 50 percent of students entering medical school, but when it comes to the number of women who choose Surgery as a career, the percentage drops dramatically. As of 2017, Women make up only 13 percent of almost 70,000 surgeons of multiple specialties in the USA [1]. But where is the disconnect? And can it be resolved? Especially in the face of a projected shortage of practicing surgeons, it is more important now than ever to investigate, understand, and work to eliminate the barriers encountered by this large, and often unique, talent pool [2].

Research demonstrates that many factors play a role in deterring women from pursuing Surgery. For example, women residents are highly likely to perceive childbearing as a career barrier [3]. Furthermore, the surgical profession certainly is demanding, carrying significant lifestyle implications, long and irregular work hours, and various ‘on-call’ responsibilities [4]. A 2010 study states that women are much more reluctant to pursue a surgical career due to these lifestyle complications [5]. However, to understand why these issues affect women more than men, it is important to recognize that the disparity also has deep roots.

The psychological depth of gender discrimination is a long discussed phenomenon, especially with regards to what is called the Gender Schema Theory, proposed by Sandra Bem in 1981 [6]. This is a cognitive theory based on how people become ‘gendered’ in the first place and how that leads to social and institutional bias. Gender schema refers to a cognitive structure, organized starting from a very early age, regarding the expectations a person has for other individuals based on biological sex [7]. Bem puts forth that as belief in the natural superiority of men has become embedded in culture, both men and women tend to internalize that as a type of ‘lens’ by which they perceive the world [8]. This perception, mixed with structural and societal inequality that confirms those beliefs, leads to bias which influences our actions and ultimately reinforces man’s dominance. Women are largely unrepresented not only in Surgery but in many science, technology, engineering, and mathematics (STEM) fields [9]. And according to a 2015 study, women are stereotyped as lacking in intellectual prowess as compared to men and therefore are discouraged from entering fields that are perceived to require that same raw, intellectual ability [9]. Fewer women involve themselves in these fields, like Surgery, and have a much different experience than men while there, which only reinforces the disparity itself.

Thus, the surgical culture itself is a major topic to discuss when it comes to bias against women in Surgery; some have referred to it as a “gang culture” or ‘boys’ club’ in the operating room [10]. Since its beginning, Surgery has been a primarily man-dominated discipline with gender roles defined along ‘traditional’ societal norms; now, that mentality creates a much more hostile environment for women surgeons in the modern age. Considerations such as the surgical culture and lack of women mentors in academic surgery have been shown to play determining roles in the career progression of women surgeons [11]. Many women have expressed that because there are so few women role models in Surgery, they are led to assume Surgery is not a viable career path for women [12, 10]. Despite strides that have been made to make the surgical profession a more equal and open discipline, as of 2017 only five percent of surgical department chairs are women in the USA [13]. It is well defined that even as these numbers have grown over the years, women are still a clear minority. According to an article published in The Bulletin in 2012, this repeated finding suggests a continued systematic bias against women [14]. However, whether unequal representation is due to a systematic bias or even certain meritocratic considerations, the lack of women mentors in surgical leadership positions persists. Determining whether systematic bias is truly the cause is an important aspect of the conversation, because it helps to pinpoint where the problem is and how to start fixing it. Therefore, it is important to delve deeper into the subject to determine whether men surgeons also perceive and/or practice systematic bias against women surgeons.

Over the years, there has been growth in the overall percentage of women physicians in the USA, from 12 percent in 1980 to 30 percent in 2009, according to the US Census Bureau [15]. In 2017, women took on top leadership roles in the American College of Surgeons and American Board of Surgery, and a record 22 women were chairs of Surgery, even though this is still a very small percentage compared to men [16]. Presumably, as society has changed, so has the perception of women in Surgery. However, in 2012, it was observed that women surgeons continue to experience active discrimination in the workforce, which differed notably for their men counterparts [17]. When women surgeons themselves were interviewed, they often denied the possibility gender has an impact on their career, but their experiences and anecdotes suggested otherwise, showing that as explicit acts of discrimination have become much less acceptable, it still manifests itself in covert forms [18]. Several studies such as these have been conducted to study women surgeons’ perspective of workplace treatment and discrimination [5, 10, 19, 20]. In addition, previous research papers have analyzed the issue through the lens of academic professionals, the number of women surgeons’ publications as compared to men, and women career satisfaction [3, 5, 21, 22].

However, the data are lacking which solely and thoroughly investigates how men surgeons, in particular, perceive the barrier for women in Surgery. This study was undertaken to determine if men surgeons’ perceptions of women surgeons represent a bias against women in Surgery today and how big of a role they play in that barrier. We hypothesize that men surgeons’ perceptions of women in Surgery both reflects and contributes to a bias against women surgeons.

Methods

Participants, setting, and ethical approval

IRB approval was obtained prior to beginning this study. An opinion survey design was used and validated by the University of South Florida Morsani College of Medicine in Tampa, FL. A convenience sample of men surgeons was recruited from this university-affiliated tertiary care center in Tampa, Florida, of which 190 men surgeons participated.

Data collection

Email addresses of men surgeons at and affiliated with the institution were obtained. Surgeons were eligible to participate if they were employed by surgical teams and affiliated with the hospital. An email was sent to all participants, which included a link to the study survey. The survey was hosted by SurveyMonkey.com, a secure web-based survey generator. An explanation of the study’s purpose, voluntary participation, and confidentiality was provided and informed consent was obtained. Subjects were informed that their responses would remain anonymous.

Instruments

Demographic data were obtained, including exact age, race/ethnicity, level of training, current practice setting, and number of years at their current practice setting. The questionnaire included 70 items on a five-point Likert scale (1 = definitely disagree to 5 = definitely agree) as well as 63 multiple choice and binary answers. With the latter, participants were given the option to explain their answer choices.

Data analysis

A tallied summary of the results (e.g., a tally of the response totals, percentages, and response counts) for each question was generated. For illustrative purposes, the survey questions were divided into 6 main categories: (1) abilities; (2) opportunities; (3) family obligations; (4) relationships; (5) physical appearance; and (6) problems. For illustrative and analytical purposes, the responses “definitely agree” and “mostly agree” were combined to indicate agreement with a statement, and “definitely disagree” and “mostly disagree” were combined to indicate disagreement with a statement. Data were analyzed using linear regression tests to distinguish a statistical relationship between responses and progressive demographic variables (specifically, age and number of years at current practice setting). Statistical significance was accepted with 95% probability.

Results

Demographics (Table 1)

Of the 190 men surgeons who responded, 84% have been attending surgeons for more than 5 years. At the time of the study, 62% of the men surgeons practiced in a community-based private practice setting; 22% practiced in an academia/medical school setting; and 17% practiced in a university hospital setting. In terms of time spent practicing at their current setting, 24% of men surgeons have been practicing in their current setting for less than 5 years, 19% for 5-10 years, and 17% for more than 25 years. White men surgeons accounted for 84% of respondents, 6% were Asian, and 5% were Hispanic.

Table 1 Demographic data
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Abilities (Table 2)

Of the men surgeons surveyed, 80% believe that women surgeons are as capable as their male counterparts, and 67% believe that women make good surgeons; 10% disagreed with both beliefs. Meanwhile, 21% indicated that men surgeons handle job stress better than women surgeons. Additionally, older men surgeons were more likely to indicate that they believe women make good surgeons and disagree that men residents are more reliable than their female counterparts (p = 0.05, Table 2). Of the men surgeons, 83% believe there is no difference in how fast men and women learn technical skills. When asked if women bring anything unique to Surgery, 37% responded ‘yes,’ while 49% responded ‘no’.

Table 2 Abilities
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Opportunities (Table 3)

While 75% of the men surgeons deem that women surgeons have the same advancement opportunities as men, 32% indicated that men surgeons are afforded more opportunities in Surgery today. In response to the statement, “If I needed a partner for private practice, I would consider a qualified women surgeon for the job,” 79% of respondents agreed.

Table 3 Opportunities
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Furthermore, 23% of the men surgeons felt that women are discouraged from entering the surgical profession because program directors question their ability to complete surgical training, even though 95% believed men and women residents are trained equally. Despite that, 39% felt it is easier to retain men surgeons in residency compared to women surgeons. When asked, “Are there certain aspects of Surgery that would discourage women from becoming a surgeon?” 66% of the men surgeons replied ‘yes,’ with older surgeons being more likely to respond this way (p = 0.01, Table 3). To explain why, men surgeons suggested that time commitment, family lifestyle, and intense physical demand could deter women entering the surgical discipline.

Family obligations (Table 4)

Of the men surgeon respondents, 80% believe it is possible for a woman to be both a good surgeon and a good mother, while 13% disagreed. Meanwhile, 96% agreed that a man can be a good surgeon and a good father, and 0% disagreed. When asked, “Does having children adversely affect a woman surgeon’s ability to succeed professionally?” 46% of the men surgeons said ‘yes.’ However, 81% felt that having children does not affect a man surgeon’s ability to succeed professionally. To continue, 84% of the men respondents believe that women have more pressure to balance work and family life when compared to men surgeons; however, 32% believe that men and women surgeons have the same commitment to families outside of work.

Table 4 Family obligations
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While 57% mentioned that they would not resent covering for a woman surgeon who took time off for maternity leave or pregnancy-related issues, 74% of respondents would not consider paternity leave if their partner was having a baby.

Relationships (Table 5)

With regards to the doctor–patient relationship, 58% of the men surgeons believe there are no differences for men versus women, with those who have been at their current practice setting longer more likely to agree (p = 0.006, Table 5). However, in a separate question, 44% believe patients do treat women surgeons differently than men; 24% believe patients prefer men surgeons instead of women surgeons. Meanwhile, 48% believe women do not interact better with patients compared to men surgeons; however, older surgeons and surgeons with more years at their current practice were more likely to believe women surgeons do have better interactions with patients as opposed to men (p = 0.002, p = 0.006, Table 5).

Table 5 Relationships
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Furthermore, men surgeons were asked whether the “team dynamic is better when a man surgeon is in charge”; 51% disagreed, while 18% agreed. In the OR specifically, 57% believe there is no difference in the team dynamic when it is run by a woman as opposed to a man, yet 20% indicated that women surgeons are more “aggressive” in the OR. However, men with more years at their current practice setting were likely to disagree that men are “easier” to work with (p = 0.03, Table 5).

Physical Appearance (Table 6)

Of the men surgeons surveyed, 44% agreed that a woman’s physical appearance helps her receive more success in Surgery; 40% agree a man’s physical appearance helps their career, as well. In addition, while 49% of the men surgeons felt that women do not use their looks to get ahead, older surgeons were more likely to respond that they do (p = 0.01, Table 6). In response to the question, “Do you feel an attractive appearance makes it easier for a woman to advance in the surgical field?” 49% of the respondents replied yes. When asked “Do you feel an unattractive appearance makes it easier for a woman advance in the surgical field?” 92% of the respondents replied no.

Table 6 Physical appearance
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Problems (Table 7)

Of the men surgeons, 43% agreed that gender discrimination against women does exist in Surgery today. Furthermore, 45% believe that the “surgical discipline” is responsible for fewer women relative to men finishing surgical training (Fig. 1). In response to question “Was/is there a negative attitude towards women in Surgery at the institution at which you received your surgical training,” 68% of respondents disagreed, while 19% agreed. With regards to salary, 53% disagree that women surgeons earn a salary less than that of their male counterparts, more of whom had more years of experience at their current practice setting (p = 0.03, Table 7); 28% state that their current employing institution is not actively working to reduce gender-based advancement and pay discrepancies.

Table 7 Problems
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Fig. 1
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“Who is responsible for fewer women finishing surgical training relative to men?”

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When evaluating the number of women in Surgery, 57% of men surgeons believe that the rate of women pursuing a career in Surgery is not a problem that should be addressed; however, men who were older and had more years of experience at their current practice setting were more likely to say it is (p = 0.003, p = 0.02, Table 7). In response to the statement “Institutional support for women surgeons should be increased to encourage more women to pursue a surgical career,” 52% of men surgeons disagreed, although older surgeons were more likely to agree (p = 0.02, Table 7).

Discussion

When taking into account men surgeons’ opinions and perceptions of women in Surgery, it is important to consider the question: what are the ‘ideal’ answers we hope to receive? If a majority of men surgeons indicate a respect for the professional and surgical abilities of women surgeons, is that enough? Consider this: if you were to receive a birthday card that states, “On a 10-2 vote, we wish you happy birthday!” would that be acceptable? By that same token, if 20%, 15%, even 10% of men surgeons continue to express explicitly prejudiced or negative perceptions of women surgeons, then it is clear a bias still persists in Surgery today. The results of this study demonstrate that, in this same manner, while men surgeons generally have favorable opinions about a woman surgeon’s abilities and potential, those favorable opinions were not universal; a bias against women in Surgery continues, and it is unacceptable. Surgery suffers a great loss of both talent and numbers when women avoid the career based on the surrounding and internal perception that they are any less capable than men. Understanding the perspective of men surgeons in particular is an important step to eliminating this bias, because perception, in many ways, becomes reality [8]. If men continue to perceive gender-based discrimination in the surgical workforce, that viewpoint inevitably trickles down to continuously discourage women from pursuing Surgery as a career. This study is important not only because it is the first to solely analyze the perspective of men surgeons of all ages and at different points in their practicing careers but also because it demonstrates that Surgery still needs to change before it can be considered a discipline equal and open to all people, regardless of gender. Men surgeons in particular must be conscious of this problem and actively work to eliminate disparity within the work environment.

The men surgeons surveyed in this study were generally older white surgeons who have been practicing for more than 5 years, similar to the demographic norm for surgeons in the USA [23]. With regards to women surgeons’ abilities, while a majority of men surgeons indicated a respect for women surgeons regardless of gender, a consistent minority suggested otherwise, indicating, for example, that women are not as capable as men surgeons, cannot handle job stress as well, and as residents are less reliable. Although a 2018 study showed that women residents do more frequently feel symptoms of stress, they are also taking longer hours in the hospital and expressing more emotionally invested care for their patients [24]. Greater stress is further induced by a more stereotyped environment, which was shown to be the case among women surgical residents [25]. The beliefs expressed in the survey may contribute to the environment where women report feeling “excluded” by men in various academic Surgery departments [17]. Perhaps consequentially, more than a third of the men surgeons indicated that men are afforded more opportunities than women in Surgery; 20%, one in five, of the men surgeons who responded could not agree that they would even consider a qualified woman surgeon as a partner. This problem may be further exacerbated by the observation that program directors question women surgeons’ abilities. Program directors questioning women surgeons’ abilities is a huge issue, especially considering that a large portion of the respondents indicated men and women are just as capable as one another. However, older men surgeons likely with more experience showed greater faith and certainty in the abilities of women surgeons, as they were more likely to believe women make good surgeons and disagree that men residents are more reliable. This is surprising considering that as times are evolving, one might expect younger surgeons to have more progressive ideas on the value of women in the surgical workforce. Perhaps the competitive atmosphere earlier on in the surgical career contributes to these polarizing beliefs.

As many, especially older surgeons, indicated that women avoid the career due to lifestyle implications, it is not surprising that the majority of bias against women surgeons surfaced in the category of family obligations. While about half believed having children greatly affects a woman surgeon’s ability to succeed, almost all of the men surgeons said having children does not affect a man surgeon’s ability to succeed. This disparity is indicative of the social norm that persists where women are perceived to have more familial responsibilities; however, at the same time, many of the respondents expressed that men and women have the same commitment to family outside work. These statistics show more clearly than anything else from the survey that there is indeed a double standard between women and men surgeons. Men surgeons are not held to nearly the same family pressures as women surgeons, who feel they must manage being both a full-time mom and surgeon, all while trying not to burn out in either job. Even though paid paternity leave is on the rise and much more common now than ever, there still appears to be a stigma against men taking advantage of paternity leave options [26]. The long held traditional belief that men should not take paternity leave persists, even though the option is now encouraged [27]. Finally, while the general perception is that familial obligations deter women from entering the surgical workforce, almost all respondents believed women surgeons can be both a good surgeon and a good spouse/mother. Our results indicate that most of these men believe women surgeons are fully capable of balancing family and work life, but many avoid this career due to the worry that it cannot be managed.

Our research also yielded unique and significant data regarding the surgeon–patient relationship and team dynamics. There were mixed responses regarding whether there is a difference that depends on the surgeon’s sex. Although many indicated otherwise, once again surgeons with more experience at their current practice setting were more likely to say there is no difference or, if there is, then women surgeons cultivate a better patient relationship. It has been shown that women surgeons have a different approach to care compared to men and may even yield slightly better patient outcomes in mortality other related surgical outcomes [28, 29]. Another study cites a possible additional subconscious difference, which depends on whether the patient’s sex matches that of their doctor, where gender concordance is associated with their agreement on advice given during consultation [30]. This further demonstrates how important it is for there to be more women surgeons, supporting that they bring a style of care unique to men and would better match the general patient population. For team dynamics, about one in five of the men surgeons consistently expressed bias against women in the work environment, especially in the operating room, deeming women to be more aggressive and less effective as a leader. But is this because women truly act more aggressively? Or is this an altered perspective based on conventional gender roles? Women are not typically considered to be ‘assertive’ or ‘aggressive’ [31]. Therefore, when women must take charge, they are unfairly perceived to be much more hostile. This is the ‘double-bind’ facing women in leadership positions when they must take on stereotypically masculine traits, such as those commonly associated with leadership [32]. Furthermore, while physical appearance does seem to play a role in the advancement opportunities given to women, the respondents also indicated that the same goes for men. Psychologically, attractive people are perceived to be smarter and more trustworthy than less attractive people [33]. Physicians are subjected to these same biases.

Overall, it is staggering to note that almost half of the respondents agreed that gender discrimination still exists in Surgery today. Even though most of the men surgeons believe there is no negative attitude towards women in Surgery at their institution, these statistics do not represent uniformity. These findings highlight that there are still strides to be made to achieve equal consideration for women surgeons, and the first step is to be aware of the issues at hand. For example, even though a majority of the men believe there are no pay discrepancies between men and women surgeons, it has continuously been proven that the opposite is true [12]. Additionally, more than half of the men surgeons believe the low rate of women entering Surgery is not a problem that should be addressed; about one-third of the men surgeons surveyed reported that their employing institution is not working to reduce gender-based advancement. This can and must be changed moving forward; Surgery can benefit greatly from the vast amount of talent and value women surgeons have to offer, especially since older surgeons with more experience do acknowledge the problem and because Surgery faces a projected shortage of practicing surgeons.

Though our study sheds light on an important perspective that has not yet been explored in-depth, it did have some limitations. These results only reflect a single institution and may not be the same elsewhere. We also had a relatively small sample size in comparison to the total population of men surgeons, which makes it a bit harder to generalize these statements to all men surgeons; however, we were still able to get a good understanding of the men surgeons’ experience with workplace bias against women surgeons. One inevitable drawback of using a survey as a design for the study is that respondents tend to answer in a way that they believe is favorable to the survey viewers, a phenomenon known as social desirability [34, 35]. Because the effect likely leads to an underestimate of the degree to which surgeons expressed bias through their answers, this suggests there is more depth to the intrinsic bias expressed in this study. For further research, we recommend a larger and more diverse sample size where multiple specialties of Surgery are represented and at different training levels, as our respondents were primarily attending surgeons.

Conclusion

While most men surgeons appear to have favorable opinions of the personal and professional abilities of women surgeons, favorable opinions were not universal; a bias against women persists in Surgery today. Our results even suggest this bias is just as prevalent if not more in younger men surgeons. Considering most medical students today are women, not utilizing this talent pool is a major detriment to the surgical profession. Both men and women bring unique and important aspects to the surgical discipline. Surgery, and men in Surgery, must evolve to eliminate bias against women surgeons, promoting an equitable and inclusive work environment for the betterment of Surgery and all its stakeholders, including patients.