Keywords

It was just past midnight on a night in mid-2004. The paramedics were just about done giving me report on a critically ill gentleman in his mid-forties who was found unresponsive at home by his wife. This man had suffered a subarachnoid hemorrhage from rupture of an intracranial aneurysm. I was near the end of my first year as a neurosurgery resident and, at this point, was quite adept at taking care of these types of patients once they arrived in the intensive care unit of the Chicago hospital where I trained.

The dangers of intracranial aneurysm rupture are many. However, my first priority was to assess him and determine if he needed an emergent bedside procedure to help drain the cerebrospinal fluid that normally bathes the central nervous system which was no longer being absorbed normally by his stunned brain. Following my initial assessment, my next task involved discussing his condition with his family in a manner that addressed all of their concerns, while staying focused on the fact that this procedure needed to happen in an expedited fashion to provide the best possible clinical outcome for my patient. I reviewed the disease process with his wife and her sister; explained to them my role on his team, clearly stating that I was a physician; and obtained informed consent for the procedure that would take place within the next few minutes.

I was very pleased when following the procedure, he showed promising signs of recovery within the first few hours. His family was also overcome with emotion and immediately declared that with what I had just accomplished, “they” should just allow me to become a doctor. This was one of the first times in my medical career that, I can very clearly recall, someone had very poignantly distinguished me from my colleagues based solely on my gender. Despite my introducing myself as Doctor, that declaration reinforced by the MD following my name on my hospital ID badge, and the embroidered indication of my station in life on my white coat, these family members instead chose to believe that I was not a physician. This was my conscious introduction to a life of being constantly underestimated. It is not lost on me that, in this particular case, I have chosen a certain interpretation of that statement that may not reflect the actual meaning intended by the family. However, I assure you, I have suffered through many other conversations during my professional life that lend themselves to much less ambiguity.

Throughout the years, I have lost track of the number of times patients, colleagues, and sometimes perfect strangers have ventured a guess on what my role within the health-care system is. On more than one occasion, I have entered a patient’s room and have been asked to place a pillow behind his head, followed by the question “do you know when my doctor will be here?” I have listened to wives, mothers, husbands, and sons end calls with loved ones because their physical therapist has arrived. I have even been asked who will actually be performing the surgery at the end of a clinic consultation. On rare occasion, I have entertained the occasional request from patients who have requested that a male colleague assist me with their procedures at the begining of a consultation.

In 1995, Dr. Greenwald lay the groundwork that demonstrated our social behavior is not always necessarily under our conscious control [17]. In developing the Implicit Bias Test, he established that we are not in complete control of our reaction to every situation. As a female neurosurgeon, I have often had to remind myself of this throughout the years. Also as a result, I have become more aware of my own implicit biases.

The History of Women in Neurosurgery

I was asked many years ago, during an interview, what it felt like being a female neurosurgeon [15]. At that time, I only personally knew two other female neurosurgeons. My answer to that question was very calculated and safe. I responded that I did not see myself as a female or male neurosurgeon, but simply as a neurosurgeon. Despite my many experiences to the contrary, I wanted desperately to believe that neurosurgery saw no gender. We all take calls, we endure long hours, and we treat our patients to the best of our ability, regardless of our gender identity, ethnicity, or religious beliefs. Throughout my entire training, I had been the only female resident. I had a very strong female mentor who never made gender the focus of any discussion. If asked that question again today, I would answer it with a bit more grit and I would shed the idealism. Years of being in practice has made me acutely aware of the challenges that women face in traditionally male-dominated fields. Neurosurgery is no exception. As Dr. Stamp stated in a recent piece she wrote for The Washington Post, “When girls or women ask me if they can be a surgeon, I’ll still say yes, they can. I’ll still encourage them because despite the obstacles, I love my job and I want to see the ranks swell with more women. And I will still tell them that just because they are female, it has no bearing on whether they can or should do a job. But I will then tell them that it may not be an easy or fair road, and that I am going to keep fighting and holding accountable the people and the system who will make a liar out of me and a tough road ahead for the next generation. Despite my fears, I don’t lie to the next generation, but I am determined to change the system, not the women who try to survive in it” [52].

In 1965, women represented only 9% of US medical school enrollment and only 7% of medical school graduates [41]. Since 2011, more women have graduated from medical school than men [13]. In 2017, for the first time in history, there were more females enrolled in medical school than males [20]. Despite this trend, following the 2018 Neurosurgery Match, only 17.5% of neurosurgery residents were women [13, 43]. This represents a slight improvement from 2015, when only 15.8% of neurosurgery residents were female, even though women represented 46% of all US medical residents [41]. While there has been an increase in female representation in neurosurgery, these gains do not parallel those seen in the general population of residents, neurology, or even general surgery. We are bridging the gap, but at a significantly slower pace [5, 58, 10]. Retention of female neurosurgery residents is also lower than their male counterparts. Eighteen percent of women do not complete residency, while the male attrition rate is only 10% [1].

Mentorship

What drives the decision process when medical students are choosing what field to pursue after graduating? While there are many factors involved, mentorship is one of the most important. Mentorship has repeatedly been shown to be very important when deciding what field to pursue following medical school. Females lacking a female mentor were less likely to apply to surgical residency [26]. Females also reported greater interest in applying to programs with other female residents and faculty members [48]. I can personally attest to this influence. When I was rotating at my home institution as a medical student, a very outspoken female chief resident encouraged me to consider applying to neurosurgery. Up until that point, while I had a very strong interest in neuroscience, neurosurgery seemed like a pipe dream. However, not only do we need mentors to advise us, sponsorship from our mentors is critical for advancement. And yet, male neurosurgery mentors are more likely to advocate for their same-gender mentees on a professional level, whereas females are more likely to receive psychosocial guidance and personal advice from their male mentors [58].

Leadership

There is a paucity of female physicians in academic medicine and leadership roles. The ones that are there earn, on average, 10% less than their male colleagues [4]. The first female chairperson of a neurosurgery department was not appointed until 2005, when Dr. Karen Muraszko was appointed at the University of Michigan [4]. If we review the academic genealogy of neurosurgery, it quickly becomes very apparent why there has not, until recently, been a female chair of neurosurgery. Of the 377 chairs identified, none were women [59]. I can confirm from my personal experience that several female peers approached me after learning that I would be entering a neurosurgical training program and commented that they did not realize that neurosurgery was an option for them. Reflecting on these comments now makes me realize how rapidly one’s perspective can change. I consider myself beyond lucky, as I was also fortunate enough to be taken under the wing of the then chief resident of the neurosurgical service during my medical school elective rotation. I am not sure if I would be where I am today were it not for the strong female role models I was fortunate enough to encounter along my journey. Even since my graduation from residency in 2010, there are now five female residents in the program in which I trained. Up until 2010, there were only two female graduates from my program. The only other female resident before me graduated in 1983 [4].

Jaclyn Janine Renfrow, MD, and her colleagues from the Wake Forest School of Medicine reviewed data from the American Association of Neurological Surgeons (AANS) and the American Board of Neurosurgery (ABNS) from 1964 through 2013 in an attempt to determine the number and trajectory of female neurosurgery graduates. During that time period, there were 379 female neurosurgery residency graduates. Only 70% became ABNS-certified and 27% pursued fellowship training. Between 1960 and 1969, only two women were board-certified in neurosurgery [43].

The ABNS was formed in 1940. As of March 2018, in its 78 years, the ABNS has certified 7142 neurosurgeons. Less than 8% of all neurosurgeons receiving board certification in the ABNS’ 78-year history have been female. Board certification is an arduous process in all medical fields. In neurosurgery, you are first required to take written boards, which most programs require before being allowed to serve as chief resident, followed by the dreaded oral board examination that takes place anywhere from 2 to 5 years following graduation from residency. The first female diplomate of the ABNS was Ruth Kerr Jakoby, MD, JD [51]. She was board-certified in 1961. This was 21 years after the formation of the governing body. After developing an interest in medical-legal issues, she also received her JD from Northern Virginia Law School in 1986, becoming the first female neurosurgeon to also be a lawyer. She is still living and is 89 years old.

Another important milestone was reached this past year. In 2018, the AANS inducted its first female president, Dr. Shelly Timmons. It has taken 78 years for the field of neurosurgery to elect a female as the leader of one of its two main congresses: American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgery (CNS).

It seems difficult to believe that as late as the 1990s, more than 30% of all US neurosurgical residency programs had never graduated a female neurosurgeon. As of 2007, there were still 4 programs that have never had a female resident [4]. Another milestone was reached in 2017, when Johns Hopkins Hospital accepted its first black female resident, Dr. Abu-Bonsrah [27].

I feel very fortunate to have been exposed to neurosurgery in medical school at a time when not many women received this opportunity. When reflecting on my journey, I feel a sense of pride at being a part of something so wonderful. I do not deny that many days are filled with unique challenges. Yet many of today’s medical students are not afforded the early exposure to neurosurgery I had. For our current generation of students to flourish in a field that would benefit greatly from a greater presence of women, we must actively combat gender discrimination, lack of female role models, and abjuration of work-life conflicts [39].

The Impact of Gender Discrepancy in Certain Fields of Study

Since graduating in 2010 from residency, I have held two faculty positions. In both environments, I have been the only female attending. I have often wondered why there are so few women in my field and the impact this has on how neurosurgery has evolved and continues to evolve as a profession. Neurosurgery, like other fields in medicine and outside of medicine, has always suffered from a lack of gender diversity. These inequalities have been shown to become even greater as one ascends in the educational hierarchy [57].

Despite the fact that higher education is available to both men and women in our current society, it seems that the environment that awaits following graduation is not always the welcoming one we would hope for as women. In 1998, Benokraitis very aptly wrote in her book, Career Strategies for Women in Academia: Arming Athena, “Subtle sex discrimination refers to the unequal and harmful treatment of women that is typically less visible and less obvious than blatant sex discrimination is. It is often not noticed because most people have internalized subtle sexist behavior as normal, natural, or acceptable. It can be innocent or manipulative, intentional or unintentional, well-meaning or malicious” [9]. What makes this behavior difficult to label and, therefore, correct is that it lends itself to multiple interpretations. What may seem offensive to some may appear harmless to others. The example she gives is a classic one: a man and woman are having dinner. When it comes time to pay the bill, the woman hands the waiter the credit card and bill. The waiter returns with the receipt, handing it to the man. No atrocious crime has been committed. Yet the waiter’s action implies a certain male authority. This authority is recognized in most settings. I have lost count of the number of times I have entered a patient’s room with a male nurse or midlevel provider, only to have the patients and their family members address my male counterpart as their doctor and me as his assistant.

Examples similar to the one above exist in everyday life and color our world. Eventually, if allowed to fully evolve, they help form our self-identity. If left unchecked for too long, Imposter Syndrome imposter syndrome may result [8]. For a female in a male-dominated field, it may be something as simple as being less likely to be called on during a meeting to share an opinion, not having your male colleagues ask what you thought of last night’s football game, having to endure sexist humor for fear of exclusion if you object, or co-workers assuming that you are always the right person with whom to discuss a difficult personal situation. Over time, as self-worth devolves, we are less likely to reach heights that a more supported individual may reach. Therefore, while subtle sexist behavior may be just that, it is important to recognize early the effect it may have on us, so that we may change our course. While we may not be able to eliminate these behaviors in others, we can at least become aware of them and alter the way we process them.

Over the years, I have used humor on many occasions to diffuse otherwise tense patient interactions involving my gender and being a surgeon. As it is not infrequent enough that patients ask who will actually be performing their surgery, I assure them that I am better at sewing than some of my male colleagues. While I find this type of humor necessary during those especially awkward times, it is also a form of self-deprecation that I do not condone. I am ashamed to admit that, on occasion, self-deprecating humor has been my escape, especially when my gender in relationship to my career choice has been called into question. However, as Hannah Gadsby so eloquently stated in her recent Netflix comedy special, Nanette, self-deprecating humor from an individual who already exists in the margins is not humility. Instead, it is a form of humiliation [34]. Using self-deprecating humor to speak is perhaps a way by which a minority seeks permission to speak – to be heard. This may perhaps be one manifestation of the commonly discussed Imposter Syndrome.

The impact on a field has to be considered from two different perspectives: First, we have to consider what it means to be a minority in your line of work. Second, we have to consider the evolution of a field. Does it follow a different trajectory when there is gender diversity? Stated in simple terms, what could a female colleague bring to the table that differs from her male counterpart?

As far as neurosurgery is concerned, women are given “less than minority” status. This is defined as a group with fewer than 15% representation [4]. A group that is assigned “less than minority” status does not meet the criteria for critical mass. Being part of such a small group does not allow that group to function as a minority, but rather as isolated individuals.

Being “the only” in any situation, a term used by David Goggins in his book Can’t Hurt Me, changes your constitution [16]. As adolescent and teenage girls, we congregated in the halls to share secrets and discover the norms of society. In a workplace where you are the only female, the congregation changes. Friendship among colleagues is an important component of any work environment. We all have an inherent need to belong. Belonging has to be very clearly distinguished from just fitting in. Fitting in requires changing who we are to be a part of a group. Belonging, on the other hand, does not require this change. We are a part of a group because of who we are. Belonging feels natural and there is no need to hide or alter our fundamental values and beliefs. We enjoy the company and value the opinions of those in our circle. In an environment such as this, one can thrive. On the other hand, when we do not belong, we are emotionally exposed, which leads to an increase in stress and distress [6]. Eventually, these may manifest as physical symptoms. One study out of Sweden found that females in male-dominated fields take twice as much sick leave as their male colleagues [46]. This corresponds to the deterioration in the psychosocial work environment as the number of women decreases in the workplace. Furthermore, absences secondary to illness are multidimensional and did not only comprise biomedical complaints. One of the most convincing findings is that the amount of sick leave was also proportional to the employees’ resources, demand of the work, and social factors. Much of the leave was related to burnout, depression, and other stress-related illnesses. A lack of mentorship was also mentioned during the interviews regarding the work environment. It has also been reported that emotional burnout may lead to changes in serum lipids [49].

Men and women have different styles of friendship formation. As a result of this, underrepresented genders are likely to have a more negative experience than those in gender-typical occupations. This includes increased psychological stress and a poorer self-assessment of overall health. This also manifests as a higher rate of sick leave in individuals working in gender-atypical occupations [42]. Women in male-dominated careers face many struggles when it comes to successful social assimilation in a gender-atypical environment. Many male-dominated work environments are described as agentic, where assertiveness, competitiveness, and a hierarchical approach to workplace dynamics are valued. This is contrary to the characteristics typically associated with women, which include collaboration, process, and equalizing behaviors [14]. This creates the dilemma of either trying to fit in or being true to one’s nature.

I offer a different perspective for the reader to consider. In my personal experience, I do not believe that the work dynamic described above is quite so simple. I believe that women working in a male-dominated environment adapt and may, on the contrary, find it difficult to make friendships with other women outside of the workplace. Over the years, while I am still a mother with maternal tendencies, I have found it increasingly difficult to form friendships with other women in the conventional sense. I do not have a group of close girlfriends and rarely find myself attending “girls’ night.” Furthermore, when attending social functions with work colleagues, I find myself in the awkward position of figuring out where I belong. Do I socialize with the “work wives,” or engage my colleagues in social banter? These types of situations defy the commonly held ideals of gender socialization. Gender socialization is a concept that describes how we are taught to socialize from a very young age. As the term implies, these norms are predominantly defined by society and are not solely rooted in biology.

When it comes time to secure a position, climb the academic ladder, or merely survive residency, negotiation is paramount. Women and men have, on average, very different approaches to negotiating. Women tend toward a “relational style.” The relationship between the two, or more, parties involved is the focus when attempting to achieve a goal. Men, on the other hand, rely on a “competitive style” that focuses more on achieving the desired result [33]. In 2002, Sandra Ford Walston wrote a piece entitled “Women Integrating Workday Courage.” In it, she describes that being more courageous in our place of employment allows us to design our lives rather than being told who we are and led down a path created for us, instead of by us. It is very common for a woman to thank an employer for a raise or an opportunity instead of understanding that it was her hard work that led to the recognition. My favorite quote from her writing should serve as a mantra to anyone and everyone who goes to work and wishes to rise above the daily chaos: “Remember, getting a promotion or some other accolade at work isn’t a gift. It’s something you’ve worked hard for and deserve. The action you take or don’t take during such a situation reveals your true courage quotient. When you fail to insist on credit for your accomplishments, your spirit slowly shrinks” [56].

There is no canon that defines with unwavering certainty what comprise the expectations of a specific role and, therefore, no objective standards by which to judge oneself. In today’s shifting society, we must all learn to wear multiple hats. Women who work and are also mothers experience a role conflict that can put them at risk for burnout. Mentoring and self-care are two techniques we can employ to prevent burnout before it happens. Recognizing that it is not easy, or maybe even impossible, to be everything to everyone is important. As such, women who work in male-dominated fields often describe feelings of social isolation and loneliness. Loneliness has been linked to almost all forms of mental illness [44]. Last year, loneliness was reported as a potentially bigger health risk than smoking or obesity [54].

As physicians, it is in our DNA to find solutions to problems. However, we cannot begin to solve the problem of gender inequality within certain fields until it has been clearly defined. Especially because women who work in traditionally male-dominated fields also defy the model of the nuclear family discussed by Talcott Parsons in 1955. In this model, there is clear role segregation, placing the female in charge of maintaining the household, while the male is expected to be in the workplace.

Current trends in the United States now tend more toward a social construct of role integration, as opposed to role segregation, e.g., work-life integration versus work-life balance, as a more realistic approach to the reality of multiple roles when managing work and home. The proportion of women comprising the total labor force participation has been steadily rising. Today, almost half of the workforce is female, which is a significant increase when compared to approximately 34% in 1950 and 43% in 1970 [53]. Despite this progress, many fields of medicine still lag behind. And regardless of the percentage of women in any given field of medicine, women still take on the majority of household responsibilities [30]. The conversation regarding gender parity in the workplace is an important one that cannot be disregarded. Until there is organizational citizenship that addresses the role conflict many women face today, we need to keep talking.

If one performs a Google search of women in male-dominated fields, it may come as no surprise that there are 27,900,000 results. You are then confronted with titles such as Male-dominated fields should remain male-dominated, as well as a piece from The Guardian published in February, 2019 entitled Female surgeons frustrated by male dominated field – study. There is no paucity of literature on this topic. I do not claim to have reviewed all these results for pertinence to this chapter, but what struck me with most everything I did read was the insistence that we are unable to look past the negative aspects of the gender discrepancy and, instead, make lemonade. It seems that it is time to move forward with embracing the inherent differences between men and women and extracting their best qualities to create a rich and diverse workplace. Gender equity in the workplace may enhance job satisfaction for women, as well as men. While a woman’s job satisfaction is not as strongly correlated to pay as a man’s, working in family-friendly work environments, and believing their place of business practices this, the perception of gender equality in the workplace has been shown to correlate with high self-reported levels of job satisfaction [22].

Navigating the Waters of Traditionally Male-Dominated Fields: How We Adapt to Our Environments

Women in male-dominated careers face unique challenges when compared to those working in gender-balanced positions. While some women integrate femininity into their work environment, it is not uncommon for women in predominantly male environments to adopt classically male behaviors in order to fit in [31]. The reality is that many female physicians experience burnout at some point in their career. One study found that female physicians were 1.6 times as likely to suffer burnout when compared to their male counterparts [32]. Some of this is due to the gendered expectations placed upon us by colleagues and patients. One theory is that patients have different expectations of care provided by females than of that provided by males. Females are expected to be more empathic and as such are often confronted with patients that offer more psychosocial complexity [28]. The result of this expectation differential may be reflected in the Press Ganey Patient Satisfaction Scores. In a 2017 study, the Press Ganey scores of female gynecologists were significantly lower than their male colleagues [45]. Please see Chap. 2 for further details regarding gender differences in patient satisfaction scores and outcomes.

Even after removing gender from the equation, some fields have a high risk of burnout. In a very poignant essay entitled “Physician Burnout: Is the Foundation of Your Life Crumbling?”, Dr. Kraig Burgess, a hand surgeon, describes the insidious nature by which neglect of our personal lives may result in the dissolution of the family unit and offers personal insights as to how one might assuage the negative effects of a surgical career on one’s family life [7].

There are many cautionary tales to be told. You can find them by the hundreds on social media sites. As that is the case, why is it taking so long for people to listen and act? How many times must history repeat itself before we remove the blinders? To some extent, we all believe that we are impervious to the ordinary. Our lives will somehow manage to defy reality. We are extraordinary. However, once you reach the summit of that hill, the fall can be steep. The abovementioned essay and many others like it are perfect illustrations that by the time you are rolling down the hill, momentum makes it difficult to reverse course.

The reality is, however, that although most physicians, both female and male, probably experience varying degrees of burnout throughout their careers, we are very likely to attribute those feelings to long hours and the emotionally demanding nature of our work and our current regulatory and electronic environment. That stress may be compounded by added sexism experienced outside the workplace. Many times, we may suffer at the hands of our own friends and family. I have been asked countless times why I decided to pursue neurosurgery as a career, given the demanding nature of the work and the impact it will have on my ability to take care of my family. I have come to the point now where I have pretty much worked out the following standard response: The fact that I work is the very reason I am able to take care of my family. Having a demanding and rewarding career like neurosurgery also fosters a desire in my daughters to seek independence and knowledge as they believe this to be the modus operandi of all individuals. While living in a dual-income household means that we rely on the help of substitute caregivers, we stress to ourselves and to our children that while our careers fulfill us, it is our family that completes us.

There is a common perception that women and men have different leadership styles. Most perceive women as having a leadership style that is more people-oriented, while men tend to be more task-oriented [24]. This misconception may be in part attributed to the social role theory in which women are viewed as nurturing and men “get things done.” This characterization pervades our society as demonstrated by the adjectives masculine and feminine. The word masculine implies strength, while feminine brings to mind something delicate. Even when describing music, feminine refers to a final chord occurring on a weak beat, while masculine is a final chord occurring on a strong beat. It is a hybrid approach that I believe characterizes the strongest leaders.

Work-life balance is perhaps the most talked about conflict that affects working women. Drs. Toby Parcel and Elizabeth Menaghan have authored multiple research articles and books regarding the effect on a child’s well-being when both parents are employed. They have written extensively about the detriment to both cognitive and social development in children who are raised by substitute providers and the resulting attachment insecurity [38].

The term work-life balance itself implies two opposing forces. Instead, they should be experienced on a continuum. While I do work longer hours than the average gainfully employed individual [3], I strive to involve my family in decisions regarding my work life. I am clear with my children regarding my work responsibilities and the importance of the work I do, all the while emphasizing that they will always be my top priority. I also involve them, when appropriate, by taking them to work functions with me, as well as visiting my office on off-hours occasionally so they can see where I am when I am away from them. Conversely, my colleagues and I speak often about our families and lives outside of medicine. Of course, in a field like neurosurgery, social capital is not viewed as important as professional capital. Despite this, even though the care of my patients is wildly important to me, I have not been able to think of myself as a neurosurgeon first since becoming a mother. While some may define this as a weakness, I believe this has helped shape me into a more present and compassionate doctor. While empathy has been shown to decline through the course of medical school and residency [35], it is through interaction with society’s most innocent citizens, our children, that we can reawaken our emotional understanding of another individual’s experience and needs [40].

As I mentioned above, while I do not miss an opportunity to tell my family they remain my top priority, that does not translate to my presence at every school function or extracurricular activity. Also, the fact that I occasionally sacrifice professional opportunities to be present at times when most of my contemporaries are not has taught me an important lesson in the last decade. We place too much pressure on ourselves to have it all. Instead of having it all, I have found a new equilibrium that has worked very well for me. I no longer strive to have it all. I strive to have enough.

Bridging the Gap and Moving Forward

We all strive to create a workplace with gender parity, so much so that we do not want to treat individuals differently. What we fail to realize is that women and men are quite different. Years of misinformation has created the belief that those difference lie in their intellectual abilities. In our pediatric rotations during medical school, we are repeatedly reminded that kids are not just small adults. I think a similar statement may be made regarding females and males: women are not just men with less bodily hair. We do not want to be treated exactly the same. We want our unique qualities and skills to be recognized, accommodated, and celebrated so that we can thrive in the professional world just as men have for hundreds of years.

Creating Awareness and Comfort

First, and foremost, we need to create awareness of the gender discrepancy that exists in some fields. Whenever there is any imbalance in nature, scientists have jumped into the field to determine the cause in order to begin work on solutions. Gender discrepancy is no exception. There is a growing body of literature regarding this topic. When performing a literature search for “females in male-dominated careers,” there are almost 28 million results. However, when researching “burnout of females in male dominated careers,” there are 4.5 million results. We have spent a lot of time observing, and now we need to systematically begin working on actionable solutions. By clearly defining an issue and assigning vocabulary to it, only then can it be tackled.

When one is a minority in his or her environment, the risk of isolation and attrition increases. Small work groups, referred to as “microenvironments,” have been shown to be beneficial in increasing confidence and comfort with speaking up and contributing to assignments [11].

Professional women need to be more visible and available to medical students throughout their training. We need to be seen. In my field, the image that most people conjure in their mind when they hear the word neurosurgeon is someone sitting under a microscope for 12–24 h. The question I am still most frequently asked when people find out that I am a neurosurgeon is how I can operate for so long without going to the bathroom. Never mind that the majority of the procedures I perform require less than 3–4 h. Also, I believe one of my patients said it best when she declared, “I expected someone much older and more male.”

Eliminating Negative Stereotypes Through Mentorship

All individuals are biased to a certain degree. Cognitive biases are shortcuts that have evolved during our socialization that allow our brain to decipher what it sees without wasting time. The most automatic calculations our brains make revolve around age, race, and gender. A person’s gender allows us to socially categorize every individual we meet [25]. In order to eliminate negative stereotypes, we need to reprogram the way we think. Implicit biases exist in most of us, despite our best intentions and conscious declarations. The Implicit Association Test (IAT) has become one of the most commonly used tools in the workplace to evaluate our implicit biases.

Research in child development indicates that the performance and interest in STEM topics is equal during early childhood between girls and boys. It is only later, due to societal standards, that participation in these fields changes [18]. The factors involved are multiple and complex. They are beyond the scope of this chapter. However, awareness of this fact and early intervention may foster interest in females and males alike, which may change societal nuances to pave a drastically different road for future generations.

I often feel like I live somewhere in the gulf between surgeon and mother. After all, the two are not typically assigned to the same individual. The old riddle about the boy involved in a car accident continues to stump many people to this day. If you have not heard it, it goes something like this:

A young boy and his father are on their way home from a soccer game when they are involved in a motor vehicle collision. The father dies instantly, but the boy survives and is taken to the nearest emergency department. Upon arrival, it is determined that the boy requires immediate surgery.

However, the surgeon assigned to the case appears and states, “Call my partner STAT to the operating room. I cannot operate on this patient. He is my son!”

This riddle has stumped many well-intentioned adults. Good Morning America approached random people on the streets of New York. Surprisingly, the majority were unable to solve this riddle. Instead, it was a group of fifth-graders in Manhattan that were almost all able to answer without hesitation [55].

It has been clearly demonstrated that there is a positive correlation between the proportion of women surgeons on a faculty and the choice to pursue a surgical career in female medical students [36]. It is often said the best way to lead is by example. It follows suit that we will only be able to shatter stereotypes through mentorship. As I mentioned earlier in the chapter, I truly believe that I am here today as a result of having positive experiences during my medical school and residency training supplied by strong, female role models.

There have been a lot of efforts made throughout the past few decades to integrate females into the STEM fields. One challenge, however, has been retention. The current environment has proven to be hostile and wrought with workplace incivility, resulting in female attrition. This can be as subtle as gendered language to interrupting someone while speaking, or addressing a colleague inappropriately [47]. By working to increase the number of female mentors in all fields, gender equity is sure to follow. In order to accomplish this task, we must continue to not only mentor, but sponsor, future generations [21].

Recognizing Gender Difference in Burnout

Burnout in medicine is an important area of study for multiple reasons. From a financial perspective, it results in a $4.6 billion burden to the US health-care system per year [19]. This is, in part, due to higher than expected physician turnover and decreased clinical hours. Burnout comprises two main components: emotional exhaustion and depersonalization. It may come as no surprise that women and men experience burnout differently. While many confounding factors prohibit any truly declarative statements from being made, it appears that women are more likely to experience emotional exhaustion, whereas men more commonly experience depersonalization. There is an inherent bias that burnout is more commonly experienced by women than men. This presents two very clear dangers: women may be less likely to be assigned more challenging tasks or receive promotions, while men experiencing burnout may go unrecognized and fail to receive much needed care [42]. As a surgeon, I am especially interested in correcting the course we are all on, as burnout affects the care I deliver to my patients, my patient satisfaction scores, and my personal risk for being involved in a malpractice suit [50].

Is “Self-Care” the Answer?

As a health-care provider, it is very easy to hide behind the work. I spend most days taking care of other people. I listen attentively to their problems. I offer advice. On the best days, I am in the operating room, surgically correcting what ails them. When we spend our days tending to the needs of others, it is not uncommon to forget our own. Over time, we become better at caring for others than of ourselves. In their book, “Leaving it at the Office,” John Norcross and Gary VanderBos pose the following conversation opener, “You are fine. How am I?” [37]. It is not very often that we ask ourselves that question. The suggestions offered in this book are both realistic and do not require finding extra time in our schedules to implement. They include things such as setting boundaries and refocusing the rewards. During our fast-paced days, we rarely take time to receive the rewards our patients unknowingly offer us. They offer the following old Chinese proverb:

  • If you want happiness for an hour – take a nap;

  • If you want happiness for a day – go fishing;

  • If you want happiness for a month – get married;

  • If you want happiness for a year – inherit a fortune; but

  • If you want happiness for a lifetime – help someone else.

We are given a gift that rare other professionals ever experience. We are entrusted with our patients’ most vulnerable moments. It is not uncommon for patients to share with us information that does not fall on any other ears. They look to us for guidance and answers. Even though we are not always able to provide solutions to all problems, the reward is immeasurable when we do.

The focus on self-care these days has shifted to tangible activities, things like manicures, massages, and yoga; the list goes on and on. I think it was said best by Catherine Dietrich when she likened today’s self-care as one more thing to add to our to-do list [12]. Self-care does not need to be complicated, but it is necessary. It can be as simple as sitting in a room alone with your thoughts for a few minutes meditating, or not.

Reproductive Life Planning

In examining the literature on reproductive planning, there are thousands of articles about how to discuss this with our patients. However, there is virtually no information specifically geared toward health-care providers and how this may contribute to burnout. Childcare in certain fields is regarded as an impediment to climbing the professional ladder. There have not been any studies that look at the importance of this for medical students, residents, or attending physicians.

I hope that a new world will be waiting for the trainees and students of the future. It was not too long ago when I found out that I was pregnant just before my chief year of residency. Although, alone in my bathroom staring at that little stick that notified me of the happiest news of my life, I was absolutely elated, the realization of what this might mean for my professional life was a different reality all together. I immediately felt complete and utter fear that I might be fired with only 1 year left in residency training. While I admit this was a rather intense reaction, the fact that the thought even entered my mind speaks to the culture at that time. Being the only female in my residency program did not offer any rational comparisons by which I could accurately calculate my fate. That, coupled with my first trimester routine of vomiting on the way in to the hospital at what I affectionately began referring to as “my” trashcan every morning, definitely made for an interesting experience.

Social Networking

It is estimated that by the year 2020, there will be almost 3 billion social network users (Statistica). Social media is how we connect on a social and professional level. This platform will continue to grow and gives us instantaneous, worldwide access to similar professionals. The role of social media in healthcare is multifaceted. It can be used to educate as well as network. It has been shown to assist with mentoring for women in male-dominated specialties by connecting them with mentors across the world [29].

Conclusion

In a recent book written by Siri Hustvedt, she states that “gulfs of mutual incomprehension among people in various disciplines may be unavoidable” [23]. Although her text does not specifically address the topics covered in this chapter, I feel that this gulf exists in any situation where all the moving parts are not necessarily the same. A multidisciplinary approach will be required to bridge the gap.

The most potent motivator for change is having a personal stake in the outcome. If society is headed for change, we will only be successful in a system where there is a culture of personal responsibility and accountability. The reason most diversity and inclusion programs fail is due to the fact that the parties involved feel as though they are being talked “at” and not an agent of change. Mutual respect is a prerequisite for any dialogue that will lead to meaningful, positive change.

At the end of the day, when I look back at my 16 years spent as a neurosurgeon, I have always been “a woman looking at men looking at women” [23]. This has offered me unique perspective. While I would seem to wax poetic if I refer myself as a perpetual outsider, my gender, ironically, has offered me an atypical advantage.

In order to transform our current society, we must draw on the collective knowledge of all its citizens. Even those considered to be “less than a minority.” No one should be underestimated, as the input of the novice may, in some cases, be more flexible and brimming with infinite potential and possibility than that of an expert in the field. It should seem unacceptable to all parties that 88% of respondents to a recent survey in the UK reported that they felt surgical subspecialties remain male-dominated and that 59% have witnessed discrimination against females in their workplace [2].

Nowhere in the literature is it stated that women lack the intelligence required to enter specific fields. To the contrary, girls score at higher levels in some areas of STEM than boys during childhood [18]. Despite this, and the abundance of literature on the topic, no significant cultural shift has occurred even though the number of women in the workplace has been steadily increasing for decades. Instead, highly educated women find themselves falling prey to Imposter Syndrome and having to endure gendered language and adopting male personality characteristics to survive the daily grind.

In a quote commonly attributed to both Anais Nin and the Babylonian Talmud, “we don’t see things as they are, we see things as we are,” we get a glimpse at how our perception affects our reaction to everyday events. It seems that it may be time we reshape our preconceptions in order to alter our perception of previously fixed roles that, thus far, have not be fully available to women. Acceptance is an essential element to feeling whole. As mentioned earlier in the chapter, Brene Brown spoke very concretely about the distinct difference between belonging and fitting in [6]. Once we all stop trying to fit in and, instead, belong, we will be able to move forward as a cohesive community in a more constructive way.

Perhaps all of our current attempts at creating gender parity have been a bit short-sighted. As sociologists attribute gender socialization to predominate during the early childhood years, perhaps it is time to consider a paradigm shift in the types of gendered language, activities, toys, and expectations to which we expose our children. While the inherent biological differences between men and women cannot be denied, we should consider allowing our children to grow into themselves as opposed to molds we prepare for them, as a society.

In the meantime, until gender roles are redefined, I suppose we can continue going it alone, together.