My International Surgery Elective

by Jane Zhao, MD

In April 2014 I spent a month with the Department of Surgery at the Affiliated Hospital of Qingdao University – Huangdao Branch. It was a marvelous experience, and I was asked to share a snapshot of my time there.

Qingdao, which means Green Island, is a major coastal city of approximately three million people in the Shandong province of China. The city boasts the world’s longest sea bridge, Tsingtao Brewery, and Lao Mountain. Reminders of its time period under German colonization in the 1800s remain visible in Qingdao’s wide streets and architecture.

View from Lao Mountain

German Governor's Mansion, a prime example of Qingdao's colonial architecture. The construction was said to be so extravagant that the Kaiser fired the governor once he received the bill.

The Field Hospital of Germany first opened its doors on the shore of the Yellow Sea in 1898. As Qingdao modernized and grew, the Field Hospital transformed into the Affiliated Hospital of Qingdao University. Today, there are three hospital branches that provide patient care to all of Qingdao and its surrounding areas. The vast majority of my time was spent at Huangdao Hospital, the newest branch, located a 40 minute drive outside the heart of Qingdao.

The outpatient entrance of the Affiliated Hospital of Qingdao University, Huangdao Branch which formally opened its doors in 2011 (picture source)

During the week, my mornings started with morning report at seven o'clock, with rounds following shortly after. The rest of the day would be spent in the operating theatre. Cases usually began around nine o’clock, with the occasional earlier start time. Rooms turned over quickly, and it was not unusual for the team to schedule multiple gastrectomys and low anterior resections each day (the department of general surgery was colorectal heavy). Elective cases took place through the weekend, but I used my Saturdays and Sundays to attend local conferences, visit a community health clinic, and observe other services, such as emergency medicine, critical care, neonatology, pediatric surgery, and hepatobiliary surgery.

Outside the Huangdao Community Health Service Center, where patients can receive preventative care or chronic care management

I learned an incredible amount during my month in China. I was given multiple opportunities to see surgery practiced differently, more cost-efficiently, and most importantly, without detriment to the patient, which made me pause, take mental notes, and ask why on a frequent basis. Take laparoscopic appendectomies for example. In the US, the cost of appendectomies including hospital stay, conservatively speaking, can quickly add up to a bill of $30K. In China, the cost is approximately 3200 RMB, which if converted to US dollars would be less than $1K. Same disease process, same step-by-step operation, but a drastic reduction in cost.

An infographic that breaks down the typical appendectomy bill generated from a US hospital (picture source)

There were plenty of other differences that I found intriguing. One of them was the observation that the hospital did not stock scrub brushes by the sinks. Instead, faculty and staff prior to each case will rinse once with a chlorhexidine solution, dry off with nonsterile paper napkins, and then Avagard. The rationale for eliminating scrub brushes is that the constant scrubbing leads to skin abrasion, increasing the risk of bacterial growth. On the other hand, if the epidermis stays smooth and intact, anything other than normal skin flora is unlikely to grow. The hospital infection control team has been swabbing the hands of random operating room personnel monthly and growing the samples for culture, but so far nothing beyond typical skin flora has grown.

Another observation led to the realization that I have been spoiled by the scrub nurses back at home. In the operating rooms at Huangdao Hospital, everyone with the exception of the attending was expected to gown and glove themselves. Also, every effort was made to conserve and reuse. Gowns, needles, and even the laps used to soak up the betadine solution used to prep the patient were recycled through the system for future use. Face masks and caps are rationed out to those entering the operating rooms by a nurse who stood guard outside the locker rooms.

An additional fascinating discovery was in learning which types of cases were considered too risky for residents to perform independently and which were not. Residents were given exceptional autonomy in performing upper gastrointestinal and colorectal cases, but if a patient needed a gallbladder out due to symptomatic cholelithiasis or choledocholithiasis, attendings and chief residents were the only ones allowed to manipulate the biliary tract during laparoscopic cholecystectomies. The most action junior residents could hope for was to drive the camera. They were shocked when I gave them examples of the types of cases US residents at their similar level were allowed to perform.

Catching a close-up glimpse of a different training structure gave me some added perspective into what mine would soon be in the US. Given the controversy in the states regarding how work hour restrictions have led to an increase in hand-off errors, it was of particular interest to me as a soon-to-be intern to see what life without work hour restrictions looked like. The residents lived in or around the hospital--most unmarried or living separately from their partners and children. Their attention was channeled 100% into become better surgeons each and every day, which showed. The residents in Huangdao were technical wizards in the operating room. They were able to dissect their way into the correct plane in seconds, without a single wasted movement. No bleeder or atypical anatomy fazed them. They knew all the patients front-to-back. Many of my mentors in the US have spoken to me of what surgery was like in the good ol' days without work-hour restrictions. Being in China gave me a glimpse into their past, and it was awe-inducing.

The thing is, the past is almost always seen through rose-colored lenses, and after the initial rosiness died down a bit, I started to better understand the rationale for why residency training in the US has undergone such tremendous changes, even if the changes have resulted in their own challenges. The residents at Huangdao Hospital had little time to stay up-to-date with the literature, spend time strengthening family ties, or maintain interest in meaningful outside hobbies. It was not unusual for residents with families to take the bus into the city to visit wife and child for half a day, spend the other six days of the week in the hospital, and then send as much of their income as possible home to help pay the bills. The residents were at the beck and call of the hospital and their department around the clock. It was only by their good fortune that they had a Chair known throughout the hospital for his fairness and kindness.

My classmate from UTHealth Amy Wang and I with the Chairs of Surgery from each of the three hospital branches affiliated with Qingdao University. Dr. Yun Lu on the far left of the screen, next to Amy, was the Chair of Surgery and our faculty mentor at the Affiliated Hospital of Qingdao University, Huangdao Branch.

I spent a significant amount of time with the Chair of Surgery discussing the differences I noted between residency training in the US and at Huangdao Hospital. He was particularly interested in the way training was standardized from program to program, so I told him that, in US teaching hospitals, each specialty is usually represented by one or more services, each composed of a mix of junior and senior residents and headed by an attending. During rounds, the senior resident comes up with a plan for each patient based on the clinical presentation, touches base with the attending for any changes he or she wants to make, and then the junior residents see to it that the final versions of the plan are carried out. By having residents rotate through different services, each with a standardized hierarchy, the residents can gain similar opportunities for graded responsibility throughout their training. By the time residents graduate, they are expected to have received comparable training, regardless of where they completed their residency. Another upside to the US model of training, I told the Chair, was that by minimizing the micro-managing, attendings can devote more of their nonclinical time to research, teaching, or other administrative tasks. The Chair of Surgery was so enthusiastic about what I shared with him that within days he had morning rounds changed, and as far as I know, they are still being conducted via the revised approach.

My conversations with the Chair of Surgery were rewarding. I was able to pick his brain on how to become a better leader based on his own his triumphs and tribulations, and he had an opportunity to learn new methods by which he could try to improve the quality of his residents' training. Our conversations were numerous, but one particularly meaningful impact I made didn't require me to make any fancy speeches. My mere presence was enough because it caused people to talk. By April, I had already found out that I would be at the University at Buffalo, the State University of New York for my next half decade of general surgery training. Women pursuing surgery in China is a once in a blue moon phenomenon—essentially unheard of. They were shocked and impressed to find out that I was one of multiple women in my class at the University of Texas Medical School at Houston who matched into a surgical specialty for residency. One circulating nurse rushed home that evening to share the news with her daughter. It was mind-boggling to see the people around me attempt to grasp the concept of a woman not only pursuing surgery but also having that accepted as normal within society. I could see the beginnings of a paradigm shift taking place in many of their minds.

There are so many more remarks I can make about my experience abroad. The 60-70% 5-year survival rate for patients diagnosed with resectable gastric adenocarcinoma at Huangdao Hospital compared to the dismal 30% in the US. The occasional traveler or expatriate who spoke English. The sick patient who still appreciated whatever counseling I provided in my broken Mandarin. The Chinese government's firewall of social media platforms like Blogger, Wordpress, Facebook, Youtube, and Twitter that allow real-time communication to take place, now so heartily embraced by our surgical community. The pay-for-service approach. The paternalism. The around-the-clock walk-in clinic. The heavy reliance on radiographic imaging. The lack of tort reform or Good Samaritan laws. The lateral rigidity in career transfer. The integral role played by family in the perioperative management of patients. There are some aspects of surgery in China that have my utmost admiration, others nothing but frustration. But that goes for most things in life.

Here I am checking up on my patient. No identifying features of the patient are shown out of respect for the patient’s privacy

My observations are all anecdotal and limited by my experience being predominantly at only one hospital. I can hardly say if the hospital where I rotated is representative of other hospitals in China or even Asia. That being so, I have had such an expansion of my worldview that I would not have had otherwise, and my undergraduate medical education has benefited tremendously.

I would never have had this opportunity without the mentorship and sponsorship of Dr. Anil Kulkarni, whose recommendation of me to his friend and former colleague paved the way for me to establish my own special project to rotate in China. Dr. Yun Lu, the Chair of Surgery at the Affiliated Hospital of Qingdao University, Huangdao Branch has invited me to return, and I definitely plan to take him up on his offer. Eventually I would like to bring other students along with me to show them how amazing of a profession surgery is, and what a comfort it is to know how quickly and easily it can be for a surgeon or aspiring surgeon to feel at home in any country simply by walking into an operating room.

An aerial view of Qingdao (picture source)

Have you ever completed a surgical rotation in a country different from your own? If so, what was that experience like? Share in the comments below.

~~~

Jane Zhao is a general surgery resident at the University at Buffalo, the State University of New York. She obtained her medical degree with a scholarly concentration in Clinical Quality, Safety, and Evidence-based Medicine from the University of Texas Medical School at Houston and completed her undergraduate studies in Medicine, Health, & Society at Vanderbilt University. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award and chaired the AWS Blog Subcommittee from 2013 to 2014. Her interests include healthcare social media, quality improvement, and public health. She can be followed on Twitter.

The Changing Face of Medicine

by Minerva A. Romero Arenas

We cannot all succeed if half of us are held back.

– Malala Yousafzai

Elizabeth Blackwell, a teacher and immigrant to the U.S., turned to medicine after a friend confided on her deathbed that she would have been spared much suffering had her physician been a woman. She went on to become the first woman to earn the Medical Doctorate in the U.S. She was admitted as a prank by the all-male students on the faculty – who allowed the students to vote on Elizabeth’s admission never thinking they would allow a woman to become their peer. The face of medicine has changed significantly in the 160+ years since Dr. Blackwell graduated from Geneva Medical College (now Hobart and William Smith College/SUNY).

Women are pursuing medical careers in record-breaking numbers. Female applicants to medical schools went from less than 10% in 1965, to approximately 50% in 2005. In 2013, 48 schools had a female majority of the class.

The changes seen in medical schools, however, are not representative of the currently active physician workforce. Women make up less than one-third of all physicians, and only 15% of general surgeons, and 4-6% of neurosurgeons, urologists, and orthopedic surgeons. Data of gender representation in residency reflect similar trends. In 2011, nearly half of female residents were training in primary care (pediatrics, internal medicine, family medicine) and less than 10% in surgical specialties.

Why are women doctors more often choosing primary care than surgical fields?

About 5 years ago, I was talking on the phone with one of my lifelong mentors when she asked me, “Minerva, why not?” I was unable to come up with an answer. I was nervous about a realization I had just a few weeks before: I loved surgery. I had just spent 2 months working long hours with excellent residents and surgeons. They had a great work ethic, were cool in the face of chaos, showed compassion toward their patients, and had a passion for their work that I had not seen in any other field. What should have been an exciting moment actually terrified me. Did I have what it takes to be a surgeon? And would it be worth making the sacrifices it would take for possibly 5-10 years of training?

Just days away from starting what we call “audition rotations” in the fourth year, switching to surgery was also a scheduling nightmare. I personally called the clerkship directors to apologize for a late cancellation. Thankfully, they were graceful and encouraged me to “figure it out,” even offering to allow me back later in the year if I ultimately decided against surgery.

It was not surprising that they were perhaps a bit skeptical of this decision. Surgery had crossed my mind during college, but fell off my list at some point in my first two years of medical school. I had planned to pursue a residency in internal medicine and eventually subspecialize in a field like medical oncology or infectious disease. These fields were friendly to women, and most importantly, I thought would help me merge my love of medicine and public health. Many of the mentors and role models I met were primary care physicians.

When I announced my interest in surgery, nobody hesitated at trying to save me/tell me why it was so hard – after all, surgery programs have one of the highest percentages of residents quitting training. “You won’t have a personal life.” “Do you want to have children?” “What does surgery have to do with public health?” The issue of lifestyle differences for surgeons is serious. In a 2009 study (the year I graduated medical school), women surgeons were less likely to have children and more likely to have their first child later in life. Male surgeons were more likely have a spouse who was the child’s primary caretaker. Reassuringly, 82% of women in that study would choose their profession again.

If I had a nickel, for every time I heard “but I never met a woman surgeon” maybe I would have paid off my student loans by now.

As a member of two key underrepresented groups in medicine (woman and Latina/Hispanic), I have felt the need to share my story with students who may have similar doubts about pursuing careers in medicine and surgery. I am involved in mentoring & leadership through several organizations (National Hispanic Medical Association, Latino Medical Student Association, Alliance in Mentorship, Tour for Diversity in Medicine, and Association of Women Surgeons). Many of the premedical and medical students I meet at mentoring events are surprised to meet a 1) surgeon, 2) woman surgeon, or 3) Latina surgeon. I was too when I met them in medical school.

In fact, many of my patients are too. When making rounds at the hospital, I have frequently heard patients tell someone on the phone, “Let me call you back, the nurse just walked in the room.” I have the utmost respect for my colleagues in nursing and do not take offense to these innocent remarks – after all, since 9 out of 10 nurses are female it is more likely that a patient will encounter a woman who is a nurse than a woman who is a doctor.

As I continue my training to become a general surgeon, I have come up with a couple of answers that I was so worried about years ago. More than halfway through my training, I can confidently say, Yes, I do have what it takes to be a surgeon. And it IS worth all the sacrifices.

Please join me on Tuesday May 13, 2014 at 8:30pm Eastern (for your local time click here) as I guest moderate the weekly #hcldr tweetchat.

• T1: How important/beneficial is diversity in health care (e.g., gender, age, ethnicity, background, etc.)?
• T2: How can we encourage women and other underrepresented minorities to pursue careers in medicine/surgery, or any non-traditional field?
• T3: What can we, as healthcare leaders, do to stop discriminatory comments or behaviors in healthcare, esp. to women doctors, minorities?
• CT: What’s one thing you learned tonight that you can use to help a patient tomorrow?

This article was originally posted on the Healthcare Leadership Blog on May 7, 2014. 

  ~~~

Minerva A. Romero Arenas, MD, MPH is completing a research fellowship in the Dept. of Surgical Oncology at The University of Texas MD Anderson Cancer Center in Houston, TX. She is a General Surgery Resident at Sinai Hospital of Baltimore. She received her MD and her MPH from The University of Arizona College of Medicine and the Zuckerman College of Public Health in 2009. She studied Cell Biology and French at Arizona State University as an undergraduate. 

Her interests include surgical oncology & endocrinology, global health, health disparities, quality improvement, and genomics. A native of Mexico City, Mexico, Dr. Romero Arenas is passionate about recruiting the next generation of surgeons and is involved in mentoring through various organizations.

She enjoys fine arts, films, gastronomy, and sports. She enjoys jogging, swimming, and kickboxing. Most importantly, Dr. Romero Arenas treasures spending time with her family and loved ones.

Resources

National Library of Medicine. Dr. Elizabeth Blackwell Biography on “Changing the face of Medicine.” Accessed April 2014. www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_35.html

American Association of Medical Colleges. Women in Academic Medicine Statistics and Medical School Benchmarking, 2011-2012. 2012. https://www.aamc.org/members/gwims/statistics/

American Association of Medical Colleges. Table 1: U.S. Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2013 www.aamc.org/data/facts

American College of Surgeons Health Policy Research Institute. The Surgical Workforce in the United States: Profile and Recent Trends. http://www.acshpri.org/documents/ACSHPRI_Surgical_Workforce_in_US_apr2010.pdf

Troppmann KM, et al. Women surgeons in the new millennium. Arch Surg. 2009 Jul;144(7):635-42. doi: 10.1001/archsurg.2009.120.

Health Resources and Services Administration. The U.S. Nursing Workforce: Trends in Supply and Education. 2013. http://bhpr.hrsa.gov/healthworkforce/reports/nursingworkforce/nursingworkforcefullreport.pdf

Image Credit

https://www.nlm.nih.gov/hmd/about/exhibition/changingthefaceofmedicine.html

"You've matched to a Preliminary position."

by Brittany Bankhead-Kendall, M.D, M.Sc.

Every medical student looks forward to "Match Day." Even non-medical people know what this "match day" is . . . . they hear about it from us, read it on our Facebook posts, and see our blogs about it. We're obsessed with it. What happens, though, when "match day" isn't all you hoped and dreamed it would be?

As I've written before, my husband and I tried to couple's match our fourth year in medical school and were unsuccessful. He obtained a residency position outside the match, and I matched to a preliminary position.

To any hopeful medical student, matching a preliminary position is bittersweet. It's devastating that no one "wanted" you long term. It's frustrating because you will, quite literally, be starting the match all over again in a few months time. And mostly, for me, you will go for another year of your life in a large amount of debt, after thousands of hours of very hard work, with an insane amount of knowledge... and no career to show for it. None. Nothing. Just a degree that says "M.D." but that you could never actually DO anything with. I, too, was devastated.

But instead of drowning in my devastation, I chose joy: Joy that I matched at all. Thousands of hopeful medical students don't match each year and are forced into non-clinical jobs that they did not really aspire to. I also found joy in matching to a preliminary position in my field of choice; I was very happy to be a surgical preliminary resident.

I chose to use my preliminary year as a gift to see if surgery was really what I wanted to do for the rest of my life. What an amazing thing! How many of our colleagues actually get to "try out" their chosen profession for a year, with no strings attached, to see if it is something that they really like? As a medical student, you have 6-12 weeks of watching residents do what you THINK you want to do, and deciding to make a career of it. I was able to walk the walk and talk the talk (and work the work :) ) to decide if this was really what I wanted to do.

When I matched to a preliminary position I communicated to my new chief residents that I wanted to be thrown into the very most difficult rotations (busiest, hardest, longest hours, however they wanted to take that request) at the beginning of my year- in July and August. This would give me an up front, real time, on the front lines view of General Surgery, as well as expose me to the most intense months that I would be encountering. For me, these months were very busy and very overwhelming at first, but I was absolutely positive at the end of it that I was supposed to be here, and I was supposed to be doing surgery.

Letters of recommendation are very important in your preliminary year, they are basically the only thing that will have changed between last year and this year's application. You should have the maturity and the responsibility to seek these early and form relationships with faculty that allow them to easily communicate how dedicated and just how good you actually are at what you do. I love my job, and that was evident to my attendings. Also important: having an answer to "So what happened last year?" I was asked this on almost every interview I went on. Be prepared for being offered about half the number of interviews you were intially offered your fourth year of medical school. Save up money on your small resident's salary for interviews. Talk to your program director early about expectations for vacation time to be able to travel for interviews. Be nice to your co-interns because they will have to cover your call now while you travel. You are no longer enjoying a lax 4th year as you travel, you are in the thick of intern year and you will be tired. I can almost guarantee that at one point during interview season, you will walk off a night call and walk straight on to a plane. The next day you will need to look as fresh and excited as those chilled out fourth years who are interviewing around you.

The absolute best part about interviewing for a categorical position as a preliminary intern: I knew my stuff.  I know what to do, and am not frazzled, when a trauma comes in to the Emergency Department and starts decompensating right in front of me... because I've done it. I walked into every interview with complete confidence that this was going to be my career, 100%, and I was going to be VERY good at it... because it's been my job for a year now. I discussed the parts of being a surgical resident that I love that medical students don't have a clue about yet... because I'm here when everyone else goes home.

Match Day 2014 was a success for me. I matched to a categorical position. I've got a career. I'm so, so happy.

If you matched to a preliminary position this year, keep your head up. Keep your eyes on the prize. View it as an opportunity to try out a field in medicine or surgery for a year. Take the high road. Work your butt off.

You'll have a career soon, too. And it will be everything you'd hoped it would be.

~~~

Brittany Bankhead-Kendall, M.D, M.Sc. is a PGY1 preliminary general surgery resident at Methodist Dallas Medical Center in Dallas, Texas and will be a categorical resident at St. Joseph Mercy Oakland in Pontiac, Michigan this summer. She obtained her M.D. from Ross University School of Medicine, M.Sc. from Barry University in Biomedical Science, and studied Biomedical Science and Spanish at Texas A&M University. She enjoys being a surgical intern and mentoring medical students. In her personal time she enjoys spending time with her husband and son, interior design, international travel, and Texas Aggie football.

A Recipe for Success: One Surgeon's Story

 by Minerva Romero Arenas, MD, MPH

 

There are two questions that students frequently ask me about becoming a doctor. One is, “What did you do to become a doctor?” and “How did you stay motivated?” I often tell students attending the Tour 4 Diversity in Medicine (T4D) that becoming a doctor is like running a marathon. The pathway to medicine is long and challenging; I jumped through a lot of “hoops” (prerequisite courses, examinations, extracurricular activities, letters of recommendation, interviewing, etc.) just to get to medical school. At this point, I swear if their eyes get any wider they will come out of their socket. Then I tell them about the time I have spent in residency, research, and fellowships – and overwhelming is probably a gross understatement.

There are many factors that contribute to a person’s success – especially the success of a doctor. In my own personal path, I credit my success to at least four essential factors.

My family has been one of the main sources of strength and motivation. Like many immigrant families, we moved to the United States to pursue the American Dream. I was 8 years old when we moved, but since that young age I knew that my family (yes, I mean my parents, tías and tíos and abuelita) wanted better opportunities for our family. While my family never pushed me to be anything in particular, they always supported and encouraged me to pursue higher education – an opportunity they did not have. When a situation challenges me, I think back to how fortunate I am to have a loving and supportive family and any doubt is erased from my mind.

I also credit my mentors – yes, more than one – with a large part of helping me succeed. Some of them were professors who helped me stay on track and grow academically. Others were instrumental in helping me develop leadership and life skills. Yet others were research mentors or clinical mentors who helped figure out my interest in these fields. Even now as I am in my surgical training, I continue to keep in touch with some of these mentors and have even gained new mentors who are helping me grow and develop as a surgeon-in-training and future leader in healthcare.

I also found motivation in programs that helped me remember why I wanted to be a doctor. In college it was when I worked in certain clinics or doctors. In medical school, student-run clinics, organizations that connected me with other students and doctors who shared similar backgrounds or interests such as ending health disparities. In fact, even now that I have become a doctor and am completing my surgical training I still find it refreshing to remember why I chose this career in the first place. This is part of the reason I joined Tour 4 Diversity in Medicine. Talking to students about my love of surgery, or helping patients, or my research – it always help make me feel more
motivated.

Lastly, I tell students the most important factor in achieving success is the one that nobody else can help you with: hard work. There have been many people who have provided guidance, support, and opportunities that helped me achieve my dream of becoming a doctor. However, I know that my own effort helped me earn the respect and time of my mentors and make the most of the opportunities that were provided. Most importantly it has given me a source of pride and confidence that will continue to make me a successful person and surgeon.

This article was originally posted on February 5, 2014 on the Tour 4 Diversity website under the title "#T4DWest Day 2: A Recipe for Success – One Surgeon’s Story"

~~~

 

Dr. Minerva Romero Arenas is a general surgery resident at Sinai Hospital of Baltimore and is completing a research fellowship at The University of Texas MD Anderson Cancer Center in Houston, TX. She obtained her MD and MPH from The University of Arizona, and studied Cellular Biology & French at Arizona State University. She is also involved in mentoring and public policy. On her personal time she enjoys spending time with friends and family, especially when it involves good food.

Changing the paradigm

by Robert Swendiman

Whether I am at Grand Rounds, a department meeting, or the American College of Surgeons Clinical Congress, it is often like looking into a mirror. I cannot help noticing the abundance of white men – especially at “the top.” While I meet numerous female and minority surgical residents and junior faculty, most of the chairs, program directors, and full professors are men.

Outside of the medical profession, surgery has an “old boys club” reputation. But I come from a school of leadership where difference and diversity are more than just opportunities for social progress – they are requirements. So I was disappointed when I perceived the stereotype affirmed. The more I look around, the more men I see.

Constant inquiry (or “quality assessment and quality improvement” in medical terminology) is an important component of leadership. Without it, we fail to analyze, understand, and improve the systems in which we are a part. Thus, I began my investigation, and what I found was shocking. Despite the increasing number of women entering general surgery residency programs – from 10% in 1980 to 36% in 2011 – as of last year, women only represent 9% of all full professors, 17% of associate professors, and 25% of assistant professors in surgery. 1, 2 While these numbers are obviously disproportionate, what is perhaps more concerning is that they also remain stagnate. In the last 15 years, these percentages have not changed. 3

Despite the fact that men and women enter academic medicine at equal rates, the rate promotion is uneven. 4-6 Though men and women start at similar ages, the mean age of attaining “Professor” status in approximately five years younger for men. 4 “Even after adjusting for number of publications, amount of grant support, tenure versus other career track, number of hours worked, and specialty, women [remain] substantially less likely than men to be promoted.” 4

Thus, female surgeons remain impressively underrepresented in the ranks of surgical faculty at 21% of the workforce (the average across all medical departments is 37%). 2 Of all academic departments in the basic and clinical sciences, surgery ranks second to last in percentage of total female faculty members (orthopedics, 15%). 2 However, in other specialties, women hold more than half of all faculty positions (obstetrics and gynecology, pediatrics, and public health and preventive medicine). 2

The famous surgeon, Dr. William Halsted, once quipped that the issue with surgeons taking call every other night was that residents would miss half of the cases. In the same manner, when we exclude 51% of the population from top leadership positions, we are missing out on half of the talent. If fewer than 10% of professors of surgery are women – and that figure has not changed in more than a decade – I wonder, “Is our academic community really moving surgery forward?”

Fellow colleague, Sophia McKinley, wrote about her own early lessons in leadership. She states, “Individuals at every position in a hierarchy can exhibit leadership.” I agree, and I see this lack of diversity as an urgent opportunity for real-time leadership at every level. As a white male, I think it is my job to participate in changing this paradigm – chipping away at the explicit and implicit barriers that male surgeons still espouse in surgery, advocating for and leveraging diversity, and staying curious about surgery’s present and future challenges. As an inspiring academic surgeon, this also meant research, which is why I joined a multi-institutional team from UNC, Harvard, and Stanford to better understand how we can change the status quo. I know it’s not enough, and change will not happen overnight, but doing nothing is not a viable option.

I was often asked on the interview trail, “Can an intern or a medical student really be a leader?”

This is the answer I give them.

~~~

References

1. Cochran A, Freischlag JA, Numann P. Women, surgery, and leadership: where we have been, where we are, where we are going. JAMA Surg 2013;148(4):312-3.

2. Association of American Medical Colleges. “Women in Academic Medicine and Science: Statistics and Benchmarking Report 2011-2012.” Table 3: Distribution of full-time faculty by department, rank, and gender, 2012. < https://members.aamc.org/eweb/upload/Women%20in%20U%20S%20%20Academic%20Medicine%20Statistics%20and%20Benchmarking%20Report%202011-20123.pdf>. Accessed November 6, 2013.

3. Sexton KW, Hocking KM, Wise E, et al. Women in academic surgery: the pipeline is busted. J Surg Educ 2012;69(1):84-90.

4. Zhuge Y, Kaufman J, Simeone DM et al. Is there still a glass ceiling for women in academic surgery? Ann Surg 2011;253:637–643.

5. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med 2004;79:310

6. Buckley LM, Sanders K, Shih M, et al. Obstacles to promotion? Values of women faculty about career success and recognition. Acad Med 2000;75:283-8.

~~~

Robert Swendiman is a dual-degree M.D./M.P.P student at UNC School of Medicine and the Harvard Kennedy School of Government. He spent his time at Harvard as a Dubin Fellow for Emerging Leaders at the Center for Public Leadership, researching how leadership principles can be applied to medical education. Robert is participating in the 2014 Match cycle, and is interested in pediatric surgery.

Blogger Q&A: Why AWS?

Brittany Bankhead-Kendall, MD: Camaraderie and advice from women in the same boat as I! As women surgeons we are in a very unique situation and it's so beneficial to have others who have walked before you and have practical advice and inspiration to offer.

Christina Cellini, MD: I originally joined AWS to take advantage of the excellent research funding opportunities that are offered. I have benefited from remaining a member by being inspired by other members who are able to balance work and family and are open and realistic about the many challenges we face in our field.

Amalia Cochran, MD: I joined AWS as a resident when I realized the networking benefits that membership provided. I attended my first AWS meeting in Chicago and still remember being very impressed with this roomful of women surgeons (because, quite frankly, we had 3 women surgeons on faculty where I was a resident, and had no women surgeons on faculty where I went to med school). It was an exciting prospect for me!

As an AWS member, I have benefitted from precisely those networking opportunities. I’ve received some great advice on wisdom over the years from women who are senior to me and I’ve had the opportunity to mentor women who are junior to me. One of the important lessons I’ve learned is that of shared experiences and what we can learn from each other; while we often have a tendency to think that a challenge is unique to each of us as individuals, more often than not someone else has been through something similar and is eager to share what they did right and what they did wrong. 

Erin Gilbert, MD: I joined as a medical student because I was concerned about being a woman surgeon in a predominantly male field (at the time!) 

Celeste Hollands, MD: I joined the AWS in order to apply for the AWS Ethicon grant. Receiving that grant funding launched my academic career. The personal and professional relationships I have developed as a result of becoming involved in the AWS have guided and supported my career and afforded me the opportunity to lead with a group of women I am proud to share my personal and professional journey with.

Bharti Jasra, MD: I was introduced to AWS by my mentor Dr Janet Tuttle-Newhall. She not only introduced me to it but also paid for my membership. Since then I had the opportunity to not only meet and get inspired by great women surgeons but also network with fellow residents and students. Overall it has been a great experience and I would like to continue to work for this organization after completing residency this year.

Sophia Kim McKinley: I joined AWS on a lark - I had just developed an interest in surgery and wanted to see what kind of resources there were for students going into surgery. I did a quick internet search for "Women in Surgery" and that is how I found out about AWS! I was so pleased to discover the electronic version of the Pocket Mentor as well as information about the annual AWS meeting. At that time, none of my friends were planning on going into general surgery, so it was a great comfort to find an organization committed to the flourishing of women like myself. I wanted career resources, the opportunity to network with like-minded individuals, and perhaps even some mentoring. AWS membership has given me all of these things and more, including the chance to contribute to the organization's mission through participating on the medical student committee and writing for the wonderful AWS Blog. When more junior medical students approach me about resources for medical students interested in surgery, I always point to AWS!

Lauren Nosanov: I initially was introduced to the AWS through one of our newer female surgeons. I was immediately impressed by the incredible level of professional success represented by the AWS membership. Through my involvement with social media and the Communications Committee, I have come to be better acquainted with a number of members and organization leaders. Each of these women continually impresses me and inspires me, and serves as a reminder of the person and surgeon I want to become. I am grateful for both the friendships and mentorships that have emerged, and expect to be involved for many years to come.

Minerva Romero-Arenas, MD: I joined the AWS to find a support network and mentors in surgery who are open to discussing ways in which women can become leaders in our field. I have truly enjoyed the initiatives from the Association for education, networking, and scholarship.

Mona Singh: I joined AWS at the end of my third year of medical school, shortly after I realized I wanted to be a surgeon. I wanted to get to know, learn from, and be part of an inclusive community of women surgeons at various levels in their career and representing diverse surgical specialties, practices, and perspectives. I was looking for inspirational and grounded mentors and role models, as well as a community where I would be welcome to contribute and grow as a surgeon-in-training. I renew my AWS membership because I have truly found both in this association.

Callie Thompson, MD: I joined because I wanted to connect with more female surgeons. I am surrounding by amazing role models and mentors and I wanted to seek out a greater community of women in surgery. I would say that I have not taken advantage of even 10% of what AWS has to offer but I have received wonderful advice and support from the online community and I look forward to experiencing more in the future.

Jessica Wilson: I study medicine in a country where doctors regularly imply (or sometimes just state outright) that I can't/shouldn't be a surgeon because I am female- that perhaps I should become a pediatrician or a family physician, because those careers are better suited to the demands of womanhood. I joined AWS to learn more about the profession of surgery, to make connections with other surgeons, and to be a part of an encouraging community.

Jane Zhao: At the time I joined, I was involved in the creation of a women in surgery lecture series at my school, and Dr. Lillian Kao suggested that I check out the AWS. Dr. Rosemary Kozar provided extra incentive by offering to sponsor my first year's membership. I can't thank my lucky stars enough that I joined. Since that time, I have forged some truly wonderful friendships and have been blessed to work with extremely talented and open-minded individuals to introduce new initiatives such as social media to the surgical community. I plan on renewing my AWS membership annually for the indefinite future, and I am excited to continue making meaningful contributions to the community via the AWS.

Why did YOU join the Association of Women Surgeons? Share with us in the comments below.