From the Journals

What makes women leave surgical training?



Being unable to take leave and experiencing poor mental health are just two of the reasons uncovered that may help explain why some women choose not to complete their surgical training, despite having wanted to be a surgeon for many years, a study of women in surgical training has found. The results were presented at a press briefing and published in a special edition of the Lancet.

These factors are in addition to some previously identified, such as the long working hours, fatigue and sleep deprivation, unpredictable lifestyle and its effects on maintaining personal relationships, and the ability to both start and maintain a family life. Then there are the more serious issues of sexism and discrimination, bullying, and sexual harassment and assault that women face in a still male-dominated field that have been noted in prior studies.

“Women are underrepresented in surgery and leave training in higher proportions than men,” study lead Rhea Liang, MBChB, and coauthors wrote (Lancet. 2019;393:541-9). Previous attempts to understand why this is the case “have been confounded by not fully understanding the problem,” they suggested in the briefing. Their research took a more qualitative and feminist approach than other studies, consulting women who had chosen to leave rather than those who continued their surgical training.

Dr. Liang is a consultant general and breast surgeon based at the Gold Coast Hospital and Health Service in Robina, Australia, who personally interviewed women who had decided to leave their surgical training, some as early as 6 months and others up to 4 years after initiation, for reasons other than underperformance.

A “snowball approach” was used to recruit women whereby women who had agreed to participate were asked to refer others. Although only 12 women were interviewed, it’s quality over quantity, Dr. Liang said in a response to a Twitter comment on the study size. “The study is carried out in Australia where about 300 training places are offered across all the specialties annually. About 30% are women; 20% of those women choose to leave. So, if you do the maths, you’ll see that we actually recruited quite well,” she said at the briefing.

According to The Royal College of Practitioners, women made up a very small percentage of consultant surgeons in England in 2016 (11.1%), which didn’t change much by 2018 (12.2%). This is despite a high percentage (58%) of women being accepted onto university courses in medicine and dentistry (58% in 2016). So why so do so few women end up as surgeons?

“Training is a ‘pinch point’ at which women leave surgery,” Tim Dornan, PhD, noted at the launch of the special edition of the Lancet in which the findings appear. Dr. Dornan is professor of medical and interprofessional education at Queen’s University Belfast (Ireland) and one of the coauthors of the research.

This choice to leave surgery deprives society of able surgeons-to-be,” Dr. Dornan said, noting that there was evidence to suggest that women make as good, if not better, surgeons than men. The decision to leave also deprives women of career opportunities and potentially deprives patients of receiving the best surgical care.

“Something very striking about this research is that women who left within an average of 6-18 months after starting surgical training might have wanted to be surgeons from their teenage years, so it seems something happens at that pinch point which makes women to choose to leave.”

Qualitative research is a good way to understand causality in complex social systems, Dr. Dornan explained. Furthermore, “it’s equitable. If you use an open exploratory method, it’s entirely up to the participants to frame the research, it’s not done a priori, and it has the potential for great policy impact.”

Dr. Liang and team found that multiple factors played a role in the decision to leave surgical training, which on their own might be seemingly small, but when stacked on top of each other formed a tower, which was in danger of toppling after a threshold of three or four factors was reached. To exhaustion and lack of opportunity to learn, for example, could be added bullying, and then being denied leave while it is granted for a male colleague for a similar requested reason. The cumulative impact of these factors may all add up to create the impetus to leave.

“Just as a tower of blocks can rebalanced with small adjustments, out study indicates that relatively small interventions (e.g., a cup of tea or a supportive chat) could have been effective in preventing them choosing to leave,” she said.

However, they advocate targeting interventions at all trainees and not just women, to reduce gender differences as focusing on women would be more likely to exaggerate the “otherness” of women further and alienate male trainees. They suggest: “Women might be best helped by interventions that are alert to the possibility of unplanned negative effects, do not unduly focus on gender, and address multiple factors.”

“If you really want to benefit women you should benefit everybody and address the root problem, which is the harsh conditions of training,” Dr. Dornan said. “The prediction would be that, if you do that, then you will actually retain men as well as women.”

The research appears in a special edition of the Lancet that promotes advancing women in science, medicine, and global health.

SOURCE: Liang R et al. Lancet. 2019;393:541-9.

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