Women in Trauma Surgery: Advancing Our Profession through International Collaboration

EILEEN M. BULGER, MD

PROFESSOR OF SURGERY, UNIVERSITY OF WASHINGTON, SEATTLE, WA USA CHAIR, AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA AND PRESIDENT-ELECT OF THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA

In 1978, Marilyn Loden, a manager at the New York Telephone Company, was asked to fill in on a panel at the Women’s Exposition entitled “Mirror, Mirror on the Wall”, which was focused on how a woman’s poor self-image can limit their advancement in the workforce. On that day, Ms. Loden is credited with coining the term “glass ceiling” in describing an invisible barrier to the advancement of women that most people did not recognize (1). The term was eventually picked up by the media and in 1986 an article appeared in the Wall Street Journal entitled “The Glass Ceiling”, which reviewed the social science on this topic and interviewed male and female managers in a variety of settings. They blamed the glass ceiling on the beliefs and preferences of male managers regarding women in leadership.

In 1989, Elizabeth Dole launched the “Glass Ceiling Initiative”, which became a project of the United States (US) Department of Labor with a goal to “identify systematic barriers to the career advancement of minorities and women” and then work with companies to address them. They defined the glass ceiling as “those artificial barriers based on attitudinal or organizational bias that prevent qualified individuals from advancing upward in their organizations into management level positions.” In 1992, Catherine Berheide conducted a study of women and ethnic minorities in state and local government and coined the term, “sticky floors” to denote those individuals who were stuck in low paying jobs with very limited opportunity for promotion (2).

As a result of these efforts, women have made a lot of progress in the workforce but there are clearly issues that need to be addressed. In 2020 women accounted for 55.9% of the labor force in the US but held only 29.9% of chief executive positions and led only 7.4% of Fortune 500 companies. The profession of surgery has mirrored these challenges. While over 50% of students entering medical school in the US are women, as of 2016, 38.5 % of general surgery residents, 25% of assistant professors, 19% of associate professors and only 9.8% of full professors in departments of surgery were women (3). This was an improvement from 1994, when only 3.4% of full professors were women, but it suggests we still have a long way to go. At this pace, it would take 121 years to reach a representation of 50%. This problem is not unique to the US. Data from the United Kingdom demonstrated that as of 2020, 13.2% of surgical consultants were women and

among the subspecialties, trauma and orthopedics had the lowest proportion at just over 7% (4).

In her Presidential address for the Association of Academic Surgery in 2017, entitled “Sticky Floors and Glass Ceilings, Dr. Caprice Greenberg discussed the many challenges faced by women seeking to advance in surgery (5). She highlighted the salary gaps between men and women surgeons and studies that have demonstrated that 40% of that gap cannot be explained by different career trajectories or specialty choices. She also spoke to the impact of implicit bias on early career investment and grant funding, which can be a significant disadvantage to women at the outset of their academic career. Finally, she spoke frankly about the challenges women surgeons face in navigating expected gender schemas.

These challenges are not unique to the US and varying cultural issues that impact women across the world can further impact women in surgery. Societal expectations of gender roles may limit opportunities for women to pursue a surgical career. A recent paper from Pakistan reported that while 70% of students entering medical school in Pakistan are women, women represent only 14% of surgeons who have completed training since 1967 (6,7). Furthermore, it is reported that approximately 50% of female doctors do not practice or undertake specialty training after graduating from medical school due to family and social pressures. In a survey of over 200 women surgeons, > 80% of Pakistani surgeons noted that gender discrimination and bias impacted their job satisfaction, and 56.4% were told they could not become a surgeon because of their gender. Particular challenges were noted in identifying senior mentors and in interacting with nurses. Another study which surveyed women surgeons in Japan identified genderbiased discrimination and a lack of family support as impeding their careers (8).

Women in Trauma Surgery

As trauma systems have developed around the world, the most severely injured patients are triaged to regional trauma centers with the appropriate resources to optimize outcome. While the initial surgical care of injured patients remains an important part of the training for all general surgeons, the advanced care of these patients has become a specialty in many countries. In the US, the field of Acute Care Surgery (ACS) which encompasses trauma,

“Women have made a lot of progress in the workforce but there are clearly issues that need to be addressed”

emergency general surgery and surgical critical care was initially described in 2005, and through the leadership of the American Association for the Surgery of Trauma has developed into a specialty with dedicated fellowships and training curriculum. In other countries, surgical care for trauma patients remains coupled with orthopedics. In any event, it is evident that more women are entering this field and the ACS model, which emphasizes a team-based approach, has been very popular among surgical residents, offering the potential for a better balance of clinical and non-clinical commitments. A recent survey of US hospitals demonstrated that 50% of hospitals had at least one woman surgeon providing Emergency General Surgery care and 9.4% had over 40% women on the ACS faculty (9).

Have we cracked the glass ceiling in trauma surgery?

Since the Association of Women Surgeons was established by Dr. Patricia Newman in 1981, the importance of supporting career advancement and leadership opportunities for women in surgery has been recognized. It is encouraging to see an increasing number of women in leadership positions in our professional trauma societies. The major trauma surgery associations in the US include the American Association for the Surgery of Trauma, the Western Trauma Association (WTA) and the Eastern Association for the Surgery of Trauma (EAST) and the American College of Surgeons (ACS) Committee on Trauma (10). The AAST has had two women serve as president in 1998 and 2016, with a third due to take office in 2023. The WTA elected its first woman as president in 2009 with additional women serving in 2015 and 2019. EAST has had women surgeons as president in 2007, 2014, 2016, and 2022. The American College of Surgerons appointed the first woman to serve as Chair of the Committee on Trauma in 2018. The European Society for Trauma and Emergency Surgery was founded in 2007 and Dr. Inger Schipper from the Netherlands was appointed as the first woman to serve as president in 2021. The International Association for Trauma Surgery and Intensive Care appointed Dr. Christine Gaarder from Norway as its first female President in 2017, followed by Dr Elmin Steyn from South Africa. Representation of women in these leadership positions offers inspiration for the increasing number of young women surgeons entering our field.

What’s Next?

In 2020, a group of senior women in trauma surgery from across the globe began meeting virtually for mutual support and advice as the challenges of the COVID-19 pandemic unfolded. Encouraged by the global reach of virtual meeting platforms and recognizing the need for ongoing dialog to address the issues facing women surgeons across the globe, this group evolved into the Women in Trauma Surgery (WITS) group, which is now sponsored by the AAST. We are an international group of surgeons, open to all (men and women) who are interested in addressing the sticky floors and glass ceilings that continue to prevent everyone from thriving in their chosen profession. We hosted two days of international panel discussions as part of the All Levels Trauma Care Conference hosted by the Saudi Arabian Academy of Sciences in 2020 and 2021 addressing topics such as: leadership in trauma, surgical ego, gender disparities in trauma care, worklife balance, navigating interpersonal conflicts, cultural challenges in trauma surgery, and empowering the next generation of trauma surgeons. We are now holding quarterly webinars to continue these challenging conversations and provide opportunities for networking. We hope that this forum will be a source of international collaboration to clean our sticky floors and eliminate the glass ceiling across our profession.

All are welcome! If interested in joining WITS, send your name and contact information to aast@aast.org and ask to be added to the WITS mailing list and you will receive the invitations to join these sessions. There is no cost to participate.

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