Surgeons Scope Magazine Issue 2 - 2023

A review of two recent papers on gender equality in urology by three RCSI alumni in the subspecialty, led to reflection on the wider issues facing female surgeons

ith gender imbalance more marked in urology than in many other specialties, the focus now is on whether enough is being done to address the historical barriers, biases and cultural characteristics stopping women taking up urology.

Two recent papers provide data illustrating the current extent of gender inequality, while offering hope this is set to improve.

Earlier this year, Women in Urology: Breaking Down the Barriers (wchh. onlinelibrary.wiley.com) addressed the topic of gender inequality in urology in the UK. As of 2021, 12% of consultant urologists in the UK were female, compared with 13% across all specialties.

However, 37.5% of current UK urology trainees are female. In Ireland, the percentage is higher at 58%.

In Women in Irish Urology: An examination of female representation amongst attendees of the Irish Society of Urology annual meeting 2008-2020 (pubmed. ncbi.nim.nih.gov), the authors drilled down into the detail of women’s underrepresentation at surgical conferences.

It will not come as a surprise to learn that session chairs and guest speakers were overwhelmingly male, as were oral and poster presentations. However, the authors noted increased representation of women in recent years. They called on societies to increase female representation as the best way to perpetuate a positive feedback loop, and encourage future female trainees to pursue urological surgery.

Ms Catherine Dowling, FRCSI (2013), Consultant Urologist at University Hospital Galway, one of the authors of Women in Irish Urology, links the current gender imbalance to the historically lower number of women pursuing careers in surgery.

“Surgery is perceived as a longer and more difficult path, attracting a harder, tougher person,” she says. “The low number of female urology consultants in the past meant a lack of female role models, and perhaps female medical students and early career doctors did not consider it a suitable career option.”

Ms Bolton, FRCSI (2017), Consultant Urological Surgeon at Imperial College Healthcare NHS Trust in London, who credits Ms Dowling as an important mentor, did most of her urology training in Dublin, before going to the UK on Fellowship in 2018. She has been based there ever since, and was appointed as a consultant in 2020. She is one of two women on a 15-doctor urology team. She says that while gender balance has improved greatly over the last decade, there remain barriers to attracting women to urology.

“The low number of female urology consultants in the past meant a lack of female role models, and perhaps female medical students and early career doctors did not consider it a suitable career option.”

“Societal stereotyping and gender bias remain the greatest obstacles,” she believes, “as well as the lack of female urologists in leadership roles, as mentors and role models.”

Ms Bolton points out that as 88% of urology consultants in the UK are male, medical students and junior trainees experience unconscious bias early on in their training, at a formative stage when they are developing interests and considering the direction of their future career.

“It is important to recruit females in urology to deliver medical education and lectures in medical schools, as this is where the process starts,” says Ms Bolton, who remembers clearly the few female surgeons, including Professor Carmel Malone, FRCSI (2005), and Ms Ruth Pritchard, who delivered lectures and teaching and made her believe a surgical career was possible. “A lack of visible representation can make it difficult for aspiring female urologists to envision themselves succeeding in this profession. Carmel Malone was very charismatic and hugely inspiring to my generation of undergraduate students.”

Ms Clíodhna Browne, FRCSI (2019) has recently been appointed to her first consultant post at Tallaght Hospital, having returned from Fellowship in Australia, and is heartened by the progress she sees.

“Over 50% of urology trainees across all years are now female,” she notes, “so although we are still lagging behind in terms of consultants the pool of trainees has broadened. A good job is being done to attract women to the specialty but that takes a while to translate to consultant appointments.”

Despite the paucity of female urologists who trod the path ahead of them, Ms Dowling, Ms Bolton and Ms Browne all say they were encouraged to pursue the specialty.

“I never met with any resistance,” says Ms Dowling. “As a medical student I decided I wanted to do surgery, and as soon as I worked in urology I knew it was the specialty for me. I never once felt discouraged by anyone.”

“Personally, I always felt encouraged in my choice of specialty,” says Ms Browne. “I had positive experiences both as a medical student and during a urology job during my intern year in Tallaght.”

Ms Browne and Ms Bolton had a similar experience.

“I have been lucky to have been met with nothing but encouragement both personally and professionally,” says Ms Bolton. “In terms of ‘seeing is believing’, I was lucky enough to be raised in a home where my mother worked full time and emphasis was placed on allowing her to develop her career and achieve her goals, so I have always had a good support system as a starting point. And I am fortunate to have a partner who understands the unpredictability and demands that are the nature of this profession.

“At NUIG, the surgical department under Professor Michael Kerin, FRCSI (1988), was notably diverse. There were many outstanding female trainees, including Professor Helen Heneghan, FRCSI (2016), Professor Aoife Lowry, FRCSI (2013), who helped mentor junior trainees. As both an intern and SHO, I worked with Ms Catherine Dowling who was a registrar on the team. She was held in high regard by the all-male consultant body, involved in operating on the major cases in theatre, and loved by all patients. I knew I liked the field of urology and watching Catherine helped me realise that I could also thrive in such an environment.

“I’ve never felt disadvantaged by anyone because I’m a woman. Urology in Ireland is a small community, and while the majority of consultants and mentors I have worked with have been men, they never treated me any differently to male trainees. My male colleagues have been a source of mentorship, friendship and encouragement.”

Anecdotally, some female urologists have felt pressure to specialise in areas such as female incontinence, urogynecology and conditions more commonly affecting women, due to assumptions about their patient preferences or expertise.

“I never felt pigeonholed into any subspecialty areas,” says Ms Dowling. “Early on I developed an interest in oncologic urology. I recall one of my consultants saying I should do what I love as I’d be doing it for many years. It was one of the best pieces of advice I ever received.”

“It is important to recruit females in urology to deliver medical education and lectures in medical schools, as this is where the process starts.”

Ms Eva Bolton, FRCSI (2017).

Ms Clíodhna Browne, FRCSI (2019).

“Although we are still lagging behind in terms of consultants the pool of trainees has broadened.

A good job is being done to attract women to the specialty ...”

“From early on I expressed an interest in pursuing urological oncology as a subspecialty. I was encouraged to pursue this and helped to secure a fellowship,” says Ms Bolton. “There are plenty of women involved in high-volume oncology and robotic work. I treat bladder and kidney cancer now but I have also been fellowship-trained in prostate and testis cancer management and it was never suggested that I should not pursue either of these tumour groups because I am a woman.”

Neither Ms Dowling, Ms Bolton nor Ms Browne has met with any serious resistance from patients to their gender.

“I can recall very few instances when a patients demonstrated resistance or requested a male practitioner,” says Ms Bolton. “If anything, of late, I have experienced the opposite in light of media reports stating that patients have better outcomes with female surgeons. I have had patients mention this to me in a jovial way, commenting on the attention to detail they see from female surgeons. I don’t work in andrology and it might be different in a genital area of specialty. The odd time in clinic a patient with scrotal pain or needing circumcision might say, 'I thought I’d be seeing a man' but it’s more surprise than resistance. Most patients are open to receiving care from healthcare providers of any gender, as long as they are competent and compassionate.”

“Other than on one occasion while working outside of Ireland a patient, due to his religious beliefs, declined to have me examine him. I never met with any resistance from patients on the basis of gender.” says Ms Dowling.

Neither Ms Dowling, Ms Bolton nor Ms Browne has met with any serious resistance from patients to their gender.

“Other than on one occasion while working outside of Ireland a patient, due to his religious beliefs, declined to have me examine him. I never met with any resistance from patients on the basis of gender.” says Ms Dowling.

All three say some of their biggest challenges come from achieving work-life balance, while acknowledging this can be an issue in any medical specialty, and for both genders.

“Medicine is a demanding job,” says Ms Dowling, “but it is important to prioritise personal and family life where possible. Early on in surgical training the hours are long but that improves as you progress. I am fortunate that I can drop my children to school a few mornings a week and still get in for the start of the working day.”

“Urology is associated with demanding and unpredictable work hours, which can be a deterrent for women, especially if they have caregiving responsibilities at home,” says Ms Bolton. “Work-life balance can vary depending on factors such as the type of practice, stage of career, and personal preferences. Recruiting additional consultants and maintaining a skilled workforce helps reduce on-call frequency and minimise the reliance of a small number within the group. I am now on a one-in-15 on-call rota which means that my work-life balance has improved greatly since being a trainee.

“On-call responsibilities depend not only on the frequency of the on-call but also the intensity of the on-call and on the skillset of the other consultants in the group. Our catchment area is 1.5 million and includes the trauma centre for West London, so the on-calls can be quite demanding. I currently work a reduced frequency rota but often help out with major on-call emergencies out of hours when I am not on call.”

As a urologist specialising in major oncology surgeries which are physically and mentally demanding, highly complex patient volumes impact Ms Bolton’s work life balance as patients need to be rounded multiple times during the day.

“I was once advised not to leave more than eight weeks between periods of leave and I have found this crucial to keeping fresh,” she says. “Time management is easier now that I have completed training and have a fixed job plan. There is still some unpredictability if called upon to help with cases in other specialties, on-call or with surgical complications. As a trainee and fellow, I did have a more demanding schedule as I wanted to build my skills and reputation and so I ensured I was always available to see patients and help with cases.

“Achieving a healthy work-life balance can be challenging in the medical field. I think it is really important that we all remember that each of our colleagues’ time outside of work is valuable, regardless of what that time is used for.”

Ms Browne agrees that work-life balance is “tricky”, but says that is the same for women in any demanding career.

“Obviously timewise, training can be challenging because fellowship comes at a time of life when you may be in your mid-30s and thinking about starting a family,” she says, “but that is a situation by no means unique to surgery. I have friends who are in different careers who have experienced the same issues. I do think that seeing Professor Laura Viani, FRCSI (1987) and Professor Deborah McNamara, FRCSI (1997) as President and Vice-President of RCSI, leads to greater visibility of women in surgery. A huge amount of work has been done with the Women in Surgery Fellowship and there is wider availability of flexible training. Personally, I chose to pause my training for maternity leave twice, but never did less than full-time training, which meant that my training took longer but in a procedure-based specialty there is no replacement for the hours and the cases logged. That made sense for me but for other people it may be different.”

While Ms Dowling observes that the barriers to career progression in urology, such as higher degrees and publications, are the same for both genders due to the competitive nature of the speciality, Ms Bolton feels that women in surgery generally have to prove their ability in the operating theatre more than men.

“Gender bias and stereotypes are still prevalent in society in general,” she says, “and this can affect how female urologists are perceived by colleagues, superiors, and patients. I have never experienced this first hand, but I have heard from other female colleagues and female trainees that these biases can lead to challenges in being taken seriously, earning respect, and gaining leadership opportunities.”

Ms Bolton points to the historical scarcity of female urologists in leadership roles which has limited the availability of role models, mentors and advocates for career advancement, but notes that this has improved greatly in Irish urology.

“I do think that seeing Professor Laura Viani and Professor Deborah McNamara as President and Vice-President of RCSI, leads to greater visibility of women in surgery.”

“Having women in prominent positions within the field,” she says, “is crucial for encouraging and supporting the progression of other female urologists.”

“I haven’t encountered barriers,” says Ms Browne. “I never felt that I hadn’t been given an opportunity or been selected for a job or a project because of being a woman, but that’s not to say that women do not encounter those issues – I have no doubt it does happen. I think there has been a significant shift in the landscape of surgical training and the legacy issues are being adequately addressed.”

It is clear that for each woman, mentorship has been a key factor in the development of their careers, but that the gender of those mentors has been largely irrelevant. Ms Bolton makes the point that the best mentorship relationships are those that happen naturally when there is mutual respect, trust, and a shared commitment to the mentee’s professional growth and success.

“I had informal mentors throughout my training,” says Ms Dowling. “Most of these were male but some female. Rather than seeking a mentor because they were male or female it tended to be someone who I thought similarly to and whose opinion I trusted and valued.”

Ms Browne acknowledges the support of both male and female mentors.

“Part of the reason I decided to pursue urology was because I encountered supportive mentors early on,” she says. “I felt from the outset it was a supportive, cohesive specialty with a culture of bringing people along. Personally, I found all consultants were very supportive in terms of me coming off the call rota when I was pregnant, taking maternity leave, and transitioning back to work afterwards.”

According to Ms Bolton, “I have also had many male mentors, including Professor Thomas Lynch, FRCSI (1988), who made a point of taking time out to tell me how important it is to aspire for gender equality in urology. He also helped me build a professional network within the surgical community by introducing me to key contacts and providing me with opportunities for collaboration and mentorship from other individuals.

“We need mentors at all stages of our careers and as a junior consultant I am still in need of a mentor. I am lucky to be in a department with another female urologist, Ms Norma Gibbons, FRCSI (1998), who continues to provide me with opportunities for skill development, leadership roles and career progression. She also provides me with constructive feedback and guidance, helping me identify areas for further improvement and offering strategies for growth.”

In her turn, Ms Bolton feels a responsibility to mentor female trainees, as a lack of support in education, training and employment can hinder their progress and confidence in the field.

“Less than full-time training has meant that many women can achieve their career objectives in parallel with personal choices,” she explains. “However, there is still a stigma attached to this, with trainees nervous about making this choice and feeling they may not be as attractive for jobs as their male counterparts.

In my own department, Ms Norma Gibbons has paved the way for female colleagues in urological oncology, but there are still very few less-than-full-time female consultants in the UK or Ireland.”

With the increase in the number of female urology trainees do the three women feel enough is being done?

“I think the issues around historical gender imbalance are being addressed,” says Ms Dowling. “RCSI’s flexible training programme allows trainees to avail of part-time training if they wish. I think it is extremely encouraging for young female trainees to see both a female President and Vice-President of RCSI. The gender imbalance will only continue to exist if doctors are not choosing surgery and then choosing urology, so the focus needs to be about encouraging them to choose these careers early on. As medical students see that half of our specialist registrars in urology are female it will not appear to them to be a maledominated specialty.”

However, while flexible training is available in Ireland, the take-up rate is far less in Ireland than in the UK.

“Flexible training doesn’t seem to be very common in Ireland in my experience, but perhaps this is something that will became more common as years go on.”

Ms Bolton agrees that attitudes to women in urology in Ireland are more progressive than they are in the UK.

“Professor Viani’s and Professor McNamara’s work in this area pre-dates similar conversations in the UK, but flexible working is much more of a thing in the UK where it’s almost expected that female trainees who have children will work less than full-time contracts, whereas this is never spoken about in Ireland.

“I did full-time training, but I have worked with some trainees in the UK who do less than full-time training and there is anxiety around that in terms of time and exposure. It does inevitably prolong the duration of training.

“I can only speak for myself, in that I don’t take those who do less than full-time training less seriously, but urology trainees in London who have opted for less than full-time training have told me they are expected to come in on days they shouldn’t be there by consultants who say they must fit their needs around the service rather than the other way round. The danger with flexible working is that people may feel under pressure to work outside their contractual hours because they don’t want to be seen as not pulling their weight within a team. In order to attract women into surgical training at a time when childcare is very expensive, we do have to come to terms with flexible working as a reality.”

As for representation on panels and at conferences, the focus of Ms Dowling’s paper, Ms Bolton notes that things have changed dramatically for the better in recent years.

“When I started training ten years ago,” she says, “it was really rare to see women on panels in international meetings. The Canadian urologist Larry Klotz first kicked off the discussion about the lack of female representation on panels, and since then there has been a conscious effort made to invite women. I think it is up to us then if we are invited to make the effort and sit on the panels. People talk about imposter syndrome and I think that is something of a genuine issue with a lot of women. As you come up the ranks you deal with it better but only by experience. Maybe as a woman you feel you have to prove yourself a little more at the start, because growing up you heard the word surgeon and you

“It is clear that for each woman, mentorship has been a key factor in the development of their careers, but that the gender of those mentors has been largely irrelevant.”

automatically thought that meant a man? Certainly every time I started a new job I felt I had to prove myself, to be as good as the boys. That said, I have never worked in an environment where I have been made to feel less important as a male trainee, but maybe I have just been lucky.”

Ms Bolton suggests training to deal with issues such as imposter syndrome should begin in medical school.

She also points to recent media coverage of discrimination against and harassment of women in surgical specialties.

“Fortunately I have never experienced this firsthand,” she says. “But the perception of a hostile environment can discourage women from pursuing or continuing their careers in urology, so it is important to implement clear policies and procedures for reporting and addressing discrimination and harassment within the field.”

In conclusion, Ms Bolton notes that by virtue of the topic being covered in publications such as Surgeons Scope, the issues surrounding historical gender imbalance in surgical careers are being addressed.

“But,” she continues, “there is still much more that needs to be done to achieve full gender equity in surgical specialties. It has certainly been an easier journey for me thanks to the female urologists who carved out that path before me. We must continue to maintain increased awareness of the gender imbalance in surgical careers. Many surgical societies and organisations are now actively discussing and acknowledging the issue and proactively inviting women to sit on panels and to speak at meetings. This increased awareness has been an important first step in addressing the problem. I think it is accepted in my generation that there are more female surgeons, and now the older generation is aware that they need to learn to adapt to that.

“The work of Professor Viani and Professor McNamara and the unveiling of the Women on Walls at RCSI have raised significant awareness about gender diversity in surgery. Their visibility and advocacy efforts are helping to inspire and guide the next generation of female surgeons. Hopefully with more women inspired by surgical careers, the inherent, implicit biases and stereotypes about the capabilities and roles of women in surgery that continue to affect hiring, promotion, and workplace dynamics will be eroded. I think it is also important to develop clear career pathways early on so that women are attracted into surgical subspecialties in the knowledge that they know they can advance.

“Whilst mentorship is usually a natural process, structured mentorship programmes that pair female urologists with experienced mentors who can provide guidance, support, and career advice may be useful.

“Women face unique societal expectations and caregiving responsibilities that can affect their ability to advance in their careers. I think there needs to be more discussion and openness about flexible work arrangements and parental leave policies which can be beneficial in attracting women into surgical specialties.

“By addressing these barriers and promoting gender diversity and inclusivity, the field of urology can become more welcoming and attractive to women, ultimately benefiting both the profession and patient care,” says Ms Bolton. ■