Women in Neurosurgery: View from Canada
Laura Nanna-Lohkamp MD, James T Rutka, MD, PhD
Division of Neurosurgery, University of Toronto, Ontario, Canada
“Women in Neurosurgery” as a topic has been informed by several recent publications and discussed more and more frequently over the last years . Why is that and what drives our neurosurgical community to pick up and reflect on this topic repetitively? What is so particular about women in neurosurgery that it deserves its own heading?
Is it because we become aware that “the barriers (for women) may neither be obvious nor even acknowledged, but they exist”, as Dr. James Bean stated in 2008 in his Editorial about women in neurosurgery published in the Journal of Neurosurgery?
The answer is two-fold: One is that that the number of women entering the field of neurosurgery has been increasing over the last decades. This is in contrast to the not-so-distant past, when the number of women neurosurgeons was described as “less than a minority.” The other one is that despite this increase and overall advances in issues related to gender equity, barriers to recruiting, retaining and “growing” women in neurosurgery continue to exist, making it an issue that seeks attention.
A recent study analyzed the numbers. Of 841 faculty members in North American neurosurgery departments, 761 (90%) were men. Women represented 12% of the assistant and associate professors but only 4% of the full professors. At the level of recruitment women comprised 16.9% of active residents in neurosurgery in the 2017–2018 academic year in North America. And, for the past 3 years, just over 15% of the incoming residency classes have been women . The challenges attracting women to the neurosurgical profession as well as retaining them in it include concerns related to gender inequality, difficulty balancing motherhood and training, in addition to the lack of female role models. Changes are warranted and the voices of women wanting to overcome these barriers reached a critical mass in order to be heard.
Where do the problems originate from?
The disparity between male and female neurosurgeons nowadays may be seen as a historical relic, but remains of upmost actuality. Surgical fields in general have not been amenable to serve both, raising families and being a full-time surgeon in the past and although our lifestyle and culture have changed over the last decades, this problem has not disappeared. There persists a discrepancy between expectations and abilities in combining these two roles, such as modern women strive to fulfill. Especially the long working hours in neurosurgery as well as the limitation of working part-time in this field may come into conflict with a family-friendly private life. But this concerns not only women. However women are more susceptible to this fact and might rather exclude neurosurgery as an attractive profession due to the silently persisting expectation of women being mainly responsible for family-related aspects in our culture. In a recent North American study, 72% of women who had children during surgical residency believed that their maternity leave was inadequate, 39% strongly considered leaving their training program, and 30% reported that they would discourage female medical students from a surgical career given the difficulties in balancing pregnancy and parenting with training. These numbers underscore the significant pressure and discomfort women in neurosurgery face.
Other experience-based reports clearly indicate discrimination by men being chosen over women when it came to the admission to neurosurgical residency programs. Moreover women still experience gender inequality with respect to salaries, academic promotion, and achieving leadership positions. The reason for these disparities is difficult to grasp, however it contributes to the so often described gender-discrepancy in the neurosurgical field. There any many points requiring adjustments. But how to approach these changes and how to identify the right levers to pull in order to achieve sustainable problem-orientated solutions?
What are the solutions?
As counter measures to these inequities, a more sound and powerful voice of women, who seek to complete their path as successful neurosurgeons, has risen and has led to the formation of mentorship programs and societies, such as the AANS Women in Neurosurgery (WINS) committee. Beyond these movements engaging a cultural change, there have been political advances as well, supporting the needs of women and reinforcing gender equity on a numeral basis. As potential solutions to the gender imbalance in neurosurgery, a zero tolerance policy on sexual harassment, the creation of workshops on negotiating skills for academic or hospital contracts, and a redesign of the medical student curriculum to more vigorously attract prospective female neurosurgical trainees has been published as a white paper by Benzil et al via the Women in Neurosurgery committee in 2008 . In response to this white paper, university programs started advertising for gender equity and special support they would offer for women following a surgical career. Meanwhile many adaptions were made according to Benzil’s recommendations world-wide. In some European countries, for instance, academic job advertisements would start to include the sentence that “disabled people and women with the same qualification will be prioritized”. In addition some neurosurgical programs made efforts to facilitate pregnancy and parental leave by offering flexibility during residency rotations and a dedicated amount of parental leave in order to accommodate access to childcare during working hours, such as seen in New York’s Presbyterian Hospital.
But the effort should not end here, as a work-family life balance needs to be maintained. The perception of not being able to lead a robust family life while being a (female) neurosurgeon requires attention and responsibility should be held by the neurosurgical departments themselves, the overseeing universities, supported by acknowledging local government agencies.
It is well known that appropriate and successful work-life balance promotes wellness, which in turn improves patient outcomes. Women in neurosurgery have to face a “double workload” which should be appreciated and not be interpreted as an excuse or weakness. A general change in the mindset of male colleagues as well as in our neurosurgical community is prerequisite for any successful change. This leads to the idea of dedicated mentorship for women in neurosurgery. In all professions, mentorship plays an important role in promoting career advances and academic productivity, both leading to greater career satisfaction and attainable achievements. Besides one-to-one mentoring, organizations like the AANS’s Women in Neurosurgery (WINS) and the WFNS Women in Neurosurgery committee have had a positive impact on the proportion of women in neurosurgery. Their goal is to educate, inspire, and encourage women neurosurgeons to realize their professional and personal goals, and to serve neurosurgery in addressing the issues inherent to training and maintaining a diverse and balanced workforce. Supporting these organizations and establishing satellite groups in each country might reinforce the support network and its accessibility on a local level.
The situation in Canada
Canada is often included in North American studies, however there are distinct numbers which demonstrate the evolution and presence of women in neurosurgery over the past decades. The Canadian Medical Association recently published comprehensive data on the neurosurgical specialty including gender distribution and evolution from 1995 to 2018. In 2018, 11% of Canada’s neurosurgeons were female, of which a third each adhered to the age group of 35 to 44 years and 45 to 54 years. Twenty percent were situated in the age group of 55 to 65, and 17% in the greater than 65 year age group, respectively. Only 4% of female neurosurgeons attributed to the age group below 35 years, indicating a regression in female recruitment. Of note is that the overall numbers of neurosurgeons in Canada is somewhat small with respect to the United States. This might also have an impact on the gender distribution, as a limited number of neurosurgical positions decreases the perceived chances of successful career planning, when women are competing with men for fewer places. Interestingly, the most up-to-date data from the last 2 years suggest that more women are selecting a career path in neurosurgery than ever before. Obviously, it will be important to follow this positive trend.
I (LNL) previously trained in Austria, Germany and France. During these times, I realized differences in the perception of women in neurosurgery. I expected all of these countries to be relatively similar due to their common Western culture, quality of education and even medical standards. Interestingly I was wrong or simply not aware of gender inequity due to my lack of this experience. In Germany the percentage of female medical students had surpassed the 50% mark already a decade ago. In parallel the number of female surgeons, also in neurosurgery increased significantly. Notably in the department where I did my residency almost 50% of the residents were female. I remember overhearing my former chief of department saying once: “females are precise, diligent and when ambitious they have the appropriate perseverance to succeed”. Apparently he was progressive enough to translate the above-mentioned claims into reality. And so did most of the neurosurgical departments in Germany over the last years. In France I experienced a more conservative approach. It is where I first heard the word “misogynist” in the context of surgical exposure and power. I was not familiar with this term before and therefore must have never perceived it as an appropriate word in my past. Looking at objective numbers, the percentage of women in the department, even though it was one of the largest university centers in France, was minimal, including one female staff neurosurgeon and 4 female residents amongst a total of approximately 30 neurosurgeons, running 14 ORs on a daily basis. From a personal perspective the main work distribution in the OR was predominantly on the male side. However, still obtaining an outstanding training I perceived it more as a cultural nuance with a distinct recognition of women and their underestimated capacities, which needed different measures to be overcome.