Why women in surgery need other women in surgery - #thisiswhatwelooklike and #ilooklikeasurgeon

I recently spoke at another university 'Women in Medicine' night. I find these events both enjoyable and educational. It's a great opportunity to meet colleagues and other young women who are studying to become doctors and try and inspire and instruct some students (both male and female) into what I hope will be fulfilling and productive careers.

But every time I get ready for one of these talks, two things go through my head. The first being that I have no idea what they really want to hear. I had some very good advice that they just want to see that we women surgeons are real and that it can be done. (Turns out that is true) The other thought I have is how relevant is this anymore? After all, over half of medical students in a number of universities now are female. And then...

Whilst waiting to talk to a patient on the phone "Hang on, the nurse is here to see me" (after seeing them every day for a week and doing the surgery)

From a male physician "Women should just work harder to make up the pay gap. And because they have time off for children."

From a colleague involved in conflict resolution, man (and recent) cases of women in distress due to discrimination in the workplace, resulting in illness or leaving the profession.

Let's be honest. In my country, I won't be injured or killed for walking down the street with a man who is not my husband. I can drive, I can vote, I can be educated and I can be gainfully employed. When you look at things that way, I am very fortunate. However, this does not mean that we don't have some problems with the way our society views and sometimes treats professional women. Whether it be medicine, corporations, politics, law, trades or engineering, women are by and large, a minority group. Which means that for younger women wanting to join the ranks of the patriarchy, finding someone to identify with is pretty difficult. And we know that gender plays an important role in mentoring in medicine.

As a junior doctor, my mentors were male doctors. They were and still are, excellent mentors and I am very appreciative of their guidance. In fact, on several occasions, they were insightful and sensitive enough to make sure that I was aware that some unique challenges may face me in my career and made sure that I was equipped to think them through as part of my career and life planning. Sometimes though, I really wanted to know how that actually played out for someone like me. I was very resolved to the fact that I was to some extent going to have to carve out my own path in life. And I have been okay with that.

There is some research around that by and large supports the availability of women mentors for young women doctors and medical students. Gender matching can have a very positive influence on a mentor-mentee relationship with the 'mentee' being more comfortable to seek out advice from a mentor of the same gender without worrying that gender will colour the perception of the question or the advice itself. What it may boil down to is as simple as my talks for women in medicine nights. We just want to see that it can be done and learn from a mentor's journey.

Finding a female mentor, in surgery especially, can be tricky. Finding any mentor can be tricky. It is a relationship like any other, where both party needs to be satisfied with in order to work. When we have a lack of women on a a sheer numbers basis, finding a gender equal you identify with can be really hard!

Social media has been awash in the last few months with campaigns and hashtags such as #thisiswhatwelook like, a campaign created by an anaethetist and a philosopher to challenge societal and professional ideals of what professional people look like. It's extended to virtually every profession and skill you can think of; CEO, drummer, programmer, lawyer and surgeons. I got on board pretty early with my 'This is what a surgeon looks like' t-shirt and it's been great fun to be a part of. Recently, engineers joined in with a hashtag #ilooklikeanengineer when a young woman apparently was not considered to be what we would consider 'looking like an engineer' and has crossed professional lines to surgeons with #ilooklikeasurgeon now trending. And I love it. Being a part of this feel inclusive, inspiring and just fun. In the last few months, I've chatted with women surgeons around the world about surgery and not about surgery. But by and large, it's been about positive change and positive role models. It's about changing perceptions and expectations and encouraging young women into a profession that we all love.

   Every time I talk about being a woman in surgery, I want to achieve a few things. Firstly, I want to show people that I have a cool job and inspire others to maybe try it out. I love when a junior doctor (male or female) tells me they've loved cardiac surgery and now they want to do it. Secondly, I want to share that you absolutely do not have to be a certain race, gender, personality, sports fan or other group to be a surgeon. In fact, diversifying our specialty to involve women, for example, is a fantastic thing. Every different person has something unique to bring to the table and we should encourage that enrichment. And finally, I want to show the world that I don't have to be a stereotype to be a surgeon. Because I am a surgeon and this is what I look like.


Mentors can certainly mentor across gender and racial boundaries. But let's be real, in a world where people can still discriminate or belittle or neglect you like my two short (and very recent) examples, a ground swell against stereotypes can only be a good thing. If I encourage one young woman to be a surgeon just by being one myself, that's wonderful. If together, we can all make positive changes in a society and a system that is imperfect, then that is amazing and is truly an achievement to behold.




P plate surgeons - teaching, learning and ethics

The New England Journal of Medicine has published a fantastic article on trainee participation in surgery. The story is told by an ophthalmology resident (registrar equivalent) with a patient, none the wiser that a training surgeon, fully supervised, has just performed successful cataract surgery. The author talks about striking the right balance between teaching and training and what the patient would wish to have happen. Hospitals, especially teaching hospitals, are home to doctors of vastly different experiences. There is the professor, with thirty years of experience on one side of the table. On the other side of the table, there may be a doctor with weeks, months or only a few years experience. It is through this vast experience that an exchange of knowledge and learning of skills takes place. And at the centre of this is the patient.

I have always found that patients, by and large, do not have an understanding of the medical hierarchy. Which is understandable. There are so many words, terms, faces. Interns, residents, registrars, fellows, consultants. Age, or rather a perception of the doctor's age, is one thing I think patients use to try and work out who is in charge or experienced. They may perceive the person they have had the most contact with as the leader or the person who spoke to them for the longest. While I'm sure the patients appreciate that a hierarchy exists, I'm not sure that they always appreciate that there can be a chasm of experience, skill and knowledge between two people.

But whether they appreciate that difference or not, the patient has a most vital and important role in closing that knowledge gap. It is through their illness that junior doctors learn. I actually loathe to use the word practice. To me, that sounds akin to shooting hoops from the free throw line, over and over, hoping you get one in. Refinement. Advancement. Training. That is what it is actually like. A process rather than a crack at the goal. And with an experienced person standing there. I'm not sure during training that we say often enough that we are thankful for the trust our patients place in us. Without them, we simply could not learn.

But we don't say it. Very often, we don't specifically inform a patient that a surgeon in training may perform some or all of their surgery. A number of consent forms have a standard provision that reads something along the lines of 'a doctor other than the admitting doctor may perform the procedure'. As the New England article mentions, the patient may well not consent to a trainee performing their procedure. Which leaves us in somewhat of a pickle. Like so many situations, we have an obligation to more than one person. We have a very important responsibility to protect our patients and their health and well being. And we also have an obligation to train surgeons, for without them future generations would not benefit from medical care.

A number of things are leading to concerns with training young surgeons. Sicker patients requiring true expert intervention, changes to surgical training program execution, excessive working hour restrictions and oversubscription of doctors at certain levels of training. The use of simulation in both high and low fidelity models has been used to teach, develop and refine skills prior to getting to the operating theatre. I had the opportunity to practice on some fantastic models during my training. Paul Ramphal, an American surgeon who works in the Bahamas, has a fantastic simulator that uses a pig heart in a model chest cavity and has engineered in a way that it 'beats'. I had the opportunity to practice coronary bypass grafting on this model several years ago. And it was great fun. There is nothing quite like the real deal, but I think we will move towards simulation more and more as a way of teaching and training. Aviation and sport have made use of such technology for years and medicine is now catching up.

But what about for the now? Well, for starters, in cardiothoracic surgery, the literature seems to support that a patient's operation will not be compromised by having it performed by a junior surgeon. For coronary artery bypass grafting and valve surgery, there have been a number of publications that suggest that the outcomes are similar between a training surgeon and an experienced operator. In my field therefore, I can tell a patient that having a trainee operate should not adversely impact on their outcome. Their grafts will still flow and their valves will still open and close.

But we do need to be more open. And we need to do it such a way that the patient is not only reassured but also happy to be part of a very important process. The New England article makes mention of another ophthalmology publication whereby the authors got 95% of patients to consent to trainee participation by honest and open discussion in the informed consent process. And honesty and openness is so important to not only the consent process but the respect for the patient's autonomy and as a fellow human.

Personally, I think that moving towards transparency is the correct move. I think if I can reassure a patient that their outcome is unlikely to be unchanged, that they will participate in a very important process and of course, that trainee surgeons have appropriate supervision, then that is a process that it is ethically sound. However, I would be lying if I thought that a proportion of patients would decline a trainee surgeon or that all of their anxieties would be put to rest by any open and honest discussion. Going for surgery is scary at the best of times, adding another possibly worry into the mix may not be helpful for some people.

During my training, a small proportion of patients have asked who will actually be doing the surgery. Most of the time, I answered that it will be the consultant they were admitted under. If I knew that I was going to be do that patient's operation, I told them that too. I am very, very grateful for the patients who taught me. Who taught me simple things like placing an IV cannula. To the ones who showed me where their good veins were for taking blood. I am grateful for donor families who trusted me to use their loved one's organs for transplant and to the patient on whom I learnt how to perform joins in arteries with a suture the thickness of your hair. I am grateful for the learning because my future patient's will reap those rewards. But most of all I am grateful that you trusted us, all of us, to look after you when we were still learning the nitty gritty of just how to do that.

Can you have it all?

A few years ago, I spoke at a women in medicine day for a university surgical society. The theme of the day was how to have it all. I felt more than a little nervous. I don't know that we can. But I had decided in fairness to both sides of the debate to try and tell these young women how I try and 'have it all'. What was ironic was the morning of the presentation, I had been called in at 4am for an aortic dissection. What was more ironic was that 5am was when I was supposed to be finishing my talk because I hadn't had time to finish it before then. But I did my best. My opinion was that you can have it all as long as you work out what 'it all' means to you as an individual, family or couple and that it may not all happen at once. A fellow speaker who was a rural GP/surgeon stood up at the end of my talk and wanted to know if I ever 'take me batteries out'. I don't know what she meant by that but she may not have listened to the bit where I said do what is right for you. A friend of mine is applying for surgical training and I fully support her and I think she will be wonderful. We had a bit of a talk last night about one thing that is really worrying her about embarking on a surgical career. That is, meeting someone and having a family. How do you do both? Can you have both? Or do you have to choose?

Women, regardless of professional standing, are more likely to spend more time with household chores and child rearing tasks. If they are married to another professional, for example two doctors, the woman is more likely to forego or change her career to a different specialty that is more conducive to family-related tasks. Even if her specialty is perceived as 'more prestigious'. Women physicians are more likely to be married to another physician while male doctors are not. And when we look at a doctors' formative years, women doctors are a lot less likely to have children than their male counterparts. But it's not doom and gloom, we're not a lonely barren lot. Women doctors are married and procreating at rates comparable to the general population. No need to break out the cat lady starter kit just yet.

I am going to go back to the statement that I made at the university function. Everybody is different. I don't think you necessarily have to pick one thing over the other. It is surgery or it is a family. It is work or it is a marriage. It is operating or exercising. The scalpel or drinks with friends. It is balancing these in a mixture that makes you happy that I think you really need to work out. At the same time, I also don't think that if you for example see family as your number one in life, the thing you will be most whole with and that you're worried how surgery will impact on that, well that's cool. Nobody wants to spend their life in a career that they resent away from something or someone that they love.

I think what I want to say is that I think it's possible to tick all of the things in life that you want. I'm reluctant to say 'have it all' because really, I think that saying in itself is rubbish. But you need to work out what the important things in life are to you. Then it's just a matter of timing.