Why do women leave surgical training? A qualitative and feminist study

Abstract

Background Women are under-represented in surgery and leave training in higher proportions than men. Studies in this area are without a feminist lens and predominantly use quantitative methods not well suited to the complexity of the problem. MethodsIn this qualitative study, a researcher interviewed women who had chosen to leave surgical training. Women were recruited using a purposive snowball strategy through the routine communications of the Royal Australasian College of Surgeons and Royal Australasian College of Surgeons Trainee Association over a 3-week period, and were interviewed over the following 4 months in the past 4 years in person or by telephone. More specific details are available on request from the authors. Supported by male and female co-researchers, and in dialogue with study participants, she then coded the findings and defined themes. An explanatory model was developed by integrating findings with different theories and previous literature. The research team developed three aspects of the model into a visual analogue. Findings 12 women participated in the study, with all Australian states and territories, and New Zealand, as well as five medical specialty streams, represented. The time spent in training ranged from 6 months to 4 years, and all participants, except two, had trained in both metropolitan and rural locations. The findings confirmed factors identified in earlier reports as reasons women leave surgical training, and contributed six new factors: unavailability of leave, a distinction between valid and invalid reasons for leave, poor mental health, absence of interactions with the women in surgery section of their professional body and other supports, fear of repercussion, and lack of pathways for independent and specific support. The relationships between factors was complex and sometimes paradoxical. The visual analogue is a tower of blocks, with each block representing a factor that contributed to the decision to leave surgical training, and with the toppling of the tower representing the choice to leave. The visual analogue indicates that effective action requires attention to the contributory factors, the small actions that can topple the tower, and the contexts in which the blocks are stacked. Interpretation 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. This should inform interventions in surgical training, with attention to local social context, health-care setting, and training programme structure.

Four types of gender bias affecting women surgeons and their cumulative impact

“…A similar finding emerges from recent research into women's reasons for leaving surgical training by Liang et al, who discovered that it is usually the combined impact of several factors (eg, unavailability of leave combined with sleep deprivation and bullying) that cause trainees to withdraw from training. 27 Liang et al have developed a simple but powerful 'tower of blocks' model for understanding the cumulative nature of trainees' decisions to leave surgery. Their model resonates with theoretical research in ethics on the way small factors can aggregate to form large harms that are more than the sum of their parts.…”

Feminism, equity and the family‐centred workplace

“…Women's usually temporary exit from the workplace to bear and care for children is a major factor in their career trajectory: they fall behind and never catch up. Women who leave surgical training report not only long working hours but also sleep deprivation, bullying, discrimination, sexism and sexual harassment . They lack sufficient supports and suitable role models.…”

“…They lack sufficient supports and suitable role models. They are also disproportionately affected by the impact of pregnancy and childbirth and child rearing . Society has competing demands: productivity and family.…”

“…Women who leave surgical training report not only long working hours but also sleep deprivation, bullying, discrimination, sexism and sexual harassment. 7 They lack sufficient supports and suitable role models. They are also disproportionately affected by the impact of pregnancy and childbirth and child rearing.…”

“…They are also disproportionately affected by the impact of pregnancy and childbirth and child rearing. 7 Society has competing demands: productivity and family. We need to challenge hierarchical medical specialist models that fail to promote specialist training for women of reproductive age due to patriarchal beliefs that to do so would take a training opportunity away from a 'more diligent and career-minded' male who will not suspend their training or ask for time off to bear and rear children.…”