The American Journal of Surgery (2013) 206, 263-268

Surgical Education

Perceived gender-based barriers to careers in academicsurgery

Amalia Cochran, M.D.a,*, Tricia Hauschild, M.D.a, William B. Elder, M.S.a,Leigh A. Neumayer, M.D.a, Karen J. Brasel, M.D.b, Marie L. Crandall, M.D.c

aDepartment of Surgery, University of Utah, 30 North 1900b

East, SOM 3B313, Salt Lake City, UT 84132, USA;Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA; cDepartment of Surgery, NorthwesternUniversity Feinberg School of Medicine, Chicago, IL, USA

KEYWORDS:Career development;Education;Gender;Glass ceiling;Academic surgery

The authors declare no conflicts of i

* Corresponding author. Tel.:11-801

E-mail address: amalia.cochran@hsc

Manuscript received April 18, 2012;

0002-9610/$ - see front matter � 2013

http://dx.doi.org/10.1016/j.amjsurg.20

AbstractBACKGROUND: Women represent roughly 50% of US medical students and one third of US surgery

residents. Within academic surgery departments, however, women are disproportionately underrepre-sented, particularly at senior levels. The aim of this study was to test the hypothesis that femalesurgeons perceive different barriers to academic careers relative to their male colleagues.

METHODS: Amodified version of the Career Barriers Inventory–Revised was administered to seniorsurgical residents and early-career surgical faculty members at 8 academic medical centers using anonline survey tool. Likert-type scales were used to measure respondents’ agreement with each surveyitem. Fisher’s exact test was used to identify significant differences on the basis of gender.

RESULTS: Respondents included 70 women (44 residents, 26 faculty members) and 84 men (41 res-idents, 43 faculty members). Women anticipated or perceived active discrimination in the form of beingtreated differently and experiencing negative comments about their sex, findings that differed notablyfrom those for male counterparts. Sex-based negative attitudes inhibited the career aspirations of femalesurgeons. The presence of overt and implicit bias resulted in a sense that sex is a barrier to female sur-geons’ career development in academic surgery. No differences were observed between male andfemale respondents with regard to career preparation or structural barriers.

CONCLUSIONS: Female academic surgeons experience challenges that are perceived to differ fromtheir male counterparts. Women who participated in this study reported feeling excluded from the dom-inant culture in departments of surgery. This study may help guide transformative initiatives withinacademic surgery departments.� 2013 Elsevier Inc. All rights reserved.

Although female medical students represent half of themedical students in the United States, the number ofwomen pursuing surgery as a career still remains substan-tially below that. By 2006, 40% of incoming surgical

nterest.

-581-7508; fax:11-801-587-9149.

.utah.edu

revised manuscript July 20, 2012

Elsevier Inc. All rights reserved.

12.07.044

residents were women.1 Although in 2010, women consti-tuted 35% of all general surgery residents, the percentageof full-time female faculty members in general surgery res-idency programs was cited at only 14%.2 Further, attritionremains a substantial issue among female faculty members,with 1 nationwide study showing that women surgeons atthe assistant professor level were almost 6 times morelikely than their male colleagues to acknowledge an interestin leaving academia within 2 years.3

264 The American Journal of Surgery, Vol 206, No 2, August 2013

Research has revealed many potential challenges towomen’s careers in academic medicine. The number ofwomen who serve as first or senior authors on originalresearch publications in major medical journals has in-creased substantially over the past 4 decades, althoughfemale authors remain a substantial minority.4 In 2008,Cropsey et al5 outlined the 3 leading causes of attrition towomen’s careers in academic medicine as career or profes-sional advancement, low salary, and chair or departmentalleadership issues. In 2010, the Association of AmericanMedical Colleges reported that only 8% of professors ofsurgery were women.6 A recent projection used Associationof American Medical Colleges data to demonstrate that al-though surgery residents may achieve gender parity by2028, professors of surgery will not achieve gender parityuntil 2096.7 The paucity of women serving in faculty roles,particularly at the senior levels, has a potential impact oncareer choices for both female medical students (whetherto choose surgical careers) and female residents (whetherto choose academic careers). To date, no studies have ex-amined specific obstacles to women’s academic career ad-vancement in departments of surgery. However, thebarriers to increasing the number of women in academicsurgery remain unclear. The hypothesis of this study wasthat there are multiple impediments to women’s careers inacademic surgery that differ from barriers that may be pre-sent for or perceived by their male colleagues.

Methods

Research design and participant selection

In this quantitative study, we used a single questionnaireadministered to the study participants. E-mail contact wasestablished with participants at each of 8 sites through alocal site principal investigator (see ‘‘Acknowledgments’’for participating sites and principal investigators). Siteswere selected in an effort to maximize geographic andinstitutional diversity. Subjects were invited to complete amodified version of the Career Barriers Inventory–Revised(CBI-R) in an online format using SurveyMonkey.8,9 Dataon other potential confounders were also collected, includ-ing individual demographic factors (general geographic re-gion of employment, age, sex, self-identified ethnicity, andmarital and parenting status), intended subspecialty (forresidents), academic track (for faculty members), andamount of medical school debt.

Perception of barriers to entry or advancement isbelieved to impede career development. The CBI wasdeveloped as a standardized self-report instrument address-ing a varied set of barriers that have the potential to affectvarious stages of career development9; the CBI’s intent wasto evaluate perceived career barriers for high school stu-dents. The CBI was subsequently modified to the CBI-Rin an effort to reduce its length and improve the clarity ofmany items.8 Table 1 describes the 13 dimensions that

are present on the CBI-R on the basis of the work of Swan-son et al.8,10 For the purposes of this study, the CBI-R wasused with minor rewording making it appropriate to indi-viduals in surgical training or in academic practice. Threeof the investigators (T.H., W.B.E., and A.C.) edited thequestions to make them appropriate for senior residentsor early-career surgical faculty members; for example,rather than beginning a series of questions with the stem‘‘In my future career, I will probably,’’ the stem was re-stated as ‘‘In my career in academic surgery, I will proba-bly’’ for residents and ‘‘In my career in academic surgery,I have’’ for faculty members. The CBI-R scores responsesusing a Likert-type scale to measure level of agreementwith each item, and the scoring system was unchangedfor this study.

Subjects in this study consisted of 2 cohorts. Cohort 1 wascomposed of fourth-year and fifth-year general surgery resi-dents of both genders at 8 US residency programs.Wording inthe CBI completed by cohort 1 was designed to captureanticipation of experiences in academic surgery. Cohort 2 wascomposed of early-career tenure-trackmale and female juniorfaculty members at these same institutions. Early-careerfaculty members included instructors, lecturers, assistantprofessors, and associate professors promoted within thepast year. Wording of the CBI completed by cohort 2 wasdesigned to capture actual experiences in academic surgery.All female faculty members who met these criteria wereinvited at each institution. Male faculty members were sam-pledon thebasis of rankmatchingwith their female colleaguesand then invited in a 2:1 ratio of male to female facultymembers to maximize variation. Sampling was conducted torecruit as diverse a sample as possible, including race/ethnic-ity, age, relationship status, and amount of medical schooldebt. Junior faculty members and residents were selected as apurposive sample to demonstrate the relevance of perceivedbarriers to academic careers to those early in their surgicalcareers. For inclusion in the data analysis, participants wererequired to complete.50%of the survey questions.Data fromquestions with the same themes were analyzed together,including both residents’ anticipation and faculty members’experience of differential treatment as equivalent events interms of their deterrence of an academic surgical career.

Stata version 11.1 (StataCorp LP, College Station, TX)was used for all data analysis. Fisher’s exact test was usedfor comparison of proportions. Institutional review boardapproval was obtained at all participating sites.

Results

Demographic data of participants

Respondents included 70 women (44 residents, 26faculty members) and 84 men (41 residents, 43 facultymembers). The mean age of female respondents was37.7 6 6.7 years, and mean age of male respondents was40.9 6 8.4 years. Response rates were 74% for residents

Table 1 Dimensions of the Career Barriers Inventory–Revised with examples

Dimension Examples of barriers

Sex discrimination Pay equitySexual harassmentDelays in promotion

Lack of confidence Self-esteem issuesNot feeling confident in job ability

Multiple-role conflict Balancing work and nonwork responsibilitiesStress in one role affecting performance in another

Conflict between children and career demands Inadequate child care resourcesInflexible training schedulesScheduling meetings before and after ‘‘regular’’ hours

Racial discrimination Pay equityRacial harassmentDelays in promotion

Inadequate preparation Sense of failed preparation for all aspects of a jobDisapproval by significant other Negative opinions of significant other and familyDecision-making difficulties Uncertainty of individual and institutional goals, values

Poor decision-making skillsDissatisfaction with career Disappointed in personal progress or opportunities available

Boredom with careerDiscouraged from choosing nontraditional careers Negative opinions of peers, potential mentors

Limiting personal beliefs and ideasDisability/health concerns Disability or health condition limits career options

Disability or health condition affects job performanceDiscrimination for disability or health condition

Job market constraints Tight economy with few opportunitiesLimited options within a specific field

Difficulties with networking/socialization No role models or mentors availableNo direct access to the right people

A. Cochran et al. Gender barriers in academic surgery 265

and 37% for faculty members. Distribution on the basis ofgeography and ethnicity is presented in Table 2. At the fac-ulty level, 26 assistant professors and 17 associate profes-sors were male, and 14 assistant professors and 11associate professors were female. Faculty respondentsself-identified as 41 clinical-track faculty members(29 men, 12 women), 23 tenure-track faculty members(12 men, 11 women), and 5 faculty members with ‘‘other’’status (2 men, 3 women). Women were significantly morelikely than men to indicate that they were single or were un-married but living with a partner (39% vs 12%, P , .001).

Table 2 Geographic distribution and ethnicities of respondents

Variable

Women

Residents Faculty m

RegionEast 7 8Central 13 15West 24 3

EthnicityCaucasian/white 37 18African American 1 0Asian 5 7Hispanic 1 1Pacific Islander 0 0

Female surgeons were also significantly more likely tohave no children than their male colleagues (67% vs31%, P , .001). In addition, female surgeons reported sig-nificantly higher educational debt loads than did male sur-geons (reporting .$150,000 of educational debt; 43% vs27%, P 5 .05).

Career Barriers Inventory–Revised responses

Of the 13 scales included in the CBI-R, the questionsaddressing sex discrimination and conflict between children

Men

embers Residents Faculty members

4 1712 2325 3

33 311 05 51 51 0

266 The American Journal of Surgery, Vol 206, No 2, August 2013

and career demands demonstrated consistent differencesbetween the male and female survey respondents. Femalesurgeons were more likely to agree that in an academicenvironment, they anticipated being or had been treateddifferently because of their sex (54% vs 16%, P, .001), thatthey had experienced or would probably experience negativecomments about their sex (36% vs 4%, P , .001), and thatthey had experienced or would experience discriminationbecause of their sex (30% vs 5%, P , .001). As shown inTable 3, male and female surgeons differed significantly intheir perceptions of sex influencing the ease of obtainingan academic position.

Table 4 illustrates responses to questions that focus ongender as a barrier to career aspirations and advancement.Nearly 20% of responding female surgeons indicated thattheir gender was a barrier to their career aspirations or ad-vancement. Perhaps more tellingly, one third of femalerespondents strongly agreed or agreed that people’s atti-tudes about their gender were currently a barrier to theircareer aspirations or advancement. However, a majorityof female surgeons who responded agreed that they couldovercome career barriers that include discrimination be-cause of gender (41 of 61), negative comments abouttheir sex (43 of 60), their gender as a career barrier(41 of 59), and people’s attitudes about their gender(36 of 59).

Although neither male nor female surgeons viewedrelationship concerns as a limitation to their career aspira-tions, nearly half of female surgeons agreed or stronglyagreed that having children would be a career barrier,compared with only 5% of their male colleagues (P , .001;Table 5). Women were also significantly less optimisticabout being able to overcome childrearing-related careerbarriers. Fewer than half of the women surgeons who re-sponded indicated that they were highly confident or confi-dent that they could overcome the career barrierrepresented by their desire to have children (47% of womenvs 72% of men); almost one quarter of women were notconfident or not at all confident that they could overcomethis barrier, as opposed to 10% of their male counterparts(P 5 .003).

Female and male surgeons did not differ significantly onany question that addressed the CBI-R dimensions ofconfidence, inadequate preparation, or dissatisfaction withcareer. Neither adequate preparation for a career in aca-demic surgery nor lack of support by senior facultymembers was considered a career barrier, and neither

Table 3 Responses to the item ‘‘In an academic surgical practice, I hposition than people of the opposite sex’’

Gender Strongly agree Agree

Male (n 5 83) 3 (3.6%) 0Female (n 5 69) 2 (2.9%) 23 (33.3%)

P , .001 (Fisher’s exact test).

group anticipated difficulty overcoming these potentialbarriers.

Comments

Our findings demonstrating female surgeons to be moreconcerned than their male counterparts about discrimina-tion in the workplace and conflict between children andcareer demands are consistent with findings in the groupof nonsurgeon women used for initial validation of theCBI-R.8 What is remarkable about our research, however,is that although Carr et al11 reported that female medicalschool faculty members in general were 2.5 times morelikely than male faculty members to perceive gender dis-crimination in the academic environment, women in de-partments of academic surgery were 10 times morelikely to perceive gender discrimination than their malecolleagues (Table 2). The results of our study indicatethat the most significant barriers for women in academicdepartments of surgery are based on their experiences aswomen.

In distinction from the group of women used for theCBI-R validation, sex differences were not seen fordimensions addressing lack of confidence, multiple roleconflict, inadequate preparation, decision-making difficul-ties, and dissatisfaction with career.8 One possible explana-tion for this is the aforementioned types of barriers areindividual factors, whereas the significant barriers foundin this study were external conditions (eg, female surgeons’experiencing negative comments about their sex). This dis-tinction suggests that women in academic surgery enjoytheir careers and feel well prepared but perceive theirmost significant career barriers to be external andinteractional.9,12

Workplace equity issues for women in academic surgerycontribute to a ‘‘leaky pipeline’’ phenomenon that, itappears, is more significant in surgery than in most otherareas of academic medicine. Female students anticipatediscrimination in their medical careers, and the results ofour study suggest that this will be especially true iftheir career choices are in academic surgery.13 Althoughwomen may have high self-efficacy in surgery, they maynot choose surgery-related careers because of exp-ected negative outcomes, which may include sex-baseddiscrimination.8,14 Anticipation of opportunities and bar-riers may offer a partial explanation for the continuing

ave had/will probably have a harder time obtaining an academic

Neutral Disagree Strongly disagree

12 (14.5%) 38 (45.8%) 30 (36.1%)14 (20.3%) 24 (34.8%) 6 (8.7%)

Table 4 Gender as a career barrier

Item Strongly agree Agree Neutral Disagree Strongly disagree

My gender is currently a barrier to my career aspirations/advancement*Men (n 5 84) 0 1 (1.2%) 8 (9.5%) 42 (50%) 33 (39.3%)Women (n 5 70) 3 (4.3%) 13 (18.6%) 14 (20%) 29 (41.4%) 11 (15.7%)

People’s attitudes about my gender are currently a barrier to my career aspirations/advancement*Men (n 5 81) 0 1 (1.3%) 7 (8.6%) 44 (54.3%) 29 (35.8%)Women (n 5 70) 5 (7.2%) 18 (25.7%) 11 (15.7%) 26 (37.1%) 10 (14.3%)

*P , .001.

A. Cochran et al. Gender barriers in academic surgery 267

ability-attainment gap in the occupational choices ofwomen in surgery.15

Decisions regarding marriage and childbearing and thechallenges of child care as an academic surgeon appear toalso represent significant barriers to the professional ad-vancement of female surgeons. Our sample group in thisstudy is consistent with previous studies showing thatfemale academic surgeons, in comparison with their malecolleagues, are less likely to marry and more likely tosignificantly delay or altogether forgo childbearing.Schroen et al,3 in a survey of 317 academic general sur-geons, found that among female academic surgeons, nearly1 in 4 reported never having been married, a marked differ-ence from the responses of professionally similar male col-leagues, for whom the never-married rate was only 1 in 25.Furthermore, female academic surgeons were significantlymore likely than their male colleagues to report that theydeferred the decision to start a family until they were fin-ished with residency and fellowship training, despite thephysiologic reality of diminished female fertility with in-creasing age.3

Zhuge et al,16 in a broad-ranging review of the glass-ceiling effect on women in academic surgery, found thatmore than one quarter of female academic surgeons hadnot had children by 40 years of age, and among thosewho chose to have children, there was a clear perceptionthat the decision to have children had come at a cost interms of delayed professional advancement. Lest the argu-ment be made that these perceptions are subjective andtherefore may not represent the reality of the academic sur-gical workplace, quantitative studies demonstrate that, onaverage, female academic surgeons without children earnroughly 95% of the amount earned by comparably matchedmale colleagues, whereas female academic surgeons whoare also mothers earn only 75% of the amount earned bysimilarly situated male colleagues.17 Although it shouldbe intuitively obvious that some percentage of female

Table 5 Responses to the item ‘‘My desire to have children is curre

Gender Strongly agree Agree

Male (n 5 72) 1 (1.4%) 3 (4.2%)Female (n 5 54) 5 (9.3%) 18 (33.3%)

P , .001 (Fisher’s exact test).

academic surgeons would choose to remain childless re-gardless of professional incentives or disincentives, thestriking differences seen in this area between male and fe-male academic surgeons suggest that women in the field areboth understanding and responding to very real professionalcosts of the decision to raise children while pursuing careeradvancement in the academic surgical setting.

Unfortunately, objective factors have been documentedthat likely contribute to the perceptions of gender disparityin academic surgery that are documented in our study.Although female surgeons are no less accomplished thantheir male peers and are generally satisfied with theircareers, salary iniquity and delays to promotion and tenuredemonstrate an environment with pervasive gender dis-crimination. Attrition before promotion is a challenge facedby both genders, yet more women exit academic surgery atearly career stages, contributing to a ‘‘broken pipeline’’phenomenon. This tendency toward early exit by women islikely due to a composite of sex discrimination, careerdissatisfaction on the basis of a lack of opportunities forprofessional development, and networking difficulties re-sulting from a paucity of senior female mentors and pooraccess to those in positions of power.

This work does have some limitations. Respondentscould admit questions at will, so there may have been aselection bias in the questions they chose to answer. Theperception of barriers or anticipation of barriers does notcapture objective elements such as academic performanceduring residency or the quality and volume of academicwork once in academia. These data were also self-reported,and the faculty response rate of 37% was lower than ideal.However, there is no particular reason to believe thatsystematic differences by sex in reporting discrimination,such as professional income, for example, are attributableto other faculty descriptors. No data show that women haveless capacity to publish research, and although women arenot as well represented as their male colleagues in major

ntly a barrier to my career aspirations/advancement’’

Neutral Disagree Strongly disagree

8 (11.1%) 43 (59.7%) 17 (23.6%)8 (14.8%) 15 (27.8%) 8 (14.8%)

268 The American Journal of Surgery, Vol 206, No 2, August 2013

medical journals, the quality of their scholarship is oftenhigher.4,18 Quite simply, across medical schools in diversegeographic areas, despite an adequate pipeline into aca-demic surgery and apparently identical training, female sur-geons advance to the full professor rank less frequently andearn less than their male colleagues.19

As a result of our preliminary attempt to define thediverse factors that may influence female surgeons’ per-ceptions of academic careers, a number of new areas forinquiry have been identified. First, future research shouldexpand on successful skills female surgeons have used toovercome discrimination and the subsequent developmentof programs to help female surgeons develop these skills.Second, the differential in indebtedness and in familystructures between male and female surgeons are issuesthat are worthy of further, more detailed exploration.Finally, delineation of the specific types of external dis-crimination women feel is most prevalent in the academicsurgical environment might facilitate remediation of theseissues, particularly if they are amenable to zero-toleranceinstitutional responses. Change may be facilitated bypresenting relevant research and narrative accounts ofwomen’s experiences in surgery by fostering mindfulnessand promoting shifts in behavior, including redesign offaculty recruitment, retention, and promotion processes;modified allocation of research resources; and creation ofnew positions for multiculturalism and diversity.12,20,21 De-partments in which these active strategies to promote equityand address inequity are implemented are also those depart-ments in which recruitment and retention of female sur-geons has been more successful. Monitoring climate andculture in departments of surgery is not enough; active in-terventions to correct course in those departments withidentified challenges must also occur. Although women inacademic surgery are the key stakeholders in identifyingthe ongoing challenges they face, development and imple-mentation of long overdue remedies must come from thehighest departmental and institutional levels. The dramaticlevel of perceived gender discrimination among theseyounger women in surgery implies a high level of urgencyto transform the culture of departments of surgery if aca-demic surgery is to attract and retain talented womenwho have alternative career options with a more favorableenvironment.

Acknowledgments

We thank the participants from the following institutionsand the site coordinators: East Carolina University: P. J.Schenarts; Oregon Health Sciences Center: Rachel Danc-zyk and Susan Orloff; Southern Illinois University: Hilary

Sanfey; University of Nebraska: Wendy Grant; and Van-derbilt University; Colleen Brophy and Kevin Sexton.

References

1. Davis EC, Risucci DA, Blair PG, Sachdeva AK. Women in surgery

residency programs: evolving trends from a national perspective.

J Am Coll Surg 2011;212:320–6.

2. American Medical Association. FREIDA Online. Available at: https://

freida.ama-assn.org/Freida/user/specStatisticsSearch.do?method5viewDetail&spcCd5440&pageNumber52. Accessed January, 6 2012.

3. Schroen AT, Brownstein MR, Sheldon GF. Women in academic gen-

eral surgery. Acad Med 2004;79:310–8.

4. Jagsi R, Guancial EA, Worobey CC, et al. The ‘‘gender gap’’ in author-

ship of academic medical literatureda 35-year perspective. N Engl J

Med 2006;355:281–7.

5. CropseyKL,Masho SW, ShiangR, et al.Why do faculty leave?Reasons

for attrition of women andminority faculty from amedical school: four-

year results. J Womens Health (Larchmt) 2008;17:1111–8.

6. American Association of Medical Colleges. Distribution of U.S. med-

ical school faculty by sex, rank, and department. Available at: https://

www.aamc.org/download/169810/data/10table13.pdf. Accessed Janu-

ary 6, 2012.

7. Sexton KW, Hocking KM, Wise E, et al. Women in academic surgery:

the pipeline is busted. J Surg Educ 2012;69:84–90.

8. Swanson J, Daniels K, Tokar D. Assessing perceptions of career-related

barriers: the Career Barriers Inventory. J Career Assess 1996;4:219–44.

9. Swanson J, Tokar D. Development and initial validation of the Career

Barriers Inventory. J Vocat Behav 1991;39:344–61.

10. Swanson J, Woitke M. Theory into practice in career assessment for

women: Assessment and interventions regarding perceived career bar-

riers. J Career Assesst 1997;5:443–62.

11. Carr PL, Ash AS, Friedman RH, et al. Faculty perceptions of gender

discrimination and sexual harassment in academic medicine. Ann In-

tern Med 2000;132:889–96.

12. Pololi L. Changing the culture of academic medicine. Lebanon, NH:

Dartmouth College Press; 2010.

13. Henry P. Educational and career barriers to the medical profession:

Perceptions of underrepresented minority students. College Student J

2006;40:429–41.

14. Lent R, Brown S, Hackett G. Toward a unifying social cognitive theory

of career and academic interest, choice, and performance. J Vocat Be-

hav 1994;45:79–122.

15. McWhirter E. Perceived barriers to education and career: ethnic and

gender differences. J Vocat Behav 1997;50:124–40.

16. Zhuge Y, Kaufman J, Simeone DM, et al. Is there still a glass ceiling

for women in academic surgery? Ann Surg 2011;253:637–43.

17. Longo P, Straehley CJ. Whack! I’ve hit the glass ceiling! Women’s ef-

forts to gain status in surgery. Gend Med 2008;5:88–100.

18. Housri N, Cheung MC, Koniaris LG, et al. Scientific impact of women

in academic surgery. J Surg Res 2008;148:13–6.

19. Ash AS, Carr PL, Goldstein R, Friedman RH. Compensation and ad-

vancement of women in academic medicine: is there equity? Ann In-

tern Med 2004;141:205–12.

20. Cottingham AH, Suchman AL, Litzelman DK, et al. Enhancing the in-

formal curriculum of a medical school: a case study in organizational

culture change. J Gen Intern Med 2008;23:715–22.

21. Ferrada PA, Anand RJ, Grover A. Virginia commonwealth university:

committed to the professional growth of women in surgery. Am Surg

2011;77:1430–1.