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Dr. Fahima Dossa, photographed outside Toronto’s Mount Sinai Hospital, found that female surgeons made 24 per cent less per hour operating than men and often did procedures that paid less.Tijana Martin/The Globe and Mail

When Dr. Fahima Dossa decided to become an oncology surgeon, one of her mentors in medical school said to her, “I hope you know that means you’ll be treating breast cancer.”

At the time, Dr. Dossa took the comment as practical advice. Most surgeons rely on referrals, so she might as well be prepared. But after pausing her general surgery residency at the University of Toronto to do a PhD, she began looking at gender bias in her field. As Dr. Dossa compared the earnings of men and women surgeons – and talked to others about their experiences – she started to feel differently about that comment.

“We pride ourselves on the idea that the proportion of women in medicine and in surgery is increasing,” says Dr. Dossa, who’s now in her final year of residency, which she will follow up with a fellowship in surgical oncology. “But what we fail to recognize is that we still have occupational segregation in medicine.”

That segregation sees women kept out of high-paying, prestigious roles in medicine while nudging them into somewhat more women-friendly specialties – positions that require shorter hours or that deal with female body parts or sick children.

Those that push into male-dominated specialties such as surgery often get paid less, struggle to advance and face what one study called “additional workplace friction.”

Lopsided numbers

Women achieved parity in medical schools in Canada in the mid 90s. In 2020/21, they made up 57.9 per cent of MD cohorts. But, as of 2021, just 33 per cent of surgeons were women.

Numbers from 2018 show that women make up a mere 9.4 per cent of cardiac surgeons and 10.9 per cent of cardiothoracic surgeons in Canada – which are among the top paid medical specialties.

Meanwhile, women want to operate. A 2020 survey of med students at Western University found both genders wanted to pursue cardiac surgery equally. However, 73 per cent of women worried they’d never get matched for a residency, compared to 25 per cent of males.

That worry may be reinforced by microaggressions.

“When a female trainee says she’s interested in surgery, one of the first thing she’s asked is, ‘Do you want to have a family? How are you going to balance that?’” says Dr. Dossa. She thinks such comments make women worry that taking time off for a pregnancy or any family-related issue will compromise their careers.

Dr. Michelle Keir, cardiologist and clinical assistant professor at the University of Calgary, recalls being pregnant with her second child during her residency when someone said to her, “You can’t be a good cardiologist and a mother at the same time. You should probably just quit cardiology and do internal medicine.” (Notably, just 22.2 per cent of cardiologists in Canada are women.)

Dr. Dossa blames unconscious bias. “We know from behavioural studies that when you’re mentally assessing someone for a job, you have a cognitive schema of what the person doing that job looks like,” she says.

For Dr. Keir, who studies gender equity in medicine, the reason is more sinister. “I think a lot of it is gatekeeping of the higher paying specialities,” she says.

Gender differences in the operating room

Dr. Tracey Adams, a professor in the department of sociology at Western University who has studied gender’s impact on jobs in medicine, says, “In residency, [women] may experience some harassment, some hostility. Many report the need to outperform their male colleagues to get any kind of recognition.”

A 2019 pay equity study led by Dr. Dossa found female surgeons made 24 per cent less per hour operating than men and often did procedures that paid less. Her 2021 follow-up report showed that male doctors were more likely to refer patients to male surgeons. Also, male surgeons were more likely to get a referral that resulted in a procedure.

Another Canadian study showed that women who take charge in the operating room can risk “being perceived negatively for displaying leadership behaviours.”

In 2022, Alberta’s only cardiac surgeon, Dr. Teresa Kieser, filed a human rights complaint, claiming she endured three decades of discrimination at a Calgary hospital. A year before, Dr. Irene Cybulsky won a gender discrimination case against a Hamilton hospital after losing her position as head of cardiac surgery. Members of the all-male team of subordinates had raised concerns about her leadership style, which led to her ouster. (“She may need to be a bit fluffier,” one doctor said of her in a meeting.)

A need for change

Dr. Dossa thinks the glut of studies on this issue in recent years is a first positive step toward making medicine less segregated.

“One of the things that’s important is to start a conversation about this issue, and that’s already happened,” she says.

While the industry could use more intersectional data around gender and race, she’d also like see systematic change be the next priority. “Although we have more women in surgery and more women in medicine, the environment that they work in hasn’t changed as much,” says Dr. Dossa.

To start, make referrals centralized, not to specific doctors, she says.

Dr. Keir says hospitals need to remediate small issues that affect women, such as making sure “call rooms” – where doctors nap when they are on overnight shifts – are safe with a new lock code every night. These kinds of changes could make more specialities more comfortable for women, she says.

Plus, “these lower stakes things are often signs that something bigger is going on,” says Dr. Keir, who talks to doctors who have had negative experiences at work through a program at U Calgary and Alberta Health Services.

Healthcare organizations need good systems for reporting discrimination, says Dr. Adams, so women can safely call out their boss or a colleague. Administrators need to root out microaggressions in all corners of their organizations, pointing out how that kind of behaviour can negatively impact budgets.

“They can say, ‘If we have surgical teams here and there are all these microaggressions likely going on, they’re not going to be the most efficient surgical team,’” says Dr. Adams.

Organizations should push to hire more female surgeons, she adds, as that will allow trainees to have more women role models and mentors, increasing overall numbers in time.

While that might seem like a common-sense move, Dr. Adams says that sadly, it hasn’t happened at most organizations in this tough-to-change corner of medicine.

”If you read studies on the experiences of women surgeons from 20, 30 years ago, and you read some of the more recent ones, they still document the same issues.”

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Stacie Campbell/The Globe and Mail

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