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Amy Paterson

June 6th, 2024

Who is at the operating table?

0 comments | 4 shares

Estimated reading time: 10 minutes

Amy Paterson

June 6th, 2024

Who is at the operating table?

0 comments | 4 shares

Estimated reading time: 10 minutes

In Africa’s diverse medical education landscape there is still a glaring underrepresentation of women in surgical disciplines. In 2022, only nine percent of surgeons on the continent were women. Here, four trailblazing female surgeons offer their insights from operating rooms across Africa, sharing the advances and ongoing challenges for women in surgical training in their contexts, why gender representation matters in the operating theatre, and measures that could improve the training pathway for women to follow.


Marcella Ryan-Coker profile pic“I envision a future where the operating theatre mirrors the diversity of society, where women stand shoulder to shoulder with men, as equals.”

Marcella Ryan-Coker

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Wongel Tena Shale profile pic“We must exercise caution when placing undue pressure on the upcoming generation of female physicians.”

Wongel Tena Shale

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Claire Karekezi profile pic“I have been expected to work twice as hard to prove myself. I have been constantly challenged to prove I have adequate knowledge and skills.”

Claire Karekezi

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Bonisile Mthombeni profile pic“The operating theatre has historically and culturally been a male-dominated environment and this idea of the ‘boys club’ has significantly impacted opportunities for minority groups in surgical spaces.”

Bonisile Mthombeni

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Marcella Ryan-Coker in operating theatreMarcella Ryan-Coker, Orthopaedic Registrar, Department of Surgery, University of Nairobi, Kenya

For me, the allure of surgery lies in its blend of art and science, and the ability to restore function and alleviate pain. Coming from a country with only two female specialist surgeons, I am aiming to become Sierra Leone’s first female orthopaedic surgeon.

Gender representation in the operating theatre is not merely a matter of equity; it’s critical to comprehensive healthcare delivery. Diverse surgical teams bring varied perspectives, experiences, and approaches to patient care. This enhances the decision-making process and fosters a more inclusive healthcare environment.

In my experience in Sierra Leone and Kenya, the challenges female surgeons face are deeply rooted in societal expectations. These expectations make balancing professional aspirations with traditional personal responsibilities a challenge. I’ve faced pressures about settling down and judgemental comments about ‘what a surgeon should look like’.

Until a few years ago, when I started actively seeking female role models in surgical disciplines internationally, the scarcity of female role models in surgery often made my experiences feel isolating. Through the Gender Equity Initiative in Global Surgery (GEIGS), which is associated with Harvard’s Program in Global Surgery and Social Change and has members in more than 65 countries, I met many female surgeons and trainees. As I progressed in my training, I also joined specialised orthopaedic organisations such as the International Orthopaedic Diversity Alliance. Through these interactions and collaborations, I’ve connected with more women in surgery than ever before, which has been incredibly empowering.

Fostering a culture that welcomes and supports women in surgery is essential. This begins with a harassment-free workplace and means urgently addressing gender-based discriminatory practices which have been allowed to silently persist in the surgical corridors. Clear zero-tolerance policies are a step towards this. Importantly, it also requires male colleagues and departmental chairs speaking up when they witness gender-based discrimination and taking appropriate action.

But changing the culture also involves providing equal opportunities for advancement, both from a surgical-skill and a leadership perspective. Training institutions must adapt to the unique challenges women face, especially regarding family and motherhood, through more flexible schedules and supportive policies, including maternity leave.

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Wongel Tena Shale working in operating theatreWongel Tena Shale, Assistant Professor of General Surgery, Jimma University Medical Center, Ethiopia

When I was doing my early medical training years, I was fascinated by what goes on in the operating theatre. I looked up to the head of department at the time as a powerful role model as she was one of the first female surgeons in Ethiopia and had to overcome great obstacles to reach her position.

Despite the fact that female representation in surgery has improved globally, there is still work to be done; I don’t think the progress in gender representation is consistent across nations. I now work as a general surgeon in one of Ethiopia’s tertiary teaching hospitals at the University of Jimma. Since the beginning of surgical training in 2006, 118 surgeons have graduated, but only five (4.2%) are female. It has been four years since I graduated from the programme and no woman has followed me yet. Of the current surgical trainees, only one is female.

We continue to encounter implicit bias and stereotypes from faculty surgeons, colleagues, juniors, and even patients and patients’ families. It is not uncommon for patients to assume the male nurse in the room is the physician and the female doctor is a nurse. At the operating table, we sometimes see female surgical trainees granted less autonomy by faculty surgeons compared to their male colleagues.

I recently compared experiences with two of my fellow female surgeons who said: “I have seen situations where senior surgeons were eager to point out my mistakes while adamantly defending male colleagues who committed more serious errors” and “I’ve occasionally found it difficult to distinguish whether the bias or barriers I encountered were the result of my gender or my own errors.”

Encouragingly, at a regional level, the College of Surgeons of East, Central, and Southern Africa (COSECSA) now has a policy for increasing women in the surgical workforce. Since the establishment of Women in Surgery Africa (WISA) in 2015, the number of women trainees has grown from 19% to 27%.

On the other hand, we must exercise caution when placing undue pressure on the upcoming generation of female physicians. We want women to pursue surgery with the appropriate goals in mind, not to prove themselves to those who doubt their abilities. Female physicians need to be reassured that, should they so desire, it is also admirable to specialise in less time-demanding disciplines.

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Claire Karekezi standing with white coat and stethoscopeClaire Karekezi, Neurosurgeon, Rwanda Military Hospital and Senior Lecturer of Surgery, School of Medicine and Pharmacy, University of Rwanda, Rwanda

In my fifth year of medical school, I participated in a professional exchange in Sweden. My interest at the time was radiology but the only department still running at full capacity over the summer was neurosurgery, so I got involved in that instead. I was amazed that you can open someone’s head, navigate the brain, and save their life. Seeing that for the first time sparked my interest in neurosurgery. However, to get into a training programme took three years of writing emails and waiting as there was no available training in my country, and only a few places trained neurosurgeons in Africa.

As women have broken into these disciplines, we have faced criticism because of gender bias. Culture, especially in the African context, remains a key barrier faced by women choosing any medical field. Hard science, like medicine and surgery, particularly neurosurgery, is still not seen as something women are capable of. More women need to break the glass ceiling to change the norms, and show other young women that they can also belong in the operating room.

As the first female neurosurgeon in my country, I have had to fight for my place in the discipline from training to consultancy. I have been expected to work twice as hard to prove myself. I have been constantly challenged to prove I have adequate knowledge and skills. As a woman it is especially hard to make it in academia and leadership positions.

There is a need not only to open doors to more women in the surgical disciplines, but also allow them equal standing once they are in the room. By this I mean we need to help women get into surgical training, and also get into leadership positions and academia within these disciplines. While this issue is not unique to Africa (only four percent of European neurosurgery departments are headed by women), it is even more pronounced in our contexts.
Having more experienced female neurosurgeons in positions of power in our institutions, would likely result in supportive leadership for the upcoming generation of female surgeons.

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Bonisile Mthombeni in operating theatreBonisile Mthombeni, Independent Medical Officer (Orthopaedic Surgery), South Africa

My motivation to pursue a career in surgery was initially sparked by a reverence for the adaptability of the human body. In the face of pathology, or trauma, surgery provides a practical, tangible means to restore, improve, and maintain the functionality of a human body.

Despite often feeling deterred, it is also the lack of gender and race representation in surgical disciplines, and finding a community of exceptional female surgeons who are creating the new demographic, that motivates me to add to the growing numbers. It is no longer about being one of few, we are forming a community of many.

The operating theatre has historically and culturally been a male-dominated environment and this idea of the ‘boys club’ has significantly impacted interest and opportunities for minority groups in surgical spaces. The operating theatre is a daunting space as women are alienated into feeling you do not belong. This manifests in the nursing team, seniors, colleagues, or even patients casting doubt or dismay at your presence, and inappropriate jokes about a ‘woman’s place’. Gender representation in the operating theatre not only changes the immediate environment, but is a step towards changing the underlying culture, making it a more inclusive and accepting space for working or healing.

The biggest challenge in surgical careers is creating a sustainable work-life balance throughout the years of training, which is not designed to promote a holistic life outside surgery. Male and female surgeons endure gruelling 30+ hour shifts, the departmental and structural challenges of healthcare in South Africa, and the rise in mental illness among surgical trainees. For aspiring female surgeons, these challenges are further exacerbated by the societal expectations of the domestic and child-rearing role of a woman.

Peer-guided mentorship initiatives and communication and resource-sharing platforms for female surgeons could significantly improve training opportunities. Joining female surgeons at the operating table is a sure way to start believing it is a space that one can thrive in. Educating male counterparts on the impact of their perpetuation of the ‘boys’ club’ can also create a healthier work environment and surgical space.

 

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This post is opinion-based and does not reflect the views of the London School of Economics and Political Science or any of its constituent departments and divisions.   

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Main image: Wongel Tena Shale

About the author

Head and shoulders photograph of Amy Paterson

Amy Paterson

Amy Paterson MBChB MSc Med is a DPhil student in the Epidemic Diseases Clinical Research Group, University of Oxford, UK

Posted In: HE across Borders

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