Organisational barriers to and facilitators for female surgeons’ career progression: a systematic review

Abstract

Objective

To identify organizational barriers to and facilitators for female surgeons' career progression.

Design

Systematic review of qualitative and quantitative studies relating to organizational barriers to and facilitators for female Surgeons' career progression. After the quality assessment of the peer-reviewed journal articles, twelve articles were selected for full review. Thematic analysis was used to identify key themes in these selected articles.

Setting

The studies solely focused on organizational factors linked to female physicians' career progression in surgical specialties.

Partcipants

Female surgeons.

Main outcome measures

Organizational barriers and facilitators

Results

Twelve peer-reviewed journal articles were included in the study which focused on barriers to female surgeons' career progression, ways of facilitating female surgeons' career progression, and female surgeons' job satisfaction.

Conclusion

The major organisational factors contributing to the lack of career progression for female surgeons are (1) organizational culture which promotes rigid career structure that is inclined to support male surgeons than female surgeons and also male domination in which male surgeons feel superior to female surgeons (2) work family conflict whereby women feel that they have to make a family sacrifice by being women; they experience the difficulty in securing a work-life balance in the masculine career structure in surgical specialties. This implies that policy makers and healthcare organizations need to pay significant attention to organizational facilitators for female surgeons' career progression such as flexible career pathways and work patterns, a variety of different viable career progressions, more family-friendly working conditions, and the promotion of female mentors and role models in surgical specialties to support female surgeons in dealing with the organizational barriers in the male-dominated organizational culture and the lifestyle issues as well.

Keywords

Female surgeons career progression organisational barriers organisational facilitators gender inequality

Introduction

The percentage of women among medical students has been growing recently in both developed and developing countries, and the number of women in medicine has increased quite rapidly worldwide.^1–3 However, women generally remain seriously under-represented in the field of surgery. For example, the proportion of women surgeons associated with the UK National Health Service was just 6.5%.⁴ Such under-representation can impact on female patients’ satisfaction with the services they receive, as research shows that gender preference with regard to doctors is more prevalent among female patients than that among male patients.⁵ For instance, women find female doctors more desirable for breast, cervical and colorectal screenings, because the procedures feel less embarrassing when women do not have to expose their body to a physician of the opposite gender.⁶

Indeed, the number of women entering the field of surgery has risen due to the positive efforts made by medical schools, medical councils and healthcare providers.⁷ Nevertheless, many women leave surgery before developing their career. The number of female physicians who change their specialty in the course of training is the highest in surgery.² Several researchers have argued that female doctors’ lifestyle preferences are the primary cause of this under-representation. They contended that women are more likely to choose a balance between work and personal life and often do not attach the same importance as men do to achieving a high income or a prestigious position.^1,8

However, other researchers have strongly argued that there are persistent organisational barriers such as a female-unfriendly work environment which includes all-hours work and on-call duties and culture of gender discrimination in surgery and that such barriers create a ‘glass ceiling’ that prevents female doctors from rising beyond a certain level in the surgery hierarchy.^9–12

As a result, some female surgeons shift to non-surgical specialties, such as general medicine and paediatrics, which do not seem to have the inconvenient obligations that come with life as a surgeon.^12,13 This implies that examining organisational barriers to female career progression in surgery is a significant research area, although there has been very little research reported on this.

Consequently, we conducted a systematic review to identify organisational barriers and facilitators for female surgeons attempting to progress in their careers.

Methods

This study systematically identified, critically appraised, summarised and synthesised qualitative and quantitative studies relating to organisational barriers to and facilitators for female surgeons’ career progression.

We conducted a systematic literature search using different electronic databases including Google Scholar, CINAHL Plus, Medline, PubMed, Science Direct, ScienceDirect, Emerald Management and Wiley Online Library. These databases were searched using various combinations of the key terms included ‘women physicians’, ‘female doctors’, ‘surgeon’, ‘obstacle’, ‘barrier’, ‘gender-based discrimination’, ‘glass ceiling’, ‘work-life balance’, ‘part-time’, ‘family’, ‘children’, ‘career’, ‘satisfaction’, ‘surgical specialty’, ‘general surgeon’ and ‘obstetrics and gynecology’, and Boolean logic using ‘AND, OR’ was used to refine a number of articles. We adapted the Preferred Reporting Items for Systemic Reviews and Meta-Analysis when conducting this search¹⁴ and identified 284 articles after title screening and excluding duplicates. Following a screening of the abstracts, 49 articles were selected by the first author for full text reading (Figure 1).

Figure 1.

Preferred Reporting Items for Systemic Reviews and Meta-Analysis flow chart.

From the retrieved 49 articles, we identified studies which met the following inclusion criteria: (1) peer-reviewed English-language journals published in the last 10 years; and (2) studies solely focused on organisational factors linked to female physicians’ career progression in surgical specialties such as general surgery, academic surgery, paediatric surgery, plastic surgery, and obstetrics and gynaecology. The exclusion criteria were: (1) studies not focused on organisational factors linked to female physicians’ career progression in surgical specialties; (2) studies focused on male physicians/doctors and female doctors working in non-surgical specialties; (3) studies not published in English; and (4) studies published before the year 2005 in order to indicate the ongoing debate in the research area.

Using the above criteria, the both authors selected 18 articles for quality assessment. These articles were assessed using an appraisal checklist by Kuper et al.¹⁵ The tool consists of six key questions, each question was categorised ‘yes’, ‘unclear’ or ‘no’. If one question was assessed as ‘yes’, it was counted as 1 point. If all questions were assessed as ‘yes’, the total quality score for a study was a maximum of 6 points. If the question was assessed as ‘unclear’ or ‘no’ it was counted as 0. Consequently, after the quality assessment, we deselected six articles because it was difficult to transfer the results of the studies reported in the papers to the setting of our study.¹⁵ All of these deselected studies have quality scores lower than 5 and some of them have very low quality scores (e.g. 1, 2). As a result, including the results of these deselected articles in our analysis would not change the final outcomes of our systematic review significantly. The 12 articles selected for full review have quality scores of −5.

We extracted study details from each article and summarised them using a standardised data extraction form in order to reduce errors and minimise bias. Both authors participated in data extraction. The first author extracted all the studies included in the review. The second author extracted a random sample of 50% to assess the reliability. Any discrepancies were discussed by both authors and resolved by consensus.

A data extraction form by Bettany-Saltikov¹⁶ was used as a data registry and as a guide for identification of the experience from female surgeons’ perspective. Details of the author, year of publication, purpose of the study, study design, setting, population, exposure and outcomes were included in the data extraction form. Study design was categorised as quantitative or qualitative, but the original study sometimes mixed both methods. Study population was only selected to the specialties relevant to the review. Data were categorised into organisational barriers and facilitators within the career progression. Every outcome was also categorised using sub-themes.

Thematic analysis was used to identify key themes from the selected articles. We began with repeated reading of data extracted from the papers. This process helped us to identify recurrence themes related to organisational barriers to and facilitators for women's career progression in surgery. From these themes, we iteratively developed final themes that helped us to examine the phenomena we studied.¹⁷

Both authors participated in thematic analysis. The first author independently developed themes and discussed them with the second author. Through this discussion more themes began to emerge and some initial themes were abandoned. This iterative process was repeated until the final themes were able to sufficiently identify and explain organisational barriers to and facilitators for female surgeons’ career progression. Any discrepancies were discussed by both authors and resolved by consensus.

Results

Twelve peer-reviewed journal articles were included in the study. Two studies focused on barriers to career progression,^18,19 one investigated ways of facilitating career progression²⁰ and two explored both subjects.^21,22 Six studies focused on job satisfaction; among these, three studies also suggested barriers^22–24 and two discussed facilitators for career advancement.^25,26 The remaining two studies in this category described the reason why female surgeons experienced or did not experience job satisfaction.^27,28 Five studies were conducted in the United Kingdom, six in the United States and one in Canada. Five studies were quantitative, three were qualitative and four used mixed methods.

Table 1 summarises the articles included in the review. We identified key themes from the results (i.e. extracted data) related to organisational barriers to and facilitators for women's career progression in surgery using thematic analysis. We discuss these key themes and sub-themes in detail below.

Table 1.

Summary of articles reviewed.

Author (year), country	Purpose of study	Study design/Quality appraisal	Study population	Study findings
Ahmadiyeh et al. (2010),²⁵ USA	To better understand the career satisfaction of female surgeons	Qualitative data/5	General surgery and some boarded in subspecialties	Female surgeons were equal and highly satisfied with their surgical careers in comparison to male surgeons. Social networks included both personal (family, friend and neighbour support) and professional (colleagues to share knowledge and expertise, mentors) and are keys to develop a successful surgical career.
Cochran et al. (2013),¹⁸ USA	To examine specific obstacles to women’s academic career advancement	Quantitative data/5	Academic surgery	Female academic surgeons feel excluded from the male dominant culture. In particular, people’s attitudes about their gender and having children are barriers to career advancement.
Crompton and Lyonette (2011),¹⁹ UK	To investigate the issues of gendered career paths	Quantitative and qualitative data/5	Consultants	Women were responsible for the main management of childcare and domestic work. Organisational culture such as male dominance and lack of equal opportunities was career barrier.
Dornhorst et al. (2005),²⁰ UK	To determine the required changes to improve hospital doctors’ working lives	Quantitative data/5	Obstetricians and gynaecologists with NHS	The provision of education/training, mentoring, childcare, part-time and flexible training was proposed to improve doctors’ working lives.
Hebbard and Wirtzfeld (2009),²⁷ Canada	To better understand how female general surgeons manage lifestyle and demands	Quantitative and qualitative data/5	General surgery	Job satisfaction was generally rated highly, but a level of parenting satisfaction was rated moderately and the highest answer was dissatisfied. The time commitments and on-call duties were often cited as the negative aspects of surgery. Work-related stress, frustration and worry were also commonly cited as negative aspects.
Longo and Straehley (2008),²³ USA	To discuss female surgeons’ personal experiences of career obstacles and the coping way	Quantitative and qualitative data/5	US board-certified female surgeons	Female surgeons perceived gender-based discrimination and sexual harassment by the male power structure in surgery. They had also experienced stress from balancing work and family responsibilities. Most of them are satisfied with their career advancement, but several factors such as unequal pay, time-consuming business activities, lack of time to pursue interests outside of medicine, and high cost of medical education and training are distressed.
Miller and Clark (2008),²¹ UK	To explore the barriers to the career progression of women and to explain the reasons	Qualitative data/5	Hospital consultants	Female doctors believed that taking time off for family respondents would harm their career. There was a male-dominated organisational culture such as gender discrimination and old-boys' network in the medical profession and women were excluded from this culture. Organisational change and professional support such as social network, financial support, childcare facilities and part-time training posts were suggested as facilitators.
Ozbilgin et al. (2011),²⁹ UK	To explore the complex interplay between professionalism and regulation of time and gender	Qualitative data/5	Hospital consultants	All-hours work and the difficulty in combining work and family were career barriers. One female surgeon was anxious about sustaining the current work patterns over the long term.
Park et al. (2005),²⁶ USA	To examine the differences in perceptions of a career by medical students and female surgeons	Quantitative and qualitative data/5	General surgery	Professional support such as job sharing or part-time practice, more flexible hours, improved parental leave and more accessible childcare options was most often suggested to pursue a career. Other suggestions were social support such as mentors, role models and changing the male-dominated attitudes. Most of them were satisfied with their career and they were happy with their specialty.
Smith et al. (2006),²² UK	To investigate career satisfaction and professional development	Quantitative data/5	Paediatric surgeons	Insufficient research time due to excessive workload such as duties and on-call was the most common barrier, and other barriers were domestic duties, lack of mentors and support from department, and the difficulty in securing part-time training. Improvement of flexibility over work shift patterns was a career facilitator. Most of them were satisfied with their career progression, but few were dissatisfied.
Streu et al. (2011), 28 USA	To assess satisfaction with work–life balance	Quantitative data/5	Plastic surgeons	Female plastic surgeons are satisfied with their choice of profession, but they are less satisfied with their work–life balance.
Zutshi et al. (2010), 24 USA	To evaluate job perception and expectation at gender differences	Quantitative data/5	Colorectal surgeons	Full-time surgeons were happy with career choice and clinical cases, but they had discontent with unequal promotion and income because of a lack of female mentors and research funding.

Organisational barriers to career progression

Organisational culture

The organisational culture focuses on the values, beliefs and expectations that organisational members come to share. As a result, the organisational culture influences behaviour patterns of professionals who work in healthcare organisations.³⁰ It has been argued that organisational culture is one of the key barriers which form the ‘glass ceiling’ that hinder women’s career progression.³¹

Seven studies cited organisational culture as a factor affecting female surgeons’ career progress. The common barriers reported in this category could be grouped into three types: career structure, male dominance, and lack of equal opportunities (Table 2).

Table 2.

Organisational culture as organisational barrier.

Organisational culture	Type of barrier	Main barriers identified
	Career structure	Inflexible working practice^21,22
	Career structure	All-hours work such as excessive workload and on-call commitment²⁹
	Male dominance	Gender discrimination^19,21,23
		Male power structure in surgery²³
		Old-boys' network^19,21
		Old-fashioned male-dominated professional attitudes, bias and prejudice²¹
		People’s attitudes about their gender¹⁸
	Lack of equal opportunities	The absence of social capital such as access to network²¹
		Lack of female colleagues in surgery²³
		Lack of mentors and lack of support from department head^18,22
		Lack of mentors¹⁸
		Fewer opportunities for women to advance careers²⁴
		A lack of mentors due to time commitments at work and home²⁴
		Inadequate research funding due to inadequate mentoring²⁴
		Male residents dislike female mentors²⁴

In our review, two studies found that rigidity of career structure requirements, such as all hours work, insufficient research time, and inflexible work practices, presented a barrier hindering career progression.^21,22 One 40-year-old female doctor noted that it would be difficult to alter the current career structure in surgery: ‘You can’t have part-time trainees in surgery, you just can’t! It’s a 24 hour job’.²⁹

Four studies in the review indicated the impact of male dominance in surgical specialties. Female surgeons reported having encountered gender discrimination in the form of being treated differently; receiving negative comments about their gender;¹⁸ and experiencing demeaning remarks, abusive behaviour, or bullying.²³ Studies revealed experiences of old-fashioned male professional attitudes, the ongoing prevalence of bias and prejudice in traditionally masculine fields,²¹ and a sense of entitlement that allows men to feel superior to women.²³ Therefore, females felt excluded from the dominant culture in surgery departments, and negative male attitudes and consequent exclusion from the ‘old-boy network’ inhibited the career aspirations of female surgeons.^18,19 For example, a cardiac surgeon at a university hospital stated that she stumbled blocks every steps of the way, and the same biases she encountered still exist today.²³ This implies that those who indicated the existence of gender discrimination believed that men and women did not have equal opportunities for career progression in the surgical field.²¹

Furthermore, five studies in our review indicated that the absence of forms of social capital, such as access to social networks and collegial support, constituted a barrier to females’ career progression.^21,23 In particular, a lack of female mentors and a lack of support from department heads were cited as causing females to have fewer opportunities for career advancement than their male peers.^18,22 For instance, one woman seeking to become the chair of a surgical department stated ‘Being a chair requires political tact and connection to a network of supporters … Women don’t often have the chance to show their political skills and lack the network of supporters their male colleagues have.’²³ Additionally, female surgeons claimed that few female mentors were available due to their time commitments at work and home and that male residents disliked female mentors. Consequently, female surgeons indicated that this inadequate mentoring negatively affected their pursuit of research funding.²³ According to Longo and Straehley,²³ one reason why young female doctors are not encouraged to pursue careers in surgery is that they lack a mentor during their formative years.

Work–family conflict

Work–family conflict refers to the impact of personal lives in the workplace. Work–family conflict has been explained as a form of inter-role conflict in which role pressures from the work and family domains are mutually incompatible. In other words, work–family conflict arises when family responsibilities hamper work activities.³²

Nine studies covered the various forms of work–family conflict experienced by female surgeons: domestic duties; career breaks; and difficulties in combining professional and family demands (Table 3).

Table 3.

Work–family conflict as organisational barriers and reasons of dissatisfaction with job.

Work–family conflict	Type of barrier	Main barriers identified
	Domestic duties, career break and difficulties combining professional and family demands	The major responsibility for the childcare and domestic work¹⁹
		Having children^18,23
		Childcare duties, homecare duties²²
		Career break for family²¹
		The difficulty in managing work–life balance^21,29
	Lifestyle issues	Birth of children during critical periods²²
		Parenthood²⁷
		Career trade-offs for personal and family²⁵
		Issues surrounding personal time, predictable time and family relationships²⁵
		Struggle with the integration of their chosen profession and personal lives²⁸
		Stress arising from the intense demands of their profession and conflicting family pressures²³
	Organisational issues	The time commitments and call obligations²⁷
		Anxious about sustaining the current all-hours work over the long term²⁹
		Too much work to do everything well such as longer hours work, emergency room call responsibilities and primarily reconstructive practice²⁸

One study found that all female participants were responsible for the majority of housework and childcare,¹⁹ and female doctors expressed the view that having children and domestic duties were barriers to their professional development.^18,22 For example, an assistant professor and director of a university surgical residency programme had to forgo the tenure track because of the difficulty in meeting both the work requirements and family commitments. She stated that having two children in a two-year period had clearly affected her academic and clinical productivity, illustrating how family concerns slowed the progress of married women’s careers.²³

Most female doctors believed that having a family would harm their careers because the masculine-oriented career structure poses a major problem for working women who also have caregiving responsibilities. One cardiac surgeon insisted ‘Women are not treated equally. We cannot have children during training. The strong women finish, but it is difficult and involves great sacrifice.’²³

On the other hand, most women in surgical specialties were satisfied with their specialty choice and their careers. For instance, female colorectal surgeons were happy with the clinical cases they saw²⁴ and 80% of female general surgeons were satisfied with their career choice.²⁶ However, most female surgeons had experienced significant stress arising from the intense demands of their profession and conflicting family pressures.²³ For example, Streu et al.²⁸ reported that female plastic surgeons felt that they had too much work to do and that they struggled with time management of both career and personal responsibilities. This view resonates in several studies (Table 3). Nevertheless, female surgeons enjoyed their jobs, but they were not satisfied with their work–life balance because of the lifestyle sacrifices they must make. A middle-aged female surgeon confessed, ‘I am working really hard now but I cannot possible carry on like this for much longer. I come at 8 in the morning and always leave late. I will always work evenings and weekends.’²⁹

Organisational facilitators of a successful career progression

Professional support

Professional support occurs when an organisation provides effective support for their employees who are highly motivated to exert effort, but the organisational work environment is not conducive enough for them to achieve organisational goals.³³ Five studies identified professional support for female doctors as a facilitator, and all of them recommended the implementation of flexible work patterns (Table 4). For instance, Miller and Clark²¹ stated that the availability of part-time training positions (e.g. so that females could work fewer hours if they had children) favourably influenced female doctors’ career choices. Dornhorst et al.²⁰ also found that providing part-time and flexible training was important to improve female obstetricians' and gynaecologists' work lives. Smith et al.²² demonstrated that shared or part-time practices, improved parental leave and more flexible hours were needed to enable women to successfully pursue careers in general surgery.

Table 4.

Organisational facilitators.

Type of facilitators	Main facilitators identified
Professional support	Improvement of flexibility over work shift patterns²²
	Improvement of flexible work patterns such as part-time and flexible training^20,21
	More flexible hours, shared or part-time practices, and improved parental leave²⁶
	Work less than the usual 80 hours a week²³
	The provision of childcare facilities^20–22
	To promote more training and further education, and to support financial issue^20,21
Social network	Social capital such as access to network and collegial support²¹
	Social network such as colleagues and mentors²⁵
	Increasing the number of mentors and role models^20,26
Organisational culture change	To change the organisational culture that perceive female surgeons as an organisational and professional liability^21,26

Furthermore, Smith et al.²² reported that greater flexibility with regard to work shifts was a factor enhancing female paediatric surgeons’ career progression. Hence, the promotion of flexible career structures would keep well-trained female surgeons in the field and would help to attract new candidates. Availability of childcare facilities,^20,21,26 promotion of additional training and further education, and adequate financial support^20,21 were also identified as important forms of professional support.

Social networks

Social networks were cited as a key to women’s career success in three studies (Table 4). Professional networks, collegial support and mentors are important to developing a successful surgical career, because social networks enable women in male-dominated specialties to share their knowledge and expertise.²⁵ In particular, mentors can provide social support and appropriate information, and can serve as valuable role models for young doctors.^25,26

Organisational culture change

Two studies recommended efforts to change problematic aspects of the organisational culture in surgery. Female general surgeons in studies propose to change the attitudes typical of traditionally male-dominated organisational culture.^21,26 For example, many women were discouraged to pursue a surgical specialty at medical school partly because of views held by surgeons that women and surgery do not mix.²¹ Some female surgeons suggested changing the organisational culture that stereotypes female doctors as an organisational and professional liability because female surgeons struggle to cope with excessive pressure to ‘do everything’²¹ (Table 4).

Discussion

This systematic review found considerable evidence of organisational barriers that hinder the career progress of female surgeons. It demonstrated that the major factors contributing to the lack of career progression for female surgeons are: (1) an organisational culture which promotes rigid career structure that is inclined to support male surgeons than female surgeons and male domination in which male surgeons feel superior to female surgeons; and (2) work–family conflict whereby women feel that they have to make a family sacrifice by being women and mothers, and the difficulty in securing a work–life balance in the masculine career structure. In addition, many women believed that it is difficult to achieve a work–life balance in higher positions and higher positions lead to more stressful work.²¹ Thereby, women frequently do not want to progress in their careers, because they believe that they have to give up their personal life in order to occupy higher positions. As a consequence, these beliefs prevent women from pursuing their careers.

Despite these challenges, most female surgeons are satisfied with their specialty choice and career. They report that they would choose a career in surgery again if they could start over,²⁷ and they think that surgery is a good career for women.²⁵ Medical students tend to assume that female surgeons do not enjoy their jobs because of the long work hours and high job demands, but in this instance there is a significant gap between perceptions and reality. Interestingly, female surgeons with families are also satisfied with their jobs, but they have sacrificed their personal lives to pursue professional careers, to the extent that they feel dissatisfied with their ability to parent.^25,27 Additionally, female surgeons, whether married or single, are displeased with some of the obligations associated with surgery careers, such as heavy time commitments and on-call duties.^25,27 Female surgeons’ job satisfaction is strongly associated with their work–life balance, because they want to work relatively ‘normal’ hours.¹

This implies that healthcare organisations need to pay significant attention to organisational facilitators for female surgeons’ career progression. First, flexible career pathways and work patterns are recommended to retain female surgeons and attract more female medical students. Healthcare organisations need to arrange and implement a variety of different viable career progressions.³⁴ Second, establishing more family-friendly work conditions to fit domestic responsibilities, especially the provision of adequate childcare facilities, would enable a more satisfactory balance between work and family for all female doctors, not only surgeons.^20,35 Third, the promotion of female mentors and role models is suggested to support female surgeons in dealing with their organisational and lifestyle issues. Increasing availability of mentors and role models would contribute to expanding the number of female medical students entering surgical specialties,⁷ and the eventual development of richer social networks resulting from the increasing number of female surgeons would further enhance females’ careers.^21,25,26 Ultimately, the greater presence of female surgeons would produce meaningful change in the currently male-dominated organisational culture, so that female surgeons would no longer believe that they are restricted by a glass ceiling. At that point, women would have greater opportunities to advance into leadership positions or to achieve the balance that they prefer between productive professional work and their personal lifestyles.

Conclusion

This systematic review has identified and synthesised the main perceived organisational barriers to and facilitators for female surgeons attempting to achieve a successful career progression. The findings described here may be useful for policy-makers and healthcare organisations as they seek to create new career structures for female surgeons and to make the work environment better suited for women.

Nevertheless, the study has some limitation; the studies included in this review lack details about doctors’ personal work patterns, such as whether they were employed part-time or full-time or their personal family contexts. More investigation of the implications of part-time work and other family-friendly work conditions is needed. For instance, Barnett and Gareis³⁶ found that reducing work hours had increased life satisfaction among married female physicians with children, but Crompton and Lyonette¹⁹ observed that part-time work can be counterproductive to careers by limiting opportunities for promotion to higher positions.¹⁹ Consequently, further research needs to examine the advantages or disadvantages of flexible work patterns, such as part-time employment and job sharing for female surgeons’ career progression.

Footnotes

Declarations

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