Celebrating women in surgery

Laughter was the response when I first voiced my desire to be a surgeon early in medical school. Unfortunately, at the time, I had yet to come across a surgeon who looked like me, so I accepted the response and decided that my desire to be a surgeon was ridiculous. That belief stayed with me for a while and contributed to the impostor syndrome I experienced for years afterwards, even after gaining a general surgery national training number (NTN).

It took four attempts to get my NTN and on reflection, I realise self-doubt was a major obstacle to my progress back then. I remember one of my consultants saying ‘if you believe you deserve an NTN, you will get it’. They were right. I got my training number the year I truly believed I deserved it, the difference that year was self-confidence, nothing changed on my CV.

Since then I have risen above several challenges; delays in my training from severe hyperemesis requiring multiple admissions in both my pregnancies, two sets of maternity leave, and now juggling life as a wife and mother of two whilst working as a full-time surgical registrar.

Mentorship in surgical training is key. And not surprisingly, having someone that ‘looks like you’ is important. I have come across a number of junior doctors who would make excellent surgeons but who have convinced themselves that they are not good enough. The belief is often that you have to sacrifice your happiness, desire for a family and other life-defining dreams in order to pursue a surgical career. I want to change that narrative. My hope is that by succeeding in my surgical career whilst happily raising two children with my husband, I can show others that it is possible. And more importantly, I want to be the example for others I did not have when I started this journey.

I knew I wanted to be a surgeon when I did my first surgical firm as a medical student. I thought I had found my home. I loved the idea that I could use all my senses and abilities to treat patients, being able to use my hands was very important to me. It never occurred to me that I couldn’t be a surgeon, get married, and have children.

I went through the system relatively quickly and got a post on a run-through surgical training scheme (which was a new entity at the time). My husband and I also decided to start a family. I went on maternity leave in my second year and planned to return at the beginning of my third. A month before I was due back, I was surprised to be rung at home by the programme director to confirm that I was coming back. It transpired that I was the first mum to return to work in the specialty in my region. As ever, it never occurred to me that I wouldn’t!

After my second child, I elected to go less than full-time. Another new thing for the training committee to contend with (and for me to research with the help of the Royal College of Surgeons of England). Spending time with my very young children as well as having days that I could completely devote to surgery was a perfect mix. I am now a Consultant and was the flexible working advisor for the College, providing the support that I was once given. All surgeons should have the choice to work how they want to, whatever the reason. That’s the way to attract and retain the very best surgeons.

Imposter syndrome is something I first heard about at a WinS conference several years ago, and it is well known that this is something female surgeons struggle with. It is something I have dealt with since medical school with a constant feeling like I wasn’t good enough to be there. For every exam and interview I took and progressed, I was surprised at succeeding. I found it got much worse after having time out on maternity leave after my first child. The break from work for a year and then coming back during a pandemic meant my confidence was at an all-time low.

On my return, I was a senior trainee (ST7), back at work after a break in training, pregnant for a second time and trying to pass part 2 of my FRCS. It all felt a bit much and self-doubt was setting in and I felt like a fraud, I felt I was failing at being a trainee, failing at being a mum, and definitely going to be failing at passing my exam! I chose to challenge myself...I am a good mum with two amazing children (and I work LTFT at 80%, which works for me), I have always got outcome 1’s at my ARCP’s and I passed my FRCS whilst pregnant, in a pandemic, with a toddler. For that, I should be, and I am, proud of myself. I think we can sometimes put too much pressure on ourselves and be our own worst critics and need to be kinder to ourselves. My aim going forwards is to have a little bit more self-belief, confidence, and encourage those around me to do the same.

Surgeons, by nature, enjoy a challenge. It is therefore puzzling that, while surgeons make up 17.8% of doctors, only 9.2% of clinical academics are surgeons.

The traditional route to academic clinical practice is via the integrated academic pathway, including the Academic Foundation Programme (AFP) and Academic Clinical Fellowship (ACF). I initially fell off the conveyor belt at the latter stage, failing to secure an ACF place. Instead, I ended up in purely clinical Core Surgical and Higher Surgical Training programmes. Despite this, I never lost my interest in research, and 10 years and 3 sets of maternity leave after completing my AFP, I have started studying towards a PhD, while caring for 3 young children. This has certainly been one of the most challenging parts of my career!

Why did it take me so long to get back into academia? Partly because I was focusing on clinical training, partly because it took me a while to find the most suitable project.

I also found that it can be difficult to get back into academia once you’re out. Some of this reflects having to regain confidence after rejection – I had suffered a few more rejections along the way, in the form of funding applications. I am extremely grateful to have been eventually accepted onto an MRC Clinical Research Training Fellowship, thanks to the incredible support of my supervisor and department.

Why did I persevere? I had many sources of motivation. One was because my passion for research grew, rather than waned, while I was out of academia. Getting involved with the British Journal of Surgery (BJS) as Associate Editor for Social Media certainly fuelled this interest, as I have been able to learn about what makes a good scientific paper. I also had plenty of time to reflect on what it means to be a woman in surgery and a woman in academia, which was furthered by joining the Medical Women’s Federation and becoming a member of the WinS Forum. Starting my PhD was only possible thanks to the flexibility and support of my supervisors, my department, and the MRC, when I informed them that I was expecting my third child and that I would need to defer my start date until after maternity leave. I had dreaded telling them, but I needn’t have worried about their reactions, which were simply to congratulate me!

Thanks to WinS, it is widely known that women make up only 13.2% of UK consultant surgeons, despite representing over half of medical school graduates. There is hope for improvement, as over one third of surgical trainees are women. However, while the proportion of female surgical professors is similar to that of consultants at 11%, readers and senior lecturers are only 14.7% women, and lecturers 25.5%. In a cross-sectional study of surgical trainees, Brown et al. found that only six of the 38 (16%) women studied, compared with 31 of the 63 (49%) men, achieved higher degrees during their training, and men had a higher number of publications, a greater first-author role, and more citations than women. These statistics make for pessimistic reading concerning the future of gender diversity in academic clinical surgery. Strangely, this motivates me further.

How do we retain women in academic surgery, or re-recruit those who, like me, fall off the conveyor belt? Visible role models, mentorship, and male allyship (including calling out gender bias in the workplace) all play a role both in helping individuals find their way back, and in fostering a more welcoming place when they arrive.

Prof Avril Mansfield became the UK’s first female professor of surgery in 1993. It is past time for women in academic surgery to be the norm. I am choosing to challenge both myself and the stereotype of the academic surgeon.