1. Gender inequity in the surgical workforce
Does it predispose to bullying and harassment ?
A / Prof David Hillis,
DEd, MHA, FRACMA, FRACGP, FRACS (Hon)
Chief Executive Officer, RACS
Principal Fellow, Medical Education Unit, Melbourne University,

2. Abstract
Surgery has traditionally been a ‘male dominated’ workforce. Currently only 11% of the surgical workforce is female although over 30% of current trainees are female.
Procedural based specialties appear to be at a higher risk of discrimination, bullying and sexual harassment. Factors in this include the hierarchical structure of the workforce, stressful healthcare environment including pressures to meet administrative deadlines, lack of support for victims, lack of leadership as well as substantial gender imbalance.
Initiatives from the Royal Australasian College of Surgeons (RACS) will be discussed.

3. Gender Equality
All human beings, both women and men, are free to develop their personal abilities and make choices without the limitations set by stereotypes, rigid gender roles, or prejudices.
Source: UN Women

4. Gender Equity
Gender equity means that women and men are treated fairly according to their respective needs. This may include equal treatment or treatment that is different but considered equivalent in terms of rights, benefits, obligations and opportunities.
A gender equity goal often requires the implementation of special measures to correct historical and social disadvantage: quotas, affirmative action, etc  
Source: UN Women

5. The Numbers 1 – MBA Registration by Gender
Registration Type (August 2015)
Female
Male
Total
Percentage
General
17640
17169
34809
51%
General and Specialist
16870
32329
49199
34%
Specialist Only
2737
5573
8310
33%
Other
4943
5872
10815
46%
42190
60943
103133
41%

6. Profile of surgeons. Total Active surgeons. Australasian figures
Specialty
Female
Male
Total
Percentage
Cardiothoracic 12
209
221 5%
General
278
1676
1954
14%
Neurosurgery 32
234
266
12%
Orthopaedic 58
1477
1535 4%
Otolaryngology 75
476
551
Paediatric 98
130
25%
Plastic 66
427
493
13%
Urology 44
432
474 9%
Vascular 21
186
207
10%
618
5215
5833
11%

7. SET intake

8. Trainee age at selection 2007 - 2013
Specialty
24-27
28-29
30-31
32-34
35-40
41+
Total
Total Age%
12.4%
26.8%
24.7%
21.7%
12.2%
2.2%
100%
Female%
36.4%
28.7%
27.4%
24.0%
18.4%
17.1%
CAR
17.7%
24.4%
28.8%
8.8%
GEN
15.0%
27.7%
17.9%
12.5%
2.0%
NEU
7.0%
29.6%
26.7%
19.7%
15.4%
1.4%
ORT
5.2%
25.9%
23.7%
29.2%
13.4%
2.3%
OHN
10.7%
29.5%
25.5%
23.4%
9.3%
1.3%
PAE
18.2%
21.1%
31.5%
10.5%
0.0%
PLA
6.5%
27.6%
24.3%
19.1%
2.6%
URO
19.4%
30.0%
22.2%
7.2%
1.6%
VAS
29.9%
20.2%
18.9%
10.8%
2.7%

9. Female proportion of PGY/specialty cohorts

10. Key Gender Indicators: Ratio of Female to Males
Specialty
2014 Appointed
Active trainees
Active Fellows < 44yo
Active Fellows
Cardiothoracic
0.40
0.23
0.10
0.06
General
0.57
0.55
0.36
0.17
Neurosurgery
0.67
0.28
0.25
0.15
Orthopaedic
0.12
0.07
0.04
Otolaryngology Head and Neck
1.00
0.56
0.38
0.16
Paediatric
0.50
1.23
0.71
0.37
Plastic and Reconstructive
0.45
0.62
Urology
N/A
0.30
0.21
Vascular
0.18
0.27
0.11
All Specialties
0.41

11. Trainee attrition (290) – gender %

12. Exit reasons across gender
Female
Male
Female / male ratio
Totals
Number
% of all female trainees
% of all male trainees
Misconduct  0 2
0.13%
Unpaid fees
0.32% 3
0.2%
1.62 5
Maximum exam attempts
0.8% 8
0.5%
1.6 13
Time expired 49
7.8% 72
4.7%
1.66**
121
Unsat. performance 4
0.6% 12
0.7%
0.86 16
Withdrawn 90
14.4% 87
5.7%
2.5***
177
Death
All exits
150
24%
187
12.3%
1.95***
337

13. Profile of leadership
Councillors
Training Board Chairs
Profile of examiners
Gender balance reflects percentage of more senior surgeons: low

14. So lets consider…
Are female doctors making a choice not to apply to surgery, or is there something about surgery that is making the choice for them?
Why do some specialty programs receive significantly more interest from female doctors than others?
Is there a single surgical culture, or are there nine (or more) surgical specialty cultures?

15. So lets consider…
Is our selection process free of gender bias?
Are the prerequisites for applying equally achievable by females and males?
Is there more the College could do to promote gender equity?
Is there more that Fellows as individuals can do to promote gender equity?

16. Key messages from DBSH Issues paper: Predisposing factors
Unhealthy work practices and training arrangements
Facilitates bad behaviour
Precludes work-life balance for men and women
Culturally embedded in practice of surgery, particularly hospitals
Excessive unpaid work hours are used as a form of bullying
Lack of diversity, gender inequity and strong hierarchies in the surgical profession are linked to increased prevalence of discrimination, bullying and sexual harassment

17. Finding from RACS surveys
49% of surgeons report being subjected to discrimination, bullying and sexual harassment (DBSH)
63% of trainees
71% of hospitals reported DBSH in last five years with bullying the most frequently reported issue
Senior surgeons and surgical consultants are reported the principal source of the problem

18. Recommendations Cultural change and leadership Education
About educating
About DBSH
About coping with stress
About ‘calling out’ DBSH and bad behaviour
Complaints management
Gender Equity
Reviewing issues like flexibility that will increase the appeal of surgery to a more diverse group
Setting targets, monitoring
Identifying champions and role models

19. Summary
DBSH is endemic. There is no workplace, no hospital that is not affected.
Gender equity is one of the many things that must be addressed
RACS has now formally apologised publically for the prevalence of DBSH within surgery and its negative impact
We must all do more to ‘call it out’, act on it locally, with our peers and across the health sector