The President of the Royal Australasian College of Surgeons (RACS), Professor Michael Grigg, announced last week, as published in Fairfax and ABC Media, the establishment of an expert advisory group to deal with concerns of bullying, harassment and discrimination in the health sector. I am proposing that the problem is a systemic one within the public health sector and I am not alone.
The panel’s deputy chair, former Victorian equal opportunity commissioner Dr. Helen Szoke said, “Many of the indicators around gender equality have not been moving ahead with the rapidity that you would expect for a reasonably wealthy western democratic country, so that suggests there are systemic barriers, that there are institutional practices and it shouldn’t be left up to individuals to change systems.”
It is not just the overt sexual harassment that Dr. Gabrielle Mc Mullin commented on, highlighted by Dr. Caroline Tan’s case.
This is just the tip of the iceberg. The real problem is that sexism is insidious and, in defense of my male colleagues, to a large extent an unconscious behaviour in the surgical profession as a collective within an institutional system, rather than any one specific individual.
An anonymous letter published in The Age on the 10th of March 2015, identified the varying degree of unpleasant experiences numerous female surgeons face at various times throughout their career. A claim I can attest to. In this regard, the medical industry is not much different to other vocations that have been traditionally dominated by men, such as politics or large corporations.
Sexism is like a veil of fog. It is there but hard to grasp and hard to define. This sexism permeates our public health system, the place where training of our future surgeons occurs. Whilst the Royal Australasian College of Surgeons is progressive, ultimately it is in our public health systems where major change needs to transpire. It here that the surgical profession merges with the world of politics in a corporate style structure to become an unenviable melting pot of unconscious, insidious sexism.
Let’s look at the numbers: Since 1996, women have outnumbered men in medical school. 23.8% of surgical trainees are women but I am unable to identify a Department of Surgery Head Director who is female in Australia and only a handful of women are head of their specialty in various hospitals. Somehow after training we end up with just 9% female surgeons.
There is a highly disproportionate number of male to female professors in surgery, positions tightly coupled with public appointments. 50% of trainees in Otorhinolaryngology, Head and Neck Surgery (OHNS) are women and the proportion has been this high for quite a number of years, yet there are no women on the Australian Society of Otolaryngology Head & Neck Surgery Council.
Even though there is an even balance of women involved in the RACS Council, I am one of only two senior female surgeons out of 13 senior surgeons on the OHNS Training Board. Training boards are derived from surgeons within the public system.
I work in the largest surgical department in Australia, with 15 consultant surgeons. And, until June last year, when we had a couple from the UK join our unit, I was the only female for nearly 10 years. Most of the other major public hospital surgical units around the country are not dissimilar.
The questions that beg to be asked are where are the women, and, why are they not being attracted back to work in the public health system? The lack of women in surgery in the public health sector is not due to a conscious, active campaign of harassment or sexism by men; it is a reflection of a system that hasn’t proactively countered the culture of gender bias.
I have experienced how the surgical profession has changed. In 1996, at an interview for advanced surgical training it came up that I had recently had a baby, the next question was “When are you having the next one?” Subsequently, a senior surgeon advised that in his day to be male and married was considered to be a barrier to a surgical career and suggested that I, being female, married, with a baby, had unrealistic expectations in pursuing a career as a surgeon.
In 1997, I became the first mother taken into advanced surgical training in Australia. In 1998, at the specialty interview I had to be accepted onto the OHNS training program. I was 37 weeks pregnant. The interview process was a textbook behavioral interview.
The Director of Surgery at the Alfred Hospital during that time, Professor Chris Christophi, actively encouraged and supported women in surgery. I have no doubt that he set the environment for enabling me to pursue a successful surgical career and contributed to a positive experience for many female surgeons.
I have overcome many challenges to build a successful career. I have worked in the public health system as a Consultant Surgeon for nearly 10 years and do not have an independent private practice. I was Executive Director of Unit for more than 6 years, a Supervisor of Training for registrars, I am currently completing a PhD and am an Adjunct Lecturer for the Department of Surgery, Chair of the Surgical Science Exam Committee and as previously mentioned, on the Training Board for OHNS. Additionally, I am a single mother of two teenagers and an entrepreneur with an established conscious corporation.
The public health system in general, and surgery in particular, is not conducive to encouraging women to work in it, to participate at a greater level or to take on higher leadership roles.
There are a number of reasons: lack of role models in key leadership positions; poor pay compared to private practice to be considered when balancing work with family commitments; conditions placed around leadership positions that by their very nature will discourage women from applying; and a resistance to change the way our public institutions work with predominantly autocratic men entrenched in the key positions of influence and power, who have a monopoly on the ear of the decision makers and politicians working often by the same modus operandi.
Autocratic leadership by its very nature crushes creativity, which is the key to change. So when positions become available, it is often “top of mind” rather than any planned recruitment process. Positions are often written around the person(s) whom it is has already been decided will fill them.
Positions ostentatiously based on a vote are presented and filled as a fait accompli rather than any robust discussion. Without a conscious, gender-bias-eliminating, discussion, men will choose men. This by default then impacts on training and the Training Boards as the preponderance of men in the public health system, particularly in key positions, persists and the cycle continues.
In an autocratic environment, this blocks the road to key positions. Female surgeons, myself included, believe that we deserve to get to where we are based on merit and ability, in spite of being female, not because of it. In an autocratic environment merit does not always count, but complicity does.
In 2008 I began work on developing a Sustainable Surgical Services Plan with the blessing of our CEO. This was based on a Private in Public business model, designed to create a work environment to encourage surgeons to have a larger involvement in the public health system, appealing to female surgeons in particular. As it progressed through the male-dominant hierarchy over a number of years this plan morphed into employing surgeons from overseas, with no focus on local or female candidates.
I spoke out against the concept of hiring overseas surgeons in place of hiring our own trainees in conjunction with exploring creative cost effective solutions to the issues at hand. I spoke out about the manner in which this hiring ultimately took place. I am the only surgeon without an independent private practice in our unit and with a proven track record in administration, and yet I found myself not offered a leadership role in the formal re-structuring of the unit, an idea that I had originated, and advocated for, whilst my male colleague who was also outspoken was invited to be involved. The message this sends is loud and clear, intended or not; it is okay to speak up and voice dissent, as long as you are not a woman.
The outcome is that women move on and gradually out of the public system because it is exhausting, unrewarding to stay, and they are valued more elsewhere. Autocrats breathe a sigh of relief because the reality is that it is easier for them to work with other autocrats than transformative individuals.
Despite the effort and progression of RACS, the surgical profession continues with few female role models in key positions in our public health system, the training ground not only for professional skills but also for professional behaviour. We lose the key ingredient required to break the cycle. Women are not only active role models for the female trainees, but they generate alternative-thinking role models for the male surgical trainees as well.
Without addressing the underlying unconscious, insidious sexism in the public health system, the mechanisms for reporting sexual harassment without fear of repercussions to ones career cannot exist. We cannot empower our trainees, female or male, to speak up directly to the perpetrator at the time of the incident to say “Stop, that is not okay”, which is the ultimate strategy for stopping harassment and bullying of any sort.
I do believe we can create proactive gender-balanced change:
1. Educate against gender bias and how certain inherent behaviors and systems entrenched within our public health system generate sexism.
2. Provide a safe platform and encourage anyone who experiences or witnesses bullying, discrimination or harassment to speak up. We need to be empowered to say when certain behavior is unacceptable and to have the support in place to assist us.
3. Actively recruit more women to key leadership positions.
4. Conduct a thorough, independent revision of the model in which surgeons are engaged in the public health system so that the needs for security, trust, input into service delivery and financial reward can be met at the same time as delivery high quality, cost effective standard of care to the Australian public and ongoing training to future surgeons.
A senior administrator recently told me that to create any significant change in the public health sector, you need a really big personality. I believe we need more than one. We need more Dr. Gabrielle Mc Mullin’s, more Professor Chris Christophi’s, more Professor Michael Griggs’, and more Dr. Caroline Tan’s who have the courage to speak up. I want to create that significant change; I’m adding myself to the list. Change in our public health system is essential for the health and wellbeing our surgical profession. I believe it is possible.
This was first published on LinkedIn Pulse and is republished with permission.