Discussion

The study provides insights into gender biases in surgery, including subtle and implicit biases. It identifies four types of gender bias that affect women’s surgical careers. The first, workplace discrimination, has been previously documented in surgery.6–10 22 23 Professional bodies are beginning to develop resources and training to improve workplace climate, such as the Operating with Respect campaign.24 The second type of gender bias identified—the impact of epistemic injustices on women’s surgical careers—has not been previously described. It refers to harm done to someone in his or her capacity as a bearer of knowledge. Epistemic injustice may be associated with propositional (theoretical) knowledge,17 or understood more broadly to include prejudicial assumptions about hands-on knowledge or skill.25 26 The broader understanding is apt for surgery, given the importance of technical skills. The third and fourth type of gender bias are stereotyped roles and objectification. Rather than focus on each of these four types of bias separately (or their many subinstances) it is important to consider how they interact and the cumulative consequences for women surgeons.

Many of the instances of bias described in the study seem minor, and were not necessarily perceived as harmful by participants (‘it doesn’t worry me’ [P9]). However, they do not occur in isolation, but interact and aggregate, which can be pernicious. Strategies for improving women’s representation and status in the profession should recognise the risk of cumulative harm and interaction between different types of bias. A similar finding emerges from recent research into women’s reasons for leaving surgical training by Liang et al, who discovered that it is usually the combined impact of several factors (eg, unavailability of leave combined with sleep deprivation and bullying) that cause trainees to withdraw from training.27 Liang et al have developed a simple but powerful ‘tower of blocks’ model for understanding the cumulative nature of trainees’ decisions to leave surgery. Their model resonates with theoretical research in ethics on the way small factors can aggregate to form large harms that are more than the sum of their parts.28 29

Many of the forms of bias found in this study involve apparently small instances. In some cases, these are implicit. This means that the biased individuals are either unaware of their biases, or are not consciously able to control them.16 Nevertheless, participants in the study often found the small instances burdensome, as they required management and led to more general changes in work practices. For example, women modified the way they introduced themselves to patients to reduce the likelihood of mistaken identity; they developed strategies for establishing trust with patients; and they arranged appointment schedules to allow additional time for the personal and empathic communication patients would expect of them.

These small burdens can accumulate and/or interact to create harms that are more serious. Consider the cumulative impact of the following: Women surgeons tend to be referred more emotional patients who require the ‘talky-talky or the touchy-feely kind of stuff’ (P33). They also perceive that patients in general will expect longer consultations with more personal communication and empathy. Many women surgeons have incorporated additional patter into their consultations to correct possible errors on the part of patients, such as introducing themselves more fully and carefully. They also take pains to build trust and respect with patients, in view of possible objectification or uncertainty patients may feel with a women surgeon. These features of women’s clinical practice combine to make their consultations longer. The study findings suggest that women do not receive higher pay for these longer consultations. In fact, participants in the study were more likely to express concern about the capacity of patients to pay, and to offer discounted fees, than to charge more for a long consultation. One participant even described reducing her fees for a patient she had kept waiting, suggesting that in some cases longer consultations might cost women surgeons money.

These cumulative harms take on a more troubling note when combined with the gendered patterns of credibility or epistemic injustices. The aspects of surgery in which women experience credibility excesses, and in which they are encouraged to excel by positive reinforcement and higher training load, are materially undervalued. Building a practice around long, affordable consultations and providing patient-centred care is likely to mean accepting a lower income. The other option is to resist these expectations. However, women who work in areas of surgery stereotyped as more masculine encounter other barriers, such as gendered referral patterns from GPs. Moreover, the findings suggest that being (seen to be) caring, empathetic and approachable is in direct tension with being credible and holding authority. One participant articulated this explicitly: ‘I think people find it easier to talk to us, and they don’t feel intimidated, so the barrier is definitely down from that point of view. But I think feeling authoritative and being able to say things with a position of authority is harder as a female’ (P29).

The gender biases revealed by this study thus appear to cause harm at two levels. The individual biased acts can be harmful (as when a women is irritated by having to explain to a patient that she is the surgeon), and multiple instances can give rise to harm of a different type (as when the strategies women develop due to common biases cause longer consultations). Kahn has described these emergent harms as ‘essentially aggregative’.30

Elsewhere I have identified three features of aggregative harms: their systemic nature, the (relative) invisibility of the forces that give rise to them, and the expedience of practices that support them.29 All three factors are present in the case of gender biases affecting women surgeons. The instances of subtle gender bias are often invisible to perpetrators, such as patients who do not realise that they have misidentified the senior surgeon in the room. Moreover, the way these biases accumulate and interact is not obvious. Expedience supports at least some of the factors. Biased GP referral patterns are likely to be expedient: in Australia, GPs come to know of local specialist surgeons informally through processes such as advertising, and via their networks from medical school. The lack of information about available specialists encourages reliance on stereotypes. In general, stereotypes support energy saving, and thus expedient, decision making.31

Aggregative harms tend to emerge in the context of complex systems, especially informal systems of practice involving many loosely connected individuals and institutions. This is true in the context of women’s surgical careers: women surgeons in Australia work in private and/or public hospitals. They are (usually) fellows of RACS, and members of organisations representing their specialty group, such as the Australian Orthopaedic Association. Their training occurs in multiple hospitals. They interact with patients, patient families, nurses and allied health professionals as well as medical and surgical colleagues. The gender biases described in this research emerge within this complex, multidimensional system.

Addressing aggregative harm requires understanding the functioning of the system from which it emerges, making the harms and the way they aggregate visible, and challenging expedient practices that support them.29 In this case, the process of making visible requires research aimed at identifying small or unexpected sources of bias (like this study, or the study by Liang et al).27 Understanding the role that expedient processes play in aggregative harm can help support the case for replacing cheap or fast processes with less efficient but fairer ones. For example, justifying the cost of developing and maintaining a platform to help GPs find specialists based on accurate information.

Perhaps most importantly, understanding that aggregative harms emerge from systems can inform interventions that focus on the nature of the system rather than the individuals within it. In particular, identifying influential nodes within the system and targeting interventions at these. In this case, it would be effective to focus on surgical training programmes. Surgical training is often overseen at the national level (this is true in Australia, where it is overseen by RACS). The training programme, thus, influences all new surgeons entering the system in a country, as well as all the surgical supervisors and hospitals involved in the provision of training. The types of bias identified in the results section indicate problem areas that training programmes should address, for example, ensuring fair distribution of emotionally needy patients between male and female trainees.