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Navigating the profession of spine surgery: narratives from women on the front lines
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Content
Navigating the Profession of Spine Surgery: Narratives from Women on the Front Lines
by
Elizabeth Walker
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
May 2022
© Copyright by Elizabeth Walker 2022
All Rights Reserved
The Committee for Elizabeth Walker certifies the approval of this Dissertation
Bryant Adibe, Committee Member
Anthony Maddox, Committee Member
Monique Datta, Committee Chair
Rossier School of Education
University of Southern California
2022
iv
Abstract
Gender representation in the profession of spine surgery is a multi-factorial problem stemming
from traditional gender norms, societal expectations, and stereotypes tied to what a surgeon
should look like as well as how a surgeon should behave in the work setting. Additionally,
research on unconscious or implicit bias demonstrates that both women and men continue to
associate men with surgeon and women with family practice physician. Subsequently, spine
surgery, a specialty further delineated by the perceived demand of a practitioner’s physicality,
holds the distinction of producing the lowest percentage of women practitioners even though
women have proven to be as competent as men with higher patient satisfaction ratings.
Therefore, the study intends to explore factors leading to the persistence and retention of women
in the profession. In the Fall of 2021, a demographic survey identified women spine surgeons of
different ages and races who were then purposefully selected to participate in one-on-one
interviews. Bronfenbrenner’s human ecological systems theory was utilized to explore how
different settings and factors impacted women spine surgeons in the work setting. The findings
exposed the complexities and difficulties that women face navigating a male-dominated work
environment, with the most significant contributor associated with expectations of traditional
gender norms.
v
Dedication
To Robert, my husband, thank you does not begin to express the gratitude I feel for your support
through my dissertation journey — your willingness to read my many drafts and provide
feedback, listening to me talking way too loudly on zoom, the numerous nights you prepared
chef-quality cuisine of which I would otherwise be indulging in boxed mac and cheese, and
ensuring that my glass was always full…with my heart, love, and deepest gratitude.
To Avery, my daughter, the one that has taught me all the lessons that I needed to learn. Your
passionate spirit and desire for equity inspires me every day. Thank you for guiding me down the
paths that I didn’t know I needed to travel. I love you mostest and always will!
To my parents who always taught me that I could do anything I wanted to do, for believing in me
even when I did not believe in myself. I am who I am because of you. I love you.
vi
Acknowledgements
This journey was not one that was planned in advance or required; however, this journey
was what I needed to understand the world better, challenge my beliefs and worldviews, and
prepare me for the next part of my life’s journey. For the teachers that were placed in my path for
a reason — Drs. Maddox, Kim, Campbell, Wilcox, Adibe, Lynch, Cohort 15 colleagues — I am
humbled by your patience, grateful for your ability to meet me where I was in the moment, and
thankful for your pearls of wisdom and insight.
To my mentor and dissertation Chair, Dr. Datta, your zest for life, surfing, helping us
learn, holding us to the highest standards while allowing space for empathy makes me grateful
for your presence and thankful of all of the teachers in my life. I am forever indebted and in awe
of your commitment to excellence. Also, we share a common spirit, and I will always be
thankful for your presence in my learning journey and in my life.
To my fellow cohort 15 colleagues, to name only a few that impacted my journey would
be insincere. My dissertation journey was realized through daily work and readings, night and
weekend discussions with you, your encouragement through virtual and real-time chats, text
messages, wall posts, and class discussions. Though we may have only met in person once, I feel
like I know you as well as some of my closest friends and now consider you as such.
Author Note
Elizabeth Walker is now at Triad Life Sciences and has no conflicts of interest to
disclose. Correspondence regarding this dissertation should be addressed to
ewalkerweakley@gmail.com.
vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables .................................................................................................................................. x
List of Figures ................................................................................................................................ xi
List of Abbreviations .................................................................................................................... xii
Chapter One: Overview of the Study .............................................................................................. 1
Background of the Problem ................................................................................................ 2
Purpose of the Study and Methodological Overview ......................................................... 4
Significance of the Study .................................................................................................... 5
Definition of Terms............................................................................................................. 7
Organization of the Study ................................................................................................... 9
Chapter Two: Review of the Literature ........................................................................................ 10
History and Trends in the Spine Surgery Profession ........................................................ 10
The Microsystem .............................................................................................................. 17
The Mesosystem ............................................................................................................... 30
The Exosystem .................................................................................................................. 37
The Chronosystem ............................................................................................................ 48
Conceptual Framework ..................................................................................................... 49
Conclusion ........................................................................................................................ 52
Chapter Three: Methodology ........................................................................................................ 53
Research Questions ........................................................................................................... 53
viii
Overview of Design .......................................................................................................... 53
Research Setting................................................................................................................ 54
The Researcher.................................................................................................................. 54
Data Sources ..................................................................................................................... 56
Interviews .......................................................................................................................... 56
Participants ........................................................................................................................ 57
Instrumentation ................................................................................................................. 58
Data Collection Procedures............................................................................................... 59
Data Analysis .................................................................................................................... 59
Credibility and Trustworthiness ........................................................................................ 60
Ethical Considerations ...................................................................................................... 60
Chapter Four: Findings ................................................................................................................. 62
Participants ........................................................................................................................ 62
Findings Related to Research Question One .................................................................... 65
Summary ........................................................................................................................... 78
Findings Pertaining to Research Question Two................................................................ 79
Summary ........................................................................................................................... 95
Chapter Five: Recommendations and Discussion......................................................................... 97
Discussion of Findings ...................................................................................................... 97
Recommendations for Practice ....................................................................................... 104
Limitations and Delimitations......................................................................................... 112
Recommendations for Future Research .......................................................................... 113
Implications for Equity ................................................................................................... 113
ix
Conclusion ...................................................................................................................... 115
References ................................................................................................................................... 117
Appendix A: #Ilooklikeasurgeon Tweet ..................................................................................... 140
Appendix B: Sexual Harassment Iceberg ................................................................................... 141
Appendix C: Recruitment Email ................................................................................................. 142
Appendix D: Demographic Sampling Survey ............................................................................ 143
Appendix E: Interview Protocol ................................................................................................. 145
Appendix F: Information Sheet .................................................................................................. 149
x
List of Tables
Table 1: Self-Identified Demographic Data of Participants ...................................................... 64
Table 2: Participant’s Experience of Gender Bias Comments ................................................. 72
Table 3: Context-Specific Recommendations Crosswalk ........................................................ 111
xi
List of Figures
Figure 1 Conceptual Framework .................................................................................................. 51
xii
List of Abbreviations
AAMC Association of American Medical Colleges
NASEM National Academies of Science, Engineering, and Medicine
NIH National Institutes of Health
NSF National Science Foundation
OR Operating Room
POC People of Color
SSA Social Security Administration
URiM Underrepresented in Medicine
1
Chapter One: Overview of the Study
Surgery is a male-dominated field, and spine surgery is the least equitable of all surgical
specialties (Association of American Medical Colleges, 2019). Two distinct training pathways
prepare students for the profession of spine surgery. Upon completion of four years of medical
school, students choose to specialize in either orthopedic surgery or neurosurgery. Further, over
half of surgeons spent one additional year dedicated to a spine fellowship in order to further
prepare for the field (Post et al., 2019).
Though gender parity in medical school was achieved in 2018, the rate of women
entering the profession of spine surgery has remained flat with only 3% of orthopedic surgeons
and 12% of neurosurgeons representing women in the surgical profession (Association of
American Medical Colleges, 2019; Jurenovich & Cannada, 2020; McNutt et al., 2020; Paturel,
2019). Furthermore, after the fellowship year, the diversity landscape continued to evolve in
favor of males as 37% of women did not persist to board certification compared to 18% of their
male colleagues (Lynch et al., 2012). Because of the extensive, specialized training required,
opting out of the profession has far reaching implications. Dr. Shilcutt stated that opting out is
“…more than a red flag. It’s a burning fire” (Paturel, 2019, para. 6). This underrepresentation of
women spine surgeons affords the male-dominated culture to advance while women’s voices go
unheard.
Both real and perceived barriers enable spine surgery to remain a male-dominated
profession. Some of the barriers included a lack of women faculty role models in medical school
and mentors in the profession; limited number of women spine surgeons in leadership positions,
limited research funding grants, authorship, and resources allocated to women; wage disparity;
gender bias, discrimination, implicit or unconscious bias, and microaggressions; lifestyle
2
considerations; and the perception that the field is for “jocks” discouraged women from pursuing
the field (Jena et al., 2016; Miller & LaPorte, 2015; Stephens et al., 2020). In summary, systems
traditionally built by men, coupled with gender stereotypes of what is considered women’s work,
disadvantaged women from both fully realizing their goals and also contributing to the patients
and organizations that they serve (Stephens et al., 2020). As a result, the focus of this study will
explore the underrepresentation of women in the field of spine surgery. Further, the study will
examine factors that contribute to retention and persistence in the profession.
Background of the Problem
By 2033, the Association of American Medical Colleges (2020) projects a physician
shortage of 54,000 to 139,000. The physician shortage is due to many factors including, but not
limited to, the increasing aging population and associated healthcare needs, physician burnout
and the corresponding opting out of the profession prematurely, and an increase in anticipated
healthcare needs due to more equitable access to healthcare. Simply put, physician demand is
increasing while physician supply is decreasing.
In addition, since the surgical profession is heavily male dominated, the field is not
always welcoming to women. Rangel et al. (2018) found that 39% of women (average age of
30.5 years) strongly considered dropping out of surgical residency because of the perceived
difficulty in navigating their career and their personal life. Similarly, Rohde et al. (2016)
discovered that 78% of survey participants assumed that work-life balance would not be
attainable. The lifestyle concern of women in surgical residency during peak child-bearing years
only increased barriers and reinforced the perception that women cannot succeed both
professionally and personally in the specialty. Moreover, even though women choose their
personal and professional paths in today’s culture, evidence showed that women continued to
3
take on more domestic responsibilities than men and also assumed more duties related to caring
for aging family members in addition to pregnancy and parental duties (Dyrbye et al., 2011).
Furthermore, research supported the fact that the surgery culture is fraught with sexual
harassment and discrimination leading to the marginalization of women (Cochran et al., 2013).
Due to abundant literature demonstrating the impact that sexual harassment plays in women’s
lives and careers, the National Academy of Sciences published a 313-page document addressing
this problem in the fields of medicine, engineering, and sciences (National Academies of
Sciences, Engineering, and Medicine, 2018). The report established two environmental factors
that significantly contributed to sexual harassment in the workplace: male-dominated work
settings and tolerant organizational work climates. Hierarchical power structures and uninformed
leadership also exacerbated these factors. In short, the literature points to today’s surgical culture
not evolving to support women, and traditional gender norms, biases, and expectations of women
still exist. These complexities that disproportionately impact women surgeons led to a 60%
increase in the likelihood of physician burnout of women as compared to their male colleagues
(Elmore et al., 2016).
In addition to overt forms of discrimination, subtle forms of discrimination, or
microaggressions, led to gendered and hostile work environments and were more difficult to
recognize and manage (Zhuge et al., 2011). One specific type, environmental microaggressions,
utilized the physical environment to exclude and was common in male-dominated fields such as
surgery (Elmore et al., 2016). As an example, male locker rooms promote cultures that
accommodate men and exclude women. Decisions about after-work social activities, crucial
networking opportunities and advancement are commonly communicated in this informal
4
setting, exclude women, and lead to gender inequities specifically in leadership and professional
advancement.
Whether overt or covert, the impact of repeated sexist behavior caused feelings of anger,
depression, decreased self-esteem, anxiety, and burnout (Stephens et al., 2020). Gender exclusive
language, women surgeons being mistaken for nurses, sexist banter, and being disregarded by
faculty send subtle messages to women that they do not belong. From the problem of physician
shortages to overt and covert discrimination, women face an uphill battle for equity in spine
surgery.
Purpose of the Study and Methodological Overview
The purpose of the study explores how women navigate the male-dominated spine
surgery profession in North America as well as factors that contribute to persistence and
retention. Though women’s leadership and gender studies have produced literature applicable to
this study, there is a paucity of research specifically looking at this problem in the spine surgery
literature. Because of the two accreditation pathways for spine surgery, the vast majority of
literature focuses either on orthopedic spine surgery or neurosurgery. This study combines both
specialties as well as a diverse group of women.
Bronfenbrenner’s ecology of human development model provides an integrated lens in
which to explore the problem of gender representation in the profession of spine surgery
(Bronfenbrenner, 1979). Developed by Bronfenbrenner in 1979, the framework seeks to
understand the interaction between an individual’s environment, systems, and human behavior
while assuming constant change and connection between the individual and influential
environmental settings. Additionally, the ecological model examines both biological and
sociological factors to better understand the interaction between the environment and human
5
behavior (Salazar & Beaton, 2000). Because the lack of gender representation in spine surgery is
a complex problem with a paucity of literature, the ecological model provides a unique lens to
examine the problem by allowing the researcher to view the problem from multiple lenses that
influence women spine surgeons. Finally, the methodology of this study is qualitative
phenomenology. Utilizing a demographic survey to identify potential participants and then
purposefully selecting a diverse group of participants for one-on-one interviews will ensure
women with different experiences and perspectives will be included. The following research
questions guide the direction of the study:
1. How do women spine surgeons balance conflicts of gender bias and social norms while
exhibiting authenticity?
2. How does a sense of belonging contribute to women persisting in the profession of spine
surgery?
Significance of the Study
This problem is important to address because gender diversity leads to increased access
to care and patient satisfaction, patient-physician trust, and competitive advantage while valuing
workforce talent and contributions. Regarding access to care and patient satisfaction, Dineen et
al. (2019) established that 14.6% of all patients prefer female surgeons and 90% of female
patients prefer a female surgeon. Moreover, women outperformed men in the areas of
communication and empathy. These skills proved to increase trust with patients, patient
satisfaction, and produce organizational gains (Hirshfield & Underman, 1983; van Ryn et al.,
2014).
Regarding stereotypes, Eagly et al. (2020) discovered that from a social role standpoint,
men maintained their status in agentic traits (traditionally linked with leadership) while women
6
were characterized by communal (nurturing) traits leading to stereotypes that continue to place
men in positions of power and authority. Since women’s leadership in spine surgery remains
low, it is important to explore this area to understand factors contributing to this issue.
Finally, regarding the connection between diversity and an organization’s competitive
advantage, Hunt et al. (2020) demonstrated that gender diverse organizations were 25% more
likely to outperform their competitors. Further, organizations that were also racially and
ethnically diverse were 36% more profitable. In summary, by increasing gender diversity in the
profession of spine surgery, patients, surgeons, and healthcare organizations benefit.
Consequences of not solving the problem of gender representation in spine surgery will
continue to impact society. Today, healthcare issues are more complicated than ever and require
leaders with complex problem-solving skills. According to Northouse (2016), collaborative and
team-based leadership styles were not only consistent with women leaders but also positively
contributed to today’s organizational needs. Without a diverse mix of leaders, problems in the
healthcare system will not be solved leading to poorer outcomes and decreased access to care.
Without women leaders in spine surgery, healthcare providers will struggle to compete in
this quickly evolving market and will be pressed to recruit top talent. As more millennials enter
the workforce, cultural dynamics and expectations will continue to shift, and organizations will
need to pivot to meet the needs of these stakeholders (McQueen, 2018). Millennials value shared
responsibility, flexibility, and equity and expect that an organization’s values align with their
own (Pew Research Center, 2010). In addition, millennials are more likely to change jobs when
an organization’s values are not in alignment with their values. Without alignment of values
between organizations and employees, unmet needs of both the organization and its employees
will result in less-than-ideal performance as well as job turnover.
7
Finally, since patients desire access to healthcare providers in which they relate, it is
critical that spine surgeon representation include all races and genders. In order to increase
access to healthcare for all individuals, trust between the patient and the physician is critical.
Without full representation of a diverse mix of healthcare providers, the healthcare system will
be unable to meet patient needs and the contributions of women in society will be silenced.
Definition of Terms
The following definitions provide insight into how these terms are relevant to this study
and gender representation in spine surgery.
• Agentic behaviors direct individuals toward oneself and include goal orientation and
mastery (Eagly et al., 2020). These behaviors (assertiveness, competitiveness) are
generally associated with men, especially in male-dominated settings.
• Attending surgeons are more experienced, teaching surgeons.
• The chronosystem consists of change or consistency over time in the developing
individual and their environment (Shelton, 2019).
• Communal behaviors, like empathy and compassion, direct individuals to the wellbeing
of others (Eagly et al., 2020).
• Environmental microaggressions (EM) consist of all forms of microaggressions and use
the workplace environment to marginalize individuals at the personal level. EM are
embedded in the workplace culture, practices, and climate and reflect systemic bias and
prejudice (Torres et al., 2019).
• The exosystem is defined as the interaction between two or more settings that impact the
developing individual (Shelton, 2019).
8
• Male-dominance, also known as patriarchy, indicates a dominant culture that values
rationalism, explanation, and reason over questioning, critique, and exploration. It does
not denote a culture of men only (Bleakley, 2013).
• The mesosystem connects two or more settings or environments that influence the
developing person. At least one of the settings indirectly influences the individual
(Shelton, 2019).
• Microaggressions are subtle forms of discrimination, verbal and non-verbal, that lead to
gendered work environments and marginalization (Zhuge et al., 2011). The four types of
microaggressions are microassaults, microinsults, microinvalidations, and environmental
microaggressions (Torres et al., 2019).
• The microsystem refers to the immediate environment or setting of the developing
individual and the direct influences from that setting (Bronfenbrenner, 1979).
• Physician burnout is a “syndrome of emotional exhaustion, feelings of depersonalization,
and a lack of personal accomplishment, specifically in relation to one’s professional
activity” (Pulcrano et al., 2016, p. 971).
• Social capital is value created in a social environment when individuals take action to
create change within that environment (Coleman, 1990).
• Spine surgeon training includes medical school, either orthopedic surgery or
neurosurgery residency, spine fellowship, board certification.
• Unconscious biases (also known as implicit biases) are personally engrained,
unintentional stereotypes that impact behavior (Backhus et al., 2019).
9
Organization of the Study
The dissertation follows a traditional five-chapter model. Chapter One introduces the
problem of practice followed by the study’s purpose, importance, and methodological overview.
Chapter Two addresses the relevant literature pertaining to gender representation in spine surgery
as well as the conceptual framework. Chapter Three delves into the research methodology
including the research design, data collection instruments, and measures addressing data
reliability and triangulation. Chapter Four presents the results of the data. Finally, Chapter Five
provides the researcher’s interpretations, recommendations, and conclusions of the results.
10
Chapter Two: Review of the Literature
This section provides a review of the literature based upon a human ecological approach
from a critical feminist lens. Key concepts addressed consist of gender and unconscious bias,
microaggressions, and discrimination; the surgery culture and organizational norms; traditional
gender roles and disparities; occupational stress, addiction, and burnout; and diversity in the
workplace. Since the lack of gender representation is not unique to spine surgery and an issue
seen in other professional disciplines, the researcher will draw upon literature from spine
surgery, orthopedic surgery, neurosurgery, and parallel fields.
For the purposes of navigating this chapter, the first section will provide a general
overview of the spine surgery profession including training requirements and specialty choices.
Next, boundary-breaking women in the profession will provide context for the problems that
women are experiencing today. To complete this section, today’s workforce expectations, supply
and demand will be addressed.
In the subsequent section, the microsystem will introduce various influences from both
the work and home environments. Next, the mesosystem will address support mechanisms that
help women surgeons navigate the profession of spine surgery as well as the home setting. Then,
organizational norms and major life events will be addressed in the exosystem leading to the
chronosystem which will explore belonging, retention, and persistence over time.
History and Trends in the Spine Surgery Profession
The following section provides key historical milestones and demographics of the field.
Next, female pioneers in both neurosurgery and orthopedic surgery will be introduced. Finally,
an exploration of today’s workforce, supply, and demand round out this section.
11
Training Pathways
Though two distinct training pathways exist for spine surgeons, the length of training is
among the longest of all medical specialties demonstrating the complexity of the profession. In
between the third and fourth years of medical school, students decide on medical specialties thus
beginning the journey to their desired profession. The next step is residency or further defined as
the physician’s first professional job (American Medical Association, 2021). Students that
specialize in spine surgery pursue either an orthopedic surgery residency or neurosurgery
residency program. Further, after residency completion, over half of surgeons completed a one-
year spine fellowship prior to Board Certification (Post et al., 2019).
Though the Accreditation Council of Graduate Medical Education (ACGME) defines
educational milestones for both orthopedic and neurosurgery residency programs, the residency
experience remains distinctly different between the two specialties leading to controversy about
the optimal training needed to perform spine surgery (Accreditation Council for Graduate
Medical Education, 2020; Arnold et al., 2009). For neurosurgery, there are seven main sub-
specialty areas (spine surgery is one of the seven), and the program takes seven years to
complete after medical school graduation. Alternatively, orthopedic surgery residency contains
eight sub-specialties and requires five years of training after medical school.
At the end of residency, neurosurgeons demonstrated increased spine surgery confidence
compared to orthopedic surgeons. Post et al. (2019) completed an analysis of medical school
graduates and revealed that more than 70% of orthopedic spine surgeons completed a one-year
fellowship after residency training compared to 51% of neurosurgeons. Since neurosurgery
residency consists of two more years of training as compared to orthopedic surgery residency,
this difference translated into more spine surgery experience for neurosurgeons. Subsequently,
12
neurosurgeon residents spent 37% of total time on spine compared to orthopedic surgery
residents at 16% (Dvorak et al., 2006).
Furthermore, in a survey of residency and fellowship program directors, 80%
recommended that both orthopedic and neurosurgical trainees should complete a one-year spine
fellowship prior to performing complex spinal procedures (Arnold et al., 2009). Since residency
program directors are best positioned to accurately judge the competency of trainees, the
extensive training time required to effectively perform spinal surgery demonstrates the difficulty
of the profession. Bean (2008) communicated that the neurosurgical profession appeals to
individuals willing to persevere “long years of difficult training, treat high-risk surgical
procedures, accept profound responsibility, and face extraordinary levels of liability. It will never
be a haven for the timid” (para. 3).
Demographics and Gender Disparity
Gender disparity in the profession begins in residency while racial and ethnic disparities
begin on day one of medical school. In medical school, demographics show an equal percentage
of women and men students, 50.9% and 49% respectively (Association of American Medical
Colleges, 2019a). Additionally, the racial and ethnic makeup of medical school graduates is
primarily White: 54.6% White, 21.6% Asian or Asian American, 6.2% Black or African
American, 5.3% Hispanic or Latinx, and 0.2% American Indian or Alaskan Native.
Once in the workforce, women physicians drop to 35.8% and men increase to 64.1%,
beginning the gender disparity continuum (Association of American Medical Colleges, 2018).
Further, of all races and ethnicities, the greatest gender disparity exists among White physicians.
At the same time, gender demographics are changing: the gender breakdown of older physicians
13
(65 years and older) is currently 79.3% male compared to early career physicians (35 years and
younger) which shows gender parity in this group.
In effect, 10+ years after completing college, the spine surgeon population is primarily
male with a large gender gap shown in academic leadership. Overall, 55% of academic spine
surgeons (n=507) were orthopedic surgeons and 45% percent (n=415) were neurosurgeons (Post
et al., 2019). Regarding gender of spine surgeons from both specialties, 4.88% identified as
female compared with 95.12% male. On the neurosurgery side, 6.97% were female compared
with 3.16% of orthopedic spine surgeons representing a combined total of 45 females out of 922
graduates. In other words, for every 100 spine surgeons, five would be women consisting of 4.03
Caucasians, 0.2 African Americans, 0.19 Latinx or Hispanic, and 0.58 American Indian or
Alaskan Native, and the racial and ethnic breakdown of women spine surgeons would be 80.5%
White, 3.8% Latinx or Hispanic, 4% Black or African American, 11.7% Asian or Asian
American, and .4% American Indian or Alaskan Native (Day et al., 2019).
Furthermore, both specialties show a low percentage of women faculty at all academic
ranks. For example, in orthopedic surgery, women faculty represented 22% of instructors, 19%
of professors, 13% of associate professors, and 7% of full professors (Association of American
Medical Colleges, 2017). In the parallel discipline of general surgery where a higher percentage
of women comprise the ranks of academic faculty at all levels compared to orthopedic surgery
faculty, gender parity of full professors is not expected until 2136 (Abelson et al., 2016). Though
women spine surgeons are underrepresented in both private practice and academic settings,
women pioneers began forging the path for today’s leaders in the early to mid-1900s.
14
Pioneers and Boundary Breakers
Pioneers from both orthopedic and neurosurgery paved the way for today’s women spine
surgeons. The neurosurgical specialty began over 100 years ago in 1919 (Corley et al., 2020).
Forty years later, Ruth Kerr Jacoby became the first U.S. neurosurgeon in 1959 (Kim et al.,
2021). Twenty-two years after Dr. Jacoby, Alexa Canady joined the ranks as the first female
African American neurosurgeon. In 2005, Karin Murasko was appointed as the first female
neurosurgery department chair and the only known neurosurgeon with a physical disability. In
2018, Linda Liau from UCLA became the first Asian American female department chair while
Odette Harris became the first Black woman appointed as professor at Stanford (Kim et al.,
2021).
On the orthopedic side, Ruth Jackson became the first woman orthopedic surgeon in the
United States in 1932 (Savvidou et al., 2020). During this time, overt gender discrimination and
inequality was the norm. Not only was Dr. Jackson not allowed to examine male patients but also
she was informed that she must earn ten points higher than her male colleagues in medical school
to be on equal footing (Day et al., 2019). Years later, Dr. Jackson was the first woman admitted
into the American Academy of Orthopedic Surgery (AAOS) when she passed the admittance
exam designed solely for her benefit (males were automatically admitted).
In 1983, the Ruth Jackson Orthopaedic Society was formed to provide networking and
social support for women orthopedic surgeons. Over 80 years after AAOS was formed, Kristy
Weber became the first female President of the AAOS. Structural racism, unconscious or
implicit biases, discrimination, and systemic inequities were everyday occurrences for these
boundary breakers but laid the path for today’s women spine surgeons (Day et al., 2019; Kim et
al., 2021; Savvidou et al., 2020).
15
Today, social media is being used to dispel gender stereotypes of surgeons in ways that,
prior to the technology, would take years to accomplish (Antonoff & Stamp, 2017; Onyango &
Bowe, 2019). Many female surgeons credit Heather Logghe’s tweet #ILookLikeASurgeon
(Appendix A) to begin the campaign to defy surgeon stereotypes (Antonoff, 2016). One hundred
twenty-eight million impressions later, Logghe showed that social media can pave the way to
increase diversity in the surgical specialties. Now, social media platforms (#ILookLikeASurgeon,
#HerTimeIsNow, #speakuportho) continue to challenge traditional gender norms of what
surgeons should look like, provide transparency of women’s experiences of bias, reach millions
of people, and provide voice and community to underrepresented women surgeons (Antonoff,
2016; Antonoff & Stamp, 2017; Onyango & Bowe, 2019).
Not only is social media providing voice to underrepresented women in surgery, but the
communication channel is also dispelling stereotypes of surgeons and communicating that
women are succeeding in the profession. In order to effectively manage the pending physician
shortage, the best and brightest of all genders, identities, racial, and ethnic backgrounds will be
needed to reduce the problem.
Today’s Workforce, Supply and Demand
The pace of growth in the aging population coupled with physicians retiring or opting out
of the field prematurely places patients at risk for access to care. By 2033, the AAMC (2020)
projects a surgeon shortage of 17,100 to 28,700. The shortage is due to several factors including
the increasing aging population and associated healthcare needs, physician burnout and
associated opting out of the profession prematurely, and an increase in anticipated healthcare
needs due to more equitable access to healthcare. Further, the population growth of individuals
over age 65 will increase by over 45%.
16
Next, 20% of the physician workforce is approximating retirement age contributing to a
limited supply of providers. At the same time, more physicians are reducing work hours and
opting out of the profession due to burnout which is characterized by emotional exhaustion,
depersonalization of patients, and decreased job satisfaction (Shanafelt et al., 2016; The
Physicians Foundation, 2018). To support this, Shanafelt et al. (2016) linked physician emotional
exhaustion with decreased work hours and lower job satisfaction. Also, though women were
more likely to work part-time over the entirety of their careers, the authors found the overall
decrease in work hours was primarily attributed to men over age 55. Further, 30% of physicians
under 45 years old plan on decreasing their hours with 11.4% of this group being women retiring
early (The Physicians Foundation, 2018).
Lastly, if underserved populations receive increased access to care, the physician
shortage projections will increase further. In 2019, over 14% of the U.S. adult population was
uninsured and one in 20 children aged four and under had unmet healthcare needs due to poverty
(Lloyd et al., 2018). President Biden intends to not only increase coverage for low-income
Americans but also reinstate Affordable Care Act policies that the Trump administration
removed (Westmoreland et al., 2021). This expansion of coverage will put more demand on
spine surgeons and contribute further to discrepancies in access to care. Since spine surgeons
primarily treat older patients, the reduction of physicians providing care in addition to policies
that provide expanded access will tax the healthcare system. To explore this problem further, the
next section introduces the theoretical framework and subsequent microsystem of women spine
surgeons.
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The Microsystem
According to Bronfenbrenner (1981), the microsystem consists of actions, roles, and
experiences by an individual in a given setting. As such, this section addresses the microsystem
of women spine surgeons starting with people who influence the woman surgeon from both the
work and home setting. Next, work norms and expectations introduce barriers that women spine
surgeons experience on a daily basis.
Self-Efficacy and The Influence of Others
In additional to personal attributes like self-efficacy, women spine surgeons are also
influenced by patients, peers, and leaders in the work setting. In the home setting, family and
friends play the most influential roles. Together, these individuals directly impact a woman’s
ability to thrive and navigate the male-dominated profession on a daily basis.
The Surgical Personae
Professional success as a surgeon can lead to personal trials. According to Olsson et al.
(2019), surgery rose to the top of prestigious medical specialties as judged by physicians of all
other medical specialties. Surgeons exhibited Type A personalities, high levels of motivation,
goal-orientation, and competitiveness (Money, 2017). These qualities bode well in the surgical
profession where excellence in procedural skills generally determines positive patient outcomes;
however, this pursuit of perfection also contributes to poor delegation and management skills.
Long and unpredictable work hours frequently led to work-home conflicts, and these conflicts
led to difficulties in personal relationships (Dyrbye et al., 2012). Additionally, the authors
showed that women experienced work-home conflicts more significantly than men, and these
factors often led to addiction. As such, alcoholism impacted a quarter of female surgeons, and
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women surgeons experienced depression and burnout over twice that of the general population
(Shanafelt et al., 2015).
Literature also cited that women surgeons chose the surgery specialty for intellectual
stimulation as well as pure enjoyment (Jurenovich & Cannada, 2020). Since they work as a part
of a team in a high stress environment, women surgeons also need to be effective team members
and exhibit strong interpersonal skills. From the hospital operating room to clinic, the academic
department to teaching and patient care, multiple settings, locations, co-workers, and leadership
required not only clinical skills but also interpersonal skills (Shanafelt et al., 2016). The authors
cited the importance of organizational, delegation, and prioritization skills for surgeons in order
to manage excessive workloads and inefficiencies in the practice environment. Though effective
interpersonal and organizational skills are required to navigate the profession, people from both
the home and work setting are also influential to women spine surgeons.
The Role of Managers and Experienced Others
Direct managers are key contributors to success within organizations. Wieneke et al.
(2019) established that direct supervisors, as compared to executive leaders, were key
stakeholders in the successful implementation of large healthcare organizational wellness
programs. Since direct managers and supervisors provided support, education, and
encouragement to employees on their teams, their role influenced employee satisfaction,
engagement, and retention as well as providing early warning signals to leadership about
potential problems.
Similarly, Heyden et al. (2017) indicated that middle level managers were more
successful in garnering employee support of organizational changes than top level managers.
Since organizational changes fostered concerns of lack of autonomy and uncertainty, and middle
19
managers were closest to the employees’ work processes, the likelihood of accurate, trustworthy
communication from mid-level managers was high leading to employee support for change.
Finally, in a Gallup Poll of 105,000 employees from 12 distinct industries, Buckingham and
Coffman (2014) specified that effective direct managers and supervisors led to retention and
increased productivity. In addition to the influence of managers, patients also impact women
spine surgeons in distinct ways.
Patient Influences
The physician-patient relationship is not only sacred from the physician’s perspective but
also proves to be essential in improving patient outcomes. Fuertes et al. (2017) revealed that a
strong working partnership between the physician and patient produced patient adherence to
treatment plans, better patient outcomes, and increased satisfaction for both the patient as well as
the physician. Further, trust was identified as the cornerstone of an effective physician-patient
alliance and the most consistent predictor of treatment.
Also, patients will continue to influence physician decisions since the federal government
has recognized the role of the patient in improving outcomes. With the establishment of the
Patient-Centered Outcomes Research Institute (PCORI) in 2012, the Institute has provided
funding to support 55 studies related to the benefits of shared decision making between
physicians and patients (Patient-Centered Outcomes Research Institute, n.d.). Also, due to the
COVID-19 pandemic, the federal government recently expanded physician reimbursement for
virtual versus in-office visits (Chua et al., 2020). With these changes supporting greater
physician access with the use of technology, physicians will need to adapt to new ways of
connecting with patients in order to maintain patient trust via technology platforms.
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To expand on this concept, Chua et al. (2020) provided best practices for maintaining
strong physician-patient rapport during virtual visits. The authors indicated that the key to
establishing and maintaining trust with patients was related to the effectiveness of a physician’s
communication style, and demonstrating empathy and reflection are fundamental verbal
practices that led to meaningful connections with patients. Further, Tsugawa et al. (2017)
confirmed that patients of women physicians had significantly lower mortality and hospital
readmission rates than patients of men physicians. As a result, the strong communication skills of
women physicians proved to contribute to better outcomes (Ferguson, 2002; Tsugawa et al.,
2017). If men achieved these same outcomes, 32,000 lives per year would be saved. Therefore,
communication skills prove to not only save lives but also provide an advantage for women
surgeons.
Finally, in today’s online and social media environment, patient reviews of physicians
provide important information to prospective patients. Kalagara et al. (2019) established that
trustworthiness was the most substantial gauge of a patient’s rating of quality and satisfaction of
care. Further, potential patients made decisions based upon online ratings. Donnally et al. (2018)
found that 35% of people chose physicians based upon good ratings, whereas 37% did not
choose a given physician based upon bad ratings. Though online ratings of spine surgeons
include many factors including patient-related outcomes, other indirect factors like wait time and
friendliness of office staff impacted ratings as well indicating the growing influence of patients
on the overall healthcare system. Though patient influences directly impact physicians, support
of family and friends can prove to provide mediating factors for women surgeons.
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Family Support and Social Connectedness
The spine surgery profession places strain on women spine surgeons, friends, and family
demonstrating the importance of strong social support. Social support provided protective factors
against physician burnout and was strongly correlated with positive wellbeing (Holt-Lunstad et
al., 2015). In addition, the authors explained that socially isolated individuals have a 29% higher
death rate than individuals who felt a sense of belonging. Further, in a review of National
Academy of Medicine articles, Southwick and Southwick (2020) connected physician burnout
with feelings of isolation and loneliness. Since women physicians have a 130% greater risk of
dying by suicide than the general population and suicide has been linked to burnout, the
importance of social connections to women spine surgeons remained increasingly important
(Brandt, 2017; Hochberg et al., 2013).
Though social support provides a meaningful buffer, women surgeons continue to
struggle with finding enough time for family as well as life away from work. The uncontrollable
lifestyle was the primary reason cited for medical residents leaving surgical training programs
(Brandt, 2017). In fact, 25% of women compared to 15% of men left surgery programs for this
reason. Finally, surgeons experienced difficulty in cultivating supportive relationships due to
time constraints outside of work, limiting their time for social activities (Templeton et al., 2020).
Regarding work hours, surgeons worked an average of 60 hours per week leading to
frequent work-home conflicts (Dyrbye et al., 2012). The authors showed that 62% of women
compared to 48% of men experienced frequent work-home conflicts. Though much of the
literature regarding the work-life integration of women surgeons focuses on pregnancy and
childcare years, Templeton et al. (2020) indicated that work-life conflicts impacted women
across the entirety of their careers. Reported by 70% of early-career versus 50% of later-career
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women physicians, frequent work-life conflicts continued to impact women. Women consistently
took more responsibility for domestic and dependent care than men, and in today’s environment,
more than 20% of women physicians were caretakers for elderly family members in addition to
younger children and grandchildren which increased risks for burnout.
Finally, spouses of surgeons experience psychological distress as well, especially during
residency training years. Spouses of residents faced feelings of isolation and loneliness leading to
depression and hostility (Sargent et al., 2012). The authors also found that a spouse’s
psychological distress decreased after residency indicating the taxing impact of residency
training specifically.
Furthermore, working spouses of academic surgeon faculty experienced greater marital
satisfaction than non-working spouses even though rates of emotional exhaustion for resident
spouses were similar to that of surgery residents. In summary, the authors found marital
satisfaction to be greatest among couples that spent the most time together which pointed to the
influence of social connectedness to the woman surgeon’s overall wellbeing. In addition to the
influence of people from the work setting and the home setting, work norms also influence
women spine surgeons on a daily basis.
Work Norms
Work norms for women spine surgeons are not always positive and may be difficult to
navigate on a day-to-day basis. Working in a male-dominated field includes barriers to entry,
different expectations for women compared to men, and unconscious biases. Starting with double
standards, women face barriers to thrive in male-dominated cultures.
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Double Standards and Leadership
Power, privilege, and patriarchy create conflict for women working in male-dominated
fields and lead to adaptations to fit in. Eagly et al. (2020) illustrated this concept by showing the
power of stereotypes that led to a lack of leadership advancement of women. The authors showed
that in our socially constructed society, women were associated with communal (emotional,
caring) behaviors while men were linked to agentic (motivated, aspiring, fearless) behaviors.
Further, agentic behaviors have historically been associated with leadership. In their 20-year
comparison study assessing the stereotypes of leadership qualities of men and women, women’s
association with communal behaviors increased over time while men held steady with an agentic
advantage. Conversely, stereotypes of competence showed women exhibiting a competitive
advantage over men. All this being said, the authors theorized that women continued to lag in
leadership due to stereotypes and a culture that links leadership with masculinity (Eagly et al.,
2020).
Furthermore, when women are stereotyped as communal, women adapt by exhibiting
characteristics that are aligned with socially accepted leadership styles (agentic) thus
perpetuating the myth that agentic leadership styles are superior to communal. In an experiment
exploring leadership communication styles of men and women, Hippel et al. (2011) established
that women in leadership positions adapted their communication style to be more masculine
since agentic characteristics were associated with leadership. Even more, the authors also
demonstrated that this adaptation by women leaders led others to perceive them as unlikable and
cold which perpetuated stereotypes of women being unlikeable and bossy.
Women working in male-dominated professions face conflicts related to adaptation to fit
in which can then lead to issues of retention and persistence. Martin and Phillips (2017) indicated
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that women who work in male-dominated environments and downplayed their gender or
feminine traits were more accepted leading to greater persistence. In addition, the authors
indicated that gender blindness, or downplaying gender, increased the risk-taking of women
while no effect was shown among men. Therefore, to avoid exclusion, many women surgeons
adapted by altering their physical appearance, behaviors, and voice to fit in.
In a recent study, Barnes et al. (2019) showed that women surgeons adapted to verbal
slights by either ignoring or dismissing negative comments so as not to be seen as a victim. In
politics, Okimoto et al. (2010) discovered that women political candidates were negatively
impacted by actual and perceived power-seeking intentions whereas male politicians benefitted
from only actual power-seeking intentions, thus demonstrating the double standard. These
examples illustrate the challenges that women face when working in male-dominated
environments.
To extend this concept, Ibarra and Petriglieri (2016) introduced the term impossible
selves to illustrate the cultural factors that interplay in a woman’s leadership journey. Gender
role and leadership expectations of women based on traditional cultural views of gender,
organizational policies, procedures, and practices that privilege men, and unconscious biases
accumulated to interfere with a woman’s ability to both view herself as a leader as well as be
viewed as a leader. Further, women were unable to reconcile the adaptations required to become
a leader compared to exhibiting their authenticity as an individual.
Additionally, though women make up half of the U.S. workforce, only 5.4% held elite
leadership positions in Fortune 500 companies (Northouse, 2016). In academic medicine, though
women make up 40% of full-time medical school faculty, women represented only 19% of
orthopedic surgery faculty showing the gender gap in medical school faculty by surgical
25
specialty (Association of American Medical Colleges, 2018). Additionally, with increasing
academic rank, women continued to fall further behind their male colleagues with increased time
to promotion (Asgari et al., 2019). In fact, women deans have only increased by one per year in
the last decade.
In support of this concept, the leadership labyrinth describes the phenomenon of the lack
of female leadership in male-dominated professions (Eagly, 2008). According to Eagly, the
leadership labyrinth suggests the intricacy and variety of trials and challenges (both anticipated
and unanticipated) that women experience. Explanations of this phenomenon consisted of
pipeline issues, less commitment, competence, and lack of leadership effectiveness even though
these factors have been disproven. Literature now points to the impact of unconscious bias
originating from cultural settings and norms as well as organizational practices that
unconsciously privilege men and disadvantage women (Kubu, 2018).
Related to leadership effectiveness, Paustian-Underdahl et al. (2014) conducted a meta-
analysis of 95 studies and found that women and men were equally effective as leaders with the
exception of male-dominated settings. Specifically in male-dominated environments, a male
leadership effectiveness advantage was uncovered. Regarding competence of women compared
to men, and consistent with work from Eagly and Karau (2002), Fassiotto et al. (2018)
demonstrated that women who worked in male-dominated fields like surgery received
disproportionately lower evaluation ratings due solely to the discordance between their gender
role compared to the dominant gender of that specialty (male). Further, the authors added that in
surgical fields, women were significantly impacted by stereotype threat which is the
psychological threat of validating a negative stereotype and proven to decrease performance in
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settings where an individual is negatively stereotyped (Bergeron et al., 2006; Fassiotto et al.,
2018).
From politics to medicine, women in leadership positions are penalized for even the
perception of contradicting common gender and social norms. Additionally, women working in
male-dominated environments face further difficulties in workplace assimilation. This conflict
between exhibiting one’s authentic self and work-adapted-self dehumanizes women surgeons
and perpetuates a lack of belonging.
Unconscious Bias and Unintended Negative Consequences
In the field of surgery, unconscious biases can lead to both positive and negative
outcomes. According to Backhus et al. (2019), the “hidden brain” searches for patterns in order
to speed up decision making (p. 259). The authors also explained that unconscious biases (mental
shortcuts) were automatic, unintentional, and based upon prior experiences. For example,
unconscious biases can lead to positive outcomes: rapid decision making after a patient enters the
emergency room, anticipating patient complications during surgery based upon typical patterns,
and patients with defined symptoms triggering medical tests that lead to a diagnosis.
Alternatively, unconscious biases can also lead to errors in decision making and negative
consequences. Zestcott et al. (2016) explained how healthcare providers’ unconscious biases led
to disparities in healthcare. First, inaccurate assumptions and biases about marginalized people
led to decisions about care that may not be comprehensive. Second, healthcare provider
communication patterns with marginalized patients led to decreased levels of trust which then
resulted in ineffective compliance with treatment. Consequently, both scenarios led to healthcare
disparities.
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Additionally, Hagawara et al. (2016) showed that physicians who fit a typical racist
profile (exhibiting high unconscious bias and low explicit bias) demonstrated decreased positive
affect and increased negative affect as compared to physicians that did not fit the same profile.
These findings reveal how unconscious biases negatively impact physician-patient
communication and trust leading to disparities in healthcare. Alternatively, Hagawara et al.
(2019) disclosed that physicians can improve racial related healthcare disparities by altering their
communication style.
In addition to patient related consequences, unconscious biases impact women surgeons
in all aspects of their careers from decisions about specialty choice to recruitment, promotion,
evaluations, and surgical autonomy. For example, when medical students were exposed to
disparaging comments about medical specialties from supervising surgeons, the students’ own
negative biases were activated partly explaining why few women pursue surgery (Mueller et al.,
2017). Also, literature showed that differences in supervisor feedback to men and women
residents who exhibited poor surgical performance translated into a lack of operative autonomy
and confidence for women as compared to men (Meyerson et al., 2017). The authors explained
that men received consistent feedback while women received inconsistent feedback.
The Implicit Association Test (IAT) is a validated instrument that measures an
individual’s implicit or unconscious bias between concepts and stereotypes (Greenwald et al.,
1998). In an analysis of data from surgeons who completed the IAT, Salles et al. (2019)
uncovered that both men and women surgeons unconsciously associated men with surgery and
career, and associated women with family practice and family. The researchers also revealed that
men consciously conveyed preference for men with career and surgery as compared to
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associating women with family or family practice demonstrating the power of gender stereotypes
and unconscious biases in the male-dominated field of surgery.
Ultimately, unconscious biases translate into implications for gender representation and
diversity in spine surgery. From poor evaluations of women that work in male-dominated
professions and reduced surgical confidence, unconscious biases produced profound impact on
women as shown by the high attrition rates (Salles et al., 2019). For women, these unintended
negative consequences led to opting out of the field or not pursuing spine surgery as a
profession. In addition, negative consequences for women also occur from daily
microaggressions.
The Changing Nature of Discrimination
The nature of discrimination is changing. Traditionally, discrimination and harassment
were overt and in the open. Now, discrimination primarily manifests as microaggressions that are
hidden, covert, and can be either intentional or unintentional (Torres et al., 2019). The authors
communicated that microaggressions come in different forms but all types produced the same
result: marginalization at an interpersonal level and negative effect on the target individual. In
fact, women who experienced microaggressions had lower confidence, lower productivity,
depression, and an increased desire to find another job or opt out of the profession altogether.
Different types of microaggressions exist, but environmental microaggressions were most
often experienced within the context of surgery (Sprow et al., 2021; Torres et al., 2019). To add,
environmental microaggressions or invalidations are a combination of all four types of
microaggressions (microassaults, microinsults, microinvalidations, environmental
microaggressions) and occur in the daily practices, climate, and culture of the workplace. In a
review of 37 articles related to gender-based microaggressions in surgery, Sprow et al. (2021)
29
identified 20 articles referencing environmental microaggressions or invalidations, the most
common microaggression experienced by women surgeons. Further, environmental invalidations
are aggressions that imply that women do not belong.
To explain the types of microaggressions further, microassaults are blatant discriminatory
statements meant to offend the targeted individual and are directed at an individual versus a
group of people. Second, microinsults are more subtle forms of discrimination that may be
unintentional by the offender. These behaviors generally communicate insensitivity of a person’s
identity. A common microinsult in surgery is confusing a woman surgeon for a nurse because the
surgeon’s gender does not fit the typical gender role. Next, microinvalidations are intended to
exclude or dismiss the individual experiences of others and are most common in the surgical
profession. Pregnancy and motherhood aggressions are common themes in this category.
Examples include deficient maternity leave policies and inadequate resources dedicated to breast
pumping. Further, Periyakoil et al. (2020) showed that microaggressions were common
experiences of women but uncommon experiences of men (Sprow et al., 2021; Torres et al.,
2019).
Microaggressions, though subtle and either intentional or unintentional, prove to be the
most problematic for women in male-dominated professions. Common consequences of
microaggressions that women surgeons experienced were exclusion and marginalization,
underrated surgical competency, pregnancy and childcare related bias, and downplaying their
gender to fit in (Periyakoil et al., 2020). Further, Derthick (2015) also found associations
between sexist microaggressions and the wellbeing of women including distress, anxiety,
depression, decreased self-esteem and perceived support systems. These associations emphasized
the impact of microaggressions on women’s mental health (Periyakoil et al., 2020; Torres et al.,
30
2019). Altogether, when these hidden insults are engrained in culture, they are relentless prompts
of systemic-level bias and discrimination.
The Mesosystem
According to Bronfenbrenner (1981), the mesosystem consists of structures that support
two or more settings in which the developing individual is involved. As such, this section
addresses the mesosystem of women spine surgeons from the lens of the work setting. Though
the mesosystem of the home setting of women spine surgeons is also important, the focus of this
section will primarily center on the work setting.
The Work Setting
The work setting of the mesosystem assists or hinders women spine surgeons in
navigating the profession. Mechanisms that provide support for women spine surgeons like
mentors, sponsors, and institutional policies and procedures that promote equitable practices
provide needed buffers from the negative aspects of the exosystem that filter into the
microsystem.
The Importance of Belonging and Social Connectedness
Exclusion and marginalization are associated with a lack of belonging. Since
environmental invalidations are common microaggressions experienced by women surgeons and
speak directly to a woman’s lack of belonging in the profession, the importance of fostering
strong social connectedness and a sense of belonging proves to have significant implications.
Elliot et al. (2017) specified that belonging is “…drawn from cues, events, experiences, and
relationships, about the quality of fit or potential fit between oneself and a setting” (p. 272).
Further, women who experienced exclusion and lack of belonging frequently missed out
on crucial networking opportunities (Zhuge et al., 2011). As an example, male locker rooms
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promote cultures that accommodate men and exclude women, especially in male-dominated
environments. Decisions about after-work activities and crucial networking opportunities are
commonly communicated via these informal channels, exclude women, and lead to gender
inequities, especially in leadership. When women are excluded from conversations, opportunities
for advancement diminish.
Alternatively, engagement at work increases a sense of belonging with that community
and encourages diversity of identities. Hill and Vaughan (2013) described the relationship
between communities of practice and how individuals make sense of career decisions. The
authors showed that increasing engagement in the practices of a specific community
strengthened an individual’s identity within that community. Utilizing a paradigmatic trajectory
of seeing, hearing, doing, and imagining, the authors also examined how women medical
students’ experiences of surgery shaped their career choices. Since women faculty role models
are uncommon, students were not likely to see women faculty role models. Similarly, women
were unlikely to experience doing surgery as compared to male colleagues. Conversely, women
students commonly hear gendered language in the surgery specialty. Therefore, during the sense-
making process of women considering medical specialty choices, their experiences detracted
them from imagining themselves in the field and pursuing surgery as a career (Hill & Vaughan,
2013). From marginalization to exclusion, women working in male-dominated fields are
disadvantaged from an environmental standpoint since many networking opportunities occur in
informal settings.
Further, engagement in professional societies or groups also lends specific support that
assists women in overcoming barriers in the field of medicine. Lin et al. (2019) revealed that a
women-centered professional group led to opportunities for support, advancement, and retention
32
in medicine. Regarding support, the qualitative study reported that women were better able to
navigate work-home conflicts by learning from other women role models. Additionally,
participants communicated that the professional group provided them with necessary networks
that led to advancement and promotions (Lin et al., 2019). Nominations by others in the network
as compared to self-nomination proved to be more effective for advancement. Finally, women
that participated in professional development opportunities had higher retention rates than those
that did not participate demonstrating the power of professional group association with women’s
advancement and retention (Lin et al., 2019; Pololi et al., 2013). Another strategy that has proven
successful for women’s advancement is sponsorship.
Mentors, Sponsors, Social Capital, and #METOO
Mentorship and sponsorship are distinctly different concepts with unique end results.
From the lens of promoting women’s advancement in academic medicine, success comes in the
form of partnering with a person in power or sponsor. Sponsors are influential leaders that
publicly support individuals with untapped potential for the purposes of advancement (Pisani,
2018).
Conversely, mentors are subject matter experts, work at all levels within an organization,
and do not need to be in positions of power (Pisani, 2018). Mentors provide support to mentees
by sharing knowledge and experience. As such, though mentoring programs provide benefit,
especially to early career surgeons, these programs have not proven to increase women’s
leadership. Alternatively, sponsorship has contributed to leadership opportunities (Cords, 2013).
In fact, the business sector has proven successful with a sponsorship approach and could lend
expertise to the field of medicine (Hewlett et al., 2010).
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Sponsorship in male-dominated professions affords men the ability to bridge the gap
between women and leadership. Until more women are in the field of spine surgery, Hewlett et
al. (2019) suggested that men can assist women with advancement and expand their legacy at the
same time. As such, the author indicated that value existed for sponsors as well as proteges since
executive sponsors saw an increase in their own promotions by 54% over executives that were
not sponsors. In summary, sponsors provide the social capital that women working in male-
dominated environments need in order to advance.
The link between social capital, sponsors, and advancement is not a new concept.
According to Seibert et al. (2001), social capital is an individual’s ability to access social
resources and networks for advancement, and this definition rings true today. Just as
discrimination is prevalent in male-dominated professions, the researchers demonstrated that
social capital proved to be instrumental to career success. The authors illustrated the value that
diverse social networks play on salary, promotions, access to resources, sponsorship, and career
advancement. Additionally, Eagly et al. (2008) showed that social capital was more indicative of
career success than job competency. Though sponsorship and social capital prove to be levers for
women’s advancement, the #METOO movement gives men pause.
The #METOO movement, intended to hold men accountable for sexual assault, has
produced unintended consequences for women’s advancement. In a Lean In and SurveyMonkey
survey (2019), repercussions of the #METOO movement manifested in the withdrawal of men
willing to sponsor or mentor women. In fact, the survey disclosed that 60% of men now felt
uncomfortable engaging in mentoring and other activities with women at work.
Alternatively, Soklaridis et al. (2018) suggested that the fear that men express in response
to the movement is socially constructed, not based in reality, and used as an excuse to perpetuate
34
men’s positions of power in society and gender inequality. The authors also explained that
fearing women proteges is about doubting women who speak out against inappropriate behavior,
and the root of the fear is about maintaining power as a dominant group. Regardless of the
reason, women benefit from sponsorship and need men sponsors for their advancement. By
extension, Hewlett et al. (2010) showed that women with sponsors enjoyed a 19% higher
satisfaction with their rate of advancement than women without sponsors.
Organizational Factors that Promote or Hinder Success
For women working in male-dominated professions, organizational support as well as
policies, procedures, and practices can be key mediators related to retention and persistence. In
general, women’s leadership has contributed several important advancements for organizational
culture that could be incorporated into male-dominated settings to change the dynamics
(Campuzano, 2019). First, women’s transformational leadership style values collaboration,
innovation, and creativity (Northouse, 2016). From an organizational lens, this translates into
shared decision-making and collaborative, team-based leadership with flat organizational
structures. Subsequently, team-based structures encourage participation from historically
marginalized groups, increasing diversity and leading to more creative problem solving
(Campuzano, 2019).
Next, organizations that create unbiased working conditions enable success for all
employees. For example, since women assume more domestic and childcare responsibilities than
men, holding important meetings during typical business hours or, alternatively, providing
appropriate technology to decrease work-home conflicts proved to be an important consideration
(Wood, 2021). Additionally, requiring sponsorship for high potential women could further
35
reduce biased working conditions since male sponsors will not unreasonably fear false
harassment claims and opt out of the program as a result.
Finally, organizational citizenship behaviors (OCB) prove to negatively impact women
more than men. OCB are unpaid, work-related helping behaviors (Armijo et al., 2020). The
authors indicated that women physicians received over three times more OCB work requests
than men. Additionally, the types of requests between men and women were different: requests
of women physicians revolved around helping students while requests of men led to networking
and research. This difference resulted in women spending 7.3 fewer hours per week on research
than men (Armijo et al., 2020). Since research is considered a high value activity related to
advancement, the difference in number and types of requests led to a biased work environment
privileging men.
Finally, policies, procedures, and practices can support or hinder women persisting in
surgery. Wellbeing programs, good parental leave policies, mental health support services, and
institutional support of professional organizations and conferences provided support for women
to succeed (Wood, 2021). With effective and supportive organizational measures, women
working in male-dominated cultures will be empowered to contribute their talents, enjoy
professional career satisfaction, and develop more women leaders and role models for the future.
Organizations that recognize, value, and embed principles contributed by women’s leadership
will not only support the persistence and retention of women leaders but also reap the
performance benefits.
Diversity Matters
Women make up half of the population yet the profession of spine surgery has remained
stagnant regarding gender diversity. Recognized as a worldwide problem, the United Nations
36
declared gender equality as one of its worldwide sustainability goals by conveying the
importance of gender equity from a human rights perspective as well as an economic perspective
(United Nations Inter-Agency Network on Women and Gender Equality & OECD-DAC
Network on Gender Equality, 2016). As such, gender and ethnic diversity have proven economic
benefits as well as problem solving benefits (Hunt et al., 2015).
Economically speaking, diverse leadership teams make more profits. Hunt et al. (2020)
revealed that companies with gender-diverse leadership teams were 25% more profitable than
those companies that are not. Additionally, a 36% increase in profits was shown in companies
with gender and ethnically diverse leadership teams. The authors communicated that the reasons
behind this phenomenon have been documented: increasing diversity increases the talent pool,
underrepresented groups have purchasing power, and innovation is fostered through diversity of
thought, life experiences, and identity. Therefore, diversity pays.
Finally, lack of diversity leads to increased unconscious biases and poorer patient
outcomes. In spine surgery specifically, patients were more satisfied with healthcare providers
similar to themselves with 16% of patients preferring female surgeons (Dineen et al., 2019;
Santry & Wren, 2012). Also, Santry and Wren (2012) confirmed that surgeons’ unconscious
biases led to racial disparities in healthcare. Negative unconscious biases of patients’ weight,
race, or ethnicity limited patient access to resources and led to poorer outcomes due to
stereotypical assumptions.
Further, diversity in leadership ensures role models exist for the next generation. Role
models encouraged more individuals that are underrepresented in medicine to see themselves in
careers previously held for only the privileged (Carapinha et al., 2016). Additionally, role models
ensure that the best and brightest talent are recruited and retained.
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Alternatively, in male-dominated environments, homogeneity of the environment
perpetuated one leadership style with shared values and assumptions that are socially engrained
over time. This tradition created a culture that is difficult to change leading to gendered work
environments (Campuzano, 2019). Since spine surgery consists of 95% men, the culture alone is
difficult to change. Additionally, without diversity at all levels in spine surgery,
underrepresented groups will continue to be marginalized for years to come and enable the
current exosystem environment to remain.
The Exosystem
The exosystem is defined by one or more settings or environments that indirectly impact
the developing individual (Shelton, 2019). From a work setting lens, organizational norms,
systemic discrimination, and culture will be explored. From the home setting, major life events
like jobs, pregnancy, marriage, and occupational stress leading to addiction and burnout provide
influences that impact women spine surgeons.
The Work Setting
Organizational norms that indirectly influence women spine surgeons comprise of
different standards for women based on traditional gender norms, systems that contribute to
stress, and stigma surrounding pregnancy and motherhood. Systemic bias and discrimination also
are prevalent in the exosystem and impact women’s advancement. Closely related to bias and
discrimination is the surgical culture.
The Surgery Culture
From unpredictable operating room schedules to parental leave, professional settings like
surgery were traditionally designed for men. In the United States, modern spine surgery became
viable in the mid 1900s with the invention of imaging as well as distribution of antibiotics
38
(Knoeller & Seifried, 2000). Around the same time, the feminist movement began addressing
equality in the workplace. Betty Friedan’s The Feminine Mystique (1963) incited interest when
her book, compiled of interviews from suburban housewives, challenged the traditional gender
and social norms that women’s work was solely that of housewife-mother.
Today, women are significant contributors to the workforce; however, literature related to
women spine surgeons indicated many barriers to entry and opportunities to opt out prematurely
(Rohde et al., 2016). Further, work-home conflicts and discrimination consistently rose to the top
of the list of deterrents. In fact, Bellini et al. (2019) reported that women surgeons strongly
identified the culture of orthopedic surgery to be sexist. Likewise, since orthopedic surgery
consists of the lowest percentage of women of all surgical specialties, the connection between
the sexist culture and women’s lack of interest in exploring this specialty provides a strong case
for the gap in underrepresentation.
Narratives of women surgeons told the story of their lived experiences and explained the
implicit rules of engagement: do not challenge the status quo, do not dress or behave in ways to
draw attention, do not wear your hair long, never wear heels (Medeiros & Griffith, 2019).
Demeaning jokes, comments about women’s bodies, referring to a female co-worker as a “bitch”
provided common examples of hostility and sexual harassment (National Academies of Sciences,
Engineering, and Medicine, 2018).
The Academies defined three groups of sexual harassment: gender harassment, unwanted
sexual attention, and sexual coercion. Derthick (2015) further classified these into seven
categories of behavior: leaving gender at the door (downplaying gender or gender blindness),
sexual objectification, environmental microaggressions, invalidation of the reality of women,
traditional gender roles, expectations of appearance, and inferiority. In summary, the impact of
39
sexual harassment and hostility leads to isolation, opting out of the profession early, and a
decrease in wellbeing.
With more frequent insults, slights, and microaggressions, the overall wellbeing of
women continues to decrease. Beagan (2001) first introduced everyday sexism which described
the cumulative effect of sexism over time. The researcher explained that one incident, in and of
itself, does not lead to systemic inequities and discrimination; however, the cumulative impact of
repeated sexist acts communicated a message of intolerance and inferiority of women.
Furthermore, individuals with intersectional identities (LGBTQ, masculine women, black
women) experienced even higher levels of sexism and harassment from both patients and co-
workers (Sudol et al., 2021). The conflict of playing by the implicit rules versus reporting
inappropriate behavior places women in difficult positions. Because women surgeons relied on
men for career advancement and networking, women coped with sexism and hostility by
overlooking or pacifying the harasser (National Academies of Sciences, Engineering, and
Medicine, 2018). These coping mechanisms, though ineffective, protect the victims from
retribution and other long-term damaging outcomes.
Traditional Gender Roles and the Stigma of Motherhood
Bias related to pregnancy and motherhood is common in the surgical field. Women took
on more domestic and childcare related work than men leading to increased levels of strain,
stress, and work-home conflicts (Jolly et al., 2014). In a study of Generation X physicians, Jolly
et al. (2014) determined that partnered women spent 8.5 more hours per week on domestic and
childcare activities than men demonstrating that traditional gender roles remained consistent
even among a younger generation of individuals that values shared accountability. Further, the
increased time was spent on childcare activities versus other domestic activities.
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Similarly, Rangel et al. (2018) found widespread negative perceptions of surgical
residents related to pregnancy and postpartum support leading to the stigma of women. The
authors showed that 72.9% of students and faculty made derogatory remarks about pregnant
residents that led to 59% of students reporting negative stigma associated with pregnant
residents. Further, 80% of residents believed the maternity leave duration to be inadequate.
Additionally, women reported breastfeeding and lactation support to be lacking: 58% of women
discontinued breastfeeding early due to work conflicts and demands, 44% of residents reported
inadequate lactation facilities, and 79% perceived faculty as not supportive.
Though much of the literature related to work-home conflicts focus on young women of
child-bearing years, this problem in not unique to early career professionals. In a recent national
survey of the first group of women physicians approaching retirement, over half of the women
aged 60 to 87 years old also experienced work-home conflicts due to primary caregiving
responsibilities for grandchildren and aging parents demonstrating the impact of work-home
conflicts throughout a woman’s career (Templeton et al., 2020).
Systemic Discrimination
Discrimination is grounded in historical roots of patriarchy. Glick and Fiske (2011)
introduced benevolent versus hostile sexism by way of the ambivalent sexism theory. According
to the researchers, hostile sexism strives to uphold conventional patriarchal power structures
through traditional gender roles of men exerting control over women through sexual
objectification and derogatory portrayals. Alternatively, the authors also coined the term
benevolent sexism to describe a romanticized view of sexism where men protect women for the
purpose of protecting their own position of power.
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From a cultural frame, men that value benevolent sexism also equally value hostile
sexism. For example, men that support benevolent sexism were likely to attribute guilt to women
that report sexual harassment since the women violated the traditional gender norm of upholding
sexual purity (Hideg & Ferris, 2016). On the hostile sexism side of the equation, these same men
viewed women as sexual objects and tools. Though benevolent sexism may be seen as
chivalrous, this type of sexism causes significant damage to women’s careers and also
undermines gender equality, especially in the promotion of women that work in
underrepresented professions.
In male-dominated cultures, these discriminatory experiences are common for women at
all levels of leadership. According to a report by NASEM (2018), male-dominated professions
like spine surgery were presumed to be sexist as well as fraught with sexual harassment and
discrimination due to the imbalance of power. In addition, women spine surgeons experience
discrimination from colleagues, patients, and their families contributing to a lack of motivation
to enter and remain in the field.
Sexual oppression is about power. From overt forms like sexual harassment and
discrimination to subtle forms like microaggressions and unconscious bias, the end result of
discrimination proved to be similar: domination, power, and control of subordinate others (Samra
& Hankivsky, 2021). The NASEM (2018) used the analogy of an iceberg to show the continuum
of behaviors intended to dominate and silence women (Appendix B). From comments including
seemingly innocent questions like “shouldn’t you choose a different medical specialty that is
conducive to mothers with small children?” to sexual assault and rape, the iceberg illustrates the
complexities of sexual oppression.
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The NASEM (2018) report on sexual harassment of women found five factors that led to
sexual harassment in the workplace: a tolerant organizational climate, male-dominated work
environments, hierarchical organizations where power is situated at the top, symbolic
compliance of organizational policies, and uneducated and uninformed leadership. As a whole,
the spine surgery profession exhibits several of these criteria. The male-dominated field,
hierarchical nature of the profession, organizational tolerance for inappropriate behavior, and
isolated settings requiring individuals to work together for long periods of time position women
to be at high-risk for discrimination.
In fact, sexism, harassment, and discrimination are prevalent in the spine surgery
literature. To support this assertion, a recent study discovered that over 83% of women
orthopedic spine surgery fellows were discriminated against because of their gender, and women
spine fellows reported a significantly higher percentage of discrimination than other orthopedic
specialties (Jurenovich & Cannada, 2020). With so few females in the field and NASEM’s
findings connecting male-dominated settings to sexual harassment and discrimination, gender
bias and discrimination remains a problem in the profession even though the nature of
discrimination is changing.
Further, disparities also exist at every level of academic faculty. Though gender parity
has been achieved in medical schools, there remains a different story regarding the diversity of
medical school faculty. With each advancement in faculty rank, fewer women surgeons moved
up with Black women significantly underrepresented (Berry et al., 2020). Of all U.S. medical
school surgical faculty, less than 1% were African American or Black with no department chairs.
Further, in the last 22 years, only 12 Black women surgeons (0.34%) have been awarded
National Institutes of Health grants. After controlling for variables, Reardon (2014) uncovered a
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ten-point discrepancy between funding awards of White people compared to Black people
leading to a 35% decrease in funding for Black scientists versus White scientists. Since grants
remain a metric critical for advancement, Black women remain disadvantaged.
Systems that Contribute to Occupational Stress
System-level and organizational-level factors contribute to the occupational stress of
today’s surgeon. The Institute of Medicine’s To Err is Human called upon the medical
community to employ organizational-level quality metrics to ensure patient safety after the
Institute reported over 98,000 deaths per year were caused by medical errors (Kohn et al., 2000).
Researchers now agree that the number of deaths due to medical errors reported by the Institute
was significantly underreported by as much as ten-fold, impacting hundreds of thousands of
patients each year (Classen et al., 2011).
More recently, system-level changes were instituted with the passage of the Patient
Protection and Affordable Care Act. Subsequently, electronic health records (EHR) became
mandatory continuing the quest to track and demonstrate patient quality and safety. Though
patient safety is essential, a 2018 Harris Poll showed that 49% of physicians perceived EHR to
detract from clinical efficacy and professional satisfaction (Stanford Medicine, 2018).
Additionally, Sinsky et al. (2016) demonstrated that EHR resulted in physicians spending two
extra hours during the work day for every hour spent with patients, and an incremental one to
two hours working at night on other administrative tasks. As a result, 71% of physicians believed
EHR contributed to burnout (Stanford Medicine, 2018). Due to inefficient reporting systems,
mandatory EHR produced an unintended consequence of excessive administrative workloads for
physicians, negatively impacting the patient-physician relationship by 69%, and leading to high
levels of burnout, especially in women (Jha et al., 2019; Shanafelt et al., 2015).
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Major Life Events
In the home setting, major life events such as pregnancy and marriage impact women
spine surgeons. Also, major career decisions and re-entry into the profession produce barriers
that impact the home environment. Finally, the continual barriers to entry drive many women
spine surgeons into high levels of occupational stress leading to addiction and burnout.
Career Decisions and Implications
Gender-based inequities produce career implications. Starting with job interviews, the
process proves to be especially problematic for women spine surgeons. In a survey of women
orthopedic surgeons, Jurenovich and Cannada (2020) discovered that 18% of women orthopedic
surgeons experienced discrimination during the interview process; however, 83% of women
pursuing spine fellowship experienced discrimination. Questions about marital status, pregnancy,
and maternity leave were most prevalent. Further, research supports the fact the women rarely
reported discrimination in fear of retaliation or reputational damage (NASEM, 2018).
Also, gendered language proves to hinder women surgeons’ career success as well as
reveal gender bias. In the least gender diverse specialties of orthopedic surgery and
neurosurgery, gendered language is common. Peck et al. (2020) indicated that the use of the term
chairman was frequently used among male-dominated specialties and at institutions with men
chairs as compared to the gender-neutral term chair. Conversely, departments led by women
communicated gender neutral language on their communication materials suggesting their choice
of language to be intentional and inclusive.
Similarly, the use of professional titles conveys credibility, professionalism, and respect.
In an analysis of speaker introductions at a medical conference, Files et al. (2017) discovered
vast differences in the usage of professional titles between men and women surgeons. Women
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surgeons referred to both women and men colleagues similarly in reference to a speaker’s
professional title; however, men surgeons did not exhibit the same utilization rate. Male surgeons
referred to their male colleagues by professional titles 72.4% of the time and introduced their
female colleagues by professional titles 49.2% of the time. These differences in usage of
gendered language have been shown to decrease a sense of belonging and connection in the
workplace as well as decrease career satisfaction (Stout & Dasgupta, 2011). For women, these
microinvalidations perpetuate that myth that women are of lower status and do not belong in
surgery.
Furthermore, gender-based disparities lead to inequities in pay as well as advancement. In
addition to gender-exclusive language impacting women spine surgeons, gender-based
disparities continued to disproportionately impact women from a financial perspective (Hoops et
al., 2018). In a study of faculty compensation and promotion rate at 24 medical schools, the
authors observed that women were paid 8% less than their male colleagues and 40% of the
discrepancy could not be accounted for. The researchers further determined that women had
fewer total publications, were less likely to receive research funding, and received lower
payments from Medicare. Moreover, the largest variance appeared in the male-dominated field
of orthopedic surgery and the surgical specialty as a whole. With 40% of the mean salaries
between men and women being unexplained, gender-based factors come into play. In addition to
gender bias leading to career implications, being a surgeon and a mother also introduces conflicts
that impact the family and home environment.
Mom and Surgeon
Being a woman spine surgeon places high levels of strain on the home environment.
Though residency training occurs during typical marriage and childbearing years, women
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residents waited longer to get married and have children compared to men residents (Chen et al.,
2013). Regarding family leave policies, the American Board of Surgeons (ABS) governs
residency program parental leave options. Rangel et al. (2018) uncovered that women believed
the ABS guidelines hindered their ability to attain adequate maternity leave with 78% of women
receiving 6 weeks or less. In fact, Altieri et al. (2019) learned that 42% of surgeons take only 2
weeks leave because parental leave placed unreasonable strain on other residents.
In addition, 57% of women surgeons perceived their commitment to childcare
responsibilities to have slowed their career progression compared to 20% of men (Dyrbye et al.,
2011). Other gender reported differences included significantly more work-home conflicts,
emotional exhaustion, and depression of women compared to their men counterparts which led to
a decrease in career satisfaction. Chen et al. (2013) found striking gender differences as well.
The authors showed that married men were happier and more confident at work than married
women, fathers felt more support from peers and senior physicians after the birth of their first
child while mothers conveyed being overwhelmed, stressed, and burned out.
Occupational Stress, Addiction, and Burnout
Physician burnout is a public health crisis. A work-associated syndrome, physician
burnout leads to emotional fatigue, depersonalization of patients, and a decreased sense of
accomplishment. Additionally, physician burnout impacted 50% of physicians (twice that of the
general population) and has been connected to negative patient outcomes, physician wellbeing,
and consequences for the entire healthcare system (West et al., 2018). Burnout led to medical
errors, loss in productivity, depression, addiction, and suicide (Pulcrano et al., 2016). Many view
the spike in physician burnout coinciding with the mandatory implementation of electronic
health records (EHR); however, EHR implementation is just one facet of a complex problem.
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Spine surgery is an inherently stressful and demanding profession. The surgeon is the
team leader who bears the brunt of patient responsibility while balancing significant risks
(Brandt, 2017). Stress and burnout start as early as medical school where 80% of students
demonstrated symptoms of burnout leading to considerations of dropping out of medical school
as well as suicidal ideation (Dyrbye et al., 2011). In fact, the suicide rate of male physicians was
40% higher than the general population and 130% higher for female physicians (Center et al.,
2003).
In fact, work related contextual and relational factors emerge as being especially
problematic for burnout of women physicians. In a recent systematic review, Sibeoni et al.
(2019) grouped physicians’ experiences of burnout in organizational, relational, and individual
themes. From an organizational standpoint, high workloads, paperwork, and work hours emerged
as contributors to burnout. Patient complications, medical errors, and the associated guilt or
helplessness topped the list for individual factors. However, inequalities in the form of lack of
opportunity, recognition, credibility, and sexual harassment surfaced as contextual and relational
factors that impacted burnout for females (Files et al., 2017; Peck et al., 2020; Sing et al., 2017).
Additionally, burnout of women surgeons is directly associated with microaggressions.
Sudol et al. (2021) specified that women surgeons working primarily with men were more likely
to experience sexist microaggressions and associated burnout. Further, burnout intensified for
women of underrepresented races and ethnicities. Cultures of sexism led to career dissatisfaction
and opting out of the field which then further contributed to the lack of gender representation,
whereas even subtle cues of belonging reinforced motivation and performance (Walton et al.,
2012). In addition to microaggressions, work-home conflicts lead to increased burnout of female
surgeons.
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Work-home conflicts appear to be a significant contributor of burnout for women
surgeons over the entirety of their careers and is seen as early as medical school. Dependent care
of children, grandchildren, and parents, coupled with gender role expectations related to
domestic responsibilities, proved to be significant causes of stress for women surgeons (Dyrbye
et al., 2012). With many surgeons in dual career relationships, work-home conflicts jeopardize
the work-life integration of surgeons, their relationships, and their families. Additionally, the
researchers expressed that recent work-home conflicts were not only associated with burnout but
also with depression, alcohol abuse, and lower career satisfaction. These conflicts also led to
increased likelihood of reducing clinical hours or plans to opt out of the profession altogether
(Dyrbye et al., 2014).
The Chronosystem
For the purposes of this study, the chronosystem consists of key training and career
milestones. Starting in medical school, women enter a gender equitable student environment
even though women faculty are underrepresented. Next, women physicians decide on a specialty
area that may lead to either orthopedic surgery or neurosurgery. The gender disparity is visible at
this stage since men comprise the majority in surgery, orthopedics, and neurosurgery specialties.
Finally, sub-specialization in spine surgery further distances women from the lens of gender
equity in the profession as only 5% of the profession are women. As a result, women drop out of
the surgical profession prematurely and at higher rates than men increasing the gender divide for
spine surgeons in practice. Concepts that weave in and out of the chronosystem encompass all
other systems and lead to isolation versus a sense of belonging as well as career satisfaction and
engagement versus opting out of the profession prematurely.
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Conceptual Framework
The conceptual framework for this study integrates literature, the ecological model, the
researcher’s experiences, and worldview (Figure 1). The problem of underrepresentation of
women in spine surgery will be explored through Bronfenbrenner’s ecology of human
development (2018). Because the ecological model provides a structure to examine women spine
surgeons and settings that influence their development and progression in the field, this
framework affords an interdependent lens in which to examine the problem.
Bronfenbrenner (1979) originally identified the microsystem, mesosystem, exosystem,
macrosystem, and chronosystem as settings or systems that influence the developing individual.
The microsystem examines the daily influences of women spine surgeons from both a work and
home setting. The systems of the woman spine surgeon’s immediate environment at both work
and home play integral functions in their development. Support of friends and family as well as
work norms and expectations of women spine surgeons in the work setting are primary
influences of the microsystem.
The mesosystem connects the microsystem, or immediate environment of the woman
spine surgeon, to the exosystem. In the mesosystem, mentors and sponsors are key influences of
both the work and home settings. Additionally, a sense of belonging, diversity of the workforce
environment, and organizational policies, procedures, and practices that support the wellbeing
and equity of women spine surgeons provide support mechanisms to help women navigate the
field.
Next, the exosystem describes societal influences and organizational norms that are
engrained in the socially constructed environment and are difficult to change. Systemic
discrimination, the male-dominated surgery culture, the stigma of pregnancy, maternity leave,
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and motherhood as well as traditional societal norms of gender roles are examples of influences
in the exosystem. Finally, the chronosystem consists of the time continuum from medical school
through retirement or opting out of the field prematurely.
In an efficient system, the mesosystem influences would mediate or buffer the negative
aspects of the exosystem for the individual over time. In this study, the woman spine surgeon
comprises the role of the individual and the time consists of the duration of her career. Core
concepts lead to either a sense of belonging and career satisfaction or, alternatively, isolation and
opting out of the profession.
Tuck and Yang (2014) define theory of change as “…a belief or perspective about how a
situation can be adjusted, corrected, or improved” (p. 10). The researcher’s theory of change is
desire centered. Though literature exists on barriers and strategies to increase women’s
representation in surgical professions, progress has not been achieved. Desire centered research
not only acknowledges the complexities of experiences but also longs for wisdom and hope—it
acknowledges the past while longing for the imagined future—the not yet (Tuck, 2009). The
theory of change aligns with Bronfenbrenner’s ecological model by considering that contexts,
settings, and influences of other people constantly contribute to an individual’s worldview.
From a worldview standpoint, the researcher views the study from a critical feminist lens.
From this perspective, male-dominated professions are not just attributed to men only but from
the lens of the dominant culture. The dominant culture in medicine values quantitative scientific
data, one truth, certainty, and explanation (Sharma, 2019). Additionally, this practice is
exemplified in medical education curriculum and research that places emphasis on the dominant
culture while attaching inferiority to the feminine or subordinate culture. The gendering of the
field places significance on prioritizing specific types of knowledge (quantitative, scientific) and
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could benefit from a critical feminist lens in order to challenge and hear the voices of the
underrepresented that are excluded when power, privilege, and dominance are the driving forces.
Figure 1
Conceptual Framework
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Conclusion
Spine surgery is a male-dominated profession. Despite attempts from professional
societies, researchers, physicians, and hospital institutions to encourage a more diverse
workforce, little has changed in the profession since its inception. Additionally,
underrepresentation of women at all levels of academic faculty and surgical leadership exists.
Further, research points to the disparities and inequities stemming from traditional gender roles,
negative stereotypes, patriarchy, and power. For women to be equitable partners in the profession
requires commitment, intentionality, support, and buy in from those in power. Organizations
with diverse teams have proven to be successful economically and in solving complex problems.
The value of diversity, inclusion, and equity in spine surgery has significant advantages, and the
time for change is now.
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Chapter Three: Methodology
The purpose of the study explored how women navigated the male-dominated field of
spine surgery in North America. The chapter begins with a review of the research questions
followed by an overview of the design and setting. Next, my positionality grounds the study by
disclosing relevant biases and explains mitigation strategies when appropriate. Then, the
methodology is depicted followed by the data collection and analysis plan. To complete the
chapter, credibility and trustworthiness address ethical considerations, limitations, and
delimitations of the study.
Research Questions
The research questions centered around exploring how women navigate the profession of
spine surgery as well as factors that contributed to persistence and retention in the profession. In
the highly specialized, male-dominated field of spine surgery, the lived experiences of women
spine surgeons provided a unique lens in which to explore the problem. The following research
questions guided the study:
1. How do women spine surgeons balance conflicts of gender bias and social norms while
exhibiting authenticity?
2. How do factors of a sense of belonging contribute to women persisting in the male-
dominated profession of spine surgery?
Overview of Design
The research design for this study was qualitative phenomenology. Qualitative research
seeks to uncover meaning defined by the research participants (Creswell & Creswell, 2018).
Additionally, the phenomenon of underrepresentation of women in spine surgery was examined
via a phenomenological case-based approach. Merriam and Tisdell (2016) defined
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phenomenology as a person’s “conscious experience of their life-world,” and a case study as
examining one thing thoroughly (p. 26). In this example, women spine surgeons affiliated with a
single organization represent the case studied.
Furthermore, to increase credibility and trustworthiness, several participants reviewed
their transcripts for accuracy, and member-checking was employed to ensure that the themes and
concepts were consistent with common experiences. In summary, although previous research
uncovered barriers of women in the surgical field, the problem of gender bias and inequity in
spine surgery has not been adequately addressed from a qualitative approach. By searching to
understand this phenomenon further, an expanded picture of women spine surgeons emerged
thus validating a qualitative, case study strategy as an appropriate lens in which to study this
problem.
Research Setting
Women spine surgeons who practice in North America and are affiliated with the
organization focus the study. Affinity’s (pseudonym) global mission is promoting excellence in
patient care and outcomes in musculoskeletal disorders by improving performance through
education, optimizing clinical treatment pathways and guidelines, and promoting innovation
through research and development. The North America headquarters of the organization is based
in the northeastern United States with employee expertise in healthcare, business, and research
sectors. Members of the organization are surgeons from various musculoskeletal surgical
specialties and practice in the United States and Canada.
The Researcher
Villaverde (2008) described positionality as “how one is situated through the intersection
of power and the politics of gender, race, class, sexuality, ethnicity, culture, language, and other
55
social factors” (p. 10). Over the entirety of my career, I have worked with surgeons. My job as a
healthcare leader positions me as a strategic relationship partner to spine surgeons affiliated with
the organization.
The surgeon leaders of the organization are predominantly White males with only 5% of
the organization’s membership being women. From a privileged standpoint, I identify as a
White, educated American of upper socioeconomic class which allows for easy assimilation with
highly educated, White male surgeons of similar class. From a subjugated viewpoint, my identity
as a woman working in a male-dominated profession has led to experiences of sexism, gender
bias, and a lack of belonging. Many of these surgeons are close friends and would be surprised to
learn that marginalization occurs even between friends. Because of my personal experiences of
otherness, I can relate to those women spine surgeons who experience the same marginalization
from colleagues while also feeling conflicted due to the strong ties that bind personal
relationships.
From the perspective of the problem of practice, men surgeons and the surgery culture
hold the privilege; however, both women and men surgeons could be harmed if I am not
cognizant of biases and power relationships. The research is intended to serve and benefit
women trainees, spine surgeons, institutions, and society. However, because spine surgery is a
male-dominated profession, gender norms and biases come into play. Male spine surgeons may
feel threatened by the research and retaliate against women spine surgeons. Further, my
assumptions that all women surgeons desire equity and that men surgeons hold the privilege,
men are not as concerned about gender equity but either do not recognize or will not admit it,
and men are uninformed about gender equity but believe they are informed, need to be
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acknowledged and balanced by a sense of reality-seeking. As a researcher, it is important to
understand women surgeons’ subjective realities to make sense of the problem.
Since the interview questions were designed, framed, and analyzed from my perspective
as a researcher and woman, it is important that I understand and disclose my positionality and
power relationships to obtain candid feedback. Additionally, since I have experienced
microaggressions and gender bias, I may inadvertently empathize with participants with similar
experiences. To mitigate factors that could impact responses and data collection, I am disclosing
my positionality to the reader so that the reader is appropriately informed (Merriam & Tisdell,
2016).
Data Sources
The primary data source for the study originated from women spine surgeons affiliated
with Affinity. Further, I received approval from Affinity’s Executive Director to utilize the email
addresses from Affinity’s database to contact women spine surgeons for possible participation in
the study. The database of the spine clinical division at Affinity contains 2157 distinct surgeon
email addresses; however, the actual number of surgeons is lower since a given surgeon may be
listed under multiple email addresses. Of the total, 90 identified as women spine surgeons with
no designation of other demographic information like age, race, or ethnicity.
Interviews
Creswell and Creswell (2018) communicated that qualitative inquiry seeks to understand
the meaning of an individual’s lived experience, and this methodology provides voice to the
underrepresented. The study’s methodology utilized interviews as the primary method of inquiry.
Additionally, relevant social media campaigns were explored and provided insight as secondary
data sources.
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Participants
For the purposes of this study, spine surgeons who identify as female, practice in North
America, and affiliated with Affinity were the focus of the study. In the spine clinical division,
2157 surgeon email addresses comprised the database; however, the actual number of distinct
surgeons is lower since there may be multiple email addresses for an individual surgeon. Of the
total, 90 were female spine surgeons with no designation of age, race, or ethnicity. In the overall
spine surgery profession, 5% are women with neurosurgeons having a higher percentage of
women than orthopedic spine surgeons. Based upon Affinity data, the female membership
paralleled the overall profession.
Since the database did not include age, race, or ethnicity and the study protocol sought a
diverse group of women spine surgeons, the researcher sent an email to all North American
women in the database (Appendix C). The email described the purpose of the study, the
importance of their contribution to the study, the participant criteria, an information sheet that
included ethical and confidentiality considerations, and a link to a demographic survey
administered via Qualtrics. Additionally, the desired participant criteria consisted of women
spine surgeons from various age ranges, ethnicities, and races.
Once the email recipients confirmed interest in participating in the study by completing
the survey administered by Qualtrics (Appendix D), I purposefully selected a diverse participant
pool from the standpoint of age and race in order to gain insight from surgeons at various career
stages as well as ethnic and racial backgrounds. The study design specified a goal of
interviewing 12 to 15 participants, and I completed 11 one-hour interviews. After the interviews
were transcribed, one participant requested that her data be removed from the study due to
potential future litigation. Additionally, two participants requested to review their transcripts for
58
accuracy and to remove any potentially identifiable information, and I promptly obliged. Upon
completion of these requests, 10 interviews were included in the study. In addition to data
obtained from one-on-one interviews, I increased credibility by member checking the data to
ensure that the findings were consistent with common experiences of participants.
After purposefully selecting participants, I followed up with the participants to schedule
the interviews. The time and date of the interview was driven by the participants to minimize my
perceived power as a researcher (Burkholder et al., 2019). At the beginning of the interview, I
intended to build rapport with the participants by explaining the purpose of the study and
acknowledging the participant’s expertise, time, and valued insights that contributed to the study
(Patton, 2002). Next, I introduced the information sheet, reiterated confidentiality, and the ability
of the participant to skip questions or stop the interview at any time. Finally, I asked the
participants if they had any questions or concerns before we got started with the interview.
Next, the interview began by asking the participant a neutral, open-ended question to
initiate the conversation. At the end of the interview, I thanked the participants for their
contribution to the study, provided my contact information, and asked if the participant had any
additional questions. Appendix E includes the complete interview protocol.
Instrumentation
In qualitative studies, the researcher is the primary instrument. Subsequently, I utilized a
semi-structured interview protocol to maintain the focus of the interview as well as allow
flexibility for follow-up probes (Burkholder et al., 2019). This approach allowed the opportunity
to gain rich, descriptive data.
To improve the quality of the interview protocol, I conducted pilot interviews with peers
to streamline the interview protocol and minimize bias. The interview protocol (Appendix E)
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was developed according to Patton’s (2002) qualitative interviewing guide. The protocol
included 15 questions and probes focused on the participant’s experience, behavior, feelings, and
beliefs about gender bias, inequities, lived experiences, and the role of gender norms in spine
surgery. These concepts connected to the research questions by exploring how women navigate
and experience the male-dominated profession of spine surgery from an overall wellbeing and
equity lens as well as from a retention and persistence viewpoint. Further, this problem explored
the impact of the dominant identity group (White male surgeons) on subordinate identities
(women surgeons).
Data Collection Procedures
Interviews were conducted from mid-August through October 2021. This timeline
allowed approximately two participants to be interviewed per week (one-hour interview per
participant) with additional time during the week spent completing the transcripts, analyzing the
data, and coding themes. Approximately five hours per interview were spent transcribing and
initially coding the data. The location of the interviews took place via Zoom, and 10 interviews
were recorded from my personal computer. One interviewee was not able to connect via Zoom,
so a phone conversation took the place of the Zoom recording. I took notes during this interview
after the participant agreed. Finally, the data will only be kept as long as necessary or for long as
required by the Institutional Review Board.
Data Analysis
Regarding data analysis, I used the Zoom transcription service and subsequently
reviewed and corrected the transcripts the same week that the interviews were conducted. The
corrected transcripts captured accurate translation of the interviews including contextual and
non-verbal cues from the participants. Next, I began coding and organizing the data according to
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themes utilizing NVivo software. In addition to thematic codes, the data was also coded into
apriori and open codes. Upon extensive time spent learning how to use the NVivo software, I
decided to abandon NVivo and manually organize the thematic data via sticky notes and poster
boards.
Credibility and Trustworthiness
Qualitative research assumes multiple realities exist and that individuals construct reality
based upon how they view the world (Merriam & Tisdell, 2016). For the purposes of qualitative
research, credibility refers to the findings being credible or valid, and trustworthiness relates to
the rigorous inquiry of the researcher as well as the research process. To ensure credibility and
trustworthiness were addressed in the study, I ensured that the research questions, core concepts
from the conceptual framework, and interview questions were aligned and supported one
another.
Additionally, pilot interviews with peers were conducted to eliminate leading questions
and ensure the questions were easily understood. When capturing the interview data, participant
comments were parroted back at certain times during the interview to ensure accuracy (Merriam
& Tisdell, 2016). Next, incorporating rich, descriptive data with participant quotes allows the
reader to analyze certain attributes or themes as well as judge transferability. Further, though the
goal of 12 to 15 interviews was not met, the 10 completed interviews appeared to reach
saturation since limited new information was forthcoming. Finally, secondary data sources
(social media posts and channels) were incorporated to support the findings.
Ethical Considerations
Rubin and Rubin (2005) communicated that researchers need to demonstrate strong
ethical standards regarding participants. Respect and truthfulness are two key principles that
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demand attention by the researcher. Strategies to address ethical issues included voluntary
participation, confidentiality, and refraining from gathering data prior to institutional board
review (IRB) approval. Additionally, regarding confidentiality, special consideration was given
to women spine surgeons who also identified as POC. Since this group is uncommon, specific
quotes from these women were examined closely to ensure confidentiality was not breached.
Furthermore, since the study was deemed exempt by the IRB and informed consent was
not required, an information sheet (Appendix F) was provided to the participants prior to the
interview. Also, key sections of the document were reviewed with the participants prior to
beginning the interview. Key sections consisted of the purpose of the study and the participant’s
involvement including the ability of the participant to skip interview questions or stop the
interview at any point. Additionally, confidentiality of the data and the participant was also
addressed. Finally, the participant had the opportunity to ask questions prior to, during, and after
the interview.
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Chapter Four: Findings
The purpose of this study was to better understand how women spine surgeons navigated
the male-dominated profession of spine surgery as well as factors that led to their persistence and
retention in the field. The conceptual framework, based upon Bronfenbrenner’s ecological
model, identified direct and indirect influences of women spine surgeons as well as mediating
factors that assist women in navigating the field. Though few quantitative studies have been
conducted to identify barriers of women spine surgeons specifically, I designed this qualitative
study to better understand the lived experiences of women spine surgeons in the highly
competitive, male-dominated field.
This chapter focuses on the researcher’s findings to the two following questions:
1. How do women spine surgeons balance conflicts of gender bias and social norms while
exhibiting authenticity?
2. How do factors of a sense of belonging contribute to women persisting in the male-
dominated profession of spine surgery?
The chapter begins with a description of the research participants. Next, findings for research
question one and two will be addressed. Finally, a summary will complete the chapter.
Participants
Experiences of women spine surgeons who practice in North America and are affiliated
with Affinity were the focus the study. An introductory email was sent to all women spine
surgeons in Affinity’s North American database, communicated the purpose of the study, and
requested willing participants to complete a demographic survey to affirm interest in
participating in a one-hour interview with the researcher. Next, the researcher purposefully
selected 12 women to complete the one-hour interview based upon diversity demographics
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identified in the survey. Eleven (11) participants followed through and consented to the
confidential interview. Two participants requested to review their interview transcripts for
accuracy and confidentiality after the researcher transcribed the data, and this process was
successfully executed. Subsequently, one of the remaining eleven participants requested their
data be removed from the study due to potential future litigation, and the researcher promptly
obliged leaving a total of 10 participants. Furthermore, since only one of the participants was
from Canada and had a vastly different experience than the women from the United States,
limited data was included from this participant. Table 1 indicates the participant names
(pseudonyms), age range, race, and practice focus. Age groups were represented in four
segments of practice: training, early, mid, and late stages of practice. At times, the participant
names will not be revealed in order to protect confidentiality. Additionally, the majority of
participants were orthopedic surgeons (80%) versus neurosurgeons (20%).
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Table 1
Self-Identified Demographic Data of Participants
Participant
Name
(Pseudonym)
Age Range Stage of Practice Race Practice Focus
Adira 25-34 In Training White or
European
American
Neurosurgeon
Althea 35-44 Early White or
European
American
Orthopedic
Surgeon
Iris 35-44 Early White or
European
American
Orthopedic
Surgeon
Vera 35-44 Early White or
European
American
Orthopedic
Surgeon
Pallas 35-44 Early White or
European
American
Orthopedic
Surgeon
(Pediatric)
Alala 35-44 Early White or
European
American
Neurosurgeon
Pera 35-44 Early Asian or Asian
American
Orthopedic
Surgeon
Cassandra 45-54 Mid Asian or Asian
American
Orthopedic
Surgeon
(Pediatric)
Alexi 55-64 Late White or
European
American
Orthopedic
Surgeon
Maia 55-64 Late Asian or Asian
American
Orthopedic
Surgeon
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Findings Related to Research Question One
Research question one sought to understand how women spine surgeons balanced the
effects of gender bias in the workplace and if these surgeons believed to be sacrificing their own
authenticity as a result. This section describes how various age groups of women spine surgeons
experienced gender bias. Next, findings regarding how the participants made sense of these
experiences as well as how they strategically navigated difficult situations will be presented. As
the overarching theme, the researcher discovered that in order for the women participants to
persist and thrive in the profession required a constant ability to pivot and respond strategically
to expectations based on traditional societal gender norms, stereotypes, and bias.
Women’s Expectations Versus Reality
Women spine surgeons between 55-64 years of age (late stage of practice) not only held
different expectations of the profession than women in training (25-34) and early practice (35-
44) but also experienced gender bias in different ways. The age difference between late stage
surgeons and surgeons in training was approximately 30 years. Further, the changing
expectations and experiences of gender bias between the groups suggested that times have
changed over the last three decades. However, the reality of being a woman spine surgeon today
showed similar but different patterns of gender bias. Thus, gender bias in the profession of spine
surgery still persists but in a different form.
Starting Out
Exposure to spine surgery led all participants to choose the profession. In fact, nine of the
ten participants stated they got into the field due to actually experiencing spine surgery first-hand
during their medical school rotations while one participant chose to do a spine fellowship
because of the limited time spent on spine during her residency. Supportive Attending surgeons
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(more experienced, teaching surgeons) as well as observing actual surgeries proved to be the
primary influencers for women self-selecting the specialty.
As an example, Cassandra explained that as an Asian American woman from an ultra-
conservative family, she was never allowed to touch tools growing up. The first time she was
handed a power drill in the operating room during a case led to her decision. She acknowledged,
“that was the end of that…these are my people.” She was hooked. Her decision to apply for
orthopedic residency was made in that moment demonstrating the link between exposure to a
specialty and a resident’s decision to pursue that specialty.
Similarly, Alexi was influenced by her Attending surgeon’s love for the field. “It was the
most fun he’d ever had and that was really infectious.” Althea (an orthopedic resident in the 25-
34 age group) chose orthopedic surgery after working for a pediatric spine surgeon as a research
assistant. After shadowing several of his scoliosis surgeries, she quickly made the decision to
pursue the field. Her employer became her mentor and “was just very supportive…from day one.
There was nothing but the expectation that I was going to Medical School and I want to go into
surgery. There shouldn’t and aren’t any barriers for me.” Althea’s comments demonstrated the
difference between her expectations of the field versus the late stage surgeons who expected and
experienced overt discrimination.
During medical school, Althea visited several residency programs to determine which
ones to apply for orthopedic residency. Though she knew there was a lack of women in
orthopedic surgery, she saw a few women in the programs that she visited and “didn’t
particularly see the [lack of women] as an issue in the upcoming generation.” She assumed,
“things have changed” related to gender representation in orthopedics. One program also had
their first pregnant resident and Althea believed, “that’s possible too [in today’s environment].
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At least two or three [of the residents]…over those two years were women.” Based upon her
upbringing and life experiences, she expected “to be in an environment of gender, ethnicity, life
experience diversity.” However, when she entered orthopedic residency, “it was a pretty big
shock…the daily microaggressions, comments, assumptions made by patients and doctors…to
this day is annoying and very persistent.” Though expectations of gender equity among early
stage surgeons are common, the reality is that the vast majority of women spine surgeons of all
ages experience gender-based stereotypes leading to discrimination, unconscious biases, and
microaggressions.
Stereotypes, Discrimination, Unconscious Bias, and Microaggressions
Stereotypes are powerful influences, especially in male-dominated work settings. Also,
these expectations of an entire group of people are reinforced through media, songs, and film
reinforcing the stereotype. Stereotypes lead to biases, and unchecked biases can lead to
discrimination, microaggressions, and unconscious bias. Though the late stage surgeons expected
and experienced discrimination, the surgeons in training, early, and mid stages experienced
discrimination and gender bias differently. For the younger surgeons, gender bias primarily
presented as covert. This hidden nature of gender bias led to constant confusion, frustration, and
analysis by the early career women making navigation of the field difficult, especially
throughout training and early stages of practice when they were learning and establishing their
careers. For mid stage surgeons advancing in their careers, there was a belief that they had
overcome gender bias until it presented again in the form of stalled career advancement. Though
all women believed themselves to be appropriately competent from a surgical standpoint,
navigating the cultural and societal norms of the work setting proved to be the biggest challenge.
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Literature cites a lack of confidence as one of the most common stereotypes attributed to
women surgeons, and the participants confirmed this stereotype. Alala stated, “the number one
term used to describe women [trainees], no matter how they are performing…is not confident;
whereas I rarely hear it with the guys, even when the guy is a puddle of mess.” As a residency
program director, she explained that the learning styles of women and men are different. Women
tend to be “more about precision than speed, and they’re more about asking to get it right than
being independent right away.” From a gender stereotype basis, since surgery is associated with
men versus women, men are viewed as the standard or ideal mental model of a surgeon as
compared to women. Further, since men do not ask as many questions as women, the women are
seen as conservative and not confident. In reality, “the careful individual who’s trying to learn
should be the standard.” Alala continued by saying that “the women [trainees] are doing a better
job, and they should be the standard…but it’s guy’s judging guys on guy stuff” indicating that
spine surgery is a male-dominated profession, especially in leadership, led by males, and based
upon biased standards of the ideal surgeon.
Other participants supported these comments about male residents being too aggressive
in surgery, not asking questions, and “operating beyond the bounds of what they should be
doing” communicated by Alala. Further, since male-dominated professions value agentic traits
(aggressive, competitive), the standard or ideal mental model of a spine surgeon is associated
with being competitive and aggressive as opposed to being precise, careful, and questioning.
Therefore, since women do not fit the standard mental model, their preciseness, carefulness in
surgery, and questioning nature is seen as a lack of confidence and being too conservative by
men. Althea affirmed this stereotype when she explained that she has routinely heard men
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faculty comment about women interviewees as being “weird,” “not good in the OR,” or
“conservative” as reasons for not hiring women.
In addition to a lack of confidence, women spine surgeons faced other common
stereotypes. Women spine surgeons were viewed as either too pushy or too passive. Pallas stated
that “in medicine, women are either cute, dumb, or bitchy. There’s no other category and if I’m
gonna pick one to be in, I think I want to be in the bitchy category.” Several of the women also
indicated that they wanted to be viewed as a surgeon first and foremost as compared to a woman
surgeon. Because of the stereotypes of women surgeons, the perception that they are pushy or
aggressive was viewed negatively as compared to men surgeons where these traits are common
and attributed favorably.
Similarly, Alexi, who served in the United States military and spent time in Iraq,
communicated that she was certain she “fell into the bitchy category… I was direct which is
exactly the same way that my other colleagues acted, but you don’t get to act that way as a
female, even today, and not be considered pushy.” She further laughed and said “I saw a cartoon
the other day that said ‘what’s the difference between being aggressive and assertive? Gender.’”
Similarly, Alala stated, “you’re very aware that if you’re aggressive like a lot of the men are,
you’re considered bitchy. If you’re nice and sweet, I mean that’s a characteristic of women, you
get pushed around…like we can’t get away from that.” Another participant acknowledged,
“you’re very aware of the stereotypes, right or wrong, and attempt to combat them.” These
comments showed the difficulty that women experienced navigating the gender stereotypes in
spine surgery.
By comparison, Cassandra described herself as assuming more of a passive demeanor
that resulted in less qualified support staff assisting in her surgeries. “They’re just not familiar
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with the instruments,” referring to her OR staff not being familiar with the surgical
instrumentation. “They throw in people who are not as qualified into my [operating] room,
knowing that I will not react negatively” in comparison to most of the men. “…as a woman in
the OR, I will never lose my temper…I can’t ever afford that kind of temper tantrum that
sometimes happens in a man’s OR…I’m expected to be less direct.” Additionally, she expressed
her reason for taking a softer approach — to get things done.
…if someone is not doing their job…I’m expected to deal with it a little bit differently. I
can’t just be like ‘you’re not doing your job right.’ I have to constantly say ‘Could you
please do this?’ ‘Could you please do that?’…lots of please’s and thank you’s…when
crap is hitting the fan…I have to spend a lot more energy going around the directness.
Cassandra’s comments demonstrated the powerful influence that stereotypes play in her daily
work. Since women are stereotyped as communal (nurturing) beings, when women display
agentic characteristics typically associated with men, they create conflict in the mind of their co-
workers whether or not those co-workers are men or women.
Experiences of unconscious bias and microaggressions toward the participants confirmed
to be common occurrences and ultimately led to behavior modifications by the women. Nine of
the ten women experienced unconscious bias and microaggressions on a regular basis from
different influencers at different levels of power: other surgeons (men and women), residents
(generally men), staff and nurses (generally women), patients (men and women), sales
representatives (generally men) as well as from specific residency and fellowship training
program faculty (generally men). The widespread nature of these experiences, perpetuated by
both men and women, demonstrated the powerful influence that stereotypes play in our society
and reinforce the myth that women do not belong in spine surgery. Table 2 describes some of the
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participants’ experiences of gender bias, what the interaction taught them, and how they made
sense of the experiences. Their resultant coping behaviors placed them in more favorable
positions to succeed long-term in the field.
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Table 2
Participant’s Experiences of Gender Bias Comments
Experiences of bias Reinforcing message Quotes
As a residency training
program director (PD), Chair
and Residents evaluated PD
as not maternal enough, not
feminine enough
Women are not treated and
evaluated the same as men
“It was interesting, and
disappointing, that even the
resident’s expectations were
gendered.”
Inaccurately blamed for sub-
optimal surgical outcome
My work does not speak for
itself
“I realized that my work
could not speak for itself, and
that I actually had to defend
myself.”
Written up by hospital
leadership for doing exactly
what the men were doing
Women are judged by
different standards than the
men
“Don’t do what the guys do.”
Reprimanded for being too
assertive in the OR after
being counseled to be more
assertive in the OR
I cannot win “I will never lose my temper
in the OR. I can’t afford that
kind of temper tantrum that
sometimes happens in a
man’s OR.”
Inaccurately being called not
good in the OR setting
Women are inferior surgeons “Because I was female, I had
to be a little bit better than
the guys.”
Being ignored or talked over
by men
Women are inferior. My voice
is not important.
“You’ve got to be loud and
obnoxious to be heard.”
Deemed not confident enough Men are confident and
women are not; Do not speak
up or ask questions
“There’s only a certain
amount of vulnerability I’m
going to show around a male
colleague…I’m worried
about making it seem a
certain way because I’m a
female.”
Women spine surgeons are
cute, dumb, or bitchy
Women spine surgeons are
inferior and not judged by
their intelligence
“You’re very aware of these
stereotypes and attempt to
combat them.”
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Judged More Harshly
In addition to navigating the daily biased work norms, women were also judged more
harshly than their male colleagues. Half of the participants (50%) provided stories that supported
claims that women working in male-dominated settings were “held more accountable for their
mistakes than men. For the minority, it’s more obvious when you do something wrong,” stated
Maia. She further elaborated that “more men got away with acting badly than women.” In all
cases, the impacted women were reprimanded either formally or informally for actions or
behaviors that men were not held accountable for.
As an example, Alexi’s military career was almost derailed when an Attending surgeon
wrote a bad evaluation of her because she was a lesbian:
I immediately went to the Chairman and demanded ‘What is this? What’s going on,
man?’ He was able to get it fixed but the way the military grades you, if you don’t get a
certain grade…that essentially stops your career.
Alexi’s experience demonstrated the challenges and added complexity of intersectionality while
also being one of the first women in the field.
Two participants also described similar experiences as residency Program Directors (PD).
They both explained the strict standards that PDs are required to follow. In one situation, the
participant’s one-over manager kept asking her to violate the residency training standards, which
she refused, but “was careful to” do so “in a professional manner” due to the power differential.
Subsequently, he reported her to the Dean stating she was unprofessional which led to the
decision that she needed a coach to help her communicate more effectively.
Cassandra and Adira confirmed that men were not reprimanded for similar actions or
behaviors. I know that “the guys weren’t written up because they continued doing it the same
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way.” Cassandra also explained how one male colleague’s bad behavior freed him from taking
call.
…one physician does not even take call anymore because he’s so awful to them [the
nurses] and they hate him, and so now I take extra call…and he doesn’t take any. I know
if I acted that way, there would be repercussions.
In another situation, Alala (also a program director who achieved full professor status
early and was on the leadership tract at her institution) had some underperforming residents “so I
pushed hard to meet…the standards.” In her subsequent performance evaluation from her
residents and Chairman, gendered feedback contributed to her career advancement being
derailed. Unlike the previous male program directors that “were actually mean and I …was a
much nicer one…and they were not maternal in any way,” her evaluators wrote about her,
I needed to be more maternal, dress more feminine…stuff like that that I was really not
expecting and hadn’t faced before. And that made me really angry. …so where’s my
career now? It is where it is, and it will always be here and that is the limit of what I’m
going to do in life.
For one who has dedicated more than 12 years in training after undergraduate study in a highly
specialized profession and identified early as a leader in the field, she was devastated that the
gendered feedback led to removal from the leadership tract. “I’ve heard of this glass ceiling and I
never had it until I smashed into it so hard I fell down.” Being a mid stage surgeon, Alala
inaccurately assumed that she had previously crossed the hurdles related to gender bias and did
not believe that she experienced gender bias on a frequent basis; however, the biases were ever
present, just undercover. These repeated lessons taught the women about the culture they were
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working in, and subsequently the women learned ways to redefine their roles and persist in the
field.
Sense-Making
As a result of being judged more harshly than the men due to their gender, the women
modified their behavior in order to persist and remain in the field. Since there are so few women
in the spine profession, they stick out and are more recognizable which contributed to the women
being singled out as well as the belief that they had to be better than the men. One participant
communicated, “…I needed to be much more careful because people can identify me very
easily.” As a girl as well as an Asian girl, she would be singled out by both her gender and her
ethnicity. Maia supported this further by saying, “women are held more accountable for their
mistakes. For the minority, it’s more obvious when you do something wrong.”
Since the women were more visible and thus held more accountable, 40% of the women
revealed that they had to be better than the men. “Because I was female, I needed to be just a
little bit better. I had to work harder…make sure I was always on top of my game.” Similarly,
Cassandra indicated that “most women try to be better to get the same recognition…we obsess
over not making mistakes, building our reputation appropriately at the beginning.” The risks
were high for the women. In many cases, the women were inappropriately blamed for issues and
thus had to be intentional about mitigating their personal risks.
By early career, most of the participants described a turning point where they trusted their
own surgical judgment and competency and no longer needed reassurance or confirmation from
others. Two findings emerged from this point in time. First, the women began to speak out more
when they disagreed with others in power. Pera said, “…after a certain point…I started
defending myself…what I was doing was right…’I’m doing this for the patient’” referring to
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criticism of her surgical decision making by other surgeons. She also adopted a behavior of
slapping her hand down on the table after listening to an Attending inaccurately communicate a
story about her and say “’that’s not what happened.’ I’d let them have their way with their
tantrum and then quietly fucking correct them, politely, with no swear words.” Alexi disclosed
that she “wasn’t afraid anymore to point out when things aren’t going the way they were
supposed to…when people weren’t living up to expectations.”
Second, the women became more intentional and resolute about “catching bees with
honey” (expressed by Pera in this example) when working with operating room staff and nurses,
either expressing more empathy for their shared experiences or strategically deciding that this
approach would get them what they needed in a given situation. Alala described her approach:
“My OR team is really special to me, the nurses…so I prioritize those relationships over ones
with fellow staff members and Attendings…a lot more [surgeons] are like ‘I’m a doctor and
you’re not’…I really disagree with that” referring to how many surgeons treated nurses poorly.
Through modeling this type of team-based leadership, Alala was teaching her residents the
importance of removing power-influenced hierarchies.
Paying It Forward and Revealing Secrets
The participants believed strongly that they could influence change in the younger
generation and subsequently took it upon themselves to actively engage and educate residents
and medical school students about the power of gender bias. In fact, 80% of the participants
either mentored residents and medical school students about gender bias or actively participated
in their own work settings to impact change.
In particular, a few years ago Pallas’s new year’s resolution consisted of making people
uncomfortable every day because she believed that “change doesn’t happen unless you’re
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uncomfortable.” She gave a Grand Rounds lecture on gender equity to her partners. Additionally,
she routinely educates students about wage disparity and the resultant career-long consequences,
the importance of men taking paternity leave so as not to single out mothers, and the fact that
women more frequently take roles that are not reimbursed as generously as roles that men take
(Medicaid patients, Veterans). She referred to educating surgeons about unconscious bias as
“uncovering the secrets” and noted that many professionals “may not be ready to hear” this
message, but she did not seem deterred.
Similarly, Adira leveraged her role as PD to impact change with residents in her program.
Though she talked about the frustration of dealing with the daily microaggressions from patients
and staff, she carved out a role for herself as PD to influence residents about the impact of
unconscious bias and obtained a newfound sense of purpose through these interactions.
Cassandra also educated residents by using everyday occurrences to show the double standards
that women face. Pointing out unconscious bias examples in real-time helped her teach junior,
male surgeons how unconscious bias presents for women. She shared a story about working with
a junior, male resident who was shadowing her. After repeating instructions to her patient 4
times and her patient still not understanding, the junior male resident then communicated the
exact verbiage to the patient 1 time, and the patient immediately understood. Cassandra told the
resident afterwards that he was her “man translator…this is what happens all the time” as she
slapped her hand down on the table as she spoke. She believes that exposing trainees to a wide
range of different people will prepare them to be more cognizant of all the biases and
microaggressions that women face. “I’m hoping to make them better people.”
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Summary
The researcher sought to understand how women spine surgeons balanced conflicts of
gender bias and social norms while exhibiting authenticity in the male-dominated work setting.
The intention of this question was to understand if the participants believed they could bring
their whole selves to their jobs, thus maximizing their talent.
Though the participants were not directly asked if they believed themselves to be
authentic in the work setting, two participants inquired (at the end of their interview) about the
specific research questions, which led to further clarity regarding authenticity specifically. Both
participants stated they were not certain they could even recognize their authentic selves
anymore. One participant further commented that she behaved in a certain way based upon the
norms of the field. “…it’s the biased standards…traditional standards…which lead to bias.
You…have to conform to what people want you to be if you want to move up…” confirming the
threat to personal authenticity.
At the same time, since there are so few women in the profession, the participants
believed they had to be better than the men surgeons—from a technical, interpersonal, and
professional conduct standpoint. For these women to persist in the profession required a constant
ability to pivot and make strategic decisions about how best to navigate the social and gender
norms associated with the surgical culture. At times and against their best efforts, the results of
gender bias led to less desirable results, primarily related to career advancement.
Regarding advancement specifically, the powerful impact of gender stereotypes led to no
win scenarios for the women. Once established, stereotypes are difficult to change and contribute
to behaviors that maintain status quo. Stereotypes of women being either too pushy or too
passive do not align with agentic traits of leadership, making advancement exceedingly difficult.
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Finally, the women not only invested a great deal of time and energy navigating daily
interactions with co-workers and patients specifically but also were called to educate the younger
generation about the consequences of gender bias in order to create positive change.
Findings Pertaining to Research Question Two
The second research question focused on how a sense of belonging contributed
to women persisting in the male-dominated profession of spine surgery. Peer-reviewed literature
of women working in male-dominated environments indicates that women downplay their
gender and assume male mannerisms to fit into their work settings. This section begins with how
the women participants assimilated and fit into their work settings. Next, the dynamics of power
relationships will be addressed. Finally, the role of mediating influences concludes this section.
Fitting In
At the most fundamental level, the physical presence of being a woman spine surgeon
means starting residency from a place of exclusion and an outsider. Out of five residents in her
residency program, Althea was the only woman and felt “surprisingly shut out” from day one.
Her four co-residents began connecting socially before their residency program started. They met
for happy hour and to go to the gym. “…for the first four or five months of residency…I just
didn’t really socialize with my co-residents.”
Althea’s experience of exclusion during residency was common among the participants.
Further, since residency is regarded as the most intense time in a spine surgeon’s career, the lack
of social connectedness experienced by the women led them to develop coping behaviors and
strategies to fit in. Downplaying their gender, not complaining or being vulnerable around men,
not talking about their families or personal lives were not only common behaviors of the
participants but also provided evidence that these behaviors were due to a desire to fit in.
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Downplaying Gender and Assuming Male Mannerisms
The participants downplayed gender characteristics common of women and assumed
male mannerisms to fit into their work settings. Because of gender bias, the women were treated
differently than the men which initially led to a lack of belonging. Alala remarked, “I am
absolutely treated differently even when I tried to be one of the boys. It’s hard to be one of the
boys when you’re not a boy” while Maia “fit in the best I could…it was common for me to be
‘one of the guys’ to be accepted. I was good at that.” Pallas credited her father for raising her “to
have a pretty thick skin and [I] can take [that kind of] stuff” regarding being present when men
were speaking disparagingly about women with crass jokes as an example.
Alternatively, Alala described the first time she felt like she belonged. She was showing
her co-residents a difficult case that she had completed, and her future husband said, “wow,
that’s pretty good. I didn’t think girls could operate.” In this moment, she felt like “one of the
guys…and so it’s funny that the super sexist comment is where you’re like ‘I’m here’” meaning
she finally felt like she belonged and was part of the team. Additionally, Althea summarized her
experience of adopting male mannerisms to fit in as follows:
There’s a personality and an attitude that you have to display that becomes more
stereotypically male. Like a way that you speak and your attitude to…spar with
everybody…and you tend to talk louder…and I have to be really pushy and really
aggressive.
She continued by communicating that since women surgeons are perceived by men surgeons as
not confident, “you’re trying to constantly fight that by being [super] assertive” and behaving in
ways that “socially, as a woman, you wouldn’t really do.”
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For the women to feel heard, they also started communicating differently. “At first in
residency, I thought my work would speak for itself…I was always taught to ‘speak softly and
carry a large stick’…[then] I realized that I had to speak loudly, sell myself, sell my story”
remarked Pera. Althea described “screaming at a guy at work” because he made disparaging
remarks about her calling in sick one night and unable to work. She tried talking to him
personally about it, to no avail, and eventually lost her composure. After screaming at him, he
apologized. “I guess you can yell at male colleagues and it’s fine” signifying that, in this
situation, she learned how to communicate on a level socially acceptable to men but not for
women. Alala explained it this way, “you walk into a room and people think you’re there to
serve them coffee…so you’ve got to be loud and obnoxious.”
Remarkably, half (50%) of the participants self-identified themselves as introverted and
expressed the difficulty of navigating the profession from this perspective. Pallas explained this
by saying, “[under normal circumstances] you might be diminutive if you’re a woman in
orthopedics…especially if you’re introverted.” “If you’re a wallflower watching things happen,
you’re going to get walked on” commented Pera, demonstrating that the cultural behavior of
talking loudly and acting aggressively was accepted in the surgical setting though not generally
acceptable for women to exhibit in surgery or society.
Though the women adopted mannerisms typical of men while at work, some of the
participants used time away from work to re-balance to their more authentic selves. Two of the
participants spoke about using their day off to “be myself”. Althea elaborated that when working,
“I’m just going to feel really gross…and have to be okay with that.” From scrub pants that do not
fit to excessive sweating in the OR due to wearing lead protection during surgery,
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I feel incredibly unattractive most of the day. As a woman in society, on my day off, I
like to feel like myself at least, whatever that is for me. I like to have clean hair, wear an
outfit that I feel looks good on my body.
Additionally, Pallas commented that she gets her nails done, wears heels, earrings. During her
residency training, others did not agree with her approach.
I don’t think I turn down who I am when I’m around male colleagues but that comes with
years of experience…and maybe got me, I don’t want to say in trouble, but maybe wasn’t
what people thought was the right thing to do…
Pallas’s comments depicted the conflict that women spine surgeons experience between their
work-selves and their authentic-selves.
Picking Their Battles
In the end, the women made choices to fit in by picking their battles. They let certain
discretions slide and pushed on others. Maia explained, “it’s a problem we [women spine
surgeons] have—the ability versus the toughness factor, how to balance it.” Cassandra dealt with
fitting in by being more tolerant in the OR. Less competent nurses were routinely assigned to her
OR, because she would not complain “like some of the men.” As a result, with the exception of
the anesthesiologist, she taught herself how to do everyone’s job in case a problem arose during
a surgical case.
Similarly, Pera let certain things slide “that I probably shouldn’t…stupid dirty jokes, boys
in the locker room type of stuff” in order for “them [men] not to be closed off to me so they’ll do
what I need them to do.” She also acknowledged that “…it’s also the funnier guys who tend to
have an opinion on things” allowing some room for their behavior. Further, Alala decided to
shoot back at the men in order to fit in.
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When I started residency, which was all guys…they’re all laughing and talking,
everywhere is a locker room, and you walk in and everyone’s silent, and you overheard
the crude comment. You can either get mad, you can pretend you didn’t hear it, or you
can shoot something back that’s even ruder, so that’s what I did. I chose to be one of the
guys because otherwise, it’s really, really lonely.
Importance of Not Being the Victim
Since spine surgery is a male-dominated profession and a lack of confidence has been
identified as a common stereotype of women in the field, the women learned coping behaviors to
fit in. The surgery culture is a “bro culture…because who usually comes into orthopedics? The
jocks…” remarked Cassandra. Maia called it a “macho culture”. Alexi described the spine
surgical culture as “very direct…it can be demeaning…high expectations. You have to be willing
to understand the culture and participate in it. Otherwise, it gets really hard, really fast.”
All participants were consistent in their descriptions of the surgery culture: “Just do it.”
“Get it done.” “Just handle it.” “Suck it up.” “Keep working until it’s done.” Further, additional
descriptions emerged regarding women specifically: “Don’t ask for help.” “Never say it’s too
hard for me.” “No tears shed at work.” “Do not share personal information.” “Do not talk about
family or kids.” These additional descriptions not only pointed to the women combatting the lack
of confidence stereotype but also demonstrated how they downplayed their gender by removing
any talk about family or nurturing behaviors. For example, Alala did not tell anyone that she was
pregnant. “I tried really hard to hide it. I hated being pregnant because people would know. I
took five days off work and came back.”
To these women, sharing personal information called attention to them specifically, that
they were women, and not the standard or ideal model of a spine surgeon. Other stories also
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emerged related to women’s health issues, fertility, miscarriages, and menstruation in the OR.
Their experiences referred to the conflicts women feel in the work setting and not being able to
disclose this type of information to co-workers in fear of validating gender stereotypes of women
spine surgeons and placing them further at a disadvantage.
Another factor that compounded the issue of women not wanting to be singled out or
seen as victims was communicated by Cassandra. “Orthopedics has a 30% [residency]
unmatched rate” demonstrating the competitiveness of the specialty. Because of the discrepancy
between the number of residency applicants and the number of matched residents, women do not
want to raise any red flags that could be used against them. Additionally, since spine surgery is a
small group of people, reporting inappropriate behavior will likely impact a woman’s future
career or access to jobs by creating the perception that she is litigious. Conversely, the choice to
remain silent continues to perpetuate the myth that women do not belong in surgery. As a result,
women do not generally speak out or report inappropriate behavior because the risk to them
personally is significant.
Power and Advancement
In the profession of spine surgery, White men continue to retain power and call the shots
regarding advancement. The participants unequivocally viewed the White, male spine surgeon at
the top of the hierarchy. Althea described the importance of gaining support from this
demographic specifically regarding access to jobs.
Male POC mentors are more sympathetic or receptive to female applicants because they
see a common…lack of representation. But they also tend to have their own concerns
with having a seat at the table…sometimes you fall into this trap of ‘if I’m only being
supported by women and people of color, are the real power players going to look at that
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as ‘oh, it’s just sympathy quotas, the underserved groups watching out for each other?’
Whereas if White men have your back, then it’s a real recommendation, a real assessment
of you…but those are the people that it’s the hardest to develop relationships with…the
hardest to be vulnerable around…the hardest to be honest with.
Further, though more and more women are being included in committees within their
institutions and professional societies, their roles are generally more worker bee in nature while
the leadership are men. Two participants recognized that though they were well qualified to be
professional society leaders, they most likely gained their position based upon their gender. “I
forget my title—it’s basically like ‘the girl’”. Though these women are involved in society
leadership, their comments represented the fact that they are there solely because of gender
versus their contributions. Since many societies have goals of increasing diversity, women are
generally hand-picked to be added to existing committees and thus end up in roles with less
authority and power.
The committees suck, you’re taking time off for pregnancy [while the men are
working]…and you end up a little behind the curve. It’s the Affirmative Action
problem…where do you get the kick back up for the unfairness? I understand the
conflict, the men are doing the work…we also just need to normalize seeing women on
the podium and in leadership positions.
Though all the participants communicated that the profession is competitive to get into
initially, three of the participants discussed how gains in their career advancement led to even
more competition among male colleagues. Alala quantified this by saying “as long as I was an
underling, people didn’t really stand in the way…until I hit ‘about to be equal’ and then the
walls came up.”
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Mediating Influences
In an ideal ecological model, the mesosystem provides a buffer between the exosystem
and the microsystem. For the participants, specific areas proved to help them navigate the
profession: mentors and sponsors, learning alternative techniques, social media influences,
professional groups, practice fit and climate, and their patient interactions. Moreover, these
factors assisted the participants throughout their career journeys.
Mentors and Sponsors
Trustworthy mentors not only provided guidance regarding difficult clinical challenges
but also helped the women navigate cultural norms associated with surgery. For the study
participants, mentors were generally defined as more experienced surgeons, supportive in nature,
and exhibiting high levels of trust. Additionally, three of the women described mentors as people
they respected and looked up to even if they did not know the mentor personally, demonstrating
the powerful influence that successful, well-known women spine surgeons play in encouraging
other women in the field. With the exception of one participant, all mentors were men.
In addition, the late stage women were not privy to other experienced women spine
surgeons due to the limited number in the field at that time, whereas the early stage women had
more access to women mentors. As an example, Alexi (late stage surgeon) revealed that she had
only met “one other female orthopod during residency and then, gosh, probably two or three
female orthopods throughout my career [and they did not practice spine].” Regarding sponsors,
only one participant (Cassandra) confirmed she had a sponsor who was willing to go to bat for
her related to career advancement.
Mentors were also delineated from other surgeons as people who the women believed
would not judge them unfairly. Three participants described some of their mentors as Attending
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surgeons who they worked with previously. Regarding the development of the mentor-mentee
relationship, Pera explained:
A lot of my mentors I earned when I became their chief on service and they could let go
control…to me, so I earned their respect in that way…they trusted my
technique…because I earned their respect and trust, when I do happen to have a question
or need something now…I know they’re not going to judge me.
This explanation underscored how important trust was to the women regarding mentors. Further,
trust was established and earned prior to the women confiding in their mentors. This pre-
requisite of trust likely stemmed from the women being judged more harshly than their peers
during residency specifically.
The one participant with active women mentors explained the interactions as helpful for
her in navigating the residency training environment. During her first year of residency, two
senior women residents in her program approached her to check in. “This was the first time I felt
comfortable being like ‘I don’t know what I’m doing at work. I’m terrified. I don’t know how to
be a doctor.’” The women mentors spent time with her explaining how to navigate the culture,
what to expect, and how to discern the difficulty of surgical training from navigating issues
related to gender bias. Interestingly, this participant did not require that trust be established prior
to confiding in her women mentors. Since they were women, trust was assumed from the
beginning of their interactions unlike interactions with men.
Learning Alternate Techniques
Developing alternate surgical techniques emerged as a common theme among the
women. In fact, seven of the ten participants cited surgical technique as an initial challenge.
Literature cited a woman’s lack of strength as a barrier for women entering the profession
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(Rohde et al., 2016). The strength needed to physically move patients (most patients are larger
than women spine surgeons), the strength required for the actual surgical procedures, using
instruments that are too large for the average woman’s hands, and OR tables at a height that are
too high for the women posed challenges.
In addition, the standard techniques taught in training are based upon the typical male,
and the surgical instruments were developed based upon male standards. Because the women
were physically smaller, they had to teach themselves alternate techniques in order to succeed.
Alexi explained, “the big knock about [women] going into orthopedics is that you’re not strong
enough…and that’s just not true…it’s all about learning techniques that work for you.” For the
late stage surgeons, learning techniques that worked for them consisted of trial and error. Maia
said, “it’s more my height. I use step stools. The hand size is a big deal. They’re [men’s hands
are] about 50% bigger than mine. I figured out how to do it on my own.” Because she is of
smaller stature, Maia needed to stand on step stools so that she could see what she was doing
during surgery. Pera also incorporated this same technique. Additionally, both Pera and Maia
commented about the surgical tools used in spine surgery. Pera said “it would be great if we had
some shorter screwdrivers…[they] are built for like a six-foot-seven man…I’ve actually drifted
away from certain vendors…in order to get a custom screwdriver.” Alexi “vividly remember[ed]
cutting a [steel] rod…and punching myself in the face because I did the technique wrong.”
From positioning of the OR tables to surgical instruments, the OR setting was built
around common male standards leading the women to create their own techniques to
accommodate. The late and mid stage surgeons commonly developed and created their own
techniques; whereas, early stage surgeons may have had some exposure and help from other
women. After seeing a successful woman spine surgeon who was physically smaller than her,
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Althea realized that “it can’t just be about that” referring to strength alone being one of the key
determining factors of a successful surgeon. She then learned tips and tricks from this woman:
“do it this way,” “use gravity,” “use this [instrument]”…“It was all about passing along those
skills but it didn’t mean that I wasn’t terrified of being bad at things because I was a woman, and
especially working with male residents.”
Both of the late stage surgeons commented that women have to be better than the men,
partly due to these inequities. Alexi described her experience:
Women…have to be more technically proficient because we can’t muscle things into
place. We have to actually be really good at using the techniques to do what we need to
do…in spine, you’ve got to bend rods…and a cold rolled steel rod is very hard…so we
become technically proficient, whereas sometimes the guys are just able to bend it.
Similarly, Maia elaborated “people don’t want women surgeons, and you must be good to be a
woman in a man’s world.”
Social Media and Technology
Social media and technology provided support to the participants but may prove to hinder
ongoing male-female mentorship relationships. Since work-home conflicts are common for
women spine surgeons, technologies (like Zoom) provided a buffer for some of the participants.
For one participant who had young school-aged children, she was better able to integrate her
work life and her family life as a result. Technology allowed her to conference into weekly staff
meetings that started before 8am without physically being present in the conference room. This
small change permitted her to take her children to school a few days a week while
simultaneously being present for important work meetings. Since spine surgery is highly patient
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centered with unpredictable hours, this modification allowed her more flexibility as well as job
satisfaction.
Regarding social media, more than half of the women viewed this communication
channel to be a positive influence for women spine surgeons. First and foremost, due to the reach
of social media, the participants believed that social media could change perceptions that spine
surgery is only for men. In fact, two surgeons previously posted pictures on social media
showing them as both a woman and a spine surgeon. For instance, Adira posted a picture of her
and her new baby rounding in the hospital, checking on her patients. In an environment with few
women, these images can be powerful influences for the next generation. “I think it’s really
important for trainees to see” referring to women who may not even consider spine surgery as a
viable occupation.
At the same time, some men have concerns about mentoring women or spending time
with women in social settings as a result of the #METOO movement. Most recently,
@speakuportho, a social media platform created by a woman orthopedic surgeon and designed to
increase the awareness of bias, inequities, and harassment within orthopedic surgery, allows
women to confidentially post their experiences related to gender bias without identifying the
offender. The intention of the platform is to promote gender equity in orthopedics through
education and awareness; however, these channels could hinder men from supporting women by
creating fear of claims of inappropriate behavior against them.
As a result, Althea (orthopedic resident) indicated that men residents believe that faculty
(highly male dominated) are easier on women residents than men residents. She stated that the
perception from the men residents is that “we [women] don’t get yelled at, we don’t get asked
difficult questions, we don’t get picked on…which is sometimes true…” Furthermore, she
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believed that this different treatment of men and women residents by the faculty led to difficulty
in her developing relationships with the faculty and was concerned about her ability to network
with faculty for this reason. “I think this is part of the reason I’ve had difficulty developing
relationships with male mentors…I feel like they feel like they have to watch their p’s and q’s
around me.”
Literature as well as the findings from this study supported the fact that women trainees
are not provided feedback in the same way as men trainees. Althea disclosed her concerns with
the differential treatment by faculty to men and women residents: “…it’s to our [women’s]
detriment…if they’re [the faculty] not being honest with us, not telling me if I’m not good at
something in the same way because they are afraid we’re going to complain…” Her comments
exemplified the complexity of gender bias in male-dominated work environments. Though social
media can help women visualize themselves in the profession and also provide women a
platform to share their experiences of gender bias, these communication channels may also give
men pause in supporting women.
The Influence of Professional Groups
Professional societies and groups have a tremendous opportunity to shape how women
spine surgeons are viewed in the profession as well as provide opportunities for advancement.
Professional societies can ensure that women are represented by including women on their
committees, leadership, and conferences. As such, Alala described the influence that societies
play in leveling the playing field.
…societies just need to make a point...just like the assessments, it’s the male model that
people are assessing. In leadership, it is again the male model that is being used, and what
that means is that when you’re like ‘hey, we need someone to chair this committee’, you
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don’t even think about the women. It’s not that they got beat. It’s that they were never at
the table, because when you picture this position, you’re picturing the guy every time.
Therefore, gender biases are not allowing [women] to be represented in society
leadership.
Women-only societies, created to support the needs of women while attempting to level
the playing field, support the advancement of women while also educating them about gender
bias, thus preparing women to navigate difficult gender-related situations more effectively they
might encounter. Adira, who is a leader in an women-only professional society, explained that
her position has allowed her to gain experience in a safe environment that is more relaxed, gain
experience in working with men in other societies, and piqued her interest in being involved in
other societies going forward. She explained, “I am learning how to deal with different men [in
my society leadership role]…” validating the impact that women-only societies can provide to
women who aspire to be leaders in integrated professional societies. Additionally, she added,
“just having that title, being on the Board of Directors of a group is helpful for your curriculum
vitae” regarding increasing her advancement opportunities. Pallas viewed her experience in the
women-only society as providing her with the skills necessary to navigate the male-dominated
environment.
At the same time, the majority of participants did not feel comfortable at integrated
professional society meetings. Adira revealed that though she was aware of the importance of the
informal networking that takes place at conferences and conventions, “I don’t enjoy going to
meetings. I feel completely isolated.” Pera commented that though she feels like she’s made it in
spine surgery, “I’m still going to feel a little out of place at scientific meetings…as a speaker.”
She further went on to say that the speakers are “at the top of their fields…have been for 20-30
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years…wrote the textbooks. Then I’m like ‘wait a second. I wrote a chapter in that textbook’,”
demonstrating the impact of both imposter syndrome and gender bias along with the realization
that she is also an important contributor in the field. All things considered, Alala and Pallas
summarized the importance of women being visible within professional societies, both from a
leadership standpoint as well as on the podium. “It just needs to be normalized.” Pallas added,
“...having us [women] there is part of it…and being more included.” In addition to the benefits
that women gain from inclusion in professional societies specifically related to advancement and
recognition, the value that women spine surgeons bring to the table, different from men, allows
them to connect with their patients in a compelling way.
The Value of Women Spine Surgeons
The women spine surgeon participants conveyed a strong sense of connection and
responsibility to their patients leading to a high level of job satisfaction. Communication,
empathy, patience, thoughtfulness, and trust were common terms describing the value that
women spine surgeons bring to their patients as compared to men. Additionally, the majority of
participants expressed their ability to form strong relationships with patients and staff. Five of
the participants specifically discussed the importance of building strong relationships with their
patients by “not talking down” to them “like the men do”. “She understands me” was another
comment that Maia heard from her patients. Pera elaborated to say that “absolutely every single
day, I get a patient who says they’ve seen a male surgeon” and was “put off” by their “take it or
leave it” communication style. Pera continued by saying that she has “not yet actually heard of a
patient [who met with a] female surgeon who complained about communication.” Alala asserted
that women’s communication skills allow them the “ability to give feedback [to residents] in a
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better way so that…education can be improved upon”. At the same time, she acknowledged that
“biased standards sell short the advantages that women bring to the table.”
Regarding gender bias by patients, Pera experienced this every day with her patients and
their families. “After they talk to me and I explain things to them like a human being…they
understand.” As a result, Pera has an extensive referral base. “…I treat so many whole
families…so my weakness as being a ‘tiny, Asian girl’ is also my strength, because when I win
them over, I win them over wholly…all the trust I have from my patients is absolutely earned”
demonstrating the trust and confidence she earns from her patients versus the automatic trust that
patients relinquish to men surgeons due to traditional role expectations.
In addition to strong communication skills, the women exhibited a holistic and
collaborative approach in working with their patients. They frequently spoke about shared
decision making between the surgeon, patient, and the patient’s family, even if that meant
spending extra time with patients that do not end up having surgery. Adira commented that the
men tend to “only want to see surgical candidates.” Several other participants also agreed with
these comments.
Finally, the women participants expressed a strong sense of investment and sense of
accountability to their patients. Cassandra described her typical day.
…most mornings, I wake up surprised at my job and what people are willing to let me
do, handing me their most precious commodity…expecting me…to make them better,
and bring them back…and so I appreciate that every day that I go into the OR with a
patient, that patient then becomes my most important thing…to get that patient safely
through…make them better…and bring them back to their families.
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Additionally, she described the anguish associated with suboptimal outcomes. “The guilt and
second victim syndrome that we have is enormous” demonstrating a profound sense of
responsibility to her patients.
Though these women experienced both highs and lows in their careers, their job
satisfaction proved to be extremely high. Cassandra said, “this job is the most satisfying job I’ve
ever had. I’ve been very lucky.” Pera said, “I love my job!” Maia said her job satisfaction is “the
highest of the high.” Alexi summed up their experiences with “I got most of my
satisfaction…from my interactions with my patients…I learned a lot from them and hopefully
helped a few…and I love doing the surgery. The surgery was just the most fun.”
Summary
For the second research question, the researcher sought to understand if a woman’s sense
of belonging in the profession of spine surgery led to persistence in the field. Since a sense of
belonging at one’s workplace has been shown to increase the retention of employees, the
researcher wanted to understand if this premise would be true for women working in male-
dominated environments.
Starting in residency training, the participants clearly struggled to fit in and belong. As a
result, the women adopted coping strategies to adapt to their environment. From downplaying
their gender to assuming male mannerisms to talking loudly and behaving aggressively, the
women traded in their traditional gender norms to persist in the profession of spine surgery.
Further, advancement proved to be fraught with additional barriers, and White men are still
viewed as the ideal mental model for spine surgeon, both from a clinician and leadership
perspective. All in all, the participants experienced frequent and ongoing gender-based conflicts
related to job access and professional advancement yet retained a high sense of job satisfaction.
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Additionally, five areas emerged as mediating influences. Mentors helped the women
navigate the profession with high trust being a determining factor of a mentor-mentee
relationship. Social media and professional groups were found to not only increase the
transparency of the gendered experiences of women but also provided increased visibility of
women spine surgeons as a whole. Two mediators emerged that were created by the women
themselves: developing alternate surgical techniques and holistically treating patients. Due to the
gendered learning environment, the women had to teach themselves alternate surgical techniques
from the men in order to perform their jobs. Further, the strong communication skills, empathic
and patient-centric approaches of the women proved to be differentiating factors with their
patients, leading to high levels of trust as well as job satisfaction. Therefore, even though the
spine surgery culture proved difficult to navigate with many ups and downs, the women were
extremely motivated to succeed with a high degree of inspiration attributed to the welfare of their
patients. Their aspirational ability to persist and thrive in the field among constant obstacles
confirmed their resilience and badassness. One participant who is now not only confident in her
ability but also skilled in navigating the environment summed up the collective strength and
resiliency of the women participants— “I don’t need people to identify me as a doctor or call me
doctor to make me feel like I’m a badass…I am a badass.”
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Chapter Five: Recommendations and Discussion
This section begins with a discussion of the findings of the research study and how the
findings connect back to the literature review. The next section proposes recommendations
related to the problem followed by limitations and delimitations of the study. Then,
recommendations for future research will be addressed. Finally, the researcher connects the study
findings to the University of Southern California Rossier School of Education’s mission and
distinguishes any resultant implications related to equity.
Discussion of Findings
The research led to four findings. Working in a male-dominated environment, the women
spine surgeons continually adapted their behavior and mannerisms to fit into the surgical culture.
Further, findings pointed to the women being held more accountable and judged more harshly
than their men colleagues. Gendered training environments in residency and fellowship also led
the women spine surgeons to develop their own surgical and clinical techniques. Cumulatively,
these factors made advancement more difficult for the women to attain.
Finding One: Gender Bias Led to Constant Behavioral Adaptations and Pivoting
Women spine surgeons conformed to traditional societal gender norms of spine surgeon
in order to persist in the field. Research Question One looked at the conflicts related to gender
bias that women spine surgeons experienced and if these conflicts led to a threat to their
authenticity. Merriam-Webster (Merriam-Webster Dictionary, n.d.) defines authenticity as
conforming to an original so as to reproduce essential features. Alternatively, the reference also
defines authenticity as true to one’s personality, spirit, or character. Based upon these definitions,
the women both externally conformed to traditional gender norms of being a spine surgeon
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(stereotyped as male) as well as remaining true to their inner values and character, especially
regarding patient care.
Though the women downplayed their gender and manifested male mannerisms (being
loud, aggressive) when around other men colleagues, some women also became more passive
around nurses who were primarily women. These behavioral adaptations were strategically
chosen, situational in nature, and designed to elicit desired responses from the targeted individual
or group. Different behaviors were employed depending on the expected gender norm of the
individual the woman spine surgeon needed to influence at that point in time. Being passive and
nice was exhibited as a way to encourage women nurses to respond as urgently as they
responded to men surgeons. Alternatively, being loud, obnoxious, and aggressive were tactics
used to fit in with male surgeon colleagues and men faculty. Further, the women downplayed
their emotions and limited sharing personal information with men as these characteristics are
stereotypically associated with women. To corroborate this finding, Martin and Phillips (2017)
found that women working in male-dominated settings who downplayed their gender
experienced more confidence in that setting, and the authors also identified this strategy as
adaptive in nature.
Though the researcher was not able to identify literature addressing the behavioral shift
of women spine surgeons (becoming more passive) working with women nurses versus men
surgeons, the researcher believes it is reasonable to assume that women spine surgeons shifted
their behavior in these situations to assume behaviors that are socially acceptable of women and
increase their influence on this group. Conversely, though the women conformed to accepted
cultural standards of the surgical environment, they also stayed true to their internal values and
character, especially with patients.
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Finding Two: Women Were Held to Higher Standards and Judged More Harshly
Since the number of women spine surgeons is limited, the women were keenly aware of
standing out and being easily recognizable. As a result, the women were not only singled out and
judged more harshly than their male peers but also driven to be better than the men in order to
stay above the line of reproach. Work from Eagly and Karau (2002) as well as Fassiotto et al.
(2018) supported this finding by demonstrating that women who worked in male-dominated
fields received disproportionately lower evaluation ratings due solely to the discordance between
their gender role compared to the dominant gender of that specialty. In addition, Meyerson et al.
(2017) described that men received consistent feedback while women received inconsistent
feedback, supporting the finding that women were not only judged more harshly than men but
were also provided inconsistent feedback. The inconsistency of feedback as well as being held
more accountable than men caused confusion and led the women to unnecessarily question their
own abilities at times, especially during residency training which was the most vulnerable time
of their careers.
Interestingly, the interactions with their patients proved to be the most authentic for the
women. Though the women expressed initial frustration with patients’ unconscious biases in
assuming that the women were nurses instead of surgeons, the trust eventually established in the
physician-patient relationship led to loyalty from patients and a strong sense of accomplishment
from the women spine surgeons, increasing their job satisfaction. This finding is consistent with
work from Kalagara et al. (2019) revealing that trustworthiness is a substantial indicator of
patient satisfaction. Moreover, the women also attributed their strong communication skills as
differentiating factors that led to high levels of patient satisfaction which is aligned with research
from Chua et al. (2020) indicating that empathy and reflection are fundamental communication
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skills that led to effective patient-physician relationships. In fact, the women not only expressed
their most authentic selves with their patients but also consistently found a sense of belonging in
this space. Their genuine love for their profession coupled with their patient relationships
provided them the encouragement and resiliency needed to persist in the field.
While patient interactions provided sustenance to the women, the cumulative effect of
unconscious biases and microaggressions coupled with their constant behavior adaptations led to
episodes of exhaustion and a sense a resignation, especially during residency. This finding
supported the link between gender bias and burnout. Sudol et al. (2021) showed that women
surgeons working in male-dominated settings were more likely to experience sexist
microaggressions and burnout. Alternatively, once established in practice with more power and
influence, the women ultimately made the choice to no longer stay silent and speak out more.
Additionally, since these women had proven themselves to their colleagues, they also felt more
accepted which led to an expectation and hope that their words would be heard.
Finding Three: Gendered Training Environments Led to Alternate Surgical Techniques
Gendered curriculum and training environments did not serve women residents’ needs,
leading them to develop their own clinical and surgical techniques to adapt. Since medical
textbooks and clinical literature have been published predominantly by men, the overall learning
environment proved to be gendered, presented from the male perspective, and depicting men as
the standard mental model. Further, since men make up 95% of neurosurgery and orthopedic
surgery residents with only a small percentage of women as clinical faculty, unconscious biases
of faculty led to gendered teaching methods (Post et al., 2019).
In support of this finding, Campuzano (2019) published that in male-dominated work
settings, homogeneity of the environment perpetuated one leadership style with shared values
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and assumptions that are socially engrained over time and difficult to change. Therefore, the
assumptions and unconscious biases of men spine surgeons in positions of power—faculty,
leadership, published researchers, medical device designers—led to the projection of their
realities and worldviews onto women spine surgeons. These assumptions are seen in textbooks,
curriculum, medical research, and clinical training approaches where the average man is the
standard (Sharma, 2019). By applying feminist theory to medical education, change can ensue by
questioning what is taught and whose stories are told, all while bridging the gap between the
medical community and the patients served.
Additionally, the medical industry that develops and manufactures surgical
instrumentation and implants relies primarily on men surgeons to not only design surgical
instrumentation but train colleagues on the use of the instrumentation. Because the women
participants were generally shorter than men, had smaller hands, and were not as strong as the
typical man, the techniques that men faculty taught and utilized were not accessible by the
women, leading the women to develop their own alternate techniques. In validation of this
finding, literature cited the lack of women’s strength as a barrier to women entering the field of
orthopedics (Rohde et al., 2016). However, to the researcher’s knowledge, the connection
between gendered learning environments contributing to women developing alternate techniques
has not been expressly uncovered in the literature. In the clinical environment though, one
participant stated that when mentoring other women or smaller statured men, a common topic of
discussion is related to alternate techniques.
Furthermore, out of a desire of the women to not be seen as victims or draw attention to
themselves, they simply found workarounds (alternate surgical techniques) without speaking up.
For these women, their own expectations for themselves consistently drove them to find a way to
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make things work demonstrating that a lack physical strength should not be a barrier for women
entering the field. Additionally, as faculty, the women spread the word by passing along these
alternate techniques to trainees. However, with so few women in the field and role models to
observe, the women generally did not realize that other women spine surgeons had the same
problem and independently came to the same solution.
Finding Four: Gender Bias Accumulates, Decreasing the Possibility of Advancement
Though times are changing regarding engrained gender norms and gendered expectations
especially by younger surgeons, gender bias remains prevalent in spine surgery and impacts
women’s advancement. After the women spine surgeons completed residency and continued to
gain confidence in their clinical judgment, findings pointed to the women making strategic
decisions about their future and whether to pursue advancement. If the decision was made not to
pursue career advancement, there was no going back or changing mindset. As a result, the
women who chose this path became more open in expressing their authentic viewpoints,
especially when disagreeing with other colleagues, and were aware they may be burning bridges
as a consequence.
The women who decided to pursue advancement and leadership proved to be both
successful and unsuccessful. These two women were aligned in their experiences of gender bias.
Nevertheless, one woman’s career was derailed due to gender bias while the other woman has
continued to forge ahead. Remarkably, gendered feedback from residents accounted for the lack
of advancement of the former surgeon and consistent with research from Kramer et al. (2021).
Because residents are younger and more open to equitable treatment, this finding was unexpected
and substantiated the fact that gender bias remains an issue even among today’s younger
generation of surgeons as well as in other settings like the boardroom and in politics.
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Equally important, feedback consistently reiterated that the women were stereotyped
either too aggressive (bitchy) or too sweet (pushover). Likewise, both stereotypes negatively
impacted their ability to advance. If they were stereotyped bitchy, they were deemed not easy to
get along with and difficult to work with, decreasing their chances of advancement. If they were
stereotyped as too sweet or a pushover, they were considered not assertive enough for leadership
expectations of the field. In this situation as in most experiences of the women participants,
unconscious biases caused unfair treatment, indicating the power of societal stereotypes and
gender norms that still exist today, and the difficulty women spine surgeons experience with
advancement. Eagly (2008) described this phenomenon when she coined the leadership labyrinth
14 years ago, depicting the complexity and array of challenges that women face in their career
advancement and leadership journey.
Finally, gender and unconscious bias remains pervasive in spine surgery (Falavigna et al.,
2021). Further, the large gender gap in the profession perpetuated one ideal and reality for all
spine surgeons. Additionally, though more women are being included by way of committees and
leadership in professional societies, women are generally on less powerful committees that are
led by men (Lincoln et al., 2012). The findings, coupled with the researcher’s informed
viewpoint, appear to point to the inclusion of women in leadership as a necessary evil by men in
power, even if unconscious in nature.
In fact, NASEM (2018) pointed to the inclusion of women by way of policies and
procedures as symbolic compliance and not sufficient enough to drive change. Further, NASEM
identified male-dominated work settings, hierarchical leadership structures, and uninformed
leadership as contributors to ongoing discrimination in the fields of medicine, science, and
engineering. Just as overt sexual discrimination has morphed into microaggressions (hidden
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forms of discrimination), the researcher posits that women’s advancement in spine surgery may,
at times, be an artificial, olive branch even if extended by well-intentioned others.
Ibarra and Petriglieri (2016) captured this concept in coining the term, impossible selves,
to illustrate the complexity that cultural factors play in a woman’s leadership journey. Gender
role and leadership expectations of women, based on traditional views of gender; organizational
policies, procedures, and practices that privilege men; and unconscious biases accumulate to
interfere with a woman’s ability to advance as a leader. Further, the authors indicated that
women were unable to reconcile the adaptations required to become a leader compared to
exhibiting their authenticity as an individual.
Recommendations for Practice
The key findings resulted in four areas of recommendations for practice. Since the
problem of gender representation in spine surgery is complex and largely based upon social and
cultural norms, there is not a one-size-fits-all approach to success. However, utilizing Design
Thinking methodology to create customized interventions will ensure that all stakeholders’ needs
are identified and incorporated into the solution. This approach, developed by Larry Leifer and
David Kelley from Stanford University, is a team-based, iterative process that focuses on human-
centered design and consists of 5 steps: empathize with stakeholders, define the problem, ideate,
prototype, and test. It is an iterative process that places people first, developing innovative
solutions for the most complex problems. The approach requires Designers to deeply examine
their stakeholders’ needs through an empathic lens, essentially walking in the shoes of another,
and quickly develop prototypes to pilot. Because spine surgeons (men and women) are
stakeholders and will be involved in the process, coupled with their strengths related to physical
manipulation, this approach could prove to be appealing and engaging, creating a collaborative
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environment for change. As such, though some of the recommendations are broader in nature
with examples of possible intervention strategies, specific interventions need to be grounded in
design thinking strategies and customized to meet the distinct needs of the stakeholders.
Recommendation 1: Establish a DEI Task Force Centered on Developing Interventions
Based Upon Design Thinking in the Departments of Spine Surgery, Orthopedic Surgery,
and Neurosurgery
The study’s findings demonstrated that women spine surgeons continually pivoted and
adapted their behavior to fit into their work setting due to social role incongruity and stereotypes
of the profession. When a small percentage of individuals take on social roles that are
inconsistent with common stereotypes like women spine surgeons, these individuals are then
grouped into a new subcategory that permits the stereotype of their traditional roles to endure
(Eagly & Koenig, 2021). Once a sufficient percentage of individuals occupy new social roles,
stereotypes will begin to change and manifest attributes consistent with the new group.
Additionally, literature has cited 30% as the tipping point for this shift to occur (Hunt et al.,
2018).
For stereotypes to change in spine surgery and women’s value in the profession to be
fully appreciated, more women need to be exposed to the profession before medical school, see
women spine surgeons and role models, provided leadership training in early practice, and
promoted into leadership roles. Further, support for these changes require men in power to buy-
into the need for change as well as be engaged in the solution. Since this work is complex and
stakeholder buy-in is required for sustainable transformation, design thinking approaches, such
as empathy interviews, ensure that the needs of all stakeholders (men and women) are identified.
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By understanding the needs, thoughts, motivations, and emotions of all stakeholders, the DEI
task force can then customize interventions based upon specific stakeholder needs.
The charge of the DEI task force consists of utilizing a validated change model to assess
current state, identify barriers, develop recommendations for change, support the change process,
and measure and provide transparency to results. When conducting empathy interviews during
the assessment phase, an experienced team should be engaged to administer and synthesize the
interview data to ensure that the needs of the stakeholders are uncovered, resulting in fine-tuned
solutions. In the profession of spine surgery, special attention should focus on decreasing gender
bias during interview and recruitment practices as well as performance assessment and feedback;
leadership succession planning with an eye toward hiring and promoting promising and qualified
women; developing a safety culture in the workplace with special attention paid to the influence
of Attending surgeons; providing visual symbols of women in spine surgery as well as
leadership; promoting efforts to create engagement by way of the inclusion of women; and
encouraging a sense of belonging in the work setting. By creating a DEI task force, interventions
will be focused on changing the social role and stereotype dynamics of the spine surgery culture.
Recommendation 2: Provide Opportunities to Increase Knowledge About Gender Literacy
and Unconscious Bias Through Engagement, Education, and Inclusion
Since the percentage of women in the field is limited, they were held to higher standards
and judged more harshly than their men colleagues. The women stood out, were more
recognizable, and held more accountable for their mistakes than the men. Further, since gender
bias appeared to be primarily unconscious in nature and exhibited with residents as well as
Attendings and leadership, education about unconscious bias can bring awareness to influential
leaders and has proven to create awareness and positive change (Stephens et al., 2020).
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Furthermore, though there is a significant need to increase gender literacy in the profession;
mandatory requirements have largely not proven successful (Dobbin & Kalev, 2016). Instead of
enforcing mandatory compliance, organizations should focus on engaging employees from an
inclusion viewpoint, especially Attendings and surgical leadership. Interestingly, the authors
found that when managers were actively recruited to help increase diversity in their workplaces,
they began to see themselves as diversity advocates due to the desire to align their beliefs with
their behaviors.
Further, mentoring and sponsoring women spine surgeons not only promotes women’s
advancement in the profession but also changes the mentor’s unconscious biases about women in
the profession. Also, research in business shows that managers have high levels of influence in
change interventions (Nielsen, 2013). In surgery, Attendings, or more experienced teaching
surgeons, translate to manager in the business segment. By engaging Attendings to mentor
women spine surgeons and involving more powerful leaders to sponsor women’s advancement, a
decrease in gender bias, an increase in a sense of belonging, and an increase in the advancement
of women in the field would be expected. Simply put, engaging with and being in contact with
diverse others breaks down barriers and decreases bias.
Finally, education on unconscious bias and gender bias should be widely available and
easy to access. Self-assessments like the Implicit Bias Association (IAT) test, Grand Rounds that
incorporate gender literacy content, and departmental culture and climate surveys create
opportunities for ongoing dialogues and reflection. Moreover, open dialogue and transparency
has shown to increase social accountability thus decreasing bias (Dobbin & Kalev, 2016).
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Recommendation 3: Training Programs and Medical Companies Should Incorporate
Inclusive Teaching and Product Design Practices
Seventy percent of the participants stated they taught themselves alternate surgical
techniques because the techniques taught in residency and fellowship programs were
unattainable for the women. This finding provided evidence of gendered learning environments
associated with orthopedic surgery and neurosurgery residency and fellowship programs.
Though not surprising that women spine surgeons would create alternate techniques so that they
could be successful, workarounds signal a systemic problem that can have far reaching
consequences. As such, considerations of gender differences in learning as well as biomedical
research led the NIH and FDA to call for the inclusion of women in pharmaceutical drug and
biomedical research studies in the early 1990s (Mazure & Jones, 2015).
In order to account for gender differences of trainees, training programs need to ensure
that women trainees shadow another woman surgeon even if the trainee must go to a different
training program for this experience. Further, since the participants discussed that women
surgeons not only manage their operating rooms differently than men but also manage their
clinics differently, these different settings should be intentionally incorporated into the woman
trainee’s overall learning experience. Additionally, to increase inclusion in the profession,
women faculty should be in positions to teach alternate techniques both from a didactic and
clinical experience standpoint. In support of this, Sharma (2019) demonstrated how
incorporating feminist theory into medical education could inform approaches to how medicine
is taught but also build bridges between medicine and patients.
Finally, medical device and surgical instrument companies need to assess their product
design practices ensuring all stakeholders’ needs are met. For example, spine surgery product
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design teams should include a diverse group of spine surgeons, incorporating individuals of
different genders, races, and clinicians with different and challenging patient populations.
Subsequently, the importance of including gender-based data into medical innovation has
confirmed to produce better outcomes (H2020 Expert Group, 2020). Furthermore, focus groups
comprised of women could provide companies with feedback on current surgical implants,
devices, and instruments and possible modifications that would benefit surgeons and the patients
they serve.
Recommendation 4: Collaboration and Active Engagement Between Women Spine
Surgeons and Professional Societies
Over time, the impact of gender bias on women spine surgeons accumulates, decreasing
advancement possibilities. In addition, though men and women faculty exhibit similar career and
leadership aspirations, women had lower self-efficacy—a predictor of perceived career
opportunities and success (Pololi et al., 2013). Further, women faculty experienced exclusion, a
lack of relationships, and discord between their values and their workplace’s commitment to
effectively address DEI in the organization.
Alternatively, professional societies and networking groups hold remarkable power in
changing the dynamics for women spine surgeons. Professional groups provide the scaffold for
individuals to collaborate on research, participate in mentorship and sponsorship, develop
leadership skills, engage in podium presentations, provide peer support, and network—all of
which have proven to provide advancement. In addition, women-only professional societies and
groups offer additional advantages to women. Lin et al. (2019) demonstrated the benefits that
women-only specialty societies provided including decreased professional isolation, increased
sense of belonging, and a direct link to professional advancement and promotions through
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opportunities for leadership development, networking, and initiatives targeted to increase equity.
Though many women would prefer to actively participate in societies open to all spine surgeons
regardless of gender, women-only societies may provide a necessary bridge to advance women
in the field while concurrently pushing for change in the profession.
In addition to providing development opportunities to women spine surgeons,
professional societies and groups are generally mission-oriented and member focused. In today’s
environment where societies are reflecting on their purpose (reassessing the value of in-person
society meetings with exhibit halls of vendors), members have more power to direct society
priorities and initiatives to better meet members’ needs. As an example, Silver et al. (2017)
issued a call to action and recommendations for medical specialty societies to address gender
representation gaps, demonstrating the weight that professional societies yield in increasing
equity for women spine surgeons. Professional societies can also challenge the traditional view
of what a surgeon leader looks like and how they behave through targeted social media
campaigns showing women in the profession, educate the younger generation about the impact
of gender bias, and establish criteria to equitably select committee members, podium presenters,
and award recipients.
In summary, this study examined the problem of gender representation in spine surgery.
Additionally, the four findings resulted in recommendations for practice. Since the problem of
gender representation in spine surgery is complex and largely based upon social and cultural
factors, there is not a one-size-fits-all approach to success. However, best practices of gender
literacy and change management should be leveraged to inform and create a solid foundation in
which to build new cultural competencies in the profession. As such, specific organizational or
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system-level interventions should be customized to meet distinct needs of the stakeholders. The
findings and recommendations are summarized in Table 3.
Table 3
Context-Specific Recommendations Crosswalk
Finding Principle and citation Recommendation
Women spine surgeons
continually pivoted and
adapted their behavior to
fit into their work setting
due to social role
incongruity and stereotypes
of the profession.
When a small percentage of a group take
on social roles that are inconsistent with
common stereotypes (woman spine
surgeon), these individuals are then
grouped into a new subcategory that
permits the stereotype of their usual roles
to endure (Eagly & Koenig, 2021).
Once a sufficient percentage of a group
occupy new social roles, stereotypes will
begin to change and manifest attributes
consistent of the new occupants.
Literature cites 30% to be the tipping
point for this shift to occur (Hunt et al.,
2018).
Establish a diversity,
equity, inclusion (DEI)
task force centered on
developing Design
Thinking interventions in
the departments of spine
surgery, orthopedic
surgery, and neurosurgery.
The impact of gender bias
on women spine surgeons
accumulates, decreasing
advancement possibilities.
Though men and women faculty exhibited
similar career and leadership aspirations,
women had lower self-efficacy—a
predictor of perceived career opportunities
and success (Pololi et al., 2013).
The benefits of women-only specialty
societies provided decreased professional
isolation, increased sense of belonging,
and a direct link to professional
advancement and promotions through
opportunities for leadership development,
networking, and initiatives targeted to
increase equity (Lin et al., 2019).
Collaboration and active
engagement between
women spine surgeons and
professional societies and
networking groups,
promoting the visual
representation of women
utilizing social media
channels, and offering
opportunities for leadership
development. Professional
societies also need to
develop objective criteria
for the inclusion of women
within the society
(selecting speakers from a
list of qualified members
versus traditional, informal
methods).
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Seventy percent of the
participants stated they
taught themselves alternate
surgical techniques
because the techniques
taught in residency and
fellowship programs were
unattainable for the
women.
The importance of including gender-based
data into medical innovation has
confirmed to produce better outcomes
(H2020 Expert Group, 2020).
Considerations of gender differences in
learning as well as biomedical research
led to the NIH and FDA to call for the
inclusion of women in pharmaceutical
drug and biomedical research studies
(Mazure & Jones, 2015).
Applying feminist theory and approaches
to medical education led to a critical
appraisal of what is taught in medical
school and whose voices are heard
(Sharma, 2019).
Residency and fellowship
training programs and
medical device/instrument
companies to incorporate
inclusive teaching and
product design practices.
By utilizing Design
Thinking practices,
creative solutions will
emerge, creating the
possibility of new
environments and spaces.
Since the percentage of
women in the field is
limited, they were held to
higher standards and
judged more harshly than
their men colleagues.
Open dialogue and transparency have
shown to increase social accountability
thus decreasing bias (Dobbin & Kalev,
2016).
Education about unconscious bias has
proven to create awareness and positive
change (Stephens et al., 2020).
Provide opportunities to
increase knowledge about
gender literacy and
unconscious bias through
engagement and education.
Limitations and Delimitations
Limitations and delimitations provide the reader with contexts in which to view the
findings. Limitations are conditions that the researcher cannot control (USC Rossier, n.d.).
Limitations for the current study included the number of volunteers for the study, the diversity of
the participants, and the truthfulness of the participant responses. Further, though the researcher
intended to include a diverse group of participants from a racial standpoint, limitations of
volunteers prohibited the researcher from reaching the desired goal.
Delimitations are judgments that the researcher makes as a part of the study design (USC
Rossier, n.d.). Delimitations for this study consist of researching one specific organization in
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which the researcher was previously affiliated and interviewing participants that the researcher
knew from a work context. Since the organization has a reputation for being skewed toward
academia, orthopedic surgeons as compared to surgeons in private practice and neurosurgeons,
this factor could have impacted the volunteers and response data. Further, the researcher
interviewed only women who were currently in the field or retired from the field since access to
women spine surgeons that opted out of the field was not accessible. Also, the researcher viewed
the study from a critical, feminist lens and utilized the most relevant categories of
Bronfenbrenner’s ecological system as deemed by the researcher. Other methodologies,
worldviews, and bounded systems may produce different results or findings.
Recommendations for Future Research
Since men are key to the success of women in the field, and especially related to
advancement in the profession, future research assessing interventions incorporating Design
Thinking could provide insight into how to best leverage the full talent of women spine surgeons.
Additionally, since women spine surgeons face gender bias from men surgeons, trainees, and
faculty as well as women nurses, research focused on understanding the dynamics between
women nurses and women spine surgeons could inform appropriate intervention strategies.
Finally, research centered on how social media informs perceptions of women in the profession
as well as the potential impact of social media on gender bias could provide valuable insight into
how technology can change perceptions, behaviors, symbolism, and ultimately equity in the
field.
Implications for Equity
For many organizations, leaders have infused diversity and DEI principles by way of
mandatory, one-size-fits-all, compliance training programs which have proven to be ineffective.
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Alternatively, sustainable, versus symbolic, equity requires transformational leadership, courage,
commitment, and grit. Incorporating Design Thinking interventions and solutions will ensure
that the complexity of the problem is approached with creative solutions involving all
stakeholders.
Today, DEI is the thread that weaves organizational cultures together and the matrix on
which organizations are built. Subsequently, without a strong matrix consisting of
transformational leaders, the matrix or culture will surely collapse. To be competitive and
sustainable in today’s environment requires diversity of thought, commitment to change, and
transformational leaders at all levels of the organization.
Tuck and Yang (2014) defined theory of change as “…a belief or perspective about how
a situation can be adjusted, corrected, or improved” (p. 10). My theory of change is desire
centered, acknowledging the complexities of experiences but also longing for wisdom and hope.
My theory of change acknowledges the past while longing for the imagined future—the not yet
(Tuck, 2009). Though my belief is that we are not yet there, we have the capacity and have been
provided with a glimpse of our possible selves, demonstrating our resiliency and desire for all
that is just and equitable, and remembering that the most difficult things in life are often the most
precious and worth the fight.
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Conclusion
The case for gender diversity and leadership in the profession of spine surgery persists
and is at a critical juncture. In addition to ethical considerations, diversity leads to economic
gains, better patient outcomes and access to care, adherence to patient treatment plans, creativity
in solving complex problems, and sustainability. Further, the current and expected shortage of
surgeons coupled with the healthcare impact of COVID-19 makes the case that healthcare is in
dire need of sustainable solutions.
At the same time, traditional gender and cultural norms play significant roles in the
profession of spine surgery. Further, though the value of diversity is widely accepted, gender
leadership in spine surgery has not progressed. This problem is further compounded by the fact
that the profession is heavily male dominated, creating stereotypes of women spine surgeons that
lead to both unconscious and explicit biases that disproportionately impact the few women in the
field. And though medicine is the backdrop of my research, the challenges of women working in
male-dominated settings are universal and can be generalized across disciplines.
For women to progress in the field, men spine surgeon leaders will need to step up to
address the problem. Fortunately, my experiences with men spine surgeons who are in positions
of power provide me with hope and optimism — these leaders are problem solvers at heart and
always up for a challenge. In fact, many have daughters that they would support wholeheartedly,
demonstrating their passion for equity. Now more than ever, my experiences with men spine
surgeons, coupled with newfound knowledge from research, cause me to understand the
powerful influence that stereotypes play in our daily lives and that gender bias in the spine
surgery profession sells short the advantages that women bring to the field. At times, gender bias
may even misinterpret women’s contributions due to the standard mental model for spine
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surgeon being decidedly male. These primarily unconscious biases are not allowing the
contributions of women spine surgeons to fully be appreciated.
We now have the tools, best practices, and competent coaches and leaders to guide us and
change the gender and leadership dynamics in the profession, be more inclusive in the process,
and ultimately help more patients. Additionally, change is constant, a non-negotiable, ever
evolving, and required for survival. As leaders, change requires us to meet the challenge (ready
or not), and we must rise to the occasion. And though Tuck (2009) posits not yet, I challenge us
to collectively progress Tuck’s work to embrace uncertainty and provide clarity through change
so that we may all reach our possible selves.
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References
Abelson, J., Chartrand, G., Moo, T.-A., Moore, M., & Yeo, H. (2016). The climb to break the
glass ceiling in surgery: Trends in women progressing from medical school to surgical
training and academic leadership from 1994 to 2015. The American Journal of Surgery,
212(4), 566–572. https://doi.org/10.1016/j.amjsurg.2016.06.012
Accreditation Council for Graduate Medical Education. (2020). ACGME program requirements
for graduate medical education in neurological surgery. https://www.acgme.org/
Altieri, M. S., Salles, A., Bevilacqua, L. A., Brunt, L. M., Mellinger, J. D., Gooch, J. C., &
Pryor, A. D. (2019). Perceptions of surgery residents about parental leave during training.
JAMA Surgery, 154(10), 952–958. https://doi.org/10.1001/jamasurg.2019.2985
American Medical Association. (2021, April 12). 2021 residency match: What we learned.
American Medical Association. https://www.ama-assn.org/residents-
students/match/2021-residency-match-what-we-learned
Antonoff, M. B. (2016). Using social media effectively in a surgical practice. The Journal of
Thoracic and Cardiovascular Surgery, 151(2), 322–326.
https://doi.org/10.1016/j.jtcvs.2015.10.016
Antonoff, M. B., & Stamp, N. (2017). The #NYerORCoverChallenge: What it means for women
in cardiothoracic surgery. The Journal of Thoracic and Cardiovascular Surgery, 154(4),
1349–1351. https://doi.org/10.1016/j.jtcvs.2017.06.015
Armijo, P. R., Silver, J. K., Larson, A. R., Asante, P., & Shillcutt, S. (2020). Citizenship tasks
and women physicians: Additional woman tax in academic medicine? Journal of
Women’s Health. https://doi.org/10.1089/jwh.2020.8482
118
Arnold, P. M., Brodke, D. S., Rampersaud, R., Harrop, J. S., Dailey, A. T., Shaffrey, C. I.,
Grauer, J. N., Dvorak, M., Bono, C. M., Wilsey, J. T., Lee, J. Y., Nassr, A., & Vaccaro,
A. R. (2009). Differences between neurosurgeons and orthopedic surgeons in classifying
cervical dislocation injuries and making assessment and treatment decisions: A
multicenter reliability study. American Journal of Orthopedics, 38(10), E156–E161.
Asgari, M. M., Carr, P. L., & Bates, C. K. (2019). Closing the gender wage gap and achieving
professional equity in medicine. JAMA, 321(17), 1665–1666.
https://doi.org/10.1001/jama.2019.4168
Association of American Medical Colleges. (2017). Women in U.S. academic medicine and
science: Statistics and benchmarking report, 2011-2012.
Association of American Medical Colleges. (2018). Diversity in medicine facts and figures:
Percentage of physicians by sex, 2018. https://www.aamc.org/data-
reports/workforce/interactive-data/figure-19-percentage-physicians-sex-2018
Association of American Medical Colleges. (2019a). Diversity in medicine: Facts and figures
2019. https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-
figures-2019
Association of American Medical Colleges. (2019b). The majority of U.S. medical students are
women. https://www.aamc.org/news-insights/press-releases/majority-us-medical-
students-are-women-new-data-show
Association of American Medical Colleges. (2020). The complexities of physician supply and
demand: Projections from 2018 to 2033.
119
Backhus, L. M., Lui, N. S., Cooke, D. T., Bush, E. L., Enumah, Z., & Higgins, R. (2019).
Unconscious bias: Addressing the hidden impact on surgical education. Thoracic Surgery
Clinics, 29(3), 259–267. https://doi.org/10.1016/j.thorsurg.2019.03.004
Barnes, K. L., McGuire, L., Dunivan, G., Sussman, A. L., & McKee, R. (2019). Gender bias
experiences of female surgical trainees. Journal of Surgical Education, 76(6), e1–e14.
https://doi.org/10.1016/j.jsurg.2019.07.024
Beagan, B. (2001). Micro inequities and everyday inequalities: “Race,” gender, sexuality and
class in medical school. Canadian Journal of Sociology, 26(4), 583–612.
Bean, J. (2008). Women in neurosurgery. Journal of Neurosurgery, 109(3), 377–377.
https://doi.org/10.3171/JNS/2008/109/9/0377
Bellini, M. I., Graham, Y., Hayes, C., Zakeri, R., Parks, R., & Papalois, V. (2019). A woman’s
place is in theatre: Women’s perceptions and experiences of working in surgery. BMJ
Open, 9. https://discovery.ucl.ac.uk/id/eprint/10066366
Bergeron, D. M., Block, C. J., & Echtenkamp, A. (2006). Disabling the able: Stereotype threat
and women’s work performance. Human Performance, 19(2), 133–158.
https://doi.org/10.1207/s15327043hup1902_3
Berry, C., Khabele, D., Johnson-Mann, C., Henry-Tillman, R., Joseph, K.-A., Turner, P., Pugh,
C., Fayanju, O., Backhus, L., Sweeting, R., Newman, E., Oseni, T., Hasson, R., White,
C., Cobb, A., Johnston, F., Stallion, A., Karpeh, M., Nwariaku, F., … Jordan, A. (2020).
A call to action: Black/African American women surgeon scientists, where are they?
Annals of Surgery, 272(1), 24–29. https://doi.org/10.1097/SLA.0000000000003786
Bleakley, A. (2013). Gender matters in medical education. Medical Education, 47(1), 59–70.
https://doi.org/10.1111/j.1365-2923.2012.04351.x
120
Brandt, M. L. (2017). Sustaining a career in surgery. The American Journal of Surgery, 214(4),
707–714. https://doi.org/10.1016/j.amjsurg.2017.06.022
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and
design. Harvard University Press.
Bronfenbrenner, U. (1981). The ecology of human development: Experiments by nature and
design. Harvard University Press.
Buckingham, M., & Coffman, C. W. (2014). First, break all the rules: What the world’s greatest
managers do differently. Gallup Press.
Burkholder, G., Cox, K., Crawford, L., & Hitchcock, J. (2019). Interviewing essentials for new
researchers. In Research design and methods: An applied guide for the scholar-
practitioner (5th ed).
Campuzano, M. V. (2019). Force and inertia: A systematic review of women’s leadership in
male-dominated organizational cultures in the United States. Human Resource
Development Review, 18(4), 437–469. https://doi.org/10.1177/1534484319861169
Carapinha, R., Ortiz-Walters, R., McCracken, C. M., Hill, E. V., & Reede, J. Y. (2016).
Variability in women faculty’s preferences regarding mentor similarity: A multi-
institution study in academic medicine. Academic Medicine, 91(8), 1108–1118.
https://doi.org/10.1097/ACM.0000000000001284
Center, C., Davis, M., Detre, T., Ford, D. E., & Hansbrough, W. (2003). Confronting depression
and suicide in physicians. JAMA, 289(23), 3161–3166.
Chen, M. M., Yeo, H. L., Roman, S. A., Bell, R. H., & Sosa, J. A. (2013). Life events during
surgical residency have different effects on women and men over time. Surgery, 154(2),
162–170. https://doi.org/10.1016/j.surg.2013.03.014
121
Chua, I. S., Jackson, V., & Kamdar, M. (2020). Webside manner during the COVID-19
pandemic: Maintaining human connection during virtual visits. Journal of Palliative
Medicine, 23(11), 1507–1509. https://doi.org/10.1089/jpm.2020.0298
Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., Whittington, J. C.,
Frankel, A., Seger, A., & James, B. C. (2011). ‘Global trigger tool’ shows that adverse
events in hospitals may be ten times greater than previously measured. Health Affairs,
30(4), 581–589. https://doi.org/10.1377/hlthaff.2011.0190
Cochran, A., Hauschild, T., Elder, W. B., Neumayer, L. A., Brasel, K. J., & Crandall, M. L.
(2013). Perceived gender-based barriers to careers in academic surgery. American
Journal of Surgery, 206(2), 263. https://doi.org/10.1016/j.amjsurg.2012.07.044
Coleman, J. (1990). Foundations of social theory. Harvard University Press.
Cords, S. S. (2013). Forget a mentor, find a sponsor: The new way to fast-track your career.
Reed Business Information.
Corley, J., Kim, E., Philips, C. A., Stippler, M., Parr, A. M., Sweet, J., & Rosseau, G. (2020).
One hundred years of neurosurgery: Contributions of American women. Journal of
Neurosurgery, 134(2), 337–342. https://doi.org/10.3171/2019.12.JNS192878
Creswell, J., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed
methods approaches (5th ed). SAGE Publications, Inc.
Day, M., Owens, J., & Caldwell, L. (2019). Breaking barriers: A brief overview of diversity in
orthopedic surgery. The Iowa Orthopaedic Journal, 39(1), 1–5.
Derthick, A. O. (2015). The sexist mess: Development and initial validation of the sexist
microaggressions experiences and stress scale and the relationship of sexist
122
microaggressions to women’s mental health [PhD Thesis].
https://search.proquest.com/docview/1752638981
Dineen, H. A., Patterson, J. M. M., Eskildsen, S. M., Gan, Z. S., Li, Q., Patterson, B. C., &
Draeger, R. W. (2019). Gender preferences of patients when selecting orthopaedic
providers. The Iowa Orthopaedic Journal, 39(1), 203–210.
https://www.ncbi.nlm.nih.gov/pubmed/31413695
Dobbin, F., & Kalev, A. (2016). Why Diversity Programs Fail. Harvard Business Review,
94(7/8), 52–60.
https://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=116330233&authtype
=sso&custid=s8983984
Donnally, C. J., McCormick, J. R., Li, D. J., Maguire, J. A., Barker, G. P., Rush, A. J., & Wang,
M. Y. (2018). How do physician demographics, training, social media usage, online
presence, and wait times influence online physician review scores for spine surgeons?
Journal of Neurosurgery: Spine, 30(2), 279–288.
https://doi.org/10.3171/2018.8.SPINE18553
Dvorak, M. F., Collins, J. B., Fisher, C. G., Murnaghan, L., Hurlbert, R. J., Fehlings, M., Fox,
R., Hedden, D., Rampersaud, R., Bouchard, J., & Guy, P. (2006). Confidence in spine
training among senior neurosurgical and orthopedic residents. Spine, 31(7), 831–837.
https://doi.org/10.1097/01.brs.0000207238.48446.ce
Dyrbye, L. N., Freischlag, J., Kaups, K. L., Oreskovich, M. R., Satele, D. V., Hanks, J. B., Sloan,
J. A., Balch, C. M., & Shanafelt, T. D. (2012). Work-home conflicts have a substantial
impact on career decisions that affect the adequacy of the surgical workforce. Archives of
Surgery, 147(10), 933–939. https://doi.org/10.1001/archsurg.2012.835
123
Dyrbye, L. N., Harper, W., Durning, S. J., Moutier, C., Thomas, M. R., Massie, F. S., Eacker, A.,
Power, D. V., Szydlo, D. W., Sloan, J. A., & Shanafelt, T. D. (2011). Patterns of distress
in US medical students. Medical Teacher, 33(10), 834–839.
https://doi.org/10.3109/0142159X.2010.531158
Dyrbye, L. N., Shanafelt, T. D., Balch, C. M., Satele, D., Sloan, J., & Freischlag, J. (2011).
Relationship between work-home conflicts and burnout among American surgeons: A
comparison by sex. Archives of Surgery, 146(2), 211–217.
https://doi.org/10.1001/archsurg.2010.310
Dyrbye, L., Sotile, W., Boone, S., West, C., Tan, L., Satele, D., Sloan, J., Oreskovich, M., &
Shanafelt, T. (2014). A survey of U.S. physicians and their partners regarding the impact
of work–home conflict. Journal of General Internal Medicine, 29(1), 155–161.
https://doi.org/10.1007/s11606-013-2581-3
Eagly, A. H. (2008). Women and the labyrinth of leadership. Human Resource Management
International Digest, 16(1). https://doi.org/10.1108/hrmid.2008.04416aad.004
Eagly, A. H., & Koenig, A. M. (2021). The Vicious Cycle Linking Stereotypes and Social Roles.
Current Directions in Psychological Science, 30(4), 343–350.
https://doi.org/10.1177/09637214211013775
Eagly, A., & Karau, S. (2002). Role congruity theory of prejudice toward female leaders. 109,
573–598. https://www-proquest-
com.libproxy2.usc.edu/docview/614368478/fulltextPDF/D12F0E284F149E2PQ/1?accou
ntid=14749
124
Eagly, A., Nater, C., Miller, D. I., Kaufmann, M., & Sczesny, S. (2020). Gender stereotypes have
changed: A cross-temporal meta-analysis of U.S. public opinion polls from 1946 to 2018.
The American Psychologist, 75(3), 301–315. https://doi.org/10.1037/amp0000494
Elliot, A. J., Dweck, C. S., & Yeager, D. S. (2017). Handbook of competence and motivation:
Theory and application (2nd ed). The Guilford Press.
Elmore, L. C., Jeffe, D. B., Jin, L., Awad, M. M., & Turnbull, I. R. (2016). National survey of
burnout among US general surgery residents. Journal of the American College of
Surgeons, 223(3), 440–451. https://doi.org/10.1016/j.jamcollsurg.2016.05.014
Falavigna, A., Ramos, M. B., de Farias, F. A. C., Britz, J. P. E., Dagostini, C. M., Orlandin, B.
C., Corso, L. L., Morello, S. L., Kapatkin, A. S., Topalovic, T., & Allen, M. (2021).
Perception of Gender Discrimination Among Spine Surgeons Across Latin America: A
Web-Based Survey. The Spine Journal: Official Journal of the North American Spine
Society. https://doi.org/S1529-9430(21)00182-0
Fassiotto, M., Li, J., Maldonado, Y., & Kothary, N. (2018). Female surgeons as counter
stereotype: The impact of gender perceptions on trainee evaluations of physician faculty.
Journal of Surgical Education, 75(5), 1140–1148.
https://doi.org/10.1016/j.jsurg.2018.01.011
Ferguson, E. (2002). Factors associated with success in medical school: Systematic review of the
literature. BMJ, 324, 952–957. https://doi.org/10.1136/bmj.324.7343.952
Files, J. A., Mayer, A. P., Ko, M. G., Friedrich, P., Jenkins, M., Bryan, M. J., Vegunta, S.,
Wittich, C. M., Lyle, M. A., Melikian, R., Duston, T., Chang, Y.-H. H., & Hayes, S. N.
(2017). Speaker introductions at internal medicine grand rounds: Forms of address reveal
125
gender bias. Journal of Women’s Health, 26(5), 413–419.
https://doi.org/10.1089/jwh.2016.6044
Friedan, B. (1963). The feminine mystique. W.W. Norton.
Fuertes, J. N., Toporovsky, A., Reyes, M., & Osborne, J. B. (2017). The physician-patient
working alliance: Theory, research, and future possibilities. Patient Education and
Counseling, 100(4), 610–615. https://doi.org/10.1016/j.pec.2016.10.018
Glick, P., & Fiske, S. (2011). Ambivalent sexism revisited. Psychology of Women Quarterly,
35(3), 530–535. https://doi.org/10.1177/0361684311414832
Greenwald, A., Banaji, M., & Nosek, B. (1998). Implicit association test.
https://implicit.harvard.edu/implicit/iatdetails.html
H2020 Expert Group. (2020). Gendered Innovations 2: How Inclusive Analysis Contributes to
Research and Innovation.
http://genderedinnovations.stanford.edu/GI%202%20How%20Inclusive%20Analysis%2
0Contributes%20to%20R&I.pdf
Hagiwara, N., Dovidio, J. F., Eggly, S., & Penner, L. A. (2016). The effects of racial attitudes on
affect and engagement in racially discordant medical interactions between non-Black
physicians and Black patients. Group Processes & Intergroup Relations, 19(4), 509–527.
https://doi.org/10.1177/1368430216641306
Hagiwara, N., Elston Lafata, J., Mezuk, B., Vrana, S. R., & Fetters, M. D. (2019). Detecting
implicit racial bias in provider communication behaviors to reduce disparities in
healthcare: Challenges, solutions, and future directions for provider communication
training. Patient Education and Counseling, 102(9), 1738–1743.
https://doi.org/10.1016/j.pec.2019.04.023
126
Hewlett, S. (2019). The sponsor effect (1st ed.). Harvard Business Review Press.
Hewlett, S. A., Peraino, K., Sherbin, L., & Sumberg, K. (2010). The sponsor effect: Breaking
through the last glass ceiling. Harvard Business Review Research Report.
Heyden, M. L. M., Fourné, S. P. L., Koene, B. A. S., Werkman, R., & Ansari, S. (2017).
Rethinking ‘top-down’ and ‘bottom-up’ roles of top and middle managers in
organizational change: Implications for employee support. Journal of Management
Studies, 54(7), 961–985. https://doi.org/10.1111/joms.12258
Hideg, I., & Ferris, D. L. (2016). The compassionate sexist? How benevolent sexism promotes
and undermines gender equality in the workplace. Journal of Personality and Social
Psychology, 111(5), 706–727. https://doi.org/10.1037/pspi0000072
Hill, E., & Vaughan, S. (2013). The only girl in the room: How paradigmatic trajectories deter
female students from surgical careers. Medical Education, 47(6), 547–556.
https://doi.org/10.1111/medu.12134
Hippel, C. von, Wiryakusuma, C., Bowden, J., & Shochet, M. (2011). Stereotype threat and
female communication styles. Personality & Social Psychology Bulletin, 37(10), 1312–
1324. https://doi.org/10.1177/0146167211410439
Hirshfield, L. E., & Underman, K. (1983). Patient education and counseling. Patient Education
and Counseling, 100, 785–787.
Hochberg, M. S., Berman, R. S., Kalet, A. L., Zabar, S. R., Gillespie, C., & Pachter, H. L.
(2013). The stress of residency: Recognizing the signs of depression and suicide in you
and your fellow residents. The American Journal of Surgery, 205(2), 141–146.
http://dx.doi.org.libproxy1.usc.edu/10.1016/j.amjsurg.2012.08.003
127
Holt-Lunstad, J., Smith, T. B., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and
social isolation as risk factors for mortality: A meta-analytic review. Perspectives on
Psychological Science, 10(2), 227–237. https://doi.org/10.1177/1745691614568352
Hoops, H., Brasel, K., Dewey, E., Rodgers, S., Merrill, J., Hunter, J., & Azarow, K. (2018).
Analysis of gender-based differences in surgery faculty compensation, promotion, and
retention: Establishing equity. Annals of Surgery, 268(3), 479–487.
https://doi.org/10.1097/SLA.0000000000002920
Hunt, V., Layton, D., & Prince, S. (2015). Diversity matters.
Hunt, V., Prince, S., Dixon-Fyle, S., & Dolan, K. (2020). Diversity wins: How inclusion matters.
McKinsey & Company, 56.
Hunt, V., Prince, S., Dixon-Fyle, S., & Yee, L. (2018). Delivering through diversity. McKinsey
& Company, 42.
Ibarra, H., & Petriglieri, J. (2016). Impossible selves: Image strategies and identity threat in
professional women’s career transitions [INSEAD Working Paper].
http://www.ssrn.com/abstract=2742061
Jena, A. B., Olenski, A. R., & Blumenthal, D. M. (2016). Sex differences in physician salary in
US public medical cchools. JAMA Internal Medicine, 176(9), 1294–1304.
https://doi.org/10.1001/jamainternmed.2016.3284
Jha, A., Iliff, A., Chaoui, A., Defossez, S., Bombaugh, M., & Miller, Y. (2019). A Crisis in
health care: A call to action on physician burnout.
Johnson, P. A., Benya, F. F., & Widnall, S. E. (2018). Sexual harassment of women: Climate,
culture, and consequences in academic sciences, engineering, and medicine. National
Academies Press. http://cds.cern.ch/record/2624484
128
Jolly, S., Griffith, K. A., DeCastro, R., Stewart, A., Ubel, P., & Jagsi, R. (2014). Gender
differences in time spent on parenting and domestic responsibilities by high-achieving
young physician-researchers. Annals of Internal Medicine, 160(5), 344–353.
https://doi.org/10.7326/M13-0974
Jurenovich, K. M., & Cannada, L. K. (2020). Women in orthopedics and their fellowship choice:
What influenced their specialty choice? The Iowa Orthopaedic Journal, 40(1), 13–17.
https://www.ncbi.nlm.nih.gov/pubmed/32742203
Kalagara, S., Eltorai, A. E. M., DePasse, J. M., & Daniels, A. H. (2019). Predictive factors of
positive online patient ratings of spine surgeons. The Spine Journal, 19(1), 182–185.
https://doi.org/10.1016/j.spinee.2018.07.024
Kim, E. E., Klein, A. L., Lartigue, J. W., Hervey-Jumper, S., & Rosseau, G. (2021). Diversity in
neurosurgery. World Neurosurgery, 145, 197–204.
https://doi.org/10.1016/j.wneu.2020.08.219
Knoeller, S. M., & Seifried, C. (2000). Historical perspective: History of spinal surgery. Spine,
25(21), 2838–2843. https://doi.org/10.1097/00007632-200011010-00020
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health
system. National Academy Press.
Kramer, M., Heyligers, I., & Konings, K. (2021). Implicit gender-career bias in postgraduate
medical training still exists, mainly in residents and in females. BMC Medical Education,
21(253). https://doi.org/doi.org/10.1186/s12909-021-02694-9
Kubu, C. S. (2018). Who does she think she is? Women, leadership and the ‘B’(ias) word. The
Clinical Neuropsychologist, 32(2), 235–251.
https://doi.org/10.1080/13854046.2017.1418022
129
Lean In & SurveyMonkey. (2019). Working relationships in the #METOO era.
https://leanin.org/sexual-harassment-backlash-survey-results
Lin, M. P., Lall, M. D., Samuels‐Kalow, M., Das, D., Linden, J. A., Perman, S., Chang, A. M., &
Agrawal, P. (2019). Impact of a women-focused professional organization on academic
retention and advancement: Perceptions From a qualitative study. Academic Emergency
Medicine, 26(3), 303–316. https://doi.org/10.1111/acem.13699
Lincoln, A. E., Pincus, S., Koster, J. B., & Leboy, P. S. (2012). The Matilda Effect in science:
Awards and prizes in the US, 1990s and 2000s. Social Studies of Science, 42(2), 307–
320. https://doi.org/10.1177/0306312711435830
Lloyd, P. C., Driscoll, A. K., Simon, A. E., & Parker, J. D. (2018). Use of the national health
interview survey linked to medicaid analytic eXtract data to identify children with
medicaid-covered births (pp. 1–11). National Library of Medicine.
https://www.ncbi.nlm.nih.gov/pubmed/29616899
Lynch, G., Nieto, K., Puthenveettil, S., Reyes, M., Jureller, M., Huang, J. H., Grady, M. S.,
Harris, O. A., Ganju, A., Germano, I. M., Pilitsis, J. G., Pannullo, S. C., Benzil, D. L.,
Abosch, A., Fouke, S. J., & Samadani, U. (2012). J Neurosurg (Vol. 3).
Martin, A. E., & Phillips, K. W. (2017). What “blindness” to gender differences helps women
see and do: Implications for confidence, agency, and action in male-dominated
environments. Organizational Behavior and Human Decision Processes, 142, 28–44.
https://doi.org/10.1016/j.obhdp.2017.07.004
Mazure, C. M., & Jones, D. P. (2015). Twenty years and still counting: Including women as
participants and studying sex and gender in biomedical research. BMC Women’s Health,
15(1), 94. https://doi.org/10.1186/s12905-015-0251-9
130
McNutt, S. E., Goss, M. L., Hallan, D. R., & Bible, J. E. (2020). Factors in residency decision
making for female neurosurgery applicants. World Neurosurgery, 140, e105–e111.
https://doi.org/10.1016/j.wneu.2020.04.166
McQueen, N. (2018). Workplace culture trends: The key to hiring (and keeping) top talent in
2018. https://blog.linkedin.com/2018/june/26/workplace-culture-trends-the-key-to-hiring-
and-keeping-top-talent
Medeiros, K. E., & Griffith, J. A. (2019). Double-edged scalpels: The trials and triumphs of
women surgeons. Narrative Inquiry in Bioethics, 9(3), 221–227.
https://doi.org/10.1353/nib.2019.0057
Merriam, S., & Tisdell, E. (2016). Qualitative research: A guide to design and implementation
(4th ed.). Jossey-Bass.
Merriam-Webster Dictionary. (n.d.). Retrieved January 16, 2022, from https://www.merriam-
webster.com/dictionary/authenticity
Meyerson, S. L., Sternbach, J. M., Zwischenberger, J. B., & Bender, E. M. (2017). The effect of
gender on resident autonomy in the operating room. Journal of Surgical Education,
74(6), e111–e118. https://doi.org/10.1016/j.jsurg.2017.06.014
Miller, E. K., & LaPorte, D. M. (2015). Barriers to women entering the field of orthopedic
surgery. Orthopedics, 38(9), 530–533. https://doi.org/10.3928/01477447-20150902-03
Money, S. R. (2017). Surgical personalities, surgical burnout, and surgical happiness. Journal of
Vascular Surgery, 66(3), 683–686. https://doi.org/10.1016/j.jvs.2017.04.034
Mueller, A. S., Jenkins, T. M., Osborne, M., Dayal, A., O’Connor, D. M., & Arora, V. M.
(2017). Gender differences in attending physicians’ feedback to residents: A qualitative
131
analysis. Journal of Graduate Medical Education, 9(5), 577–585.
https://doi.org/10.4300/JGME-D-17-00126.1
National Academies of Sciences, Engineering, and Medicine. (2018). Sexual harassment of
women: Climate, culture, and consequences in academic sciences, engineering, and
medicine (p. 24994). The National Academies Press. https://doi.org/10.17226/24994
Nielsen, K. (2013). Review Article: How can we make organizational interventions work?
Employees and line managers as actively crafting interventions. Human Relations, 66(8),
1029–1050. https://doi.org/10.1177/0018726713477164
Northouse, P. (2016). Leadership: Theory and practice (7th ed.). SAGE Publications, Inc.
Okimoto, T. G., & Brescoll, V. L. (2010). The price of power: Power seeking and backlash
against female politicians. Personality & Social Psychology Bulletin, 36(7), 923–936.
https://doi.org/10.1177/0146167210371949
Olsson, C., Kalén, S., & Ponzer, S. (2019). Sociological analysis of the medical field: Using
Bourdieu to understand the processes preceding medical doctors’ specialty choice and the
influence of perceived status and other forms of symbolic capital on their choices.
Advances in Health Sciences Education, 24(3), 443–457.
http://dx.doi.org.libproxy1.usc.edu/10.1007/s10459-018-09872-3
Onyango, J. M., & Bowe, S. N. (2019). Seeing is believing: How social media is challenging
physician stereotypes. Journal of Graduate Medical Education, 11(5), 495–497.
https://doi.org/10.4300/JGME-D-19-00266.1
Patient-centered outcomes research institute. (n.d.). [Federal]. Patient-Centered Outcomes
Research Institute. Retrieved May 4, 2021, from https://www.pcori.org/
132
Patton, M. (2002). Chapter 7: Qualitative Interviewing. In Qualitative Research and Evaluation
Methods (3rd ed., pp. 339–380). SAGE Publications, Inc.
Paturel, A. (2019). Why women leave medicine. https://www.aamc.org/news-insights/why-
women-leave-medicine
Paustian-Underdahl, S. C., Walker, L. S., & Woehr, D. J. (2014). Gender and perceptions of
leadership effectiveness: A meta-analysis of contextual moderators. Journal of Applied
Psychology, 99(6), 1129–1145. http://dx.doi.org.libproxy2.usc.edu/10.1037/a0036751
Peck, C. J., Schmidt, S. J., Latimore, D. A., & O’Connor, M. I. (2020). Chair versus chairman:
Does orthopaedics use the gendered term more than other specialties? Clinical
Orthopaedics and Related Research, 478(7), 1583–1589.
https://doi.org/10.1097/CORR.0000000000000964
Periyakoil, V., Chaudron, L., Hill, E., Pellegrini, V., Neri, E., & Kraemer, H. (2020). Common
types of gender-based microaggressions in medicine. Academic Medicine, 95(3), 450–
457. https://doi.org/10.1097/ACM.0000000000003057
Pew Research Center. (2010). Millennials: A portrait of generation next.
https://www.pewresearch.org/wp-content/uploads/sites/3/2010/10/millennials-confident-
connected-open-to-change.pdf
Pisani, M. A. (2018). Women in medicine struggle with mentorship and sponsorship [Medical
Education]. Op-Med. https://opmed.doximity.com/articles/women-in-medicine-struggle-
with-mentorship-and-sponsorship
Pololi, L. H., Civian, J. T., Brennan, R. T., Dottolo, A. L., & Krupat, E. (2013). Experiencing the
culture of academic medicine: Gender matters, a national study. Journal of General
Internal Medicine, 28(2), 201–207. https://doi.org/10.1007/s11606-012-2207-1
133
Post, A. F., Dai, J. B., Li, A. Y., Maniya, A. Y., Haider, S., Sobotka, S., Germano, I. M., &
Choudhri, T. F. (2019). Workforce analysis of spine surgeons involved with neurological
and orthopedic surgery residency training. World Neurosurgery, 122, e147–e155.
https://doi.org/10.1016/j.wneu.2018.09.152
Pulcrano, M., Evans, S. R. T., & Sosin, M. (2016). Quality of life and burnout rates across
surgical specialties: A systematic review. JAMA Surgery, 151(10), 970–978.
https://doi.org/10.1001/jamasurg.2016.1647
Rangel, E. L., Smink, D. S., Castillo-Angeles, M., Kwakye, G., Changala, M., Haider, A. H., &
Doherty, G. M. (2018). Pregnancy and motherhood during surgical training. JAMA
Surgery, 153(7), 644–652. https://doi.org/10.1001/jamasurg.2018.0153
Reardon, S. (2014). NIH to probe racial disparity in grant awards. Nature, 512(7514), 243.
https://doi.org/10.1038/512243a
Rohde, R., Wolf, J. M., & Adams, J. (2016). Where are the women in orthopaedic surgery?
Clinical Orthopaedics and Related Research, 474(9), 1950–1956.
https://doi.org/10.1007/s11999-016-4827-y
Rubin, H., & Rubin, I. (2005). Qualitative interviewing: The art of hearing data (2nd ed.).
SAGE Publications, Inc. https://doi.org/10.4135/9781452226651
Salazar, M. K., & Beaton, R. (2000). Ecological model of occupational stress: Application to
urban firefighters. AAOHN Journal, 48(10), 470–479.
http://www.proquest.com/docview/219378577/abstract/FFB5804F0F214DC7PQ/1
Salles, A., Awad, M., Goldin, L., Krus, K., Lee, J. V., Schwabe, M. T., & Lai, C. K. (2019).
Estimating implicit and explicit gender bias among health care professionals and
134
surgeons. JAMA Network Open, 2(7), e196545.
https://doi.org/10.1001/jamanetworkopen.2019.6545
Samra, R., & Hankivsky, O. (2021). Adopting an intersectionality framework to address power
and equity in medicine. The Lancet (British Edition), 397(10277), 857–859.
https://doi.org/10.1016/S0140-6736(20)32513-7
Santry, H. P., & Wren, S. M. (2012). The role of unconscious bias in surgical safety and
outcomes. The Surgical Clinics of North America, 92(1), 137–151.
https://doi.org/10.1016/j.suc.2011.11.006
Sargent, C., Sotile, W., Sotile, M., Rubash, H., & Barrack, R. (2012). Quality of life during
orthopaedic training and academic practice: Part 2 spouses and significant others. The
Journal of Bone and Joint Surgery, 94, e145. https://oce-ovid-
com.libproxy1.usc.edu/article/00004623-201210000-00014/PDF
Savvidou, O. D., Zampeli, F., Antoniadou, T., Beeck, A. V., & Papagelopoulos, P. J. (2020).
Pioneer female orthopedic surgeons as role models. Orthopedics, 43(1), e8–e14.
https://doi.org/10.3928/01477447-20191031-04
Seibert, S., Kraimer, M., & Liden, R. (2001). A social capital theory of career success. Academy
of Management Journal, 44(2), 219–237. https://doi.org/10.2307/3069452
Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P.
(2015). Changes in burnout and satisfaction with work-life balance in physicians and the
general US working population between 2011 and 2014. Mayo Clinic Proceedings,
90(12), 1600–1613. https://doi.org/10.1016/j.mayocp.2015.08.023
Shanafelt, T. D., Mungo, M., Schmitgen, J. S., Storz, K. A., Reeves, D., Hayes, S. N., Sloan, J.
A., Swensen, S. J., & Buskirk, S. J. (2016). Longitudinal study evaluating the association
135
between physician burnout and changes in professional work effort. Mayo Clinic
Proceedings, 91(4), 422–431. https://doi.org/10.1016/j.mayocp.2016.02.001
Sharma, M. (2019). Applying feminist theory to medical education. The Lancet, 393(10171),
570–578. https://doi.org/10.1016/S0140-6736(18)32595-9
Shelton, L. G. (2019). The Bronfenbrenner primer: A guide to develecology (1st ed., Vol. 1).
Routledge. https://doi.org/10.4324/9781315136066
Sibeoni, J., Bellon-Champel, L., Mousty, A., Manolios, E., Verneuil, L., & Revah-Levy, A.
(2019). Physicians’ perspectives about burnout: A systematic review and metasynthesis.
Journal of General Internal Medicine, 34(8), 1578–1590. https://doi.org/10.1007/s11606-
019-05062-y
Silver, J. K., Slocum, C. S., Bank, A. M., Bhatnagar, S., Blauwet, C. A., Poorman, J. A.,
Villablanca, A., & Parangi, S. (2017). Where are the Women? The Underrepresentation
of Women Physicians among Recognition Award Recipients from Medical Specialty
Societies. PM & R, 9(8), 804–815. https://doi.org/10.1016/j.pmrj.2017.06.001
Sing, D. C., Jain, D., & Ouyang, D. (2017). Gender trends in authorship of spine-related
academic literature—A 39-year perspective. The Spine Journal, 17(11), 1749–1754.
https://doi.org/10.1016/j.spinee.2017.06.041
Sinsky, C., Colligan, L., Li, L., Prgomet, M., Reynolds, S., Goeders, L., Westbrook, J., Tutty,
M., & Blike, G. (2016). Allocation of time in ambulatory practice: A time and motion
study in 4 specialties. Annals of Internal Medicine, 165(11), 753–760.
https://doi.org/10.7326/M16-0961
136
Soklaridis, S., Zahn, C., Kuper, A., Gillis, D., Taylor, V., & Whitehead, C. (2018). Men’s fear of
mentoring in the #MeToo era-What’s at stake for academic medicine? The New England
Journal of Medicine, 379(23), 2270–2274.
Southwick, S. M., & Southwick, F. S. (2020). The loss of social connectedness as a major
contributor to physician burnout: Applying organizational and teamwork principles for
prevention and recovery. JAMA Psychiatry, 77(5), 449–450.
https://doi.org/10.1001/jamapsychiatry.2019.4800
Sprow, H. N., Hansen, N. F., Loeb, H. E., Wight, C. L., Patterson, R. H., Vervoort, D., Kim, E.
E., Greving, R., Mazhiqi, A., Wall, K., Corley, J., Anderson, E., & Chu, K. (2021).
Gender-based microaggressions in surgery: A scoping review of the global literature.
World Journal of Surgery, 45(5), 1409–1422. https://doi.org/10.1007/s00268-021-05974-
z
Stanford Medicine. (2018). Doctors call for overhaul of electronic health records.
https://www.prnewswire.com/news-releases/doctors-call-for-overhaul-of-electronic-
health-records-300659100.html
Stephens, E. H., Heisler, C. A., Temkin, S. M., & Miller, P. (2020). The current status of women
in surgery: How to affect the future. JAMA Surgery, 155(9), 876–885.
https://doi.org/10.1001/jamasurg.2020.0312
Stout, J. G., & Dasgupta, N. (2011). When he doesn’t mean you: Gender-exclusive language as
ostracism. Personality & Social Psychology Bulletin, 37(6), 757–769.
https://doi.org/10.1177/0146167211406434
137
Sudol, N. T., Guaderrama, N. M., Honsberger, P., Weiss, J., Li, Q., & Whitcomb, E. L. (2021).
Prevalence and nature of sexist and racial/ethnic microaggressions against surgeons and
anesthesiologists. JAMA Surgery. https://doi.org/10.1001/jamasurg.2021.0265
Templeton, K., Nilsen, K., & Walling, A. (2020). Issues faced by senior women physicians: A
national survey. Journal of Women’s Health, 29(7), 980–988.
https://doi.org/10.1089/jwh.2019.7910
The Physicians Foundation. (2018). American’s physicians practice patterns & perspectives.
www.physiciansfoundation.org
Torres, M. B., Salles, A., & Cochran, A. (2019). Recognizing and reacting to microaggressions
in medicine and surgery. JAMA Surgery, 154(9), 868–872.
https://doi.org/10.1001/jamasurg.2019.1648
Tsugawa, Y., Jena, A. B., Figueroa, J. F., Orav, E. J., Blumenthal, D. M., & Jha, A. K. (2017).
Comparison of hospital mortality and readmission rates for medicare patients treated by
male vs female physicians. JAMA Internal Medicine, 177(2), 206.
https://doi.org/10.1001/jamainternmed.2016.7875
Tuck, E. (2009). Suspending damage: A letter to communities. Harvard Educational Review,
79(3), 409-427,539-540.
http://www.proquest.com/docview/212268515/abstract/972FB310754A4B52PQ/1
Tuck, E., & Yang, W. (2014). R-words: Refusing research. In Humanizig research:
Decolonizing qualitative inquiry with youth and communities. SAGE Publications, Inc.
https://doi.org/10.4135/9781544329611
United Nations Inter-Agency Network on Women and Gender Equality & OECD-DAC Network
on Gender Equality. (2016). Implementing the 2030 agenda for sustainable development:
138
A game changer for gender equality, women’s empowerment and women’s human rights
(Joint Biennial Meeting).
USC Rossier. (n.d.). Chapter 3 Methodology: Tips. Retrieved April 27, 2021, from
https://zoom.us/rec/play/tJQvceGq-
js3GYDDswSDVPRxW9W6eqqs2iRK8vAFnR62B3YCN1CnNLIaZuAKYi7TIYa44tJz
q7tuxrSU?autoplay=true
van Ryn, M., Hardeman, R. R., Phelan, S. M., Burke, S. E., Przedworski, J., Allen, M. L.,
Burgess, D. J., Ridgeway, J., White, R. O., & Dovidio, J. F. (2014). Psychosocial
predictors of attitudes toward physician empathy in clinical encounters among 4732 1st
year medical students: A report from the CHANGES study. Patient Education and
Counseling, 96(3), 367–375. https://doi.org/10.1016/j.pec.2014.06.009
Villaverde, L. E. (2008). Feminist theories and education: Primer. Peter Lang.
Walton, G. M., Cohen, G. L., Cwir, D., & Spencer, S. J. (2012). Mere belonging: The power of
social connections. Journal of Personality and Social Psychology, 102(3), 513–532.
https://doi.org/10.1037/a0025731
West, C. P., Dyrbye, L. N., & Shanafelt, T. D. (2018). Physician burnout: Contributors,
consequences and solutions. Journal of Internal Medicine, 283(6), 516–529.
https://doi.org/10.1111/joim.12752
Westmoreland, T. M., Bloche, M. G., & Gostin, L. O. (2021). Executive action to expand health
services in the Biden administration. JAMA: The Journal of the American Medical
Association, 325(3), 217–218. https://doi.org/10.1001/jama.2020.25888
Wieneke, K. C., Schaepe, K. S., Egginton, J. S., Jenkins, S. M., Block, N. C., Riley, B. A.,
Sifuentes, L. E., & Clark, M. M. (2019). The supervisor’s perceived role in employee
139
well-being: Results from Mayo Clinic. American Journal of Health Promotion, 33(2),
300–311. https://doi.org/10.1177/0890117118784860
Wood, D. E. (2021). How can men be good allies for women in surgery? #HeForShe. Journal of
Thoracic Disease, 13(1), 492–501. https://doi.org/10.21037/jtd-2020-wts-11
Zestcott, C. A., Blair, I. V., & Stone, J. (2016). Examining the presence, consequences, and
reduction of implicit bias in health care: A narrative review. Group Processes &
Intergroup Relations, 19(4), 528–542. https://doi.org/10.1177/1368430216642029
Zhuge, Y., Kaufman, J., Simeone, D., Chen, H., & Velazquez, O. (2011). Is there still a glass
ceiling for women in academic surgery? Annals of Surgery, 253(4), 637–643.
https://doi.org/10.1097/SLA.0b013e3182111120
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Appendix A: #Ilooklikeasurgeon Tweet
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Appendix B: Sexual Harassment Iceberg
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Appendix C: Recruitment Email
Hi Dr. ___:
I am conducting a research study to explore how women spine surgeons navigate the profession
of spine surgery from an equity and wellbeing perspective. This study is being conducted as a
part of my doctoral dissertation. Further, the intention of the study is to learn about the lived
experiences of women spine surgeons from various ages, races, ethnicities and understand how
these women have persisted in the profession over time.
If you are interested in contributing to this completely confidential and voluntary study, please
click the link below (INSERT LINK) to complete an 8-question demographic survey. The survey
is expected to take less than 5 minutes. Once completed, I will review and select up to fifteen
women spine surgeons to participant in a 1-hour one-on-one interview.
Your identity (including name, place of work, and any other identifiable information) will be
kept strictly confidential, and you may discontinue participation in the study at any point.
Thank you, in advance, for your contribution to the study.
Sincerely,
Elizabeth Walker
Walkerel@usc.edu
901-xxx-xxxx (mobile)
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Appendix D: Demographic Sampling Survey
Thank you for volunteering to contribute to this confidential study. As mentioned in the initial
email, the purpose of the study is to explore how women spine surgeons navigate the profession
from an equity and wellbeing perspective. From the responses to the initial email, approximately
12-15 spine surgeons will be selected to participate in a 1-hour interview between the researcher
and the participant volunteer. In order to identify and represent women from various ages, races,
ethnicities, and backgrounds, the following 8 question survey will assist the researcher in
selecting a diverse group of women to include in the study. As previously stated, your identity
will be kept confidential. I will not include any identifiable information including your name or
where you work in my report or dissertation. Additionally, you may decide not to participate
further in the study at any point in time.
Recruitment Demographic Survey:
1. Please provide your email address.
2. What is the year of your birth?
3. What was your sex assigned at birth?
4. What are your gender identities?
a. Cisgender
b. Transgender
c. Female
d. Other
e. Unsure
5. What are your racial/ethnic identities?
a. African/African American/Black
b. American Indian/Alaskan Native
c. Asian/Asian American
d. Latinx/Hispanic
e. Native Hawaiian/Pacific Islander
f. Middle Eastern/North African/Arab/Arab American
g. White/European American
h. Other
6. What is your relationship status?
a. In a relationship
b. Not in a relationship
7. How would you classify your practice type?
a. Hospital-employed
b. Academic
c. Private practice
d. Other
8. If academic, what is your academic rank?
a. Full professor
b. Associate professor
c. Professor
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d. Instructor
e. Other
9. How long did it take you to get to this rank?
a. 0-5 years
b. 5-10 years
c. 10-15 years
d. Greater than 15 years
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Appendix E: Interview Protocol
Thanks for your time in joining me today. As an introduction, I’m a doctoral student at the
University of Southern California and have worked with spine surgeons for 15+ years now.
Some of my best friends are spine surgeons, so though I am not a spine surgeon, I do believe I
have a good grasp on some of the issues in the field.
The purpose of my study is to explore gender-related issues that women surgeons face regarding
working in a predominantly male profession, how you navigate the profession as well as factors
that contribute to your persistence and retention in the field. I’m interested specifically in your
experience as a woman and a spine surgeon, things that have caught your interest, details that
might not seem important to you but might be helpful with my study, and definitely your stories.
As I stated in my email, your identity will be kept confidential. I will not include any identifiable
information including your name or where you work in my report or dissertation. I’ll assign a
pseudonym for you in my documents. Is there a pseudonym that you’d like for me to use?
Do you have any initial questions? Do I have your permission to record our session as well as
take notes? Do I have your consent to participate in this study? Also, as a reminder, you may
withdraw or stop at any time. This is also highlighted in the information sheet that I emailed to
you. Have you had a chance to review this document? Are there any other questions at this time
that I can answer?
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Interview Questions Potential Probes RQ Concepts
Choosing the Field &
Training
1.What led you to decide
on this field?
P1. How were mentors involved in your
decision-making process? Ortho? Neuro?
Male? Female? (MESO)
P2. What was the role of the mentor (career
only or life as well)?
P3. What is your opinion about the
importance of a “good fit” between a person
and their job?
P4. Where on the food chain does spine
surgery fall? What medical specialties are
considered prestigious?
P5. What makes it prestigious? Lucrative,
power, etc?
1, 3 Wellbeing,
persistence, gender
norms
2. How would you describe
your satisfaction with your
career choice? P1. What do you like most about it? Least?
3 Wellbeing,
persistence
3. When you’ve
interviewed previously,
have you been asked
questions that you didn’t
think were appropriate or
relevant to your job?
P1. Can you give me some examples?
P2. How did that impact your decision?
2 Gender bias, social
norms, implicit bias
Now I’d like to ask you
some questions about your
work.
4. Please describe your
typical day.
P1. Are you excited at the beginning of the
day? Tired at the end of the day?
P2. Tell me of a time that you got lost in
your work.
1 Lived experience,
persistence
5. Some say there is a
“surgical culture”. How
would you describe the
general surgical culture?
P1. How do you fit in the surgical culture?
P2. What doesn’t fit for you?
P3. What do you bring that others don’t?
P4. What are your biggest frustrations?
P5. Describe some common stereotypes
about spine surgeons?
P6. How do you think social media
campaigns like #ilooklikeasurgeon and
#heforshe will impact perceptions of
women surgeon stereotypes?
1, 2 Gender bias,
implicit bias, social
norms
6. Describe some common
causes of stress for you?
P1. How difficult is the work-personal
balance for you?
P2. How do you deal with that?
P3. Does this conflict lead to burnout?
1, 3 Wellbeing, burnout,
adaptation
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P4. How does your Chair support your well-
being?
P5. What about your Department?
P6. What about the culture of the hospital?
Finally, I’d like to ask you
some questions that are
related to your gender and
your work settings.
7. Do you self-identify as
underrepresented in any
way? Feel free to share if
you’d like.
P1. Do you have children/dependents?
P2. Are you in a relationship?
1 Lived experience
8.Women in many
professions say they have
to balance being too
aggressive and therefore
called “bitchy” versus
begin “too sweet”. How do
you balance your personal
traits while at work?
P1. How do you navigate this?
P2. How has your gender benefitted you in
your work? (If more than 1
underrepresented identity, ask which
benefitted. For example, Asian female. Did
being a “women” benefit you in this
scenario or the “Asian-descent”?)
P3. How has your gender hindered you in
your work, if at all?
P4. More women than men leave surgery,
what’s your experience with women leaving
the profession of surgery?
2 Gender bias, social
norms, gender
norms
9.In your opinion, what is
the value of women spine
surgeons?
P1. What about women spine surgeons that
identify as a person of color?
P2. What value do women spine surgeons
bring to the table differently than men?
P3. Have you had a woman mentor or role
model? What was that experience like?
Have you worked with women spine
surgeons?
P4. What could be done to get more women
involved in spine surgery?
P5. What could be done to advance more
women in the profession?
P6. Literature demonstrates inequities
between men and women at work (for
example – pay). What has been your
experience related to any discrepancies that
seem to be related to gender only (wage,
promotion, research funding, podium
presentations, publications)
1, 3 Lived experience,
wellbeing,
persistence
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10.Some people believe
that surgeons who are
mothers are not able to
balance both their
professional and personal
life. What is your opinion
of this?
P1. What is your opinion of women spine
surgeons who take leave for pregnancy or
maternity leave?
P2. How does it feel to be a spine surgeon
and a mother?
1, 2 Gender bias, social
norms, lived
experiences
11.What types of
expectations do you think
that others put on you?
P1. What about expectations that you put on
yourself?
P2. Can you give me an example?
1, 2 Adaptation, gender
bias, social norms,
gender norms
12. Describe your support
systems.
P1. What about your Department?
P2. What about your Chair? (Meso)
P3. How about the OR/hospital?
P4. How do the organizations that you work
with support women spine surgeons? DEI
Policies, procedures, practices? Are they
effective?
P5. What support systems would encourage
more women to enter the field?
3 Wellbeing, burnout
13. In thinking about
comments that you hear at
work that are offensive to
you, what are the top 3?
(Group into Looks,
Attitude, Ability, Other)
P1. What is the most insulting comment
you’ve heard at work?
P2. What type of person typically says these
things?
P3. How is this language received by
leadership?
P4. What has been done about these types
of situations?
2 Gender bias,
discrimination,
microaggressions,
implicit bias
14. From medical school to
fellowship to practice,
describe a point in time
when you felt that you
belonged.
P1. How important is a sense of belonging
to you at work?
P2. How does feeling included impact your
satisfaction at work?
3 Wellbeing,
belonging
15. Imagine your ideal
work culture. What would
it look like?
P1. How would you feel in that job?
P2: What would you experience as you
walk into work that would be different than
your current experience?
1, 2, 3 Lived experience,
wellbeing, social
norms
Conclusion to the Interview:
Thank you so much for your candid responses. I really appreciate your time today, and your
insight will greatly enhance my study. Are you aware of any documents or pictures that might
provide more insight to me on the culture of spine surgery? If so and you would be willing to
share with me, I would like to confidentially include these in my data collection. Is there
anything else that I should have asked that I didn’t? Again, I really appreciate your help with
this. Is it ok if I contact you if I have any questions afterwards? Email, phone, text best?
149
Appendix F: Information Sheet
INFORMATION SHEET FOR EXEMPT RESEARCH
STUDY TITLE: Navigating the profession of spine surgery: Perspectives from women on the
front lines
PRINCIPAL INVESTIGATOR: Elizabeth Walker
FACULTY ADVISOR: Monique Datta, Ed.D.
You are invited to participate in a research study. Your participation is voluntary. This document
explains information about this study. You should ask questions about anything that is unclear to
you.
PURPOSE
The purpose of this study is to explore how women spine surgeons navigate the male-dominated
profession of spine surgery from an equity and wellbeing perspective. We hope to learn about the
lived experiences of women spine surgeons from different racial, ethnic, and age backgrounds
and understand how these women have persisted in the profession over time. You are invited as a
possible participant because your responses to the demographic survey match the intended
participant criteria for the study.
PARTICIPANT INVOLVEMENT
For the purposes of the study, the researcher will be conducting interviews from a group of 12 to
15 women spine surgeons from mid-August to mid-October. The interviews will primarily take
place over Zoom; however, some may take place in person if the researcher and the participant
are in the same location. In the case that Zoom is used, the researcher will record the interview
from a personal computer and take notes if the participant agrees. If an in-person interview is
conducted, the researcher will locate a quiet meeting room in which to conduct the interview and
record the session via the researcher’s phone if the participant agrees. In the case a phone is used
to capture the recording and audio, the data will be immediately transferred to the researcher’s
personal computer as soon as possible and deleted from the phone. The data will only be kept as
long as necessary and will be deleted once no longer needed for the study.
Once a participant decides to take part, the researcher will email an information sheet to the
participant prior to the scheduled interview time for the participant to review. The information
sheet will also be reviewed at the beginning of the interview so that any questions may be
answered. Once the interview starts, the researcher will ask the participant as many as 14
questions and follow up probes. The participant may decide to skip questions or stop the
interview at any point, and the interview is expected to take about an hour. If the interview is not
finished in an hour, the participant may decide to spend extra time with the researcher to provide
additional information.
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The researcher will be the only person reviewing the recording, and the recording will be very
helpful as the recording is transcribed. The participant can also decline to be recorded.
Additionally, the researcher may take notes if the participant agrees. At the end of the interview,
the participant has no further obligations; however, the researcher would like the opportunity to
reach out to the participant if questions arise during the transcription phase. The participant can
decide to respond or not respond.
PAYMENT/COMPENSATION FOR PARTICIPATION
n/a
CONFIDENTIALITY
The members of the research team and the University of Southern California Institutional
Review Board (IRB) may access the data. The IRB reviews and monitors research studies to
protect the rights and welfare of research subjects.
When the results of the research are published or discussed in conferences, no identifiable
information will be used.
The researcher will assign a pseudonym for the participant which will be included in coding the
database. Names and identifiable information will not be included in the study database. When
the data is no longer being used, the data will be deleted. If the participant agrees to record the
session, the researcher will be the only person accessing the recording. Alternatively, the
researcher may contract with an independent transcription service provider to assist with this
process. In this situation, the researcher will follow the service’s privacy policies regarding
maintaining confidentiality. Once the data is transcribed and the recording is no longer needed,
the recording will be deleted.
INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact Elizabeth Walker at walkerel@usc.edu
or Monique Datta at mdatta@usc.edu.
IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at (323) 442-0114 or email
irb@usc.edu.
Abstract (if available)
Linked assets
University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Walker, Elizabeth
(author)
Core Title
Navigating the profession of spine surgery: narratives from women on the front lines
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Degree Conferral Date
2022-05
Publication Date
04/08/2022
Defense Date
02/28/2022
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
authenticity,Barriers,design thinking,Discrimination,diversity,downplaying gender,equity,gender bias,gender literacy,gendered teaching methods,human-centered design,inclusion,OAI-PMH Harvest,persistence,professional advancement,retention,sense of belonging,spine,spine surgeon,spine surgery profession,stereotypes,unconscious bias
Format
application/pdf
(imt)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Datta, Monique (
committee chair
), Adibe, Bryant (
committee member
), Maddox, Anthony (
committee member
)
Creator Email
ewalkerweakley@gmail.com,walkerel@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC110886263
Unique identifier
UC110886263
Document Type
Dissertation
Format
application/pdf (imt)
Rights
Walker, Elizabeth
Type
texts
Source
20220408-usctheses-batch-920
(batch),
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Repository Email
cisadmin@lib.usc.edu
Tags
authenticity
design thinking
downplaying gender
equity
gender bias
gender literacy
gendered teaching methods
human-centered design
inclusion
persistence
professional advancement
retention
sense of belonging
spine surgeon
spine surgery profession
stereotypes
unconscious bias