Women Build Bonds and Break Ceilings to Redefine Leadership in Cardiothoracic Surgery

One might ask the question, why examine leadership through the lens of gender? As with many aspects of career development, gender plays a significant role both inwardly and outwardly. It shapes how we relate to others and how they relate to us. It also is a social construct that is deeply rooted in history.

When we examine the field of medicine, and surgery more specifically, the data show that women are woefully outnumbered—and this disparity is multiplied several-fold when the leadership ranks are examined. Historically, women have been systematically and deliberately excluded from medicine and surgery, giving rise to our underrepresentation. Thankfully, systematic exclusion is no longer the threat it once was, but change is slow.

Pipeline efforts to increase women entering the surgical field have been successful, but currently the majority are clustered at the junior level of training and seniority. Unconscious bias and remnants of exclusionary practice persist at the higher ranks, creating a dearth of women leaders.

It seems like circular logic, but one way of increasing representation of those underrepresented in an exclusive group is to have more underrepresented members in positions of influence, specifically in leadership roles. And knowing that we have more women in the queue for leadership positions, we need to be deliberate about how they are prepared to lead. In doing so, we take a hard look at the requisite skillset of female surgical leaders and capitalize on strengths to increase our chances of success.

Qualities of Inspiring (Women) Surgeon-Leaders

One of the first women surgeons was Miranda Stuart, a British army medical officer who dressed and presented herself as a man, using the name of James Barry to gain acceptance in her specialty. Dr. Stuart spent 56 years as “Dr. Barry” and developed a reputation as “bombastic, opinionated, and tactless.” Despite these traits, Dr. Stuart/Barry was perceived as a very skilled military surgeon.¹

We certainly are not advocating the adage of “act like a man” as a route to leadership in surgery. In fact, if these traits had been exhibited by women surgeons, even today, the perception of their abilities would likely be very different. Rather, there are several leadership qualities—such as empathy, resilience, strong communication, humility, and emotional intelligence—that, while not exclusive to women leaders, are exhibited more often among successful women in these roles. We should be aware of these attributes as we aim to amplify the positives and minimize the negatives. The playing field is anything but equal, and failing to recognize some of the differences can thwart the ascent of even the most brilliant surgeon-leader.

Several leadership styles have been attributed to different professional sectors. In a survey among 20 women surgical chairs in the US, two leadership styles are predominate: servant and transformational leadership.² Servant leadership is the dominant style that emphasizes a collaborative team with shared goals and consensus building. This style of leadership builds camaraderie, often resulting in a happier and more harmonious work environment where people are more likely to flourish than flounder.

Transformational leadership is defined by inspiration and rooted in tailored mentoring that motivates individuals to strive for more. This style involves leading with a carrot rather than a stick and seeks to promote and elevate individuals, which in turn, elevates the collective team. Having a mixture of leadership styles is helpful because it allows for tailoring incentives to motivate team members.

The approach by which a leadership style is successfully implemented depends on communication, and productive communication begins with listening. Good listening skills facilitate dialogue and intellectual discourse. Great women leaders often are effective communicators, using their skills of observation to distill complex situations down to basic components.

In addition, women leaders often display empathy—which can be one of the most important skills of any leader. Strong communication skills also are critical for managing conflict and resolving difficult interpersonal problems. Having a nonconfrontational communication style can disarm would-be opponents and create a clearer path to conflict resolution. Women, too, can be excellent at multitasking and masterful at balancing multiple competing agendas.

One of the most powerful traits that women surgeon-leaders possess is resilience. While a woman surgeon’s creativity and skill are key to her success as a clinician, it is her resilience that is her greatest strength and has allowed her to excel and advance in her profession despite the odds working against her. Through resiliency, she has adapted, persevered, and pivoted, all while maintaining forward momentum.

Challenges Faced, Victories Achieved

While women surgeons are growing in number and continuing to shatter glass ceilings by taking on new positions of leadership within the specialty, ample challenges still remain.

On our own career journeys, we have experienced plenty of bumps in the road, and, undoubtedly, these circumstances have shaped our pathways. In the end, such obstacles ultimately have enabled new strategies for growth and opportunities for subsequent victory.

It’s been shown that women in surgical specialties are more likely to desire same-gender mentorship, yet are far less likely to find it in their home institutions compared to male surgeons, as well as compared to women in nonsurgical specialties (see Figure).³ This reality is even more extreme in surgical specialties that tend to be more male-dominated.⁴ However, while this circumstance can be daunting, we have found that in the absence of women mentors in our immediate reach, efforts to broaden our networks nationally, and even globally, to women and supportive male sponsors have only strengthened our leadership trajectories. By cultivating collaborative, supportive relationships and networks, we have experienced greater opportunities for involvement and recognition.

While striving to develop academic surgical careers, we have faced challenges—to which many women can relate—centering around our roles as mothers.⁵ As one aims to reach certain career milestones and landmarks, there is a very complex balance in the interplay between jumping on opportunities while trying not to “lean out” as related to family planning.⁶ 

Even after navigating these issues, it’s inevitable that time can be lost regarding career progression during childbearing and parenting. Nonetheless, the skills, perspective, joy, and balance that we have gained from our roles as mothers have genuinely made us better doctors, stronger surgeons, and more versatile leaders. 

Perhaps counterintuitively, women who choose not to marry and/or have children can face a different set of biases that can impact their leadership opportunities. Some may interpret the lack of a partner or children as antithetical to being female, and thus their absence can be viewed as a deficit or mark of inadequacy. So, for many women surgeons, they may feel you’re damned if you do and damned if you don’t.

A number of potential barriers have been identified for subgroups of individuals aiming to climb the academic surgery ladder, ranging from work-life balance, to personal medical conditions, toxic hierarchies, financial disadvantage, and the lack of diversity contributing to noninclusive environments and discrimination on the basis of gender, race/ethnicity, religion, sexual orientation, and country of origin.^7,8 These challenges can be addressed by anticipating them, carefully planning navigational strategies, and putting a heavy lean on support networks and mentors. The best leaders learn to be aware of others’ barriers in the academic surgical arena.

Certainly, we have encountered many other challenges on our pathways, such as the disparate opportunities for sponsorship, the pervasive presence of implicit (and explicit) biases, and inequities in recognition for achievements and contributions. However, seeking solutions, establishing collaborative support networks, and working toward systematic change for others in the future have all had great impact on our own leadership journeys—enabling us to gain resilience and lead change.

Strategies for Leading and Encouraging the Next Generation

In order to move the field of surgery and all of our subspecialties into the future, it is imperative that our workforces far better reflect the communities of patients whom we aim to serve. Women currently make up half of all medical student bodies in the US, yet women continue to be a minority in leadership roles in the field. Disparities in progress occur at every stage of the career pathway, beginning at attrition during training, matriculation into advanced specialty training, and climbing ladders of leadership in academia and community practice. Surgical subspecialties, such as cardiothoracic surgery, have lagged even further behind general surgery in shifts toward a more diverse workforce.^9,10

To encourage and support the future generations of women in surgery, there are a number of key steps that should be taken by current surgeon-leaders.

Be a role model.

We often hear that you can’t be what you can’t see. For trainees and early careerists, visibility and access to women leaders in surgery are pivotal. Access to representative role models can help draw young, talented trainees from a wide range of backgrounds and experiences into surgery and its subspecialties. Don’t be afraid to be approachable and be very public. Have a strong social media presence and be a known entity to the young and inexperienced.

Almost by definition, any of us who is currently within the House of Surgery in whatever capacity has someone who is trailing behind them and looking for inspiration. Even if you have no desire to be a role model, you are in a position of influence—so use that opportunity for good.

Be a mentor and sponsor.

Mentors are critical to career development, and the presence of strong mentorship has been recognized as one of the most important factors in determining career success. Effective mentoring relationships can drive mentees’ goals to fruition by providing support, so that opportunistic risk can be taken, and failures can be translated into learning experiences.

Mentoring can play a critical role in diversifying the surgical workforce. Mentors should allocate time and effort, provide research and training opportunities, offer constructive feedback, and support networking by direct sponsorship or linking to sponsors. Beyond these activities, outstanding mentors can help provide a vision with purposeful, individualized tailoring. They exhibit admirable traits worth emulating, while also respecting privacy, wellness, and work-life balance.

Change the stigma.

We all know that biases are held about women in surgery by colleagues, patients, caregivers, and the public. But there also are false narratives perpetuated by women themselves regarding what a career in surgery looks like, the role that a surgeon-mom holds in the lives of her children, and the potential satisfaction that women can have in the surgical world.

As surgeon-leaders, women and men need to work to explicitly show young women that they are wanted, needed, and able to make a significant difference in the world through their careers in surgery—and, even more, that they can live fulfilling lives while doing so.

Encourage change.

It is undeniable that current women leaders in surgery fought some very tough battles and climbed huge hills that may no longer be present. We must work to ensure that things are better for the generations of women surgeons who follow us, just as parents work to try to allow their children opportunities to achieve more than the previous generations of family members. 

There is nothing to be gained by pushing for other women to have the same struggles that have existed for those in the past and present. If we can make things just a little bit easier, that does not mean future women surgeons will be weaker or that the bar will be lower, but rather that they will have greater opportunities to reach their true potential. There is no place in surgical culture for someone who climbs the ladder and pulls it up behind them. For women who already have climbed the ranks of surgical hierarchy, this is a chance to lead change for the future. 

Offer skills training.

Leadership is innate to some, but for many of us, it is a learned skill. Recognize the unique skills required to do it well, and arm those who are ascending into new positions with the proper tools to do the job. These actions require more than providing new titles or allocating resources. This type of support means providing training opportunities to help cultivate the requisite leadership skillset.

Many more training opportunities are available now than in the past. There are external programs available through the ACS and many other organizations, in addition to local programs. These resources should be mandatory (along with coaching) for those taking on new leadership roles. They also are critical for those who are identified as future leaders, so they can be prepared for the opportunities when they arise. In essence, you have to stay ready, so you don’t have to get ready.

Future of Women in Surgeon Leadership

Within the future of surgical leadership, we aspire for a day when women are equitably represented in surgery, its subspecialties, and all echelons of leadership. Yet, even with more balanced representation, aspects of gender still may permeate the experience of women striving for leadership growth.

To ensure ongoing success of women in the field and opportunities to reach their full potential, a number of goals are necessary in order to modify the current culture and infrastructure of the surgical profession, such as providing clear pathways and programs to bring women into leadership and offering equitable opportunities for all, with inclusive support of mentors and sponsors.

In the end, we must alter our expectations of what a leader should look like, what she should do, and how she should behave. We strive for a day when women are leading other women and men, with support from men (and other women).

With deliberate effort and conscious steps to reach these ends, women may ultimately lead our specialty to a new era of growth, in the end achieving more favorable workplace environments, greater job satisfaction, and equitable career development opportunities for members of our specialty at large with a downstream positive impact on the patients being treated by a more diverse workforce. 

Disclaimer

The thoughts and opinions expressed in this viewpoint article are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. Mara Antonoff is an associate professor and program director of education in the Department of Thoracic and Cardiovascular Surgery at The University of Texas MD Anderson Cancer Center in Houston, TX.

Dr. Leah Backhus is a professor of cardiothoracic surgery at Stanford Medicine and chief of thoracic surgery at the VA Palo Alto Health Care, both in California.

References

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