A total of 1365 responses were obtained from the 9 US medical schools. The response rate is unavailable, because the method of distribution precluded calculation of the total respondent denominator. Sixty-five students did not state their sex and were excluded from further analysis; 680 (52%) of the remaining 1300 respondents were male and 620 (48%) were female. Female respondents were more likely to be in the youngest category (21-25 years; P<.001), less likely to be married (26% vs 36%; P<.001), and less often white (73% vs 84%; P<.001). There were no differences between male and female students with regard to debt at graduation, with 46% of male and female students anticipating graduating $100 000 or more in debt. Respondents were equally distributed across the 4 years of medical school: 353 men (52%) and 322 women (52%) had not yet started their clerkship. The remaining students were either doing their clerkship or had completed it. A total of 24% of men and 15% of women were interested in pursuing a career in general surgery, and 22% of men and 18% of women were undecided. One or more descriptive comments were entered in the spaces provided after each section by 410 male students (60%) and 342 female students (55%). Most written comments demonstrated a negative opinion of surgeons and their lifestyle. Some comments were unprofessional and indicated a gender bias, but we report them verbatim because they are representative of the opinions expressed by the study participants. Unless otherwise stated, for each Likert scale question "agreed" represents the sum of agreed and strongly agreed and "disagreed" represents the sum of disagreed and strongly disagreed. The results are summarized in Tables 1, 2, 3, and 4 and are discussed by survey section.
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Table 1. Responses of Male and Female Students to the Survey Sections on Surgical Life, Residency, and Surgeons as Influence*
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Table 2. Responses of Male and Female Students Unlikely to Study Surgery Compared With Those Likely to Study Surgery to the Survey Sections on Surgical Life, Residency, and Surgeons as Influence*
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Table 3. Responses of Male and Female Students to the Survey Sections on Equity, Family, and Other Influences*
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Table 4. Responses of Male and Female Students Unlikely to Study Surgery Compared With Those Likely to Study Surgery to the Survey Sections on Equity, Family, and Other Influences*
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DEMOGRAPHICS
Approximately 20% of the data came from 1 school (Drexel), with the remaining 8 schools each contributing approximately 10%. The finding that women were less likely to be married is consistent with known social demographics in medicine,20 but we do not have an explanation for the younger age of the women in our study. Although similar percentages (20%) of preclerkship and postclerkship students said they were likely to study surgery, the percentage unlikely to study surgery increased from 51% to 72% after clerkship at the expense of the undecided group. The percentage of women likely to study surgery increased from 11% in the preclerkship group to 18% in the postclerkship group, whereas the percentage of men decreased (30% to 20%). O’Herrin et al21 noted an increased interest in surgical careers in postclerkship students in a much smaller study, but other investigators have shown that women compared with men are more frequently discouraged from a career in surgery by their clerkship experience.22 One questionnaire-based study reported that although student ratings of surgeon compassion and respect for surgeons increased during the clerkship, interest in surgical careers did not increase.23
SURGICAL LIFE: SURVEY QUESTIONS 1 THROUGH 6
Men and women equally agreed and disagreed with statements on surgical life, but men were more encouraged to consider a surgical career than women by each statement (Table 1). Traditionally, men are more likely to be the primary breadwinner, which may explain the greater priority that male students attached to income potential in our study. Both men and women were most discouraged from a career in surgery by the statement that surgeons who have completed their residency do not lead well-balanced lives (Table 1). The written responses pertaining to surgical life from men and women were similar: "I want to enjoy my career; however, I also want to enjoy my life outside my professional setting. That includes, for me, having adequate time to pursue outside interests" (man).
Not all students were discouraged by negative perceptions of surgical life: "Having worked with surgeons, the only thing discouraging me is the endless hours at the hospital, but if you truly love what you are doing then it should not matter" (man).
"I have my priorities straight, so I will make my life balanced whichever residency I pursue" (woman).
"I feel that these challenges would make me more likely to pursue surgery" (woman).
Most preclerkship and postclerkship students demonstrated agreement with statements on surgical life, butthe percentages were lower in the postclerkship groups for the statements that surgeons have higher income potential and rewarding careers (82% to 77% in both instances; P<.001). The percentage of students who disagreed that surgeons appear happy in their work was higher in the postclerkship group in this (46% vs 60%) and in similar studies.13, 24-26 However, when the data were stratified by sex, there was a slight increase in the percentage of postclerkship women who agreed that surgeons appear happy in their work from 11% to 20%. This apparent increase may reflect the lower expectations of the preclerkship women.
A statistically significantly higher percentage of male and female students who were more likely to study surgery agreed that surgeons appear happy in their work, have rewarding careers, and lead well-balanced lives compared with those students who were unlikely to study surgery (Table 2). Students unlikely to study surgery were most discouraged by the lack of balance in the lives of surgeons, whereas students intending to study surgery were most encouraged by the fact that surgeons have rewarding careers and witness the results of their work immediately (Table 2). These findings are consistent with data from other investigators.3, 6, 27-28 In this and other studies,11, 15, 29 women entering surgical fields more often cite factors such as prestige and job opportunities as contributing to their decision than female students not interested in surgery.
Medical students applying to general surgery expect to have a higher income than students pursuing other specialties,30 although a recent report25 suggests that an increasing number of medical students believe the income of a typical surgeon is inadequate for the workload. This contention was supported by comments from some male students: "I was/am very interested in surgery, it was one of my favorite rotations. However, I am planning a residency in family practice since this will afford more time for a family as well as less time in residency for not that much less $$"(man).
"The hours are very long for compensation that does not parallel the workload" (man).
"Too much work for too little pay" (man).
RESIDENCY ISSUES: SURVEY QUESTIONS 7 THROUGH 10
Men and women expressed similar agreement and disagreement on issues pertaining to residency life (Table 1). The written comments reflected student disillusionment with the surgical environment, including working conditions, the psychological demands, and the surgical personality: "Long hours are not the problem. Repetitive service work (discharge planning, etc) disrespectful treatment from attendings and increasing lack of autonomy are the real problems" (man).
"A surgery residency is notorious for poor working conditions and egotistical co-workers. The poor working conditions may be true for other specialties as well, but unpleasant co-workers are not as likely to be part of the mix" (man).
"I think that after residency, surgeons have more of an opportunity to control the amount of time spent at work. However, for residency students are trapped into exhausting, unpleasant experiences that taint their views of themselves, their profession" (woman).
However, not all comments were negative: "The vast majority of surgical residents I have worked with have been well rounded, interesting, and motivated people who are dedicated to educating themselves and others" (man).
Women were more discouraged than men by the lifestyle of surgical residents and by the demands of residency, although some women were attracted by these same challenges: "I absolutely loved surgery, but had to look long and hard at my career choices [because] of the longer hours and more grueling residency programs versus non-surgical subspecialties. I finally decided on a surgical career in spite of the time commitment" (woman).
"The high demand and the fast pace of surgery are qualities I like about it" (woman).
Some expressed optimism about future change:"80-hr workweek is changing things, and hopefully programs are realizing the need to educate in those limited hours per week; it takes time to change the structure of educational programs and the culture will take even longer to change" (woman).
A higher percentage of students likely to study surgery agreed that a surgical residency is more demanding than other residencies (Table 2). A total of 32% of men and 39% of women likely to study surgery were discouraged by the demands of a surgical residency compared with 59% of men and 69% of women unlikely to study surgery (P<.001).
SURGEONS AS INFLUENCE: SURVEY QUESTIONS 10 THROUGH 12
Although only a small percentage of respondents (1%-8%) commented on surgical personalities and the training environment, these comments were almost entirely critical: "Highly malignant people, with exceptions" (male).
"I would not be able to stand these people for a whole career" (man).
"Patient-doctor relationships seem to be less important. Often times they do not interact very well with support staff (God complex)" (male).
"Most general surgeons that I have worked with seem like miserable individuals who like to take out their misery on whoever is closest" (male).
"Some of the most sadistic of all residents I encountered have been surgical residents. In fact, this was the only clerkship in which I encountered blatant cruelty" (male).
"Some of the surgeons I have met so far are OK, but there are also plenty that are malignant, disrespectful towards those below them while kissing up to those above them and feel that it is ok to treat medical students like dogs and to act unprofessionally" (woman).
"A less competitive mentality/environment would go a long way in encouraging less aggressive people to choose surgery for a career. Is it really necessary to be aggressive to become a technically gifted surgeon?" (woman).
Once again, not all the comments were negative: "All of the attendings and residents I worked with were excellent. They were all examples of great men and women and made me look more favorably on the specialty. I went into surgery with some preconceived notions that all turned out to be false" (man).
"Although the rare one or two surgeons I have met have made a lasting negative impression, the vast majority has strongly influenced my decision to become a general surgeon" (man).
"I think women surgeons tend to be very good role models because they appear to have more balanced lives, are more considerate of others, and work very hard" (woman).
"The good surgeons balance out the really bad surgeon types" (woman).
Other investigators have demonstrated that medical students may influence one another's career choices by "badmouthing" particular specialties.5 A total of 91% of students interested in surgery reported hearing negative comments about the specialty, and 17% of all respondents reported altering their career choice in response to these negative comments.5 In our study, 41% of students who had not yet taken their clerkship admitted to being discouraged from a career in surgery by the surgical personality, suggesting they had been influenced by critical comments. A number of studies3, 12, 31-35 support the hypothesis that students interested in studying surgery have many of the traits typically ascribed to practicing surgeons: they are aggressive, self-confident, competitive, more resistant to stress, and frequently male. Our data demonstrated that both male and female students intending to study surgery were more likely to be encouraged and less likely to be discouraged by the factors that adversely influence students not interested in surgery, particularly personalities in the field (Table 2). In addition, medical students encouraged by positive role models to pursue a surgical career are less likely to be discouraged by lifestyle, time commitment, call schedules, or length of residency.4, 6
EQUITY ISSUES: SURVEY QUESTIONS 13 THROUGH 17
As predicted, fewer men than women agreed with these statements and whether the statements discouraged them from a career in surgery (Table 3). Many of the written comments supported these statements, with some men clearly understanding the issues faced by women: "I think that the ‘good old boy’ issue is highly institutionally dependent, but still a valid concern for women these days" (man).
"Women are not welcomed into surgery as frequently as men. When they do choose a residency they do not adjust to it as well as men, and as a result are seen as overcompensating by medical students" (man).
Other students (including some women) expressed some resentment: "I think things are too PC [politically correct] now and most women have it easier than the male residents. There are many strong women in surgery and I only think sex becomes an issue when females abuse the considerations that are given for menstruation or pregnancy" (man).
"Actually female surgeons that I met were much more mean than the men" (man).
"It is clear that women are treated differently than men . . . especially residents. There is either a lot of flirting or too much leniency. Woman either get away with doing less work or they have to do more work to prove themselves depending on the attending" (woman).
"Most male doctors have both a challenging career and a family. Why should it be any different for me?" (woman).
The impact on family was raised: "I have many female role models in general surgery, but I would have to say that although they are very good at their jobs, they allow the job to take over their lives, and so that discourages me from wanting to join a field where I will turn out like them" (woman).
Some women perceived discrimination: "I have seen at more than one hospital how women are not taken very seriously as surgeons" (woman).
Yet, this was not always a deterrent: "The stubborn part of me was tempted to do surgery ‘just to show them’" (woman).
"The ‘old boys club’ attitudes made me want to do surgery just to dispel the current attitude" (woman).
Once again, the students likely to study surgery were less discouraged by each statement compared with those students unlikely to study surgery (Table 4). In this and other studies,23, 36-38 women were discouraged by a lack of female role models. Neumayer et al37 noted that female medical students' choice of surgery as a career was strongly associated with a higher proportion of women on the surgical faculty. A total of 88% of women in their survey who chose a career in surgery were from schools with 40% or more female surgeons. In addition, women applying for residency are more likely to consider the faculty sex composition of a program.23, 37 Women are less likely to consider a career in surgery and more likely to be deterred from a surgical career while in medical school. Only 24% of women, but 50% of men, interested in studying surgery on entering medical school went on to match in surgery, a difference that appears unchanged since 197016, 22, 39; in addition, only 6% of women compared with 19% of men become interested in surgery during medical school.22 Reasons given by female students for rejecting a career in surgery include negative attitudes of surgeons, male bias, competition and lifestyle, and experience with sexual harassment while on a surgical service.40-42
FAMILY: SURVEY QUESTIONS 18 AND 19
Men and women were equally discouraged from a career in surgery by opinions of a spouse, family member, or significant other, but a higher percentage of women than men were discouraged by their decision to have a family (Table 3). Written comments from both men and women testified to the importance of family in making a career choice: "I feel that surgery and surgery residency would not facilitate my being a good husband/father" (man).
"I think the long hours of a surgeon are very hard on families, but I also think that I would not be happy doing anything else" (woman).
"The attitude of many surgery programs is that family should simply ‘understand’ that the resident is a surgeon and therefore not expect him or her to be home often. This is not conducive to creating or maintaining good relationships" (man).
"My husband disliked my clinical surgical clerkship so much that he does not want me to go into surgery at all. He never got to see me and when he did I was too tired to spend a lot of quality time with him" (woman).
"I have yet to see a female in general surgery with kids and raising them the way I hope to some day" (woman).
"While I plan to have a family, a large one, I do not have one at the moment and cannot make current life decisions on what might be in the future" (woman).
Those students interested in surgery were less likely to agree that their career choice was influenced by their decision to have a family; however, those interested in surgery were less likely to be married (25% vs 36%; P<.001), a finding consistent with other studies.2-3,28, 43 Although married students may have different priorities, a lack of spousal support for a career in surgery may also be a deterrent. In our study, a higher percentage of women compared with men, regardless of career choice, was influenced by a decision to have children. These opinions confirm the findings of other authors with regard to gender priorities: men state that they are more likely to miss family activities because of job demands, whereas women are more likely to miss work activities because of family functions.2, 44 A single-center study that looked at attrition among surgery residents found that men were 4 times as likely to leave for preference of another specialty, whereas women more frequently cited family reasons.45
OTHER INFLUENCES: SURVEY QUESTIONS 20 THROUGH 23
Overall, more men than women agreed their skill sets were compatible with those required for a surgical career (Table 3). A total of 93% of men and women likely to study surgery said skill sets compatible with a surgical career encouraged them (Table 4). Of the total number of medical students who agreed that their skill sets were compatible with a surgical career, 30% of men (24% of women) said they were likely to study surgery and 49% of men (54% of women) said they were unlikely to study surgery. These differences were not statistically significant. The written responses in this final section echoed concerns previously expressed about abusive training and environment, as well as the impact on family: "I am very interested in the field of general surgery, but not the lifestyle" (man).
"General surgeons are the best of all worlds from medical to surgical care, however the lines on all their faces tell the story that no ACGME [Accreditation Council for Graduate Medical Education] requirement will prevent. It is highly stressful" (man).
"I would rather open a vein" (man).
"It was fun, but not fun enough" (woman).
"No matter what everyone is trying to say, surgery is very hard for women with family goals and the residents are clearly miserable and exhausted and the female ones are all childless" (woman).
"Everyone passes the grief and malignancy down the food chain" (woman).
Some students found the demands of a surgical career attractive: "General surgery is an optimal career choice. The field should stay demanding and competitive to ensure the right kind of student follows through with the decision to be a general surgeon" (man).
Some expressed regret and offered suggestions for improvement: "If the surgical rotation was more about teaching and less about boot camp indoctrination, I might have had a more positive attitude towards a surgical career" (man).
"I like surgery; I liked being in the OR [operating room]. If humanism and compassion were emphasized more during surgeon training, the field would be more appealing" (woman).
"If I thought that work hours and residency were more compatible with having a family life and time for children I would definitely be more interested in general surgery" (woman). "I do think the field is changing, albeit slowly, and becoming more receptive to non-traditional residents, i.e., females, older students, non-white" (woman).
"Thanks for having this survey. I needed to vent, as I really had wanted to go into surgery but have been talked out of it" (woman).
COMMENT
2 test. Continuous data were found to have a nonnormal distribution and were analyzed using the Mann-Whitney U test. All variables were 2-tailed, and P<.05 was considered statistically significant. Two qualitative researchers (J.M.N.-Y. and Jo Oppenheimer, PhD) independently read and coded the written responses using constant comparisons of data and then engaged in joint discussions of emerging categories and ongoing revision of categories as patterns in the responses became evident. Discrepancies in the coding structure were resolved by consulting the data and reaching agreement as to the relationship of the data to the emerging categories and themes.