Gender differences in the learning and teaching of surgery: a literature review

Objectives To explore evidence concerning gender differences in teaching and learning in surgery to guide future initiatives. Methods This systematic review was conducted searching in the following electronic databases: MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Web of Science, Scopus and PubMed. All studies related to gender differences in surgical education, teaching or learning of surgery at an undergraduate level were included. Data was extracted and critically appraised. Gender differences in learning, teaching, skills acquisition, perceptions and attitudes, interest on surgery, personality and factors influencing interest in surgical careers were differentiated. Results There is an underrepresentation of women in surgical academia, due to lack of role models and gender awareness. It is not clear whether or not gender itself is a factor that affects the learning of surgical tasks. Female students pursuing a surgical career had experienced sexual harassment and gender discrimination that can have an effect on the professional identity formation and specialty choice. There are differences in personality among female and male students interested in surgery. Gender is a determining factor to choose surgery, with a consistent lower proportion of women compared interested in pursuing a surgical career. Mentoring and personality fit are important in medical student’s specialty selection. Female students are more likely to be discouraged from pursuing a surgical career by a lack of female role models. Conclusions Bias against women in surgery still exists. There is a lack of studies that investigate the role of women in the teaching of surgery.


Introduction
A considerable demographic shift has occurred and continues to occur in medicine as older physicians retire and a greater proportion of women enter the profession. The number of women entering medical schools today exceeds 50%, and the number in hospital specialties is expected to exceed 50% by 2016. 1,2 As the gender ratio in the profession changes, the term "feminization of medicine", referring to the medical profession becoming less dominated by men, has been a topic of debate in the medical literature. 3 Women are increasingly entering the surgical profession, 4 although the specialty is still male-dominated, with women representing 10-20% of the surgical workforce according to different studies. 2,5 Also, the percentage of women as medical school faculty members holding associate or full professor rank remains well below the percentage of men. 6 There is a global concern regarding the trend towards decreased interest in surgical careers: family considerations, increased stress and long work hours, sacrifice of personal time, and lack of (or negative) role models are the most common negative factors. 7 In this context, very little is known of genderrelated differences among medical educators in surgery at an undergraduate level. The apparent disparity in numbers and gender ratio relationship could possibly have some impact in students' interest in pursuing a surgical career.

Objectives
The overall objective with this review was to further the understanding regarding gender equality in surgical education to guide future initiatives. We aimed to explore the literature to ascertain whether there are gender differences in the teaching and learning of surgery, and if there are any gender differences when choosing and progressing in a career in surgery, and to explore the possible explanations to gender disparities within surgical education.

Focused questions
We aimed to explore evidence concerning gender differences in teaching and learning in surgery at an undergraduate level by answering the following questions: 1.
Does gender influence the teaching of surgery? Is there any gender that is predominantly involved in teaching surgery for undergraduate medical students? 2.
Does gender influence the learning process of surgery? 3.
Is there any gender that predominantly is interested in surgical specialties? 4.
If there are differences, how can they be explained? 5.
We focused on studies that investigated gender differences in the teaching and learning of surgery in medical education. We applied the PICO terminology as described by Cook and West. 8

Search strategy
The search for relevant literature was performed in March 2013 by two investigators (CMB and AJ), who independently searched the following electronic databases: MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Web of Science, Scopus and PubMed.
The key search terms used included: gender, medical education, surgical education, surgery, undergraduate, academia, teaching and learning; and the following MeSH terms: education, medical, surgery, undergraduate, faculty, teaching, female, male, sex distribution, students.

Inclusion and exclusion criteria
All studies related to gender differences in surgical education, teaching or learning of surgery, at an undergraduate level were included in the first stage. All articles not relevant for our purpose (gender differences in outcomes after surgical procedures, gender differences among professionals in surgical specialties) were excluded after reading the title (Step 1). After removal of duplicate records, all the titles and abstract were screened, and the final selection of articles was based on the following criteria (Step 2): 1.
Studies that focused on gender differences in academic surgery, or 3.
Studies that focused on gender differences in the teaching of surgery at an undergraduate level, or 4.
Studies that focused on gender differences in the learning of surgery at an undergraduate level, or 5.
Studies that focused on gender differences in interest on surgical specialties

Data abstraction/extraction
A standardized data extraction and critical appraisal instrument was constructed by the investigators using an electronic spreadsheet (Microsoft Office for Macintosh 2011) for the purpose of this review.

Analysis
Discrepancies in opinions between the investigators were identified and final consensus was reached through discussion. The study methodologies were analyzed, and common themes from study findings were defined. Gender differences in learning were differentiated from gender differences in teaching. Gender differences in learning were differentiated in skills acquisition and perceptions and attitudes. Gender differences in interest on surgery were differentiated in factors influencing interest in surgical careers and personalities.

Trial flow
The literature search produced a total of 547 articles in the Web of Science, 705 in Scopus, 1,465 in PubMed, 127 in ERIC, 29 in Medline, 150 in EMBASE, 13 in PsycInfo and 58 in CINAHL, with a total 1,650 non-duplicated titles.
After screening all titles, many were excluded for not being relevant for our purpose. After screening all titles and abstracts for potentially relevant articles, a total of 173 non-duplicated articles were obtained in full text for closer inspection, and of these 77 met the selection criteria ( Figure 1).

Study characteristics
The selected studies were classified in four categories:

I. Gender differences in academic surgery
There is a gross underrepresentation of women in the leadership positions of surgical departments. Both Flannery and Zhuge discuss the perception of a "glass ceiling", a metaphor for the observation that how, despite the increasing numbers of female medical students, and increasing number of women entering surgical specialties, fields traditionally held by men, their advancement into the most prestigious, highest-paying, and leadership positions is still limited. 9,10 Women in academic surgery seem to be less likely to be promoted than their comparably credentialed male colleagues. 10,11 Despite the year of publication, the same pattern seems to persist according to a recently published survey, where the female participants, senior surgical residents and early career faculty members, experienced gender as a limitation to access a career in academic surgery. 6 Similar results were reported by Sexton and colleagues when they examined the trends in gender-based advancement in academic surgery by performing a comparative analysis of the rate of change in the percentage of medical students, surgery residents, and full professors of surgery who are women, and concluded that percentage of full professors in surgery who are women is increasing at a rate disproportionately slower than the increases in female medical students and surgery residents. 12 Jonasson reviewed the number of women in the major surgical societies and organizations in US, and found that women are underrepresented, also in the leading positions of academic departments of surgery. 13 Neither does the representation of women in professional societies and editorial boards reflect their presence in medical specialties, with an overrepresentation of men holding these positions (83%). 14 Despite being in minority, women are more likely to engage in clinical teaching. Klingensmith and Anderson performed a cross-sectional survey of membership of the Association for Surgical Education, and although the precise numbers of women in the US who are involved in educational scholarship is unknown, the numbers appear to be substantial; the percentage of women who have participated in the American College of Surgeons' "Surgeons as Educators" course over the past 11 years of the course's existence is 20.4%, and the number of women who have participated in the Association for Surgical Education's "Surgical Education Research Fellowship" is 32% over the 10 years of its existence. These data suggest that women seek advanced training in educational scholarship in greater proportions than do men, given the proportions of female to male surgeons at large. 15 Mendoza and colleagues also reported a majority of female educators, 58%, with doctoral degree and full-time faculty appointment in a surgery department in an American or Canadian institution. 16 Although the number of participants in this study is low (only 12 respondents), the results are in accordance with those from the survey performed by Tesch and colleagues, where women are more likely to engage in clinical teaching (16.7% of female vs. 14.8% of male surgeons). 11 There are no significant differences between male and female junior surgeons involved in teaching undergraduates. They have similar attitudes toward, and practices in, voluntary undergraduate teaching. 17 Prichard and colleagues performed a survey in an attempt to clarify whether there are differences between the attitudes and practices of male and female junior doctors regarding the practice of undergraduate teaching in the UK. With a majority of male doctors in surgical specialties (68.1%), there were no significant differences between the genders regarding the self-reported quantity of teaching provided to undergraduates. There are, however, differences in attitudes and personalities. Male doctors perceived themselves as more confident educators when compared to female doctors, but this could reflect cohort demographics in which a greater proportion of male doctors were more senior 17 (Table 1). To explain the fact that the percentage of women members of medical school faculty with professor rank is lower than men Women physician medical school faculty are promoted more slowly than equal qualified men.

II. Gender differences in skills acquisition among undergraduate medical students learning surgery
Lee and colleagues tried to identify variables associated with clinical clerkship grades in a large survey, and found that females tend to obtain lower grades in internal medicine and surgery, whereas males got lower grades in obstetrics/gynecology and psychiatry. 18 Male students are more exposed and perform surgical procedures significantly more often than female students, and working experience seems to enhance the surgical skills of medical students, but research experience may impair the learning of these procedures. The systematic use of logbooks seems to be useful for both male and female students. 19 When e-learning is used as a complement to traditional teaching methods in undergraduate surgical teaching, there are no significant gender differences in the utilization of the online program. Student utilization of the multimedia learning tool was not associated with improvements on final-year examination results. 20,21 Lee and colleagues did not find objective differences in dexterity in students interested in surgical fields when compared with those interested in nonsurgical fields, 22 whereas Elneel and colleagues found that right-handed males exhibited a greater level of ambidexterity than lefthanded males and right-handed females, and more efficient task performance as measured by execution time. 23 The majority of the studies that investigate gender differences in surgical skills acquisition are related to laparoscopic skill acquisition in a simulator environment, and the results are contradictory. Some studies have shown that males tended to perform better than females in completing tasks that required the use of visual-spatial manipulation of the instruments within a simulated laparoscopic or endoscopic environment, [24][25][26][27][28][29] whereas other studies have shown no difference in performance. 28,[30][31][32][33][34][35] Even though men completed the tasks in less time than women in some studies, there were no statistical difference between the genders in the number of errors and unnecessary movements. 29 Despite that, women display initial lower performance, but respond to simulator training at least as well as men and reach parity with men's performance after training 24 (Table 2).   Females were seen as being disadvantaged both in terms of career choice and their ability to achieve career goals. Female students were more likely to suffer discrimination in specialties as surgery, and to be dissuaded from pursuing a career in that specialty.

Attitudes
Snelling and colleagues investigate how attitudes toward dissection vary with gender and ethnicity. Females were consistently more concerned about the physical aspects of dissection whereas there were fewer gender differences in the emotional responses. 36

Perceptions
Experiences of sexual harassment and gender discrimination have an effect on the professional identity formation and specialty choice of medical students. Female students choosing general surgery were those most likely to experience gender discrimination and sexual harassment during residency selection, and to be dissuaded from pursuing a career in that specialty. 37,38 Female medical students do not feel equipped to respond to the unprofessional behavior of male supervisors, resulting in feelings of guilt and resignation over time that such events would be a part of their professional identity. 39 Lempp and Seale 40 performed semi-structured interviews of 36 medical students throughout their medical education. Students did not report any gender-related differences in their training, although they used genderrelated terms in their answers consistent with traditional gender stereotypes. A majority stated that surgery was dominated by men, reporting that the specialty required physical strength, competitiveness, unusually hard work and long working hours in order to succeed. Nevertheless, four female students (of 21) and four male students (of 15) were considering surgery as a career option. Most students (23/36) identified certain specialties as being 'suitable' for women, these being (in descending order of frequency) obstetrics and gynecology, general practice, pediatrics and palliative care. Eleven students (7 females, 4 males) used the word 'sacrifice' in relation to women and their medical career, for example in having to limit either their career or their family aspirations, but none used this remark to describe the careers of male doctors. 40 The perception of women medical students of the career satisfaction of women surgeons did not appear to be affected by the proportion of women surgeons on the faculty at their medical school. Their choice of surgery as a career was strongly associated with a higher proportion of women on the surgical faculty 41 (Table 3).

IV. Gender and personality differences in undergraduate medical students' interest in pursuing a career in surgery
Several of the studies have shown that gender has the greatest impact on specialty choice, with males choosing medicine, surgery, orthopedics and urology and females choosing obstetrics, pediatrics, anesthesiology, primary care and ophthalmology. [42][43][44][45][46][47][48] There is an overall declining popularity for surgical careers among both male and female students. 7,[49][50][51][52] On the other hand, other authors found general surgery to be the second preferred choice for men and the third preferred choice for women, with a total interest of 21% of the students. 43 Gender significantly influences the choice of surgery as a career, with a consistently lower proportion of women compared to men interested in pursuing a surgical career in different studies, in a range of 15-42% for male students and 2-29% for female students. 42,46,49,[54][55][56][57][58][59][60][61][62][63][64] Only two studies have shown that gender has no independent influence on choosing surgery as a career. 44,45 Male gender, updated preference, peer tutoring and selective training were the most significant predictors in the pathway to choosing surgery 46 (Table 4).
Gender, prestige, career opportunities, direct patient care, immediate intervention, and personal interest are common positive influential factors for choosing a career in surgery. 7,47 Gender discrimination, concerns about lifestyle, family considerations, increased stress and work hours and sacrifice of personal time are the most common negative factors to the pursuit of a career in surgery. 7,51,54 Several authors have investigated the relationship between personality and specialty interest. Students interested in 'surgical' specialties obtain higher scores on 'impulsive sensation seeking' 'aggression-hostility' and 'sociability' scales and lower scores on a measure of 'neuroticismanxiety'. Male students had significantly higher scores on the 'impulsive sensation seeking', and surgery was the single most popular specialty among male students. 48,49 Coulston and colleagues found that significantly fewer females than males rated surgery highly likely as a career. They also found that females interested in surgery had higher neuroticism and agreeableness scores, and placed greater importance on the ability to help people, and less importance on prestige and financial reward compared to males interested in surgery. Compared to males not interested in surgery, females interested in surgery had higher Openness scores, and placed greater importance on ability to help people, interesting and challenging work, and less importance on lifestyle. Also, females interested in surgery had lower Agreeableness scores, and placed greater importance on prestige and less importance on lifestyle compared to females not interested in surgery. Common findings were that surgeons compared to non-surgeons are more tough-minded, less patient-oriented and less empathic, and may be a function of the prevalence of males in surgery. 50 Professional attitudes in particular patient centeredness were shown by Batenburg and colleagues to be related to specialty preference in the final year of graduate medical training and specialty as a career choice: general practice trainees showed more patient-centeredness than surgery trainees. Gender was not related to patient-centeredness. 51 Significant gender differences were found when comparing empathy levels in medical students at different levels of education, on "emotional intelligence", "empathy" and the "Utilization of Emotion" subscale, with females scoring higher than males on all three scales. There were no significant gender differences in end-of-year marks in any of the 3-year groups, with male empathy scores increasing between years 1 and 2, while female scores declined. 52 Frantsve and colleagues examined the effects of the applicant's personality and gender on faculty rankings and matching to surgical residency program. Male applicants were more likely than female applicants to enjoy teamwork and assume a submissive role when interacting with authority figures. The faculty interviewers perceived female applicants as less likely to effectively cope with stress. They also found that female applicants might be less likely than males to be as friendly and deferent in their interactions with male authority figures. When compared to the general population, however, female applicants did not demonstrate evidence of difficulties with stress management 53 (Table 5). 10% of students chose surgery (10 males and 5 females) Only 16% of the faculty department were female. To describe differences in specialty choices and qualifications between male and female physicians at the start of their residency in Denmark 1998Denmark -2003 Gender differences in specialty choice and in the way men and women qualify for residency: women achieved higher points for clinical qualification and theoretical courses, while men achieved higher points for scientific and pedagogical qualification. Most of residents in orthopedic surgery were male, in psychiatry or obstetrics female.  Male more likely to choose a surgical career than females (27% versus 10%). Males were more likely to identity technical challenge, earning potential, and prestige whereas females were more likely to identify residency conditions, part-time work, and parental leave availability as important qualities in a specialty. Females were less likely to take surgical electives and more likely to identify a lack of role models. Professional attitudes, in particular patient-centeredness, seem to be related to specialty preference in the final year of graduate medical training and specialty as a career choice: general practice trainees showed more patientcenteredness than surgery trainees. Gender was not related to patient-centeredness.

Discussion
Despite the dramatically increased entry of women into surgery, a traditionally male-dominated field, there remains a gross underrepresentation of women in leadership positions of these departments. 10 Female surgeons perceive gender as a limitation to pursuing a career in academic surgery, 6,[9][10][11] this is not only a perception, since women are underrepresented in the major surgical societies, organizations and leading positions of academic departments of surgery. [12][13][14] However, female surgeons seem to be more actively involved in teaching undergraduates, 11,15,16 but there is an overall lack in the literature of recent studies that investigate this observation.
As Zhuge and colleagues pointed out, the major constraints of contributing to the glass-ceiling phenomenon are traditional gender roles, manifestations of sexism in the medical environment, and lack of effective mentors. 9 Gender roles contribute to unconscious assumptions that negatively influence decision-making when it comes to promotions. The lack of role models in surgery in general, and academic surgery in particular, has been discussed in different articles as a possible explanation for the underrepresentation of women in surgical academia. 9,54,55 Mentoring women to success in academic surgery, and identifying barriers to women entering surgery and achieving positions in academic surgery are prerequisites for correcting the existing gender inequities.
Sexism has many forms, from subtle to explicit forms, and some studies show that more women report being discriminated than men. Gender discrimination and bias has been reported as a consistently and significant career deterrent reported by female medical students. 56 Female students pursuing a surgical career have experienced discrimination, 37,38,57,53 although this is not an isolated phenomenon for the specialty: female students interested in a career in orthopedic trauma, or male students interested in obstetrics had such experiences. 37,38,58,59 It is not clear if gender itself is a factor that affects the learning of fundamental surgical skills. [24][25][26][27][28][29][30][31][32][33][34][35] Work experience, interest in surgery, training and previous video game experience seem to enhance the surgical skills of medical students. 19,24,26,28,30 Greater exposure to surgery and previous experience in video games among male students could be some of the explanations for the better performance observed in various studies measuring laparoscopic skills, even though training seems to level out those initially observed differences. The overall decreased interest among female students in surgery, 22,25 could be a possible explanation for women's poorer early performance. 30 But it seems clear that gender is a determining factor for choosing surgery, with a consistently lower proportion of women compared to men interested in pursuing a surgical career (15-42% males vs. 2-29% females). 42,46,49,[54][55][56][57][58][59][60][61][62][63][64] The choice by females of surgery as a career is strongly associated with a higher proportion of women on the surgical faculty, 41 again highlighting the importance of role models and mentoring. 10, 60-62

Limitations
The majority of the authors of the reviewed articles are women, and this can be a potential source of bias. Most of the articles that investigate students' attitudes, perceptions, personality and interest for surgery are surveys, where the students are self-selected for each study, itself representing a limitation of the study and thus being a source of potential bias. The intervention studies were done with the purpose of setting up baseline laparoscopic skills or to demonstrate the hypothesis that training laparoscopic surgery in a simulation environment improves performance. As the majority of the studies come from North America, the results may not apply to other countries. There are, however, some studies from other countries with consistent overall results.

Implications
Gender equality, defined as the absence of discrimination on the basis of a person's gender in opportunities, is not a spontaneous process. However, gender differences must first be identified and the imbalance between the genders should be addressed and rectified. There are known differences between male and female physicians, and gender also plays a role when it comes to choosing a specialty. 63,64 To highlight these differences and the apparent gender inequalities is the first step of working towards gender equality within surgical education.
Choice of surgery as a career by women is strongly associated with a higher proportion of women in the surgical faculty. 41 The negative loop of few female role models in academic surgery that results in few female students interested in surgery will hardly change the trend of gender inequalities in surgery.
Many have postulated that women are deterred from a surgical career because it continues to have an aura of being an ''old boys' club'', and unfortunately, this review supports that statement. Bias against women in the field of surgery exists, and is a reality in the 21 st century.