Objectives To perform a mixed-methods study identifying motivators and deterrents to female doctors interested in core surgical training (CST). To provide tangible implementations based on the findings.
Design This study used quantitative (questionnaires) and qualitative (semistructured interviews (SSIs)) analyses. Participants completed online questionnaires on Qualtrics and SSIs were conducted remotely on Microsoft Teams. Questions were derived from previous studies and a novel term, the gender impact rating (GIR), was coined to assess the impact of gender on opportunities available during CST application.
Setting Participants were working in the UK National Health Service and data collected from December 2020 to January 2021.
Participants A total of 100 female surgical trainees in the UK ranging from Foundation Year 2 to Core Training Year 2.
Main outcome measures Participants ranked factors by their influence on their CST application. Of the 100 trainees, 21 were randomly selected for an SSI to explore their questionnaire responses. Statistical analyses were performed using MATLAB and SPSS, alongside a thematic analysis of the interviews.
Results A total of 44 out of 100 questionnaire respondents ranked early exposure to surgery as the most influential motivator, while 43% selected work-life balance as the greatest deterrent and 33% suggested mentoring schemes to encourage women to apply to CST. The median GIR was 3 out of 5, indicating a moderate perceived impact of gender on opportunities available during CST application. Qualitative analysis found four overarching themes: institutional factors (including mentorship schemes), organisational culture (including active engagement), social factors and personal factors.
Conclusion Thematic analysis suggested that seniors involving women in theatre and a supportive work environment would encourage entry of more female surgeons. Therefore, the proposed implementations are the active engagement of women in theatre and destigmatising less than full-time training. Further research into ethnicity and personality on motivations to enter surgery is advised.
- MEDICAL EDUCATION & TRAINING
- EDUCATION & TRAINING (see Medical Education & Training)
Data availability statement
No data are available.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
First mixed-methods study covering motivators and deterrents in the National Health Service.
Most recent study looking at entry-level surgical trainees.
First study to implement ranking system for factors.
Extensive reach across the UK.
Saturation was reached for thematic analysis.
Limited generalisability of statistical analysis due to sample size.
Fifteen-minute interviews may not be enough time to explore entire narrative.
Participants agreeing to be interviewed may have stronger opinions than those who don’t, thus skewing results.
Currently in the UK, just over half of all medicine graduates identify as female.1 However, this is not reflected in senior roles (eg, consultant or professor), and neither is the disparity explained by the time lag between the increase in female graduates and their progression through surgical training.2
Previous studies have examined factors that affect the career choices of women considering surgical training.2 3 Hirayama and Fernando2 conducted a systematic literature review using studies from the UK, USA and Canada and identified seven studies which cited the common organisational barriers as ‘career structure, male dominance, and lack of equal opportunities’ in hindering career progression. They also identified role models and early exposure to surgery as important decision-making factors. Previous surveys of members of the Royal College of Surgeons (RCS) have found that surgery is perceived by a significant proportion of female trainees as an ‘old boys’ club leading to some respondents feeling out of place.3
While previous research has focused on female medical students and surgeons completing their training, there are no studies examining the perceptions and attitudes of female trainees who are at a level of training immediately prior to the surgical application process. This a key cohort as it is the juncture at which the decision to pursue a career in surgery is pivotal, and studies that analyse the perceptions of females who are already in core surgical training (CST) using retrospective recall are subject to recall bias.4
To understand the motivators and deterrents for women entering surgical specialties, and provide tangible interventions to overcome these, using a combination of quantitative and qualitative analyses.
Setting, study design and participants
This study was motivated by the application of feminist theory to medicine,5 which promotes that men and women are equal and so gender issues from a feminist perspective need to be addressed to encourage more women into surgery. The approach to qualitative research was guided by the grounded theory which was used to identify influential factors of applying to surgery and produce tangible implementations.6 From previous studies and these theories, it was sought to perform a convergent parallel mixed-methods study in the UK, encompassing a national approach.
Data was collected during December 2020 to January 2021. Social media adverts promoted the online questionnaire and snowball sampling enabled a wide reach across the UK. Participants were encouraged to share the social media adverts with their friends and colleagues but participants were not known to the investigators. Participants were all NHS doctors with no patient or public involvement.
Our questionnaire was based on a combination of previous studies, which were further refined following a pilot interview.2 Questions were tailored to suit females who are applying or just completed application to CST. A self-administered online programme was developed using Qualtrics.7 The introduction page had information about the rationale of the study and how the answers would be used. Participants would need to click ‘consent’ before being allowed to continue. The participants were asked to rank the influence of popular identified motivators and deterrents. A Likert scale assessed the impact of gender on opportunities available during surgical training application. This novel concept was termed the gender impact rating (GIR) on a scale of 0–5, where 0=no impact and 5=major impact. A copy of the questionnaire can be found in online supplemental appendix A.
The methodology of this study was concurrent with the Consolidated Criteria for Reporting Qualitative Research checklist.8 The Trustworthiness, Auditability, Credibility and Transferability (TACT) framework was used to ensure a rigorous approach.9
The interviews were recorded, limited to 15 min per participant and were held via Microsoft Teams10 due to the COVID-19 pandemic restrictions. These questions (online supplemental appendix A) allowed participants to elaborate on and contextualise their answers from the questionnaire. Pilot interviews were carried out to test the quality of data extracted.
All interviews were audio recorded, transcribed and anonymised. The resulting transcripts were then analysed using the Braun and Clarke method of qualitative analysis. No interviews were repeated and interviews were not given back to participants for feedback. Important features from the data set of transcripts were identified and coded. Themes were then inductively and semantically determined from the collated codes. These themes were validated against the data set and the themes that reflected the data were retained, which were further analysed and more fully described. This thematic and analytical narrative was then interwoven with the quantitative data derived from the questionnaire. Twenty interviews were sufficient as data saturation was reached and we gained no new information after 15 interviews.
Inclusion and exclusion criteria
The inclusion criteria were as follows: female, doctor employed by the National Health Service (NHS), Foundation Year 2 (FY2) doctor or Core Trainee Year 1 (CT1) and CT2. Non-surgical trainees and trainees identifying as male or non-female were excluded.
Questionnaire data were collated from the online hosting solution and imported into IBM SPSS V.27.11 As the data consisted primarily of Likert scales and rankings, non-parametric tests were used in the analysis, which included independent sample median tests. As individuals could select multiple surgical specialties, it was not possible to assess the impact of the subspecialty itself on the dependent factors. Some individuals chose more than one surgical specialty, and therefore existed within multiple groups simultaneously, making a χ2 test invalid.
The researchers acknowledge their biases and influence on the outcomes of this study. The research team consisted of four female and two male medical students, and a male consultant surgeon as the supervisor. The diverse backgrounds and experiences have led to personal aims and impetuses that influence the research process. To minimise this bias, multiple interviewers carried out the interviews so that the perception of the qualitative data was done with many different perspectives to increase the validity.
Quantitative analysis: overall
A total of 100 participants were questioned of which 35% were FY2, 36% were CT1 and 29% were CT2. The respondents spanned all 24 of the geographically distributed UK deaneries. The median age was 27 (range: 23–40); 55% identified as black, Asian and minority ethnic (BAME), 46% White/British/Other; 19% were married and 4% had dependents. The typical respondent was between 26 and 29 years of age, identified as White/British/Other, was unmarried with no dependent and completing CT1 at a deanery outside of London online supplemental appendix B.
Gender impact rating
Differences in median GIR were noted across training stages and ethnic groups. CT2s had a median GIR of 2, whereas CT1 and FY2s had a higher GIR of 3 (figure 1A). GIR of White/British/Other respondents was skewed towards lower values with the median rating of 2 which was lower than both the BAME and global median of 3 (figure 1B). Both results were not statistically significant (α=0.05) online supplemental appendix C, see online supplemental appendix B tables 1.2 and 2.2.
Motivators, deterrents and interventions
Of the factors that participants regarded as influential to their application to CST programmes, ‘early exposure to surgical specialties’ and ‘professional support’ were the highest median ranked motivators (Mdn=4, figure 2A). ‘Work-Life Balance’ was the deterrent with the highest median ranking (Mdn=3, figure 2B) and ‘mentoring schemes’ (Mdn=3, figure 2C) had the highest median ranking as the most valuable intervention to CST application suggested by our applicants.
The highest ranked motivator in ‘Married/Civil Partnership’ participants was ‘Professional Support in Specialties’, whereas ‘Early Exposure to Surgical Specialties’ was the highest ranked motivator in ‘Unmarried/Divorced/Widowed’ participants online supplemental appendix C.
Meta-themes that arose were of deterrents, motivators and implementations. Each of these sections could be further categorised into the following four themes:
Institutional factors which included aspects of the RCS.
Organisational culture, including the hospital environment.
Social factors which included friends/family.
Personal factors which were individualistic.
The main deterrents table 1 mentioned in the interviews were career progression, discouragement and discrimination by other staff, difficulties with family planning and finance.
Positive motivational factors included exposure to surgery throughout medical school, conferences, mentors, positive changes to attitudes towards female surgeons and the varied technical aspect of surgery.
The implementations participants viewed as most valuable were increasing exposure to surgical specialties. Furthermore, improving the work environment by raising awareness of existing stigmas, social and professional support from mentors and allocating time for self-improvement. Run-through programmes were highly praised and encouraged to be more prevalent. These programmes allowed trainees to stay under the same deanery after a single competitive selection process.12 Currently, there are only three specialties not offering a run-through programme: paediatrics, plastics and academic.12
Our mixed-methods study used a questionnaire and semistructured interviews to determine deterrents and motivators considered by female trainees early in their career when applying for a surgical training programme. This study confirmed that the most influential motivator was ‘early exposure to surgical specialties’ (table 2), while the greatest deterrent was ‘work-life balance’. Income was ranked as the least influential motivator. The establishment of mentoring schemes was suggested as the most valuable implementation to the surgical training application process (table 3). Furthermore, median GIR of the cohort was 3 (some impact) out of 5 (major impact), confirming that there continue to be significant barriers that discourage females from applying for a career in surgery.
Motivators, deterrents and interventions
The findings of this study concur with those of Singh et al13 which showed early exposure to surgical specialties and professional support were the most influential motivators. However, Walker et al14 contradict these results having found, in a cohort of male and female surgeons, that role models and well-structured career progression were more important driving factors than early exposure. Walker et al14 further contradict our study finding that 90% of their participants believed there was sufficient time for training during working hours. The women interviewed in our study believed that more time is needed to be allocated for self-development and training activities. Further analysis of our qualitative data suggests that this difference may be due the perceived greater involvement of male doctors in surgery by consultants leading to less training opportunities being available to females.
The results showed that work-life balance was ranked the most influential deterrent which corroborates with a questionnaire conducted by the RCS.3 Qualitative analyses suggest that this is due to the lack of flexible working hours as well as stigma around less than full-time training (LTFT).
The most valuable intervention found in the quantitative analysis was the establishment and availability of mentoring schemes. In 2017, Faucett et al15 emphasised that same-sex role models were essential to promote the entry of women into surgical specialties, as well as motivating them to take higher academic roles in the field. This study also highlighted a statistically significant difference in exposure to role models between the genders, which further emphasises the importance of providing these, particularly from an undergraduate level.15
Income as a motivator was ranked lowest in most specialties, which is supported by existing literature.14 16 Financial support was also often a low-priority implementation in our cohort. However, participants who ranked it higher often mentioned that training courses and entry examinations were ‘very expensive’. Financial support could potentially be a more important factor for women than expected due to the gender pay gap as mentioned in interviews. Stephens et al17 suggested that women in surgical subspecialties have the largest difference in mean income compared with their male counterparts than other specialties, which alongside the increased cost of surgical career pathways makes entrance and progression through CST more difficult.
Gender impact rating
The median GIR of participants varied by specialty, similar to Dixon et al who identified variation in the disadvantages faced by women in the entry to different specialties.18 In our study, neurosurgery had the highest GIR, drawing parallels to a previous study that found >70% of female medical students expected inequality in a male-dominated profession like neurosurgery (online supplemental appendix D).18 19 However, female neurosurgeons in our study ranked male dominance the second least influential deterring factor to application. Qualitative analysis suggests women are already aware of the male dominance, hence it does not deter them from entering the specialty.
Our quantitative data highlighted differences in the application experience of CT2s compared with CT1s and FY2s, having completed their application only 2 years earlier. The median GIR for CT2s (MdnCT2=2) was lower than that for both FY2s (MdnFY2=3) and CT1s (MdnCT1=3). This reduction in GIR among CT2s may be due to their place in the team hierarchies. The qualitative analysis showed that treatment was dependent on one’s position in the workplace hierarchy as well as seniors noticing a reduction in the need to ‘prove themselves’. A possible explanation for why they believe their gender has less of an impact is the recall bias CT2s experience when recollecting the application process given their current seniority, a phenomenon that is well explored in literature.4 20
The median GIR for BAME individuals (MdnBAME=3) was higher than that of individuals who identified as White/British/Other (MdnWhite/British/Other=2). Notably, the GIR of the White identifying group was negatively skewed towards lower values. The difference in GIR between these groups could be explained by the intersection of one’s gender and ethnicity. BAME participants in the interviews described cultural norms and expectations they had to overcome to pursue surgery. Cultural norms and attitudes to females in surgical specialties vary between ethnocultural groups and geographical regions.21 A scoping review on the topic identified that countries with extended family support systems allowed female surgeons to have children during training.21 These cultural norms allowed better support for female surgeons.21 However, studies in Pakistan and Zimbabwe have shown that cultural norms and expectations may also act as deterrents for female surgeons, such as the belief that surgery is not compatible with the expected role of women as the primary caregiver of children.22 23
Marital status and dependents
Majority of the cohort was unmarried and expressed concern over the compatibility of surgery with a fulfilling family life. Quantitative analysis showed a significant number of married participants ranking ‘Professional support within the specialties’ as their most influential motivator. Difficulties in parental leave and LTFT were quoted by participants, which could explain this trend. Previous studies showed that females of childbearing age stated organisational/financial worries when planning, and on return from maternity leave.16 Therefore, doctors considering having children may value professional support to overcome this barrier.
In contrast, the deterrents emphasised by interviewees were around sustaining long-term relationships and choosing an appropriate childbearing time. The current selection process of CST does not consider the location and marital status of applicants resulting in many relocating multiple times during their career.24 This creates uncertainty towards settling down and building a family home, which could explain the popularity and preference in the interviewees towards run-through CST programmes.
Flexible working hours
Flexible working was ranked highest among CT2s and FY2s. However, destigmatising LTFT was ranked equally for all levels of training. This suggests that flexible working hours are needed to meet the requirements for progression onto surgical training programmes. This was reflected in the qualitative study where participants described the need to find time to complete ‘check box’ tasks (eg, basic surgical skills courses, trauma courses) to be eligible to apply for surgical training, especially during FY1. A 2019 study by Walker et al14 also supports our study’s finding as pre-CST individuals are more likely to suggest flexible working/LTFT as an intervention than those currently in a CST programme.
Interviewees reported experiencing discrimination at work, especially from other healthcare professionals. Participants also mentioned unwanted comments, showing sexual harassment is still an issue. A questionnaire by Freedman-Weiss et al25 found only 7% of incidents being reported by surgical trainees, especially if perpetrated by a senior clinician who may impact an individual’s progression. Literature also showed that women were held to higher standards when applying to surgical specialties.26 Moreover, our participants described a stereotypical view of senior female consultants; cold, detached and unapproachable by other staff. Previous literature established this phenomenon as a female ‘surgical type’, without providing a successful intervention.27 Our participants said this motivated them to pursue surgery to dispel these perceptions and encourage other women to pursue the field.
The implementations suggested by the questionnaires were varied, yet they are not specific enough to address the issues discussed by the interviewees. However, we propose a few ideas as suggested by the interviewees.
A centralised, easily accessible portfolio checklist to guide trainees in their application process.
Qualitative results highlighted interviewee’s frustration in the application process due to difficulties in finding easily accessible information.
Bulletins for up-to-date information when applying.
Especially given the current uncertainty after the COVID-19 pandemic, interviewees stated the importance of wanting up-to-date information.
Networking events led by female consultant surgeons, inspiring young applicants.
Literature states the importance of role models, which echoed the sentiments of the interviewees. These events would also serve as networking opportunities to enable trainees to build contacts and get involved in projects.
Workshops to encourage open dialogue about destigmatising LTFT and how to handle negative comments in the workplace.
Participants expressed that there is a stigma surrounding LTFT and a culture of discrimination of women in surgery.
Undergraduate same-sex mentorship schemes with mentors gaining points to enhance curriculum vitae (CV).
The benefits of mentoring schemes for the mentees are discussed extensively. This, combined with a point system to incentivise mentors, would lead to a mutually beneficial scheme.
Groups to practise surgical application interviews, led by a senior surgical trainee.
Interviewees mentioned having informal practice groups which they found helpful during applying.
Allocated time during working hours for professional development including being on a rota for theatre.
Existing literature and our study found that trainees need extra time to develop skills and gain experience to build their portfolios which is not currently adequate.
Strength and limitations
This is one of the most recent studies discussing the deterrents and motivators for women entering surgery, making the implementations relevant to current CST applicants. Other strengths include the extensive reach of the questionnaire and interviews across the UK. Furthermore, the use of mixed methods of both quantitative and qualitative data aided in verifying themes observed in the interviews. Additionally, a ranking system for factors was used, which has not been done in previous literature. In line with the TACT framework, the study shows transferability as the demographics of participants were recorded. Consequently, the findings from this study can be generalised to the wider population dependent on certain demographics.
However, this study also faces some limitations. The small sample size for quantitative analysis means that the conclusions may not be generalised. However, for qualitative analysis, data saturation was reached as after 15 interviews, no new themes were recorded. The use of snowball sampling can cause selection bias. Additionally, 15-min interviews were performed, which may not allow sufficient time for participants to explore the whole narrative. Another limitation of this study is that it only explored the perspective of women pursuing surgery, hence those who decided against applying due to their gender were unaccounted for. Furthermore, the questionnaire format of ranking existing factors may cloud and bias their judgement when asked to explore other factors and themes. This may have caused difficulty to bring out any new themes from the women. Similar to any study involving interviews, participants who agree to be interviewed often have stronger opinions than those who refuse,28 which may explain the lack of significance in quantitative results despite recurrent themes in the qualitative interviews.
Further studies should explore motivators and deterrents that arise in various surgical specialties as studies show disparities across the CST programmes. A larger cohort for the study would also allow the exploration of the impact of ethnicity and gender together, as well as the importance of ethnic representation and its contribution to GIR. It would also be helpful to recruit international cohorts to investigate the continuing paucity in female surgical trainees seen globally,21 and compare geographical differences, as well as those between different healthcare systems (eg, state funded vs private).26 Additionally, future research should explore personality traits commonly shared by female surgeons, which drive their intrinsic motivation against deterrents during their career as exhibited by the interviewees.
This mixed-methods study aimed to identify the deterrents and motivators to women entering surgery, followed by suggesting implementations for healthcare organisations. In concordance with existing literature, this study found work-life balance and early exposure to surgical specialties the most influential factors and suggested mentoring schemes and normalising LTFT as the most suitable interventions for women in surgery. Although there is much change afoot to encourage female surgeons in the NHS, acceptance of diversity and flexibility would be a key factor in this.
Data availability statement
No data are available.
Patient consent for publication
This study involves human participants and was approved by the Imperial College Research Ethics Committee (reference number: 20IC6452). Participants gave informed consent to participate in the study before taking part.
KR, RB, RNT, SC, RM and AR are joint first authors.
KR, RB, RNT, SC, RM and AR contributed equally.
Contributors KR, RB, RNT and SC are cofirst authors and have contributed substantially to the conduct of this study and the writing of the manuscript. All researchers were responsible for data collection. KR, RB and AR have prior experience with qualitative studies and were responsible for transcribing, coding, data analysis and interpretation. RNT, SC and RM contributed to the statistical analysis and interpretation. CMG was responsible for overseeing the study design, process and writing of the manuscript and is guarantor of the study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.