Entrenched sexism in surgery

For decades, the Royal Australasian College of Surgeons turned a blind eye to the entrenched sexist culture within surgery. After recent publicity, they have finally opened their eyes. They can no longer deny sexist surgeons operate within hospitals around Australia.

The college appointed a group of independent experts – Rob Knowles, Helen Szoke, Graeme Campbell, Cathy Ferguson, Joanna Flynn, Judith Potter and Ken Lay – to advise them on what should be done.

The first thing was to determine the extent of the problem. Was it just a few rogue sexist surgeons? Or is sexism pervasive within surgery?

The Expert Advisory Group found sexism is commonplace in surgery. A survey found 49% of fellows, trainees and international medical graduates were subjected to "discrimination, bullying or sexual harassment."

The large number of victims comes as no surprise to those of us who have worked in a hospital. Hospitals operate on a hierarchical structure with surgeons positioned at the top of the pecking order. They call the shots.

Sexist surgeons do not leave their bullying behaviour at the operating theatre door. They bully other health care professionals and patients. They also take their bullying behaviour home.

Sexist surgeons have a strong sense of entitlement. They are in command, both at work and home. Not surprisingly, the expert committee found protagonists had a lack of insight about their bullying and sexist behaviour. This lack of insight into their internalised misogyny will make changing their behaviour difficult.

The expert committee noted that sexist behaviour has negative implications for patient care. I recently observed a senior surgeon disagree with a colleague about a female patient's analgesia. The surgeon spoke very loudly whilst the patient lay quietly in her bed. Afterwards, the patient was very distressed. She asked me if the surgeon wanted "to euthanise me?"

I later asked the surgeon not to talk about the patient within her earshot. I explained how upset she was about the altercation at her bedside. He stormed off, shouting: "I will not listen to this."

The Expert Advisory Group found "known bullies" are untouchable. Bullying among surgeons has become normalised as a culturally accepted behaviour. Perpetrators are more likely to be promoted than held to account.

Most surgical departments have at least a few bullies. It is likely that these bullies are well known to the hospital's management. Yet, despite legal obligations to provide a safe workplace, hospital managers rarely reprimand surgeons for their sexist behaviour.

The demonstrable lack of consequences for perpetrators encourages some surgeons to continue to abuse their power. Hospital managers may be reluctant to take action on badly behaved surgeons for a range of reasons. They may fear the financial and reputational consequences. Hospitals fear both publicity and litigation.

There is an expectation among some senior surgeons that junior trainees should endure the same training circumstances as those in place when they trained. Trainee surgeons do not complain for fear of being seen as weak or unsuitable for surgery. They fear being black-balled.

Those who have the courage to complain risk career suicide. Sometimes a surgical career is over before it starts.

The expert committee also identified "bystander silence" as a serious problem. Within a culture of fear and reprisal, colleagues who witness bullying, discrimination and sexual harassment are rarely prepared to complain. They see no point in making a complaint.

Complaint processes protect the status quo. The person responsible for dealing with complaints is often a close colleague of the person who is being complained about. Not surprisingly, complaints often hit a brick wall.

The college has responded to the current toxic professional culture within surgery with a 21-page action plan. The document "Building Respect, Improving Patient Safety: RACS Action Plan on Discrimination, Bullying and Sexual harassment in the Practice of Surgery" claims to show "RACS' commitment to dealing with unacceptable behaviours; strengthening surgical education and training; and reshaping the culture of surgery on foundations of collaboration and respect".

The action plan is difficult to read, let alone understand. It is replete with weasel words. Phrases create an impression that a meaningful statement has been made, when only a vague or ambiguous claim has been communicated.

According to the current President of the Royal Australasian College of Surgeons: "We must make it safe for victims and bystanders to speak up. There must be clear consequences for those whose behaviour is unacceptable." Unlike the action plan, his statement is clear.

The Royal Australasian College of Surgeons plans to provide education in countering discrimination, bullying and sexual harassment. Once again, the onus is on the victim to take action. However, with better complaints mechanisms, perhaps the victims will now get justice.

The college also plans to change the way surgeons are trained. Current surgical training arrangements provide disincentives for doctors seeking work-life balance to join the surgical profession. The current arrangements favour those without family commitments or with partners who have less demanding careers.

They aim to embrace diversity and foster gender equity. However, simply bringing females into the surgical boys club will not change this culture. Changing the toxic culture among surgeons requires structural change.