Serena S Hu, MD is a professor of orthopedic surgery and, by courtesy, of neurosurgery at the Stanford University Medical Center, Stanford, California, United States.

 

Christina Goldstein, MD is an assistant professor of orthopedic surgery at the University of Missouri, Columbia, Missouri, United States.

 

Yu-Mi Ryang, MD is associate professor at the Technical University Munich and head of the Department of Neurosurgery, Helios Klinikum Berlin-Buch, Berlin, Germany.

 

 

It is well known that there is a shortage of female leaders in spine surgery. How do you feel this impacts on our profession?

 

Serena Hu (SH): It’s so important that we collectively find ways of opening the doors to diversity of gender, background and training. If your practice or your profession doesn’t have enough diversity of opinion, if it’s just a bunch of people who all think the same way, you simply won’t find the real opportunities. WomenIf your practice or your profession doesn’t have enough diversity of opinion, if it’s just a bunch of people who all think the same way, you simply won’t find the real opportunities. are good leaders, we’re good listeners, and we’re consensus builders. We are also more likely to support diversity of opinion and diverse hiring. Some of the old stereotypes are true; we’re generally not good at speaking up in meetings, and social norms mean that in order to be heard, we have to assert ourselves. However, the data shows that women who are assertive or aggressive are frowned upon, whereas the same traits in men are often perceived as strengths. It’s the likeability trap; we need female leaders to be likable, but we don’t have the same expectation of men. Therefore, we need to manage a fine balance of being effective leaders without antagonizing people.

 

 

What role do you feel mentoring can play, and how would you summarize your own approach as a mentor?

 

Christina Goldstein (CG): Our fellows come to us with lots of skills and confidence, so we try to give them some degree of autonomy—give them a push within safe boundaries. I like to find out where they see themselves in the future, not only from a professional standpoint but also from a personal standpoint and get an idea of who they are. Their goals will change how I mentor them as individuals. Mentors of either gender are great, and I’ve been blessed to have had some wonderful male mentors. The main thing is that you connect with your mentor and he/she understands your values. However, sometimes it’s good to try to find a female mentor—even from a different area of surgery—as there are some things all women surgeons will understand. One of my first female mentors was a general surgeon who did laparoscopic surgery, but she understood what it was like to be a mom, wife, and a full-time academic surgeon.

 

Yu-Mi Ryang (YMU): In the beginning of my career I thought it was really important to have a female mentor, but I could not find one. Now I think it’s just about having someone who will support you simply asSometimes it’s good to try to find a female mentor—even from a different area of surgery—as there are some things all women surgeons will understand. the person you are and of course as a surgeon, and not only as a female surgeon. I did not really have a mentor in my career. But I was very fortunate to learn many things from my former head of department. He taught me a lot about how to be very effective in what you do, not to waste time on things you can’t change, and how to challenge yourself as much as possible to get where you want to go at a very fast speed. Of course, this approach also brings a lot of sacrifice.

 

So, one of the biggest challenges for me was to find out what I want and how to get it. It took me a long time to understand how the system works and how to achieve things. With a mentor, I probably would have succeeded earlier in my career. So, I see part of my role as a mentor not only as a mental and moral support but in giving insight into a system that has unwritten rules and invisible barriers, in encouraging female surgeons that it is worth it to go the extra mile and that it is necessary that we start breaking the glass ceiling.

 

 

There’s growing awareness that work/life balance is one of the things surgeons of both genders may sacrifice. Is that an issue that has affected you?

 

SH: In our profession we are asked to do a lot, and it’s important to know that we don’t have to say yes to everything. For me, one part of work/life balance is that for every new responsibility I take on at this point in my career, I have to give up something else. Otherwise, I feel I am always teetering on the edge. I know I can’t possibly get any less sleep and still function, so if I want to do more, I have to give something up. That’s not always about loss; there were committees I gave up but that created anThe situation changed when I became the head of the department. The perception was different, sort of like “if she is the head of department, she must be capable”. But it’s been a long way for me and I hope other female surgeons to follow will not have such a hard time proving that in fact they are capable. opportunity for someone else, too. My advice is to consider your professional goals, and that changes over time. Periodically look at your trajectory but don’t forget your personal goals, either. The age-old question is: Can we have it all? I’d say yes, if you prioritize what’s important to you, but not all at the same time!

 

CG: It’s easy to get on a track where, to be successful, you’re expected to be involved in more and more things. That’s good for your ego and reputation, but I feel that teaching trainees to never say no may be dangerous. If you’re always saying yes to joining another committee, seeing another patient, doing another surgery, you might start saying no to things in other areas of your life. That’s what happened to me. I was on the tenure track, saying yes to everything until I started saying no to the things that were healthy for me: sleeping, eating well, exercising, socializing with friends and family. Those are the things we need to do to stay healthy and maintain connection with the people we care about, who can help us in times of stress. Unfortunately, I started to experience symptoms of burnout quite early in my career—about three years in—which exacerbated a long-standing history of depression and anxiety. We are all successful at work and people see us as having it all together, but we need to be mindful of the things that we must do to avoid failure in other areas of our lives. We are all different and need different things to succeed, and my hope is that health care organizations are able to support those needs so we may enjoy long, successful, rewarding careers.

 

 

In addition to work/life balance, many organizations are becoming increasingly aware of the role of unconscious bias in the workplace. Do you see evidence of that from a gender perspective?

 

CG: Sometimes with patients, our abilities are questioned because of our gender. What role we play in their surgery seems uncertain to some patients. They’ll say, “You actually do the surgery?” and I would reply, “Well, yes, I am your surgeon, Dr Goldstein.” That’s still a thing. There are a lot of misperceptions and many people continue to have expectations about what life should look like for a female surgeon, particularly related to family planning. Many assume that because you’re a woman, you’re going to have children and that will negatively impact your career while others assume that as a surgeon, you’re career-minded and won’t have children. Every woman has different goals. What’s important is to recognize these basic differences between men and women and have an open, early dialogue about it with women in your department. This will ensure the best outcome for everyone involved.

 

Sometimes with patients, our abilities are questioned because of our gender. What role we play in their surgery seems uncertain to some patients. They’ll say, “You actually do the surgery?” and I would reply, “Well, yes, I am your surgeon, Dr Goldstein.” That’s still a thing.YMR: Yes, that happened to me all the time, too! The more you talk to patients the more they realize you are very knowledgeable but in the beginning there’s a lot of prejudice. I faced situations where people would confuse me with a nurse or ask to see the “real” doctor. When I told them I was “real” doctor, they would ask for the surgeon who would perform the surgery on them. When I told them that that would also be me, patients often times got scared asking me whether I had ever performed that surgery before. So I told them “no” and that I was just as excited and anxious as they were. Of course, that was a joke, but it helped to loosen up the situation. But also, male colleagues would ask me, whether I perform surgeries at all and as a teacher, some participants would not come to my table during hands-on sessions or cab labs, because they thought I could not teach them anything. The situation changed when I became the head of the department. The perception was different, sort of like “if she is the head of department, she must be capable”. But it’s been a long way for me and I hope other female surgeons to follow will not have such a hard time proving that in fact they are capable.

 

 

What advice would you offer to female surgeons navigating these issues?

 

SH: One thing that’s good is to learn the best aspects of all the people you come across, and you work from there. You ask them how they did things, learn from their mistakes, and take their advice—not just your superiors, but those under you, too.

 

YMR: First of all, we need to get away from the typical female mind trap, that we need to please everybody and let ourselves being patronized or feel intimidated. Many women think that they might not be as capable and strong or as deserving as their male peers. That is just not true. Women have the same abilities as their male counterparts and therefore deserve the same chances and opportunities and equal salaries. Being a good surgeon is not about being strong in a physical sense. It’s about being There are subtle things, like ensuring there are female moderators and that committees are diverse. You see women in these roles and it perpetuates itself.strong in every other sense. For women in general and probably even more so in a male-dominated field such as surgery, it is about finding a healthy balance in an environment where they can co-exist and are recognized as equal peers independent of gender. It’s a process that needs a lot of work and commitment from both sides. I think it’s important to recognize that unconscious bias and gender diversity are not just issues concerning women. Lots of male surgeons feel this issue needs to be addressed, too. We need to include everybody in this discussion. It’s about equal access to opportunities.

 

 

What can AO Spine do to encourage change?

 

SH: The symposium on women in spine was great. There are subtle things, like ensuring there are female moderators and that committees are diverse. You see women in these roles and it perpetuates itself.

 

CG: We need to focus on highlighting the amazing aspects of our specialty and cultivating and supporting our female trainees at a very early stage. AO Spine can also continue to shine a light on these issues, bringing them to the attention of its members.

 

YMR: During the networking event, we learned that the number of female surgeons in AO Spine is very low and there are virtually no women on any committees, let alone in any leading positions within the community. It is time for women to be more actively involved in AO Spine activities. And I see the responsibility within the community to achieve that. The acceptance of and awareness for female surgeons and female teachers needs to improve greatly. Unconscious bias is not only a problem originating from male peers but just as much or even more so from our female peers.

 

I have been an AO Spine faculty member for more than six years and was asked to participate as a teacher only twice during this entire time. I guess it is a sort of vicious cycle in the sense, that men will only ask their male peers to be part of any activity, not because they actively discriminate, but just because they do not know too many female surgeons. So, if the number of female surgeons in leading roles does not improve, this might never change.