Cassandra M. Kelleher, MD, FACS

Why Do Female Surgeons Perform Less Complex Procedures? Interview with:

Cassandra M. Kelleher, MD, FACS

Dr. Kelleher

Cassandra M. Kelleher, MD, FACS
Surgical Director, Fetal Care Program
Surgical Director, NICU
Quality and Safety Chair, Pediatric Surgery
MGH eCare Clinical Informaticist
Pediatric Surgery
MassGeneral Hospital for Children
Boston, MA What is the background for this study?

Response: Only about one in five surgeons practicing in U.S. is female. Unemployment is virtually nonexistent among surgeons, but many female surgeons, as well as professional women in other fields, experience underemployment—the underuse of skills—according to the Federal Reserve Bank. Women in surgery talk among themselves about how they may be perceived as less confident or competent, and for those reasons they may have less opportunity to do exciting and challenging cases. We wondered if this was true, and if so, why? What are the main findings? Could personality types ie risk taking, fear of making a mistake or poor outcomes account for some of the differences?  Perhaps a study including Myers-Briggs testing would be useful?

Response: We analyzed 551,047 case records from operations performed by 131 surgeons at MGH between 1997 and 2018. To compare the difficulty of surgeries that females and males performed, we used a universally accepted metric known as the work Relative Value Unit (wRVU), which measures the technical complexity of a procedure. The study found that the mean wRVU for cases performed by male surgeons was 10.8, compared to 8.3 for female surgeons, a difference in complexity of 23 percent. If you multiply that over the course of a year or a career, that’s a huge difference.

The study’s design ruled out common explanations for why female surgeons perform less complex procedures, such as their choice of subspecialty, or that women are less available due to family commitments. The study also found no sign that the problem has improved over the last two decades and indicated that underemployment was a more significant problem for female surgeons with greater seniority.

It may be suggested that risk averse surgeons may choose sub-specialties that have less complex cases overall, but this is a phenomenon that crosses subspecialties and therefore is not a repercussion of a female surgeon’s subspecialty choice. Our data shows that the difference in case complexity between female and male surgeons is most likely due to gender inequities in patient referrals rather than any characteristic attributable to individual surgeons themselves. What should readers take away from your report?

Response: To our female colleagues, I might say, This is not on you. You may think you are the only one who is struggling with your career in your small corner of the world, but this is in fact a widespread problem that affects many female surgeons and physicians.

For the healthcare system, I might say, in addition to leadership training and negotiation training, let’s examine how we can fix the healthcare system so that we can take the onus off of the female surgeons and physicians. Just like a college graduate working in Starbucks cannot fix his or her under-employment problem, we need to think systemically if we want to fix this under-employment for female surgeons and physicians. What recommendations do you have for future research as a result of this work?

Response: We are currently investigating several aspects of employment including the volume of new patient referrals, how often female and male surgeons operate on new patients, and in what other area of work surgeons may feel under-employed.

We would also like to test an intervention that would equalize the case complexity for surgeons such as a centralized referral system or standard sponsorship system and track case complexity over time.

No disclosures


Ya-Wen Chen, Maggie L. Westfal, David C. Chang, Cassandra M. Kelleher. Under-Employment of Female Surgeons? Annals of Surgery, 2020; Publish Ahead of Print DOI: 10.1097/SLA.0000000000004497


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Last Updated on October 15, 2020 by Marie Benz MD FAAD