Erika L. Rangel, MD,MS Instructor, Harvard Medical School Trauma, Burn and Surgical Critical Care Department of Surgery, Center for Surgery and Public Health Brigham and Women’s Hospital Harvard T. H. Chan School of Public Health Boston, Massachusetts

Why Do So Few Women Enter or Complete Surgical Residency? Interview with:

Erika L. Rangel, MD,MS Instructor, Harvard Medical School Trauma, Burn and Surgical Critical Care Department of Surgery, Center for Surgery and Public Health  Brigham and Women’s Hospital  Harvard T. H. Chan School of Public Health Boston, Massachusetts

Dr. Rangel

Erika L. Rangel, MD,MS
Instructor, Harvard Medical School
Trauma, Burn and Surgical Critical Care
Department of Surgery, Center for Surgery and Public Health
Brigham and Women’s Hospital
Harvard T. H. Chan School of Public Health
Boston, Massachusetts What is the background for this study? What are the main findings? 

Response: Although women make up half of medical student graduates in 2018, they only comprise a third of applicants to general surgery. Studies suggest that lifestyle concerns and perceptions of conflict between career and family obligations dissuade students from the field.

After entering surgical residencies, women residents have higher rates of attrition (25% vs 15%) and cite uncontrollable lifestyle as a predominant factor in leaving the field. Surgeons face reproductive challenges including stigma against pregnancy during training, higher rates of infertility, need for assisted reproduction, and increased rates of pregnancy complications. However, until recently, studies capturing the viewpoints of women who begin families during training have been limited. Single-institution experiences have described mixed experiences surrounding maternity leave duration, call responsibilities, attitudes of coworkers and faculty, and the presence of postpartum support.

Earlier this year, our group presented findings of the first national study of perspectives of surgical residents who had undergone pregnancy during training. A 2017 survey was distributed to women surgical residents and surgeons through the Association of Program Directors in Surgery, the Association of Women Surgeons and through social media via twitter and Facebook. Responses were solicited from those who had at least one pregnancy during their surgical training.

39% of respondents had seriously considered leaving surgical residency, and 30% reported they would discourage a female medical student from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood with training (JAMA Surg 2018; July 1; 153(7):644-652).

These findings suggested the challenges surrounding pregnancy and childrearing during training may have a significant impact on the decision to pursue or maintain a career in surgery. The current study provides an in-depth analysis of cultural and structural factors within residency programs that influence professional dissatisfaction.

We found that women who faced stigma related to their pregnancies, who had no formal maternity leave at their programs, and who altered subspecialty training plans due to perceived challenges balancing motherhood with the originally chosen subspecialty were most likely to be unhappy with their career or residency. Since surgical training can last throughout most of a resident’s prime reproductive years, and early/mid careers can involve even longer hours and stress, how can a surgical career be made appealing to women, or men, who also want to be involved parents?

Response: Studies that look at the factors that drive surgical career selection show both genders place equal value on interest in the field, intellectual challenge, technical aspects, and clinical opportunities. Our study shows that female surgeons who altered their fellowship training plans due to difficulty balancing pregnancy and childcare with their original fellowship choice had about two-and-a-half-fold higher odds of professional discontent. These women most commonly chose to forgo subspecialty training altogether and pursued general surgery instead.

For both genders, residents who feel compelled to sacrifice career prospects and the rewards of a preferred specialty to reconcile domestic responsibilities may be less enthusiastic to complete the rigorous training. Fostering the development of trainees and early career surgeons must include helping them achieve professional milestones while acknowledging the importance of personal relationships and parenthood in a surgeon’s personal growth and wellness. Strong mentorship in medical training is priceless and role models in the desired subspecialty who have similar family priorities are needed to provide experience-based advice on balancing childrearing and career.

Unique to women, stigma related to pregnancy and maternal discrimination are distinct phenomena from gender discrimination, and have been linked to higher levels of burnout among female physicians. Fortunately, there are straightforward workplace interventions that can mitigate perceived stigma, including increasing duration of maternity leave, hiring extra workforce support to cover the expectant surgeon or surgical resident, and providing childcare and lactation support.

Having these supports in place reduces resident apprehension associated with requesting accommodations, provides predictability for colleagues who are concerned about increased workload during a pregnant surgeons’ leave, and increases the appeal of the specialty to future candidates. What recommendations do you have for future research as a result of this work?

Response: The demographics of the medical profession are evolving, with a steady increase in women physicians, who now make up half of medical school graduates. Yet there is a gender gap in surgery with just 38% of current surgical residents being women, and women more susceptible to attrition than men. The perceived negative effects of a surgical career on lifestyle, and more importantly on the ability of a woman to begin a family during her prime reproductive years while in training, must be examined and addressed. As the country faces impending surgical workforce shortages, finding solutions to these highly complex issues will help inform policy changes to better support childbearing residents and help us recruit and retain the most talented candidates to the field. Is there anything else you would like to add?

Response: The impact of parenting support on perception of work-life balance is incredibly important. There is a lot of data that shows that lifestyle issues are heavily weighed by both genders. We need to study how paternity and parental leave policies in surgical training impact same sex couples and those who choose to adopt.

The social and financial support of a resident is critical during this period of high stress. I think it would also helpful to investigate additional factors that may contribute to attrition or job dissatisfaction, such as income level, marital status, spouse/partner job, distance from parents or in-laws, and cost of living. 50% of partnered female surgeons are partnered with another physician, so there may be stressors unique to dual physician parents worth exploring as well. For those without family support, mentorship may play an even more critical role to foster a sense of inclusion and camaraderie in the surgical community. 


Rangel EL, Lyu H, Haider AH, Castillo-Angeles M, Doherty GM, Smink DS. Factors Associated With Residency and Career Dissatisfaction in Childbearing Surgical Residents. JAMA Surg. Published online August 01, 2018. doi:10.1001/jamasurg.2018.2571

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Last Updated on August 9, 2018 by Marie Benz MD FAAD