Why Is Life Still So Hard for Female Surgeons?

Doris Maugg, PhD

December 02, 2022

Women are better surgeons, particularly for female patients, according to a study recently published in JAMA Surgery. The study showed that male and female patients do a lot better after a procedure if a woman had performed the operation. In addition, a significant proportion of surgical trainees are women ― 37% of trainees younger than 34 years are women, according to figures from the German Medical Association. But are the needs of women considered when equipping an operating room?

An ongoing review by an Italian research group is investigating this subject. Maria Irene Bellini, MD, PhD, and her colleagues from the Sapienza University of Rome performed a systematic search of the usual databases for studies on the topic, "ergonomics for women in surgery."

The search terms included combinations of the keywords "ergonomics" and "women in surgery." The systematic search identified 15 studies from an initial 425 studies, which were mainly based on questionnaires. Nine of the studies were from the United States,

A review of the 15 studies found that the main ergonomic challenges were women's generally smaller body size and smaller glove size. Female surgeons develop musculoskeletal complaints almost twice as often as their male counterparts.

The authors of the review study found a correlation between small glove size (<6.5) and a general dissatisfaction with anastomosis clamps and laparoscopic instruments in general in at least three studies.

Many surgeons of both sexes also complained about neck tension and chronic pain due to poor and strenuous postures during operations lasting several hours, report the authors. These complaints occur more frequently if smaller women are unable to adjust the operating table or chair to the appropriate height.

The investigators concluded that surgical instruments, as well as facilities and equipment in the operating room, have been developed for men with correspondingly larger body sizes. As a result, there is an unconscious, sex-specific prejudice throughout the surgical fields, say the authors.

Ergonomics No Obstacle

Are women therefore not actually considered users of surgical equipment? "In my opinion, women are absolutely being taken into account," Doris Henne-Bruns, MD, emeritus director of the Clinic for General and Visceral Surgery of Ulm University Hospital, Germany, told Medscape Medical News. In 2001, Henne-Bruns was the first woman in Germany to receive the call to C4 professorship, the highest level in Germany, in surgery. "I think this discussion is a bit of hype. People ask why there are so few women in this field and then try to find an explanation for it. But I do not think that ergonomics are an obstacle. The biggest obstacles are still the difficult working conditions per se and the compatibility between family and career."

Never in her 40-year career has she countenanced the idea that women are not finding their way into surgery purely because of the ergonomics, not even when mentoring female students. "Other reasons have a much bigger impact," said Henne-Bruns. These reasons include operations that last for many hours, shift work, and the difficult working hours.

Beate Blank, MD, senior physician at Kulmbach Hospital in Germany and deputy chair of Perspektivforum Junge Chirurgie, a youth-targeted initiative by the German Society of Surgery (DGCh), sees isolated cases and differences between the surgical disciplines. "There are cases like this in visceral surgery, where some disposable equipment is too difficult to use with small hands. Trauma surgery is generally a little more crude, as you must already consider during training whether you are suited to it, and experience has shown here that it is a question of correct technique and practice, of course. In general, however, I do not see the ergonomics of instruments and equipment in Germany as a topic specific to women."

The problem of ergonomics still outranks the very well-known problem of work-life imbalance in surgery, write Bellini and her colleagues in their article. All these factors directly affect women's options, how they work, operate, or garner practical experience, and eventually lead women to decide against a surgical career.

"The fact is, in trauma surgery, if you have to lift the leg of a 1.90-meter-tall man, it can be exhausting," said Henne-Bruns. "However, equipment has undergone a lot of innovation. For example, there is now the mobile ultrasound device in abdominal surgery. In this respect, the industry has definitely begun to see value in manageability. Manufacturers are now recognizing that this equipment must also be used by women. A lot has been done in this respect in the last 20 or 30 years."

Problems With Gloves

The US website 1001 Cuts has reported on this topic too and draws attention to the special requirements of women in surgical fields.

The video article ("The Gloves Don't Fit") focuses on the problem of unsuitable clothing and equipment in operating rooms. "If the gloves and aprons don't fit you, it's a subtle but significant indicator that says you don't belong here."

Henne-Bruns adds, "The purchasers are male, which is a problem. Standard sizes are ordered that are not intended for women. In the past, the inventor of a surgical instrument was male, and the order has been implemented in this way by the manufacturer. But a lot has happened with this in the past few years."

In Japan, female surgeons are taking the initiative and are developing suitable endoscopic instruments in cooperation with manufacturers. Emiko Kono, MD, a surgeon at Osaka Medical College in Takatsuki, Japan, told Medscape, "I am collaborating with some companies to customize specifications for female surgeons with small hands and weak grip. At the moment, I am developing a female specification for a laparoscopic surgical device."

"The biggest innovations can often be found in the smallest details; for example, in how a female surgeon uses our instruments. That's why direct feedback from surgeons such as Kono is so important to us," Johannes Pawlata, product marketing at Karl Storz Endoscopy Japan, told Medscape.

"Here, sales associates are now forcing manufacturers' doors open," said Blank, "if the departmental head is open to it and the clinic's financial situation generally allows it. A little while ago, we replaced a drilling machine in the department, which we used to drill holes in bones, with a lighter and much smaller model. Since most of our team are female, there was a strong enough argument to purchase a smaller model that could be held with just one hand," she added.

Female surgeons in Germany are faced with other challenges, Blank continued. "Young female surgeons must first prove themselves in the men's club of surgery and are put under a lot of pressure. They must work harder to be accepted by their colleagues. They also encounter patriarchal and outdated thought processes all too often, even among younger colleagues. But surgery is an incredibly beautiful and satisfying profession. After an operation, you can see the result, what has been achieved, just like an artisan."

She emphasized that the awareness of female trainees has increased greatly and that women are now more integrated into this field, something that is high on the agenda for the DGCh. "I take my son with me to events, and no one there bats an eye at it. I am a surgeon, and I can also be a mother. As more and more women follow suit, the picture will slowly change."

This article was translated from the Medscape German edition.


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