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Ann Thorac Surg 2001;71:S8-S13
© 2001 The Society of Thoracic Surgeons

"The XX files": demographics of women cardiothoracic surgeons

^a Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA

Address reprint requests to Dr Hartz, Department of Surgery, Tulane University, 1430 Tulane Ave, SL22, New Orleans, LA 70112
e-mail: rhartzmd{at}aol.com

Presented at the Women in Thoracic Surgery Symposium, Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31, 2000.

I hope to have a little fun with this talk and would first like to voice my appreciation for being a token women on a female symposium for the very first time. Second, to provide you with the thoughts of women cardiothoracic (CT) surgeons themselves (I was able to interview almost 90% of American Board of Thoracic Surgery [ABTS]-certified women by phone or by questionnaire) I will intersperse many of their direct comments (unattributed) throughout the presentation. Thus, the data itself will be supplemented by additional, perhaps just as powerful, subliminal messages.

It’s nice to showcase the women but have we really done much? Few women advance in cardiac surgery in a meaningful way ... some progress in thoracic ... academic progress unacceptable, and women have not been properly prepared for the politics.

Yesterday Carolyn E. Reed gave a wonderful summary of women in thoracic surgery at the postgraduate course [1]. She virtually set my talk up by saying that the "last 500 years have really been an aberration, and one can foresee a resurgence of the role women will play in the future." Certainly, when one analyzes the activities of this small group of women, our activities can easily be construed as not only "aberrant" but also as somewhat "paranormal." I have thus elected to model this presentation after the television series "The X Files." Since XX equals 20 we occasionally joke that we are better than the average "10," but on a more serious note we are still an extremely insignificant group in the overall scheme of women physicians, and even of women in surgery over the last 500 years.

To put ourselves into the larger perspective we must scrutinize this 500-year period more closely. In medieval times, a 1341 papal edict forbade women to practice medicine and in 1541, the Guild of English Surgeons still mandated that no carpenter, smith, weaver, or woman could practice surgery [2]. In 1700, The Compleat Servant Maid, a sort of Farmer’s Almanac kept in all households, stated that a housekeeper should have knowledge in "chyrurgery" so that minor ailments and injuries could be attended to in the home. In 1897 Gertrude Stein attended Johns Hopkins Medical School and quoted Professor William Osler as saying "Human beings may be divided into three groups: men, women, and women physicians." This statement must be left to the reader’sown interpretation [3]. Finally, an astute academic surgeon noted in 1950 that "there is a silent quota. Nothing is ever said, but there is the underlying concern that if you take in too many women they’ll start taking over" (anonymous; concerning the general surgery interview process at his University).

Despite these repeated historical admonitions, some women have found unique ways to practice medicine. The Greek midwife Agnodice practiced cross-dressing in the third century BC [4] and hundreds of years later (1865) "James" Barry, who enjoyed a 50-year career as a male physician in Edinburgh, was found at autopsy to be a woman. This feat was particularly relevant in that "he" was inspector-general and a ranking medical officer [4].

I have had a lot of gender and race discrimination in private practice but have succeeded despite them.

At this juncture, I must discuss the almost superhuman accomplishments of Elizabeth Blackwell, the first woman to graduate from medical school in this country, and refer you to a wonderful biography of women physicians, Storming the Citadel [5]. Elizabeth was a small woman who hated anything to do with the human body and was a schoolteacher by profession (Fig 1). A series of events conspired to prompt her to attempt medicine as a career. First, although the Industrial Revolution had begun (a time when women became "unnecessary" and though the Queen was revered it became fashionable for wives and daughters to stay at home and was a sign of gentility for them not to work), Elizabeth’s family did not follow the rules. Her father, an "incorrigible reformer," provided the same opportunities and similar education for all of his children. Simultaneously, Elizabeth had a close friend dying of cancer who poignantly stated to her "if only I had a woman doctor, I would be spared half my suffering." Finally, Elizabeth herself was suffering the pains of a strained love affair with a man who "didn’t have very good brain power." Always driven by challenge, she decided that if she applied to medical school she could perhaps "cut the knot of this love affair and restore full mental freedom." Thus medicine found Elizabeth Blackwell rather than vice versa. She refused to cross-dress to accomplish her goal, applied to 12 medical schools, and was accepted by none. Due to her persistence the University of Geneva in New York eventually passed the vote along to the student body who unanimously accepted her for admission. The day she matriculated "the New York farm boys threw their straw hats in the air and cheered and stampeded." Elizabeth graduated from the University of Geneva in 1849 and thus became eligible to have her name inscribed in the prestigious medical register in Britain in 1859. Originally designed to dispel quackery from the practice of medicine in Britain, Elizabeth’s inclusion on the register nonetheless set the stage for many European women to attend medical school. Elizabeth Blackwell was a true paranormal pioneer in the XX-File analogy, both in the United States and in Europe.

View larger version (121K): [in this window] [in a new window]   Fig 1. Elizabeth Blackwell, MD. Sketch by the Contessa Charnacee. Reprinted from "Storming the Citadel" by Moberly Bell, Constable & Co., Ltd., London, 1953.

Before continuing this discussion of women in thoracic surgery, it is important to gain a little more perspective on the role of surgeons in American society. Figure 2, from Perez on Medicine [6], depicts a modern medical central. Prominent in the photo is the central and pivotal position of the surgeon. Today at our Women in Thoracic Surgery luncheon this phenomenom was repeatedly addressed, especially by Joan Cassell, a noted anthropologist and our guest speaker. Thoracic surgeons are likened to the fighter pilots of our society. They are frequently adulated and treated almost like rock stars. Certainly, they would love to continue to occupy this prominent position, but due to changes in the climate of medicine, such is unlikely to be the case. Specifically, will this surgeon continue to be an anglo, wealthy male, idolized by our society? After all, thoracic surgeons are truly a minor part of the world’s population. In a recent Time magazine letter to the editor [7] the author condensed the 6 billion people on our planet into a village of 100. Of these, 57 would be Asian, 21 of European descent, only 14 from the Western Hemisphere, and 8 would be African. Even more importantly, 70% would be nonwhite, 70% illiterate, and 50% malnourished. More than 50% of the world’s wealth would be controlled by 6 people (all of them American) but only 1 person in the village would have had any college education whatsoever. Thus, when Webster defines "normal" as "corresponding to the median or average of a large group in type, appearance, achievement, function, development, etc." thoracic surgeons in general, much less women thoracic surgeons, do not fit the definition at all.

View larger version (112K): [in this window] [in a new window]   Fig 2. Day in the Hospital. Reprinted with permission from Spence [6]. Source: WRS Group.

Although my main assigned task was to describe the demographics of women CT surgeons, our numbers are really too small for meaningful analysis of changes over time. Therefore, I will quote the longitudinal study of surgical residents published by Kwakwa and Jonasson [8]. The numbers of trainees overall has not changed and 78% remain Caucasian (Fig 3). Importantly, although the number of women in various subspecialties has not changed significantly, it is crucial to point out that the number of women and minorities who drop out is no greater than the number of Caucasian men who do so.

View larger version (17K): [in this window] [in a new window]   Fig 3. Ethnic backgrounds of graduates of all surgical residency programs in 1996. Reprinted with permission from Kwakwa and Jonasson [8].

Elizabeth Blackwell spoke of "slipping in a little truth." Some of this information was shared with you yesterday by Dr Reed and I would like to expand on this theme. In 1970 only 9% of medical students were women. Doctor Kouchoukos emphasized in his Presidential address today that there will be 43% women overall in the 2000 class, and that some institutions will have more than 50% women in their medical school classes. Currently, 36% of residents and 23% of surgical residents are women. A key distinction, however, is that if obstetrics and gynecology residents are factored out of the calculation, only 14% of surgery residents are women.

To delve further into the "truth," Table 1 represents the numbers of women in the various surgical subspecialties in 1997. The column on the left represents the overall percentage of surgeons represented in the specialty, and the column on the right represents the percent of female surgeons. The take-home message from this table is that thoracic surgeons represent only 2% of surgical specialists, and furthermore, that women represent only 2.2% of that small group. Thus, the celebration we are having tonight is remarkable in its own right and also highlights the tremendous obligation we few women have who must accept the challenge of being role models and mentors, and who must spread the word that we love our jobs and our specialty to medical students and residents. We must also network with our female colleagues to support them in times of stress.

Just who are we? Eugene Braunwald, MD, spoke eloquently about his wife, Nina Starr Braunwald, the first of 98 women certified so far by the ABTS (April 1961). As there have been 6,400 surgeons certified by the ABTS, this number represents about 1.5% of the total. Not as well known as Nina Braunwald’s accomplishments are those of Ann Stitt McKiel and Nermin Tutunji, both of whom were also certified in 1961. Figure 4 is a photograph of Ann McKiel and her daughter. Ann did her thoracic training in Pittsburgh, and received her ABTS certificate on October 8, 1961, 6 months after Nina Braunwald. Although Ann actually completed her residency before Nina, pregnancy delayed her taking the Board examination. Ann is often quoted as saying that having her daughter prevented her from being "number one" but that she has never regretted her decision. Ann unfortunately could not deal with the rigors of a private practice in thoracic surgery while raising her daughter, and changed careers (to radiology). She died of breast cancer in 1988.

View larger version (140K): [in this window] [in a new window]   Fig 4. Ann Stitt McKiel and her daughter Patricia.

View larger version (112K): [in this window] [in a new window]   Fig 5. Nermin Tutunji at present (center), graduate from American University of Beirut (left), in Jordanian army (top), and in surgical residency (right).

Although Drs Cosgrove and Urschel have been given the task of discussing the accomplishments of women in thoracic surgery, I have chosen to list those women who are so important that they must be included in any discussion of changing demographics. Table 3, which lists several of these women, is not meant to be inclusive but to challenge these women to continue their pursuits and to help other women attain those goals that are important to them. It is most impressive that 3 of our 98 women are now members of the prestigious American Surgical Society and that a woman is a director of the ABTS (Carolyn Reed). For the aspiring women thoracic surgeons in the audience, remember that you too can achieve your academic and clinical goals just as these women have.

In my efforts to determine the true level of productivity for this small group, I was (with considerable difficulty) able to achieve almost a 90% response rate to a questionnaire that revealed the following information. Figure 6 depicts the distribution of women in the subspecialties of our discipline: 34 practice private cardiac surgery, 13 academic cardiac surgery, 6 private thoracic surgery, and 10 academic thoracic surgery. Thirteen women have gone on to another medical or nonmedical profession. As can be seen from the figure, the highest mean degree of personal happiness is found in private cardiac surgeons. For professional satisfaction, both private cardiac and academic thoracic surgeons gave high ratings but the level of professional satisfaction in the small number of private thoracic surgeons was low. The 3 women who perform congenital heart surgery are not shown so as to preserve confidentiality.

View larger version (13K): [in this window] [in a new window]   Fig 6. Mean level of personal and professional satisfaction. AC = academic cardiac practice; AT = academic thoracic practice; PC = private cardiac practice; PT = private thoracic practice.

Because calculation of a mean did not seem to tell the whole story, I elected also to determine the median levels of happiness and display the numbers of women who claimed to be "happiest" (scoring 4/4) and those who were "least happiest" (scoring 0–1/4). Figure 7 shows that the median level of professional satisfaction is similar for private and academic cardiac surgeons but that only 1 woman in private practice rated her professional satisfaction as least happy whereas 3 of the 13 academic cardiac surgeons were least happy. The greatest numbers of women who rated their professional satisfaction 4/4 (happiest) were found in private cardiac surgery. Figure 8 depicts the same information for the degree of personal happiness. For women who have gone on to other professions not a single women interviewed rated her personal happiness 0–1. Fourteen of the 34 women practicing private cardiac surgery rated their professional happiness 4!

View larger version (17K): [in this window] [in a new window]   Fig 7. Levels of professional satisfaction. AC = academic cardiac practice; AT = academic thoracic practice; PC = private cardiac practice; PT = private thoracic practice.

View larger version (13K): [in this window] [in a new window]   Fig 8. Levels of personal satisfaction. AC = academic cardiac practice; AT = academic thoracic practice; PC = private cardiac practice; PT = private thoracic practice.

All of these data and personal commentary raises for me the very real issue of whether women’s groups, such as the one sponsoring this symposium, are necessary. I must admit that I have been skeptical for years, despite my active participation. This seminar and the tremendous networking it affords help me answer the question. The very fact that there are enough data to analyze is reason enough for the existence of Women in Thoracic Surgery and for the newly formed Archigia Circle founded by Dr Scott. Those of us included in the tables, and living this life, must be leaders and mentors for our students and residents. If not, we may soon be losing out on the best and brightest of the 50% of physicians who will be women. Second, in 1979, Julie Clayman, MD, and Lorraine Rubis, MD, were able to determine that there were 9 or 10 women with ABTS certification, but they barely knew of each others’ existence. Even the 3 women certified in 1961 did not know that there were 2 others! Twenty years later, most of know each other by sight, or at least by name and reputation.

Dear Renee,

I am very happy to see that finally you are standing up to talking your mind openly and bravely. I stopped keeping in touch with "Women in Thoracic Surgery" because I saw so much hypocrisy and denial when we met as a small group.

Finally, much has been made of the "glass ceiling." It is time for us to move beyond this concept so that a few of us can live the life above the glass ceiling as comfortably as do many of our male colleagues. In the XX-File parlance, I will refer to this as "adapting to low atmospheric conditions." Recently, several reports have been published on the significant "marginalization" experienced by women at high levels of academics. Perhaps our greatest challenge is to blur these margins so that the best and brightest women can be promoted and retained at high academic levels, or to become equal partners in private practices.

A recently published Massachusetts Institute of Technology (MIT) survey [10] contains the most important information on women at high levels of academics to date, and contains an astonishing admonition from MIT’s Dean:

I have always believed that contemporary gender discrimination within universities is part reality and part perception. But I now understand that by far the greater part of the balance is reality.

The MIT study clearly documents what all of us in medicine and science have known all along: that women are very happy at lower levels of academics but become extremely isolated (marginalized) and often drop out at the higher levels. Besides the MIT study other projects underway to blur these margins include the National Institutes of Health effort to establish women’s centers of excellence at major universities (there are currently 17), each of which has a core dedicated to the advancement of women in medicine and science. Mayo Clinic and Johns Hopkins Universities both have commitments to increase the number of women at high levels at a more rapid pace than that previously seen in their own institutions or elsewhere [11].

In the final analysis, a comment from one of the women surveyed sums up the overall tenor of the group interviewed:

The only real tenure that any surgeon is the respect of colleagues and patient referrals.

Thus, Figure 9, from Perez on Medicine [6], depicts how not only I personally but virtually the entire group of women surveyed view the true concept of today’s surgeon. In this particular drawing, the patient overwhelms the photograph. The patient should be the focus of our efforts and discussions. Most gratifying from my survey, virtually none of these women were concerned with actual salary. Their most important concern was to continue to be allowed to provide excellent patient care. This, I hope, will continue to lead the efforts of Women in Thoracic Surgery, along with our networking and mentoring objectives.

View larger version (157K): [in this window] [in a new window]   Fig 9. The Surgeon. Reprinted with permission from Spence [6]. Source: WRS Group.

I thank Patricia Ann Penkoske, MD, and Ina Carolin Ennker, MD, for supplying the Canadian and European data respectively, and also my secretary, Lara K. Watson Alder, for her numerous contributions to this project.

References

1. Reed C. Contributions of Women to Thoracic Surgery, Society of Thoracic Surgeons Thirty-Third Postgraduate Program, January 2000.
2. Mead K.C. A history of women in medicine: from the earliest times to the beginning of the nineteenth century. Haddam, CT: Haddam Press, 1938.
3. Wagner-Martin L. Favored strangers: Gertrude Stein and her family. New Brunswick, NJ: Rutgers University Press, 1995.
4. Barass P. Fifty years of midwifery. Health for All Press, 1929.
5. Bell M.E. Storming the citadel; the rise of the woman doctor. London: Constable, 1953.
6. Wayman R. Spence. Perez on medicine: the whimsical art of José S. Perez. Waco, TX: WRS Publishing, 1993:7,57.
7. Musnitsky H. 6 billion ... and counting [Letter to the Editor]. Time, 1999 Dec 31.
8. Kwakwa F., Jonasson O. The longitudinal study of surgical residents, 1994 to 1996. J Am Coll Surg 1999;188:577-585.
9. Ennker I.C., Schwartz K., Ennker J. The disproportion of female and male surgeons in cardiothoracic surgery. Thorac Cardiovasc Surg 1999;47:131-135.[Medline]
10. Members of the First and Second Committees on Women Faculty in the School of Science. Women faculty in science at MIT. The MIT Faculty Newsletter 1999;XI:4.
11. Heid I.M., O’Fallon J.R., Schwenk N.M., Sherine E. Increasing the proportion of women in academic medicine: one institution’s response. Mayo Clin Proc 1999;74:113-119.[Medline]

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