 All right, again, worst case, they all just have to see. Yeah, yeah. Okay, like all together. Yeah. Yeah. Great. All right. Welcome everyone to the McLean lecture series. My name is Julie Euler. I am in a general internal medicine and the chair of the department of medicine women's committee, which led me to this role in ethics department running the seminar series on gender equity and ethics. And we've had a great seminar series so far. I'm going to show you extra of these if you'd like. We are, we finished our fall and winter lectures, and we're in the middle of our spring series. So, obviously today I'm looking forward to introducing some of our surgery colleagues. Next week, followed by Dr. Chor, who's one of our own OB gynae faculty talking on gender equity and family planning, followed by the next week, Dr. Valerie Montgomery Rice, who's the president and CEO of Morehouse School of Medicine talking on gender equity and ethics at Morehouse School of Medicine, followed by a number of other lectures. So please feel free to join us on Wednesdays at noon for the upcoming lecture series. But without any further ado, I'd like to introduce my surgical colleagues who I've been working closely with as they have started their own women's committee in the department of surgeries. First, let me start with Dr. Sarah Ferris, followed by Dr. Wallace and Dr. Donnington. So Dr. Ferris is an associate professor of urology at the University of Chicago where her practice focuses on male and female avoiding dysfunction and reconstructive urology. She completed her undergraduate at Princeton University, her medical degree from the University of Michigan, followed by urology residency at Vanderbilt, and a GRS fellowship at the University of Iowa. Her current leadership roles include the urology residency program director, founder and president of the interdepartmental women's, women's surgeons committee, prior ambulatory medical director for urology and the current surgical director of the DKAM operating room. Her research interests include an ongoing RCT looking at the role of antibiotics and prosthetics, urologic trauma and reconstructive surgery outcomes. She's a senior editor for the AUA core curriculum. So welcome Dr. Ferris. Next, I'd like to introduce Dr. Donnington who will be joining us here on the panel here. She's a professor of surgery and the chief of the section of thoracic surgery at the University of Chicago. She obtained her bachelor's degree from the University of Michigan, and her medical degree from Rush. She completed surgical training at Georgetown University, cardiothoracic training at the Mayo Clinic, and a surgical oncology fellowship in the surgical branch of the NCI. She was on faculty at Stanford and NYU prior to accepting her current position in 2018. Her current clinical interests is in the diagnosis and surgical treatment of non small cell lung cancer. She has expertise in the use of multimodality therapy for locally advanced lung cancer, clinical trials and lung cancer and treatment options for the medically high risk patients with lung cancer. She's a past president of the New York society for thoracic surgery, and the women in thoracic surgery. She's a surgical chair for the thoracic section of energy oncology so welcome Dr. Donnington. And then, finally, Dr Wallace is going to be joining us. Yes. Yes. So she's I'll just introduce her now so we know but she's an assistant professor of orthopedic surgery and rehabilitation medicine who specializes in joint care. Dr Wallace treats a wide range of common and complex hip and knee conditions performing surgical procedures such as minimally invasive needs and hip replacements to restore mobility and reduce joint pain. She has experience in managing cases of arthritis, osteonecrosis, AVN, post traumatic arthritis and hip dysplasia, and she helps patients who have damaged and painful joints to improve their quality of life. In addition to providing comprehensive joint care, Dr Wallace is an active researcher committed to investigating the newest treatment and surgical techniques for patients with joint pain and arthritis. She's been published in notable peer-reviewed journals like the Journal for Arthroplasty, Ortho and Trauma, and the Journal for Women's Health so please welcome me and please join me in welcoming our surgical colleagues we're looking forward to hearing about the state of women in surgery. I think we're good afternoon now. I think we hit it so good afternoon. Got it. Is that better. Good. Okay. And we're here today to talk about the state of current state of women in surgery. So I'm going to go through and touch on a few topics and then ask the panel questions, just to give you an idea of some of the literature that's out there currently. No relevant financial disclosures and I have to give a very special thanks to Dr Mary and Henry who shared some of these slides with me and help provide some valuable data on this so it's very interesting. Overview I'm going to run through kind of main topics as background and then topics specifically about building a clinical practice, compensation, work-life balance, research academics and leadership and then how can people help. I really like this quote, are we standing is it a glass ceiling that women are hitting or is it a foundation of sand and I think this really hits it a lot of the biases that happen and hinder progression of women in surgery. The quote is, when women are in the hiring or promotion process, they are judged on their social skills, while men typically are not. This likability becomes a key attribute. And for women who want to get ahead in their careers, but likability does not drive the outcomes sought by academic institutions, journals, school superintendents, college boards or corporate search committees. So part of the implicit bias that we as a society hold valuing niceness in women and toughness in men, suggest that women aren't limited by a glass ceiling but perhaps by a foundation of sand. Women can't find their footing within the attributes they bring to professions without seeming to act out of sync with these external expectations. So currently practicing women, we have about 21% of general surgery in teas about 12 urologies 11 and neurosurgery is eight orthopedic six and five so those are the current practicing numbers. You can look at our residency programs and is abs like it's definitely increasing so general surgery 40% of women going into general surgery or women. ENT is 35% urology is 28% neurosurgery almost 20 same with orthopedics and cardiothoracic. So we're seeing doubling of numbers right across the board, and it's going to be really important to support women as they move forward. This is from the orthopedic literature. But basically you can see as things have moved up, or as people get younger, the prevalence of women surgeons is rising and it's just going to keep going as people are getting older as we see more people going in. One of the sorry Sarah is a little late who's going to talk about this but one of the things that was really interesting is what persuades or dissuades residents from going they asked female residents what persuades you to dissuade you from going into a surgical subspecialty, and positive influences on women who choose our personal attributes was a big piece of it, and dissuaders are more like experience and exposure and work life considerations. So following a practice. Women have good outcomes as surgeons. So this was a comparative post op outcomes for patients treated by male and female surgeons, it was a population based study. We matched patients between male surgeons and female surgeons patients based by age sex, comorbidity surgeon volume surgeon age and then hospital to the same operation performed. And they found that out of 100,000 patients, fewer patients treated by female surgeons were likely to have a mortality, and that overall they had similar surgical outcomes including late this day complications and readmission. People are probably familiar with this study that was out of jama was a Medicare study that looked at one and a half hospitalizations by treating physician gender among hospitalists. They found that patients treated by female physicians had a lower 30 day mortality and lower 30 day readmission rate. So women have good outcomes essentially is what we're finding. Prior studies have showed that female doctors are more likely to adhere to clinical guidelines and evidence based practice. This was so despite having good outcomes. This was a nice study. It actually looked at 40 million referrals in Ontario to male surgeons versus female surgeons. And essentially what they found as that male surgeons were more likely to be referred to they received 87% of the referrals. Female surgeons were also less likely to receive proceduralist or surgical referrals specifically. This disparity did not narrow over time as more women entered surgery. And this was another one that was an academic center direct referrals and again, female surgeons were found with equal training and seniority to receive fewer new patient referrals so about five and a half per month. And this reflects clinical practice. So this was looking at pediatric surgeons and the female surgeons had a lower case volume quite substantially actually it was almost 60 per year and had lower shares of specialist cases which results and left focus practices. That from our standpoint is less practice to gain experience right and also it makes it harder to build a specialty practice. This was a really interesting study where they looked at what happens to women after they've had a bad outcome so specifically they're looking at referrals from primary care doctors after mortality. And essentially interestingly what it shows is that women referrals to women decreased whereas for men they actually increased after a bad outcome. So some of the questions that I wanted to ask the panel is do you think that gender has affected your clinical volumes and referrals and I Dr. Doddington's are one here right now so we're working and getting your mic. We're going to need another one. So I do feel I mean first I guess I don't want to apologize or say that somehow appropriately the women's surgery committee is led by women who live within the dregs of surgery. You saw us we were on the bottom 11% 6% 5% so we really are we're not we're not gynecology we're not breast surgery we we live in the hardest realm and so yes do I. Have I seen that throughout my practice where male colleagues who are fine surgeons seem to be able to build big practices effortlessly. Yes, I've definitely seen that. Have I seen male surgeons who I thought maybe we're not as good a surgeon build and maintain a strong practice based on I don't know what, but it definitely happens. I do think but then again I come from a field, especially, I think in cardiothoracic surgery we are really hindered by cardiology and what cardiology looks like because again, very male dominated, especially when you get into the interventional realm of that where so many referrals from our field come from. So we get kind of done in by all those things. I feel like I've had a similar experience where it's just been more of a struggle to build surgical cases. Now I admittedly I'm in probably the most challenging area in urology I do male reconstructive urology so some of that is also maybe patient preference as well and and it's always a bit more of a hurdle to gain their trust, especially in clinics where they're asking like are you going to be the surgeon or just even like, I don't know if I'm comfortable talking to you and so I have to overcome that hurdle as well to be like I talk about this all day every day give me a shot and usually it's all good by the end of the appointment but there's definitely differences. And it makes it just that much harder. Women are more likely to get non surgical referrals so for me like I get a lot of recurrent urinary tract infections or pain syndromes or other things like that, rather than the cases for say so just it's harder to build that practice. Um, what have you done to try to help overcome those barriers. It's a good question you. I mean I think the same thing that other surgeon does you go out of your way to talk to your referrals to be good to respond to be very communicative and things like that. I will. I always say that I do think most of there is a portion of my professional success, which is based upon the fact that I'm nice and yet non challenging to my male colleagues. I go out and play golf with them and I never win. It's great. They love it. So I can talk their language but not keep threatening and I think that's unfortunate that I've had to find that role but I think many successful female surgeons do find that role. I think it gets back to that initial thing where it's, and I'm going to bring up some of the biases later but it's having that niceness right where you have to just make an extra effort almost to be pleasant and nice because it's expected and the role you have to play in the extra communication. I've definitely found for me since I've had. I get try to get cell phone numbers because then I can ping people and this is what's happening this is how your patients doing and it's kind of a reminder to them to that you're here that you're doing things which has been helpful. And then I this is specifically for you because you're a chief a section chief but what would you kind of do to help overcome the barriers for say you or other female physicians in your group. I don't have the right answer to that I mean we try to set a very level playing field and all those things I try to go out with you know out into the community with my women. The same way I do with my male faculty to always be going out it's more about just equal opportunity. I'm talking everyone up on the same level of this is my great junior faculty not my great male or female junior faculty. Yeah. So compensation. So looking at the sociological research experiments have shown that women who push hard and pay no gate negotiations are actually penalized more than men who do the same thing. And perceptions of niceness and demanding this explained the resistance to female negotiators so this has actually been proven within the sociological literature. And this can make a big difference so that everyone's quoted this I finally found the study $5,000 at the start of your career can make a million dollars difference over a lifetime of earnings. And that's because most raises are going to be percentile based as they go forward, and a person who's willing to ask for raise the beginning may be willing to ask and push a little bit more as their career goes on. The largest pay gap has been found in women with advanced degrees and you can see top 15 major occupation with largest gender weight gaps again. Physicians and surgeons is in here. So to give you some money numbers which are a little terrifying as a woman general surgery $83,000 difference per year medscape general surgeon compensation report urology double amc data on average women make 50 to 60,000 less per year. There's a really nice study done of the a ua met urology sorry membership. And they adjusted for work hours call frequency age practice sitting fellowship training APP employment they try to control for everything. They found adjusted salary $76,000 less so hitting around that 80,000 less. And this is thoracic surgery I didn't know if you wanted to talk about the data specifically. But it was also the same and I will tell you it's, I fall entirely into the stereotype it is painful for me to ask for more money for myself. And yet I can, if Matthew's here is me complain one more time about not paying my children well he's like they're not your children know your faculty I go, but you got to pay him you got to pay him now you got to pay him more. I it's so easy to argue for them and it's really hard to argue for myself and it's it's bad you listen to look at that stuff and I get angry. So there is this study that came out, I think it was around last year, and they simulated a 40 year career for women and they found that female surgeons over 40 career, two and a half million dollars less over their career which is that you can imagine is the substantial money for them and that adjusted for hours work clinical revenue practice type and specialty. So some possible explanations right why are we seeing this $80,000 pay gap per year, essentially. Are we going into some specialties that pay a little less like breast surgery in general pays less than or the rv you compensation is less female urology is the same way a lot of these some specialty areas have led or less and there's a question of whether or not women are more likely to take on uncompensated jobs such as education or committee work. And they may pass up promotions there, they are and I'm going to get into this later more coming more limited geographically or the threat to move, which is also a reason people can get pay raises women are more likely to be married to full time working partners. So it limits that limits their ability to move to a different place if needed differences in negotiation we touched on and some unexplained variants. And you touched on this but do you think gender has affected your compensation you've ended a few different institutions. Absolutely. There's no doubt about it I look at my last institution it was quite bad it was one of the reasons I left. And you know, the men are much more willing to go in every year and ask for more money. I just think they are and they're more willing to say we're going to leave and they look at you and they like know where your husband works and they're like you're not going anywhere. I think we all need to do a better job around family leave also, as I watch my junior faculty go out for family leave and I watch all their metrics go red. There's just no reason in 2023, we can't pre schedule that they if they're doing great for eight months and it goes to zero that they don't still stay green. But that has to get in the way, and women are still more likely to take family leave than men. I think all those things definitely contribute. I am very lucky my husband is kind of talks we talk about like the sociological data and some of the business data, and he was I've learned about these and so going and I'm like I'm just going to push myself to ask. And as much as it's uncomfortable I've kind of, I know the data so I forced myself to ask pretty much every year. And I think it helps but it's it's challenging right that balance and it's a little uncomfortable to have to do that. And also to know, especially since we're in an academic institution for both the chair of the chief and for the faculty to know what that double AMC data is, know what the numbers are know what the range is for you. That data is pretty specific it gets down to where you live what you do kind of how busy you are, where you are in your timeline and you should have an idea if I'm falling in or not falling in. And I think arming yourself with that data makes that difficult discussion so much easier, and really gives you it makes it a stronger argument. I think keeping things objective. That's where that data is helpful to be like oh my goodness like I'm really low on that percentile and my numbers my reviews I'm really producing. So I think having that objectivity is makes it easier and makes an easier argument as well. It also makes it easier to leave when you realize you're not hitting it. That too. What do you do to try to limit gender bias as a section chief. I mean I think I don't know. It's a good question I always wonder if I'm too biased the other way in favor of my female faculty. You try and just put everything on the table very evenly you try to look at everyone's pluses and minuses you try I think we all have gender biases. I think as a woman in surgery you're much more sensitive to them and therefore you try very hard to put them away I think I don't think we could ever get enough bias training. Whether that be gender race religion whatever we always need to be keep reminding ourselves that it exists it exists in my head. I need to come to the meeting prepared to be able to put that away. Um, so work life balance of course a big question mark I don't think balance actually exists is more like a teeter totter. And I really thought some of this information was interesting because it gets back to some of the biases so amaryllis slaughter if you haven't read a book it's a really great book called unfinished business. She had the article that came out it's one of the most popular articles. It was in the Atlantic, and it was called by women still can't have it all. And this is a follow up book but some of this information was 40% of American women are now primary breadwinners, which I was floored that's a huge number of women being primary breadwinners for their family across the board in America. Mother spend trouble still spend roughly twice as much as fathers on childcare, so they breadwinners still having to work hard at home. And in 2013 women were earning 82 cents to a man's dollar now I think this is fascinating, but single women without children may 96 cents to a man's dollar versus married mothers made 76 cents. So there seems to be this like motherhood tax is what I would like to call it. And this holds out so this is really interesting this is physicians who have NHK awards. And they found that women were more likely a full time employed partners, 86% versus 45% so twice as likely to have full time employed partner at home. Women with children spend eight and a half more hours per week on domestic activities so I will personally say I maybe have an hour of night at night to myself, maybe if I'm lucky. Oh, it's glorious. But that if that's, if you think about it, that's gone. That's every hour that hour one night a week that every night a week I get is gone eating up by those eight and a half hours. And the women were basically if there were disruptions in the usual childcare, women were four times more likely to be the one to have to step back from work to cover that child, then their partners. So this was one looking at career satisfaction based on, if you're a physician mother, and many women reported sole responsibility for most domestic tasks. And I thought, since we're talking about surgery physician mothers and procedural specialties, I had higher levels of domestic with higher levels of domestic responsibility was associated with career dissatisfaction. So this, this extra work at home is associated career dissatisfaction and this is proven within the AUA the American Urologic Association so they surveyed men and women about work life balance. 37% of women were dissatisfied or very dissatisfied, and 50% of women said no they did not have enough time for personal and or family life. So this was the thoracic surgery data as well. Right, this is work that we did within cardiothoracic surgery. One good thing about having only 350 women who are cardiothoracic surgeons ever in the US, you know, all of them and you get to ask them questions and they all respond. The cons rates high the 70% on our surveys, but this looked at the concept of who does what at home. So if you look at most domestic chores related to maintaining the house and childcare, women said they were primarily mine. Men tended to do more things related to automobiles and I think finances and that was kind of about it. But it really goes to that whole concept of the more you had to do at home the less satisfaction there was on the job and it's a little bit of Cheryl Sanford cleaning it. You know, if you don't have kids you get to lean a lot harder than those who have, you know, two or three small children at home. So, yeah, this was very informative work and I think it's one of the places we have to really do a lot more work. Yeah, I, as much as I live somewhere in between because I don't have children so that takes a lot of it away. I think I'd be way more productive at work if I had a wife. Yes. So, and then kind of getting into some of the sexual harassment and also burnout if you will. This was a survey among surgeons and 58% of women surgeons reported sexual harassment and either verbal or physical conduct, or unwanted sexual harassment. And this looked at our trainees looking at discrimination abuse and harassment during surgery training. So, 65% of women reported gender discrimination. 66% reported any discrimination on the basis of gender race or pregnancy and childcare, 20% reported sexual harassment which is kind of an alarming number when you think about it to have 20% of trainees reporting sexual harassment, 15% reported it up to a few times a year, and 70% reported any mistreatment exposure. I really like this it broke it down where is this happening so for women, and this is getting into like the systemic biases where does it come from for women, 50% of the time is patient or patients family, or nurses or staff. And so it's not just who were it's like, our patients are their families the staff around us, thought that was really powerful data, and then verbal or emotional abuse. It's typically from the attendings is what they reported. Again, sexual harassment 31% for women is from patient or patients family. So it's a very high number or else attendings which again is a little alarming, and then 43% reported pregnancy or childcare discrimination from attendings and 23% actually from their co residents. Now this is some I want to post is interesting. Now, the verbal or emotional abuse was actually equal between men and women residents reporting it from the attending so they're both about 50%. And really interestingly, men reported sexual harassment from nurses or staff 22%, which I just thought was interesting kind of fits into some of the stereotypes we've had. And then pregnancy and discrimination, the male men reported the same number of discrimination from their co residents as well so it gets back into that, maybe not motherhood tax a little bit of parenthood tax in general. I'm not even going to touch on this because this is a huge topic that's very important and definitely affects women and burnout as well. But it gets into perceptions of pregnancy and motherhood as a trainee or as a surgeon, and also the infertility and pregnancy complications I mean this is a massive separate issue, which deserves its own top. Basically, we're looking at things like harassment difficulties establishing legitimacy going into this unfavorable work environment. The challenges in motherhood right insufficient support work life balance negative perceptions of working mothers that we see as an actual financial tax. It's a male dominated culture. Dr. 90 was just talking about playing golf with them feeling you have to fit in and put yourself into that male culture, and then societal pressure those we talked about patients nurses families right it's not just our colleagues it's also within all around us kind of those pressures to hit stereotypes and higher expectations. And not surprisingly what do we see emotional exhaustion. So for women. You can see if they're single or divorced here if they're married it goes up higher right because there's you kind of your caretaker for your husband I think a lot of the time. Again the same and for men actually it goes down roughly if they're in a committed relationship or married. The same thing for women if they have children it's not protective against emotional exhaustive where for men actually it is protective which is really I'm not sure exactly where that comes from I think that's really interesting information. So, I'm Sarah thank you for joining us. How do you feel, or do you feel like work life balance, do you have in your life. How do you achieve this. You know, probably nobody has exactly the right balance, men or women but I think it's just important to recognize that it's constantly something that needs to be re evaluated. So what might work for me this month might not work for me in three months. And that means that my entire family is constantly trying to rework and rearrange schedules and make sure that we have the proper support to make it work. And it's not coming just from my side but from my husband side and from all the caretakers that are involved in our family I think it. It's a constant reworking of the system that that's working for you or not working for you. I don't have a divided household. I don't have any specific tips on that. I think, rather than actually dividing up labor in our household it's just the recognition that everybody's busy and everybody, you know, needs to chip in and one thing is not necessarily my job or my husband's job, or my kids job. But again, we just constantly need to be all recognizing what's out there and and what needs to be done. I think one thing that's worked for us is making lists in our house. So if everybody sees what's on the list to do, you know, everybody can chip in to try to get those tasks done on a daily basis and that's what we do every single day, you know, I might wake up an hour before everybody else but I'll start a list and leave it in the kitchen. And then my husband might add to the list or do something off the list and our nanny helps as well so I think just transparency and communication can be really helpful in that sense. I call it team sport in our house at getting everything done. It's just a team sport and Absolutely. Yeah. And I think late in life I recognize that there's nothing you can't pay to have someone else do. I guess the older you get you have a little more income to play with but I learned early that I was never going to be good at cleaning or at laundry and that all of that could be done by somebody else. Yeah, one of my my friends across town in Northwestern always says delegate so she's always delegating every single little thing to somebody else which is a great tip I think and not easy to do always so It's super easy just like Not easy for me I should clarify So I think I'm gonna say one thing about being a chief here. I try to actually help my faculty do this to that recognize that there are times that you can lean in and that times you will not be able to lean in and to try and plan that way and I don't and I don't I mean everyone should know when they're going on maternity leave and that you know you're not going to do stuff but recognize that there's stuff that we have to do now. This deadline is now because you're going to be busy. And this is going to happen and and that's going to happen as your kids grow and as your family changes but recognizing those periods where you where you can encourage your faculty to lean in when you can because you're going to have to step back and to try and plan that way I think it's really important. I love that that was something that Anne Marie Slaughter's book talked about because that's what happened to her she was really high level, one of the first international policy advisors for Hillary Clinton when she was Secretary of State as a woman. And so she was trying to commute between Princeton and the White House basically and one of her kids was struggling and she had to step back. And so one of her points is like there are times you can lean in, and there are times when you can't. And so, allowing yourself kind of that ability and having someone hopefully above you who appreciates that that there's times you're going to be able to be more full force and, and that's life, and that's what happens and that's okay. So this is a big one, research leadership and academics. So I'm pulling from our urology literature, but basically this study found when it comes to publications, female authorship has an upward trend. And interesting women were more likely to publish actual research articles as opposed to things like case reports or review articles or editorials. Interestingly, they're less likely to get cited though, which I thought was really fascinating and I don't you know it's just names on a paper so I don't know where that bias would come from but that thought that was interesting. And then our a way plenary panel so 91% of those have a male moderator and 64% are male only panelists. So lots of again, granted my society it's like 10% women. So the numbers is not entirely surprising but I think people are trying to make an effort. And on the editorial boards, we have in general surgery about 15% are editors associate editors or board members but only 5% are women of editor and chiefs and now this is I love this in urology. The major journals there has never been a female chief editor of any single one of them. And since 2020 we've gone from like four on the editorial board up to 20. So it's only gone as only doubled in 20 years. So this is where I start to think about a glass ceiling effect, because this is like getting women, how do you get people into leadership it's like elevating them and getting women on to, how do you get promoted, you know you need to be publishing, you had to be cited it's index factor, right, you need to be on editorial boards. So leadership, no change in gender to society, private presidents from 2012 to 2021 it stayed the same. This is the R01 grant so orthopedics zero women when the study came out had an R01 grant. If you were in surgery you're going to get about 45,000 less if you're in urology you're looking at almost $80 to $90,000 less if you even do get the grant. So what happens, it's all these little things add up right so promotions typically are based on research academics, being, you know, nationally known, right. If you're lower numbers and it's harder to break through that you're going to see less women and leadership, right that's what we're promoted on. The same thing here we go from assistant professors 25% women, 3% women chairpersons urology is the same way this is leadership again 3% and cardiothoracic surgery. I didn't know if you want to touch on the numbers there too. This was what we did but the similar kind of going through the all. It's easy to do all of us and looking at where we lie. We have a subspecialty issue and cardiothoracic surgery three subspecialties general thoracic adult cardiac and congenital. There were no when the survey went out there were no female congenital heart surgeons who had made it to professor in the country. You're kidding. No, there still isn't made one who almost made it. So yeah, it's, it's, it's very sad. And in our field, cardiac thoracic is actually very well populated by women and that's where the most professors live lead the professors are the dark blue surf hide there within adult cardiac it's still quite small. It's it's amazing, but it's all gets to if you're not being promoted there's pay and equity and difficult to make it to leadership most definitely. Um, so some questions. What have you done to advance your career. So some of it is perseverance, you just keep going, just keep your head down and you go you found a job you like you found a surgery like even if you're not well represented. You just keep pushing I think my society my specialty is at a point where it really wants to change. So I actually feel like I found myself at the right place at the right time. But it is it is very much, I think for those of us at the cracking of the glass it's a lot of work to crack the glass there's no doubt about it. The hope is that we've made it easier for those who follow us most definitely in that you open the doors for others and you set up pathways that make more sense. So do you feel like as an assistant professor you've encountered obstacles along these lines. Maybe not yet, but I'm assuming that's coming. You know, I think things that I'm doing now to try to advance my career in the next few years are things like maintaining relationships with folks at the national level, you know, my professional association is the American Association of hip and knee surgeons which is a far, far minority women. But there's a group of us that are are well connected and, you know, try to promote one another within the association and I think it's working. So I think just maintaining that sort of relationship, doing my service at the hospital level, you know, being as involved as I can at the hospital level. Those are sorts of things that I'm doing now I think it's again really hard to kind of hit all the marks that are going to matter for a promotion, you know, the. The things that are going to fall to the wayside when my time in the day run short and I don't think that's specific to women but I think it's, it's challenging. Yeah, we buy, as I mentioned my girls group is very male dominated, but recently I have one of, I have a woman who I'm close friends with me went to medical school together, and she's worked with a couple others and there's that we're doing like a women and girls and this to start maybe doing research together and to try to help promote how can we help promote one another because it's just so incredibly male dominated to try to tip the balance a little bit and maybe get women more speaking and that kind of thing and have some of the senior women help some of the juniors who at least know their names and find out who they are so you can recommend them. I think those groups are incredibly helpful for any underrepresented minority. The women in thoracic surgeon is a group that has been around actually for almost 40 years, and it is amazing, the amount of work they have been able to do, because they got together they got organized. Those surveys that go out to every single woman, every single one gets one if you're alive and your cardiothoracic surgeon we know how to find you. But it can't it does so much for advocacy. It does so much for support, and it has really done so much to bring up those junior numbers I think in the current class almost one third of trainees going into cardiothoracic surgery this year were women from, I mean there were six in my class out of everybody. So to say that you know, we're up to a third that's just that says a lot about what a group like that can do in terms of research advocacy support all those things are really, really important. I'm wondering what advice would you, if someone was interested in going into surgery like what advice would you give women to look for that their institutions doing to try to support their careers. I mean I think you want to look at the institution and look at the departments and see you know who's in them. You know, and I think it you that I've been at three now and you can see institutions where diversity matters and where diversity doesn't matter it's not. It's not a secret and it's not hard to see. And there are many really good institutions in this country where diversity is not a priority. And if you're going to go that way it's going to you're going to be challenged and I think you just have to have go in with eyes wide open that that things may be more challenging there but I think I don't think these things are hard to recognize I really don't. So I wanted to touch a little bit I feel like I've kind of hounded on the bad, if you will, like where are the barriers where are we seeing problems what is this so I'm getting into a little bit about what can you do to help. I talked about the women's surgeons often violate gender schemas, and we have implicit bias against us. There's significant disparities in salaries up to 80,000 a year. There's disparities in patient referrals, we have work life balance issues right and it's especially tricky for women, where there's more at home, which can, you can replenish yourself right that's your time, and it's gone and so you're going to have higher burnout. Women are often more dissatisfied in residency. There's higher rates of emotional exhaustion and burnout higher rates of harassment and discrimination, and women aren't advancing at the same level. I, I love this, it was a little entertaining because it hits exactly at what Dr. Dyington was saying so they surveyed special some special urologists, and the male urologist perceive that the practice culture towards women as more equitable than their female colleagues across all such categories equal access work life balance freedom from gender bias leadership support right so it's a little about the blinders. And I love this quote studies suggest the studies suggest that there are gender based differences and how gender inequities are perceived and experienced in urology acknowledgement of these differences is the first step in identifying opportunities for improvement. So I just showed you a whole bunch of data I don't think anyone would disagree with me that these biases actually do exist. And so this is where we move through how do we start to help. It starts with awareness. So recognizing that it actually exists. And then getting it be motivated to help to start giving yourself some self efficacy and positive outcome expectations and then the action piece of it right so it's moving through how we help people. I think this is another piece of it and I wanted to touch on this when it comes especially to leadership. Women apply for a job when they meet 60% of the qualifications but women will often will only apply if they meet 100%. This is I finally found the study where this came from because people quote this all the time. It was from a Hewlett Packard internal report, and they actually looked at the nuances in this so it's not a confidence issue. Rather it was a belief that women thought the required qualifications are actually required when the hiring process when it's really one where advocacy relationships are creative approach to framing one's expertise could overcome, not having those expectations. My husband always likes to say he's like, it's a wish list. That's a wish list. That's what they wish they could get. If you have most of them, you have the right background. This is where I encourage women to think, and also people sponsoring them, and you know you can figure it out and you have the resources to help you figure out the other areas. You can apply it goes like men I mean it's just, it's this belief that you have to have all the requirements which is kind of crazy I mean you are going to learn on a job. You already met all those requirements you should already be doing the job and then looking at doing the next step. And this gets into mentors versus sponsors so mentors are really important especially early in the career. They give you advice. And the mentorship program which we're working on establishing here is really important to help you advise with advice and figuring out your career, but sponsors are different and sponsors I think are really the key and kind of a rare golden egg. They're the people who help you get to the next level. They're the ones who are going to advocate for your promotion. They're going to work in the back right make connections to senior leaders and promote your visibility. This is up from the Harvard Business Review about the real benefit of finding a sponsor. And this is what they call breaking through the last class ceiling. So it's when holding women back is a surprising absence of advocacy for men and women in positions of power. Women who are qualified to lead simply don't have the powerful backing necessary to inspire propel and I think this is really interesting protect themselves on the journey through upper management it does take someone if you make a little mistake to have someone who is your back and protects you. It's a lack and a word sponsorship. So women are 50% less likely to have a sponsor and they in these studies underestimate the pivotal role it plays in their advancement. Women feel that getting ahead based on who you know is an unfair tactic and then hard work alone will get them rewards and recognition. But the reality is sponsorship is a normal part of career advancement and it really takes people I mean I put the golf course when I love. Can you share the story of you're talking about the golf course for the decisions were all being made at this golf game at the meeting and not at the table. So, what was about sponsorship is, you don't get to go get a sponsor, a sponsor finds you. And you often don't know who your sponsors are, you don't know who put your name in for that position, but somebody did. And yeah, I do think that's where women lack we have plenty of mentors, we don't have sponsors, we don't have people who are willing to put their neck out by putting our name in. But I recently got put into a nice from the American Board of Thoracic Surgery someone sponsored me someone put me up and I got on only I realized that we would like come to the table for all these votes but someone already had the conversation. The conversation happened on the golf course when we went to the spa the three of us three women on the board went to the spa. The 12 guys went and played golf and they'd already made the decision. And it was really upsetting. So I got my clubs out and I started taking my lessons again I'm like okay I'm not going to spa next year I'm going to go play golf. I know how to play this is why I learned. But I think it was so to me you told me the story and I was reading this and I was thinking about it because I think that goes to show like so much happens behind the scenes, including those sponsors like hey you're out golfing and like oh I've got this great young colleague and whatever those informal conversations are that are happening. And it's not even like they're deciding on what they're going to make but the conversation comes up and then they're in a social casual environment. And I think one of the problems is like I don't I mean I'm an athlete but I don't play golf. It just was not my thing you really don't want me to play golf it's not pretty. So if I'm not there in those typical arenas. I'm not going to be able to be in the room where it happens where the discussions happening and so I would encourage like this gets into people who are leaders. Have your discussions and conversations in place that are gender neutral or like not where where everyone can be there. And so everyone has is able to provide input because the reality is is women and people minorities have different perspectives that are incredibly important and are really going to drive institutions forward. And if you leave them out of the conversation you're really your institution or your group is going to suffer. Right and I have to say in defense of the guys who went to play golf they're all really good people. And we were having conversations in the spot it's just that when you're still a minority and your group doesn't represent that bigger group. Yeah the way of those conversations is very different. And it's hard and we all when we sit on committees and workforces and do these things we want to be. We all want to have a good time and trust the people we work with. It's just we have to recognize where other people get left out. So, individual individual interventions what can you do. I would say look for opportunities to acknowledge women's comfort. Sorry, contributions to amplification. So one thing that happens to women is they're sitting around the table they may suggest something, and then someone else will say it later and they're like oh great idea Larry. When really it was someone else at the table said it so I think it's important if someone said something to be like Jessica that was a really great point I just want to amplify what she said. So it really helps to bring their thoughts and opinions to the table. This is definitely something that happens. Recognize and acknowledge microaggressions and comments or assumptions based on gender schemas and that can be people around you and also within yourself. Before you say something to a woman think it how it would say to a man and my I was reviewing this with my slides with my husband he's like, thanks honey. And it's true like thanks doll or that like sweetheart or whatever it is if you said that to a man, like it just doesn't you're like thanks honey it's not going to sound good or another great one is like, Oh do you really need that raise like your husband works at home or your husband works. Is anyone going to say that to a man, like oh do you really need that raise your wife works like that's it if you think about how it sounds and how that your gut reaction is just different so if you can, if you something comes out and you pause you think about something. Think about how it sound if you said it to a man and actively encourage women to apply for leadership and promotion I would say and sponsor them through the process so if there are women who you think are stars. Promote them sponsor them talk about how great they are, because they need an extra boost. And I said it's help your wife at home and be a role model so I think for men, especially walk to walk. You know if you show that you're doing these things and you talk about doing these things that normalizes it and people below you are going to see it residents are going to see the example that you're leading. Hey, I'm if you say out loud, I'm leaving work to go pick up my kids right it helps to normalize that behavior and makes it acceptable. I think that's really important to be role models for the next generation. And this gets to what Dr. Dyington was saying about having just admit we all have bias, both men and I will say men have bias against them too so there's really good data showing, especially in business that men are significantly penalized for taking paternity leave. Like huge penalties for it, because they're not the manly man they they get like they won't get the promotions either. So there's bias both ways. And one of the books I read recently said that the next women's revolution is really a man's revolution. And that's what it is it's allowing men to help at home it's allowing men to be more involved in childcare, and it includes any of this data but there's some good studies like the Harvard Business School show that men now are like 20% more likely to be want wanting to be involved in childcare. And so gender, like this norms and the scheme as in desires are changing. And I think it's important to support both ways. Institutional interventions, I think giving women surgeons extra assistant with outreach and equal diet considering equal diagnosis distribution within the call center and new patient referrals. And to help with the building the practice. I think transparent objective constant compensation plans and keeping this in mind as you're going through and making sure you don't have that bias as you women are not going to be as comfortable asking for a raise just period end of story so you it takes a little helping hand I think for that work life balance and burnout. I think implicit bias training is important this institution's doing a really nice job with that supportive leave and with RVU and call adjustments and lactation policies really support supports through I think that gets into exactly what you talked about salary. You know, you use a terrible during your year you have a kid, so you don't get that raise. And then every raise after that you've missed out on a percentage raise so it literally your salary just it will never get as high because of those limitations. And I think equal parental leave helps because mental, it'll be, you know, there are be use will go down to. So you have some of that will balance out but just keep that in mind. That would help her on site daycare options. And then we have good backup care assistance which is good. And then more of like a systemic level, explicit explicit to purposeful and fair distribution of uncompensated teaching and service look what workload, just if you have a woman on in your team will say yes and how is interested in more of these things does not mean that it should be just her doing it. So some of these things if there's workload that is unpaid doesn't get RVU whatever it is. It should be equally distributed between men and women in the group so that women aren't being penalized by taking up more of that. I think about equal leave policies and 10 o'clock extensions. I think, and we have a brief bit of this but objective measures of success and milestones for promotion that are defined ahead of time so everyone knows the rules. And Dr. Dyington really led this and I have some of the slides from their promotions committee which really makes it objective. And when I presented this information at our society for women urology they loved it. People were a lot of like chairs for other departments across the hospital really excited by our promotions, how it was laid out and really were interested and wanted that information to take back to their institutions. Some other things I think improve flexibility around part time and times in need it gets back to Dr. Dyington was saying sometimes you can lean in sometimes you can't. Sometimes a family member gets sick sometimes you get sick and allowing adjustment for that. And then when there's times in need is important. And then it gets into blind. I showed you the NIH grant awards are lower on publishing lower people in editorial journals all that so blinded manuscript grant hiring and promotion practices. I think gender and diversity close for society meetings representation is good there's Mary cues with ophthalmology was talking about how there's almost some oversight, where they suggested people for the panels. And they looked at me like, we wanted to be more maybe look for another woman so it's not the same person doing the same thing every time. So having some people on a higher level kind of looking and evaluating and having goals is good. So I wanted to touch briefly on what has been happening here at University of Chicago. And to me retention is really important and on a big picture level, it costs over a million dollars for an institution to replace the surgeon, possibly more depending on their level a million dollars and you think about if you can retain one doctor, what that million dollars can pay for to support them. And I think getting into clinical productivity, as I talked about this maternal like motherhood bias. People think that people will be less productive when they come back but they're not so this was a study that looked at clinical productivity after maternity leave, and maternity leave any other type of leave it bounces right back people are right back because women are hard workers. So our institution and thanks to Julie big shout out to Julie for helping me with putting this all together a couple years ago was supportive of an interdepartmental women's surgeons to committee with the goals of trying to help women and pay them. It's funded because I think it's a little bit of put your money where your mouth is so if you believe this is important the departments do fund it. The chairs compensated and we have subcommittees ones advocacy and so we've been working with our department of surgery. It's normal it's in the final bit but they're based on the data, they're going to pro rate RV use for those four months around parental leave because you go down by 50% going in takes 50% of a month, you know, to ramp back up. So they're working on adjusting that so the numbers don't look so bad, and also doing a point oh five FTE reduction to support lactation because it does take time away from clinical activity. And during that year when you're, if you choose to. Sorry, I'm like lactate lactation to pop basically. We also have approved a new department of surgery resident lactation support, and as done or dying to mentioned the transparency was important to us around the salaries and productivity so we're able to send out the WMC competent comp data and RVU data for their family so they're just able to take a look at that. We also are doing professional development for faculty and residents, and have new newsletter letter website and social media to promote what women are doing. Dr Henry has been huge for the nominations committee and has just been incredible and we've actually had a number of women win local and national awards just because they're being nominated so if you're not nominated you're not in the running and so having this to promote is huge is important for promotion. We're hoping to do some research based on these changes to see if it helps the med student committee trying to encourage women to go into surgery and give them practical good advice. They've been, we have mentors suturing workshop panel events to try to support women and encourage them to go into surgery, and then a membership committee. This is Julie's research, which was she for she and it just they did this with their women's medicine and medicine committee, and just by per nominating women, the percentage of female awardees increase from 26, like about 30% up to almost 60% and almost double just by nominating and that was across all award types, educational clinical and research. The Department of Surgery DEI group, I think it's been very progressive what they've done. And so they've come up with a new promotion criteria. Leslie, do you want to talk to about it or do you want me to run through just I mean we basically put together promotions committee, which was an outside eye between section chiefs are still responsible for promotions but to be an outside set of eyes and resources for the junior faculty and we want to make sure that, you know, we all knew what the rules were of engagement because it's such an opaque process from below and so clear from above how it all works. And we want to make sure that it was equitable cost services and genders and everything else and it has really been quite, I think useful it's only in its second year now. But I think it's, it's provided someplace for junior faculty to come with questions and for guidance. And then I think we have a yearly discussion with the chiefs which we've had one so far. One round of those and I think they were really insightful to learn what each chief is looking for and to try and get a very organized approach. Check this on the next couple sides, I think the junior faculty really like having the list lists of like these are the basic kind of things you should be doing. And like I said some of it seems so obvious when you're above and some of it was is so not obvious from below, but it has really helped I think not change the criteria but drive conversations in the right direction. And I think it's really nice as a like even for me I look at this and I'm like what am I checking what boxes where do I still have deficits as I'm going through and it's just like you said I don't know Sarah if you have any thoughts like I had no idea what what what what makes you promoted I don't know as a junior faculty you come in you're like I just want to work hard and be a good citizen and be a good team player and help out my group and I don't know if you feel the same way but I mean I had no idea and you you helped us out you know a couple months ago so I think this has been really useful for junior faculty. So I was going to think I have to say I learned that in the promotion process, at least at the University of Chicago Department of Surgery, men live in the middle. The women are the least engaged and the most engaged. It was really, it's striking how that dichotomy set up we have some really engaged women, some really women who would prefer not to ever have to be promoted or look at it, and the matter all kind of much more down the middle. That's interesting. We'll have to see how the second year comes through whether as a pattern that continues. So just kind of along the lines of trying to help and what kind of tactics have you found to be effective at creating change. Being the squeakiest wheel all the time. Probably works against me as well but I think just persistence with a lot of this you know, just speaking up and making sure that that everyone is heard and represented at the table. I agree I think there is something to being a squeaky wheel sometimes it does seem like you're annoying people to death, but I think it's important and I think that you sometimes kind of just keep having to be the voice. When I think about, you know what our panels and stuff look like at our meetings. I mean five years ago people were just hated by guts because I'd be like, Oh, there's no woman. Excuse me, no woman, you know, like I felt like every meeting and now it's finally other people are saying it it was like, but someone had to start it so I think those things are really important. I mean, we I was just at the, it's a way core curriculum sets the, it's like information that basically pretty much every residency program the country is now using it used to be called Campbell's Club from a textbook. And now it's core club because it comes from the data and the information that was put together. And they were talking about our DI group had met with our core group to talk about some stuff we could do to adjust. And at the very end there, we're breaking up and talking about people turning over and who you might bring in who you might want to promote. And I was like, there's only two women in the room and I was like, Hey, you guys just remember like think about diversity when you're, because it's right as they broke off I was like the squeaky wheel just like you like hey, remember to think about diversity think about women think about promoting people you wouldn't necessarily think about it so I think it's important to have people the table, kind of raising their hand to do that too. And what changes if you get there's like one thing you could help with changing for women surgeons what do you think would be the most beneficial things. I still worry a lot about, you know, the early years and women having children I think it's just I still think it's something that's keeping women out of surgery and that makes surgery really challenging. So, I think better family supportive care I think is still something that's so important for us and and I mean I guess maybe I mean I've read parent nation too many times it's a societal issue it's not just surgery we just happen to be a group with a lot of, you know, work responsibility and a lot of unsure and unsure hours and things like that which really don't go well with childcare. I think it's a huge stress for for young mothers and and young fathers and so I really wish we we could do that better. And because I think that would. I think we I think we need to do it better for our trainees, you know I think that's where I really like to see that benefit. I think that surgeons trained for a long time right through their childbearing years and we don't do a good job for our trains. Yeah. Yeah, I think I can just agree with that and just say that it starts early right so you mentioned with trainees and with pregnancy support. And for me personally, the hardest time is not even having a newborn but when you're actually pregnant and dealing with exposures and the OR and you know just trying to make it to all sorts of appointments but still work towards your promotion. It's, it's challenging so just any sort of support and as you mentioned you know the changes in parental leave I think having it be parental leave and not just maternity leave is extremely important and having full support for both men and women in that period of time I think is critical. The Dana the book, just this referring to Dana Susskin wrote it it's called parent nation. It's incredible and she showed this graph this is graffin it about the unhappiness index and or happiness index I think and basically it's like people who don't have children versus people who have children. And in a lot of countries especially you can imagine skin and avian countries where there's a lot of support, it just goes down a little bit if you have kids. America's like at the bottom of the bottom I mean it is actually a little terrifying how unhappy people who have kids are when you I mean they're supposed to be his blessings enjoy, but it's just so much stress and in the United States to her part of our argument is we have this like, you're supposed to be able to do it yourself like I can do it myself but no one can do it themselves and so having the culture of helping each other is is kind of not part of our culture. So she's arguing for how can people help and parents start supporting each other it's a really great book. I have at self advocacy stuff about because I don't want this just about what you can do for us I have advice in here, but I'm going to pause because I think we're about at time for questions from the audience. And there's a few questions on zoom that I'll ask and but we're open for questions from the audience. I did want to say about the double amc data because I think that's relevant to all obviously the Department of Access to it, the Office of Faculty Affairs has it so you can email the Office of Faculty Affairs, the Department of Medicine, women's committee also has it and shares it freely, and you can download it for $40 off the double amc website so accessible to all. Are there any questions from the audience that we want to ask them. Otherwise I'll read these questions from the from the chat. There's a lot of a lot of questions throughout one of them came about the kind of asking for more money and have we ever have you ever done any kind of, have you ever mentored colleagues by conducting conducting mock interviews or how do you relate to younger faculty asking for promotion for salary. I've heard of it but I've never done it. And I would encourage it. Like I said I think with any uncomfortable conversations practicing them helps. So right if you don't feel comfortable asking for money a mock interview would be a great thing. Yeah. And maybe we should think of that for our women's group. Yeah, we should do that. There's one last question. There's a few funny jokes about like old girls network like you were saying that there's no boys network there's no girls network and there's one about the men and the women to go to the spot together. Oh, I agree that would be much more fun. And it was talking about the intersectionality like you were, there's, we were talking a lot about binary gender but what about intersectionality and, and is there any data about, you know, women surgeons with, you know, partners that are not binary but, you know, women partners or polyamorous relationships like is there data did you see data about that. There is not a lot of data. There's not surprisingly little I will tell you I remember this is like I always say like one of my leadership courses, which ended up being they did two years after this little bit of a drunken walk home one night with one of my friends there was a we did a women's women's leadership, but it came out of the fact that we said, you know, why in our field are there no homosexual men, we have, you know, heterosexual men and there are a few homosexual women but why are there none. And everyone was like, I don't know this is like a drunken conversation but it was really true. Like, and in 2023, I don't know any openly gay men in my field. I do know some openly gay women, and they seem to have very good practices, but it's funny how that that would be maybe a bias in the other direction within cardiothoracic surgery but it's a little scary. We had a few good talks in this lecture series, but not from surgery it's been from medicine. Yeah, it's there is a. I just found out about it last year. I think it's called the pink voting party I could be wrong a camera the name of it there is like a informal like very informal it used to be incredibly hush hush is my understanding in urology for gay men and women essentially and they will go out they I'm sure it's somewhere this year I don't know where it is, but I think they're it's becoming more comfortable for people to talk about it. We've had a number of residents here. And I think people it's becoming more common and much more comfortable for people talking about it I don't know how much. Yeah, it's just such a small number of data, but not ready to be a group yet, at least not within my field. So I think it's a little bit of an anthropographic surgery which you consider. Yeah, I bet you could probably I bet you there's, I would, yeah, I would venture to guess, they have an informal group, which I am feeling probably yeah. All right, well we'll wrap up there and say thank you to our speakers. And I, I'll go ahead and stop the recording will ask the ethics fellows to come down to the front and have a more informal conversation with our speakers.