Unconscious Bias #AWSChat- May 24, 2016

May 2016 Association of Women Surgeons Tweetchat


Mind the (author credit) gap?

HT to my Dad, who is a more reliable NPR listener than I am (it’s an advantage of retirement, I’m told). Yesterday he shared a short segment from All Things Considered that discusses the gap in women as first and senior authors in medical publishing.

I have two key concerns looking at the article they discuss and after digging a bit more deeply into the literature in this area.  One is the evidence of a plateau in women as first or senior authors in the last 7 years.  Is this because we’ve hit a glass ceiling in science? Is it because we’re not trying? Is it because of implicit bias? Or is it some combination of the three?  Those concept are all subtle enough that it’s almost impossible to determine the role that each plays without employing qualitative methods. Of course, the beauty of qualitative methods is that more reasons we aren’t even thinking of might be playing a role and this would help to identify them.

My second concern is the one alluded to in the conversation with the female cardiologist in the NPR piece. We know from many areas of the business and academic literature that as women we tend to advocate poorly for ourselves; most of us culturally can’t get comfortable with the probability of being viewed as pushy, which is a documented consequence of aggressive negotiation tactics. Is our absence as first or senior authors a result of us failing to negotiate and advocate effectively for ourselves in yet another realm? Is this another manifestation of “Women don’t ask” in a way that is perhaps even more insidious than failing to negotiate salary?

And, of course, I can’t help but wonder if this isn’t generally representative of our global shortcomings in attracting and retaining women into careers in academic medicine.  Until we have a system that provides the professional development opportunities, the hard resources, and the work-life integration capabilities that are expected in the modern world, there may be little additional room for change.

The aftermath

This week has been dedicated to recovery/ clean up after being out of the office for a week, as well as “catching up” on my call load.  I can’t say that any of those things are enviable but they’re part of the package if I’m going to stay engaged with the broader surgical world.

When I have these long trips (this one included three separate meetings), I’m reminded of the great parts of what I get to do. I mean, I get to spend time with amazing colleagues like these:

ACS Leadership and Advocacy Opening Reception
ACS Leadership and Advocacy Opening Reception


ACS Advocacy Reception at the Top of the Hay
ACS Advocacy Reception at the Top of the Hay


Association for Surgical Education Twitterati on the loose!
Association for Surgical Education Twitterati on the loose!


Celebrating the always-fabulous Celeste's birthday in Boston
Celebrating the always-fabulous Celeste’s birthday in Boston


Did someone say chocolate fountain at the Presidential reception?  I'm there!
Did someone say chocolate fountain at the Presidential reception? I’m there!


Shhh...don't tell anyone I was playing hooky and clearing my head...
Shhh…don’t tell anyone I was playing hooky and clearing my head…

I realized coming home that I would have to do a lot of “next manageable bites” because of three different deadlines I’m juggling these next two weeks, and that’s been largely successful. One of the deadlines is making me nutty, mostly because I don’t think I have all of the information I need to make it happen, but that’s something I’ll brainstorm the next few days.

And, of course, coming home is always great.  I’m back in my “native” eating environment, I get pet therapy every time I walk into the house, and I’m able to process lots of things that happened during some spectacular meetings last week. Oh, and I got to go for a little run on Sunday and spend time with my running tribe.

Mile 7.8 of 13.1
Mile 7.8 of 13.1


We run because we get to- and it's a wonderful thing on a beautiful April day like this one!
We run because we get to- and it’s a wonderful thing on a beautiful April day like this one!

It’s a privilege to get to travel and be part of amazing things.  It’s a joy to come home, even with a wackadoodle (and busy!) call schedule this week.



The clothes make the…woman?

It’s consistently true that how we dress gives people a certain impression of us; it’s a way that we communicate nonverbally.  For many, there’s that idea of the professional “uniform” that gives them the proper identity.  Some of us target a look that is “professional but fashion forward” (my usual self-description).  Much like you wouldn’t expect an artist to show up in a skirt suit with a very traditional blouse, we don’t expect someone interviewing for a surgery residency to show up in a skirt and blouse reminiscent of Stevie Nicks in the 1970s..  Quite simply, there are fashion norms for all professions, and in order to have professional credibility, you find that you need to stay within them.

While the above is simply a reality, the one catch lies in the fact that women are often held to a somewhat more exacting standard than the men who are their colleagues.  Example, compliments of my own experience:  I was at a professional meeting in a pair of nice wool pants with a complementary jacket.  I was wearing brown suede Dansko Mary Janes that color coordinated with the rest of my outfit.  I was critiqued about my “shoe fashion sense” by a senior male colleague.  Now, those who know my lifelong shoe addiction well are assuming there’s a bit more to this story, which there is- I was nursing a broken metatarsal and simply couldn’t wear any other shoes except for running shoes (which seemed a  bigger faux pas at the time, but perhaps not).

Dear male readers, be honest:  How many of you have been publicly chastised for your shoe choice at a professional event by someone trying to mentor you?  I suspect it won’t be more than a handful, if that many.  But, somewhat ironically, the bandwidth of shoes that are considered “professional” for men is far, far more narrow than it is for women.

Lest you think I’m turning anecdote into data, think again.  Obese women suffer in terms of roles available to them and how much they are paid, but their male counterparts don’t.  Then there is the message in academia that “unless women dress modestly and conservatively, they look out of place in academia…they don’t have the right bodies to be academic authorities.”  This image preference for masculine styling for women to be credible isn’t a uniquely academic phenomenon, either.

So, what’s a girl to do if she wants to be taken seriously but doesn’t want to be a cookie-cutter of everyone else around her?

Personally, I have a stylist who knows that I’m a bit bound by a Very Traditional Career, but who also recognizes that I have no qualms about labeling things, “Boring!”  She does an amazing job finding things I consider smart- both in terms of their fashionability and because they navigate that narrow space I’ve got to work in.  That enables me to put together things like this, which are within the “rules” but quite the opposite of boring:

Mixed designers- Akris Punto (jacket) + St. John (skirt)
Mixed designers- Akris Punto (jacket) + St. John (skirt)

And, not surprisingly, I have a shoe “dealer.”  So that I can find functional but fun things like this:

Red Thierry Rabotins
Red Thierry Rabotins

As Don Henley said, I will not go quietly.

Women surgeons, leadership, and confidence

Did you happen to read this piece in The Atlantic on the Confidence Gap in April of this year?

If not, I’ll start by asking you to take a few minutes to read through it.  Yes, by definition I just violated my own “blog posts should be approximately 500 words” rule.   Then I want you to think about the last time you praised a successful man and a successful woman.  With rare exceptions, I strongly suspect that their responses differed.  Why?  A man will often respond in a way that shows they believe they deserve their success; sociologically, it’s simply how boys are programmed.  In stark contrast, a woman is more likely to tell you that she got lucky…that she happened to be in the right place at the right time…that she has succeeded because of exogenous factors that are in fact outside of her control.  The woman who publicly owns her success, who takes credit for it, is a rare thing.  With the number of highly successful women I know, particularly in surgery, I simply can’t believe that women are succeeding because of luck and men are succeeding because of talent.  To hear us talk, though, you would be left with that impression.

One of the critical impacts of women’s tendency to underestimate their talent is that they aren’t considered for or don’t ask for “stretch” positions.  While men are promoted or ask for leadership roles based upon their potential, women are promoted and ask for leadership roles based upon their accomplishments.  In fairness, the underpinnings of this phenomenon probably lie both with leadership and with those seeking advancement, but it’s something that is both anecdotally and scientifically true.  Anecdotally, I know that I personally have been guilty of asking for leadership roles only when I can demonstrate that I am more-than-qualified based upon my prior accomplishments.  Scientifically, the article from The Atlantic cites data showing that women apply for promotion only when they are 100% qualified, as opposed to men who apply when they are 50% qualified.

While as women we may be guilty of undervaluing ourselves and our potential, we’re also hamstrung by “cognitive shortcuts” that result in systematic undervaluation of our work.  While we want desperately to believe that we’re functioning in a meritocracy, self-promotion (and perhaps a bit of good-old-boy network?!?) seems to make a substantial difference in achievement of leadership roles and career advancement.

Obviously the generation of a “solution” to this issue is complicated by basic social mores, the acculturation of boys and girls, and the fundamentally different communication styles typically demonstrated by men and women.  I don’t have a simple fix for those things.  What we can do, however, is to move these issues from a place of unconscious bias to a place where we can discuss them openly and honestly.  To the men who mentor women surgeons (or who are in positions to sponsor women surgeons), please look at what we’re capable of, not just what we’ve already done.  Be a multiplier for us by putting us into those “stretch” roles and let us excel.  To my women surgeon colleagues, ASK for that role you aspire to, even if you think you’re not quite ready.  Don’t come to the table with excuses about why you’re not there yet and don’t point our your deficiencies.  Come to the table with faith in your ability to excel.  If our talents aren’t being fully used, it shouldn’t be because we’re not offering.

(With thanks to Justin Dimick for encouraging me to write something on this…even if that was about 6 weeks ago.)


A place of our own

Apparently there are a number of men who, upon hearing about a women surgeon’s activity will state, “We don’t get to have a men in surgery group!”

This statement is both true and untrue.

While it would probably be considered politically incorrect to have a formal “men in surgery organization”, it can easily be argued that academic surgery remains the “men in surgery” club.  Between 2001 and 2011, the number of women in surgery residencies increased from 24% to 37% of trainees, breaking that 33% number often associated with achieving “critical mass” for any non-majority group.  However, in the ranks of academic surgery in 2012, women constituted 21% of surgery faculty, and women are apparently stalled as 9% of full professors in surgery.  This paucity of women in academic surgery does matter, both in terms of availability of role models for our residents and students, and in terms of how women are seen and perceived in academic surgery.  If you were to ask most (if not all) of my male colleagues if they have walked into a room at a surgical meeting and felt out of place, the vast majority would tell you no, and many would look at you like you were crazy for asking.  In contrast, I know experientially from speaking to many of my female colleagues that we’ve walked into any number of surgical settings and felt fairly certain we didn’t belong there.  My first experience of this nature came during my fourth year of medical school while on the interview trail- I was one of 40 interviewees at a program that shall remain unnamed on a given date, and I was the only woman in the interview group.  While I knew I deserved the interview, I inferred that being a resident there had the potential for me to have to fight lots of battles that involved being judged not on my work, but on my gender.  I didn’t have an interest in that.  I still occasionally make jokes about it when I find myself seated in a room of surgeons in which I am the only woman- and yes, this does still happen in 2014.

My support for and involvement in organizations like the Association of Women Surgeons, is predicated on this idea that as women we do need a place where we are exclusively looked at for our body of work and where we aren’t judged for being any of the stereotypes associated with single/ married/ divorced/ childless/ childed women surgeons.  For me, and for many others, it’s been a “safe” environment to expand our leadership skills and to experiment with authentic engagement with colleagues.  My experience in a social sorority in college was similar, in terms of it being a place where my leadership skills were cultivated and I learned to collaborate with people who were very different from I.  While I recognize that many horror stories exist about the collegiate Greek system, I remain passionate about the benefits of sorority life when it’s done “right.”

Would I have the leadership and team skills that I have today without Alpha Delta Pi and without the Association of Women Surgeons?  Maybe.  Would I be where I am in my career without the support of some wonderful men who focused on who I was as a student, then as a surgeon?  Absolutely not.  Did opportunities in these women’s-only organizations change my life for the better?  No doubt, and I am absolutely certain that they helped make me into who I am today.  For me, and for many women leaders in varied professions (particularly historically male professions), this idea of having a “place of our own” is critical to our professional and personal development.

Can we negotiate that?

Did you cringe when you read the title question?  Was it the word “negotiate” that caused it?

And how are your skills at asking for things you need in your work environment?

Sure, salary is important, but what about other resources?  Office or lab space, technology, support staff…the list is almost endless in academic surgery.  Ordinarily, I like to remind my mentees to be grateful for opportunities.  Negotiating is the one exception- while it’s okay to be a bit grateful, don’t let that gratitude stand in the way of getting what you both need and deserve.

So, how good are you at asking for those things?

Chances are if you’re a woman, the answer is, “Not very good,” and that’s if you ask at all.  This isn’t a problem isolated to women surgeons, but one that impacts nearly all women in business- and one that certainly impacts quite a few men.  I first became cognizant of the extent of this problem when Evelyn Murphy from The WAGE Project spoke at an Association of Women Surgeons meeting.  One of the important things that Evelyn did during that meeting- and again when we had her speak at a regional women surgeons’ conference- was make all of us boldly state, “I want my two million dollars!”

Where does that number come from?

Over a professional lifetime, what starts as a $34,000 difference (per annum) adds up to $2 million.

Wage gap by education

US Census Wage Data from The Wage Project

How does this happen?

Quite honestly, the root of the problem is that women are less likely to ask/ negotiate.  One statistic that sticks with me is that while 57% of men will negotiate salary for their first job, only 7% of women will. Nice girls don’t ask for things in the workplace, right?


Yes, sociology says that as women we are more likely to expect to simply be recognized for our good work (author’s note:  I am absolutely, positively guilty of this, and it’s a topic we’ll have more of on another day).  Unfortunately, that’s not how the world works.  If we’re going to succeed, we must negotiate.

How do I change my mindset-because I really do NOT like negotiating?

So much of this is simple semantics.  Maybe you tend to view negotiation as a zero-sum game, one in which there is a clear winner and loser.  The truth is that it’s not simply about getting to an agreement- it’s about achieving a good agreement.  Negotiation is best when it is conducted with the idea of a positive-sum game, in which all parties win.  I’ll share something from Margaret Neale later that might just help you become more comfortable negotiating.

How can I better negotiate?

Plenty of resources exist out there, and all of them point to a few common themes:

  • Bring objective data supporting your request
  • Know your “ideal” position as well as your preferred alternative (BATNA- Best Alternative to a Negotiated Agreement)
  • Try to understand the motivation or interests of the other party, as well as their likely positions
  • It’s NOT personal.  Not even close, and don’t make it personal (or take it personally)

Women Don’t Ask is widely recommended, and should probably be mandatory reading for every female chief resident or fellow as they navigate their first faculty position.  Getting to Yes is another classic, and one that is less gender-specific.

And if you simply want a 15-minute reset, here’s a great talk from Margaret Neale of Stanford Business School teaching you how to use negotiations in both big and small areas of life.  It seems to me that practicing in the small-stakes settings sets you up for success when the stakes are big- such as your 2 million dollars.