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“A person may cause evil to others not only by his actions but by his inaction, and in either case he is justly accountable to them for the injury.” —John Stuart Mill TO THE EDITORS In a recent article in the Journal of the American Medical Association, Dr. Julie Story Byerley described the “gender-based neglect” in mentorship within medicine in the wake of the #MeToo movement.1 She implores, “It is especially important that men spark this conversation in groups with power and authority.” This letter is written for a specific audience: male surgeons. Simply stated, we need to do better. Despite improving gender diversity in many medical specialties, women are underrepresented and undersupported in surgery.2–5 They experience training differently and have higher rates of burnout and poor psychological well-being.4 They also have less mentors like them (ie, female) to emulate. In fact, “Among surgical faculty at US medical schools in 2014, women were less likely than men to be full professors,” even after adjusting for age, years since residency, subspecialty, and research productivity, among other potential confounders.3 As of 2015, surgical faculty comprise 23% women, whereas full professors of surgery comprise 10% women.2 Similarly, very few women currently maintain leadership positions in major surgical societies and organizations.6 For example, the American Society of Plastic Surgeons has only had 2 female presidents.7 This mirrors the current state of chief executive officers of Fortune 500 companies, of which only 32 are women.8 It is true the proportion of female surgical residents is increasing; the percentage of female residents among all surgical specialties has increased from 11.6% to 30.3% from 1991 to 2015, respectively.2,9 Yet if we continue to rely solely on female mentors to guide female mentees, the mentoring capacity of the 10% full professors of surgery will undoubtedly surpass meaningful capacity. The #MeToo movement has increased the accountability for gender-based discrimination and mistreatment, but an unintended consequence has been men's aversion to hiring and mentoring women. Male leaders report “fear of false accusations of sexual misconduct that could compromise their reputations.”10 A 2018 Lean In survey found these fears may be as high as 30% to 50% in the business environment and have profound implications for women's career advancement, for example, excluding women from networking opportunities.11 While the precise extent of this response in the surgical field is unclear, it is undoubtedly present and insidious, and female physicians have received reduced mentorship pre-dating the #MeToo era. Female physicians cite the paucity of mentors as a barrier to many aspects of equity in surgery including compensation, career trajectory, academic productivity, and overall personal and professional development.6,12 Although both male and female surgical trainees would highly benefit from both personal and professional mentorship, it is evident that mentorship of female surgeons is lacking and should be considered an ethical failure by all in the field. Female mentors advancing to surgical leadership positions will reduce the stark gender inequities that exist at the upper echelons. Male surgeons’ aversion to mentoring female surgeons is rooted in a fear that is ultimately inhibiting progression. Although the surgical field requires a systems-level recalibration, including more transparent compensation, better hiring practices, and a shift toward more gender-equitable social norms, this article focuses on each male surgeon's role in fostering gender equity through better mentorship practices. Given the current power dynamics in surgery (ie, majority males in senior positions), it is impossible to expect women to successfully promote their own inclusion alone. Male surgeons must consciously pursue intentional mentorship relationships, which by definition, encompass 2 major functions: (1) career-related support through “sponsorship, exposure and visibility, coaching, and protection,” and (2) psychosocial support, which enhances the mentee's “competence, identity, and effectiveness,” in the professional setting. To provide a construct for both assessment and for furthering discourse, the authors offer the following action items for both self-reflection and improvement among male surgeons, which can be applied to all mentors regardless of gender. SELF-REFLECTION AND AMELIORATING COGNITIVE DISSONANCE Cognitive dissonance is described as “the uncomfortable sensation of having two conflicting thoughts at the same time.”13 It is this mental framework that ultimately drives male surgeons who, perhaps subconsciously, believe, “Women's advancement could only come at their expense,” to perceive mentoring female surgeons as risky to reduce this dissonance.10 This mentality harbors potential sequelae similar to those fueling HIV denialism, which devastated South Africa at the turn of the century.13 Soklaridis et al10 in their important article on male mentorship amidst the #MeToo movement recommend implementing systems that “address implicit biases toward women” and allow men to “admit bias and accept feedback that does not align with our perceptions of our private and professional selves.” Likewise, the American Surgical Association recently recommended “ongoing self-assessment” to mitigate against both implicit and explicit bias in pursuit of advancing diversity, equity, and inclusion in academic surgery.14 Male surgeon leaders must reflect in an effort to become more consistent, in that their views match their actions, and their current and future actions continue to match their dedication toward mentoring and supporting female surgeons. MUTUAL RESPECT In response to a “Letter to the Editor” in Plastic & Reconstructive Surgery, Cooley and Cooley detail a fear “voiced by residents and research fellows in reference to mentoring medical students and by academic faculty” of misinterpretation by their mentees.15 The authors encourage mentors to “embrace the challenge” under circumstances in which “we push ourselves in ways we find slightly uncomfortable.” Respectfully, this declaration is insufficient and frames this “uncomfortable” “challenge” in a manner that congratulates male surgeon leaders for mentoring female mentees. There must be no award given for treating another colleague with the mutual respect she deserves. Framing this interaction as a “challenge” is a form of microaggression; it inadvertently highlights male benevolence toward women as a generous act for which women should be grateful, perpetuating the “dependent role, a condition of vulnerability.”10 To that end, we hope male senior surgeons mentor female surgeons and trainees based on merit rather than charity, the latter of which reinforces problematic gender roles. A multi-institutional study of internal medicine faculty identified key determinants for successful mentoring relationships: “reciprocity, mutual respect, clear expectations, personal connection, and shared values.”16 Soklaridis et al10 argue that men who fear mentoring women believe women “are not intelligent or perceptive enough to know the difference between a mentor's good and bad intentions.” This view exhibits lack of reciprocity and mutual respect with implications devoid of personal connection. Dr. Julie A. Freischlag, one of the first female chairs of surgery, posits, “Now is the time for mutual respect, and for women (and men) to be brave.”17 Although women continue the arduous, emotional task of speaking out about these issues, men in surgery must unlearn the mentality that frames female surgeons’ progress as a zero-sum game. Men must unlearn the behaviors contributing to the “boy's club” within surgery, especially at senior leadership levels, as strong evidence suggests more diverse teams improve outcomes.14 DON’T SHUN PROBLEMATIC BEHAVIOR; IDENTIFY AND ADDRESS IT Inevitably we will see male surgeons exhibiting implicit and explicit misogynistic behavior toward women in surgery. Rather than ignoring this behavior, we must speak up more effectively. Although severe, explicit, negative behaviors (eg, sexual assault or harassment) require hardline consequences, insidious, implicit actions of gender-based discrimination are more difficult to approach. Byerley recalls an instance where her male mentor received a sexist comment from a colleague regarding their mentor-mentee relationship. By quickly responding to the colleague praising her credentials, she states, he “sent an affirming message to me that he recognized that comment might have been demeaning.”1 Responses to such comments should be framed constructively, rather than alienating those who behave misogynistically. Reacting with anger and dismissal can be isolating and damage relationships. Tactfully acknowledging problematic behavior and educating in these instances turns a harmful situation into an opportunity for unlearning and collegiality. MENTORSHIP AT EVERY LEVEL IN A SYSTEM OF GENDER-BASED BIAS AND DISCRIMINATION The authors of this editorial have benefited greatly from the mentorship of both male and female surgeons at each career stage. In turn, we encourage men in surgery at all levels to acknowledge their role as potential mentors to women at earlier stages in pursuit of becoming a leader in the surgical field. Gender-based discrimination exists at every level, and absolving oneself of the responsibility until “in a position of power” is an artful elusion; being a male surgeon is already a position of privilege. The male to female mentorship relationship requires an awareness from the mentor that at all stages of training, men benefit from privileges their female counterparts do not.12 Studies have shown that due to male dominance in leadership positions, male to male mentorship relationships offer the greatest benefits to the mentee of any other gender combination.18 Just as treating health disparities requires a level of empathy from the provider, male surgeons must work to empathize with female surgeon trainees to narrow the disparity in mentorship opportunities. CONCLUSIONS The field of surgery is a profession, but it is also a trade, the latter of which takes pride in its apprenticeship model of training. Even more so than other specialties, direct mentorship and interaction is critical to training the future surgeons of tomorrow. Women leaders bring unique talents that enhance effectiveness, nurture creativity, and augment organizational performance.7,14 As all surgical fields become less male dominated, it is clear that, at the moment, we are not properly investing in our future. The #MeToo movement has diminished male surgeon leaders’ ability to shirk their responsibilities as mentors to women. Rather than approach this movement through a construct of fear, we must actively mentor women in surgery if we are ever to rectify the current inequity in the surgical profession, for which we are all accountable.
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