Our goal in this study was to identify the effect of a role model in general surgery, we also wanted to assess the impact of the presence of female surgeons in the field. Our results revealed several interesting findings, the majority of female surgical residents had a role model, half of them, sixty-seven percent reported that the role model, regardless their gender, have a positive influence on them at the level of specialty decision making. Moreover, female surgical residents provide preliminary evidence that the presence of female surgeons in the field and working directly with female residents and male consultants before applying to general surgery residency program significantly influenced their choices at that time. A further novel finding is that female surgical residents rarely cited the childcare and their spouse relationship as strong influential factors in their decisions when they pursuit a career in surgery.
Several factors influence a female surgeon's decision to pursue surgical training. Among these are surgical clerkship experiences and interactions with attending physicians and residents (20). However, few literatures have studied the association between exposure to role models and decision to pursue a career in surgery (21).
It has been demonstrated that the influence of role models is a significant factor determining the choice of postgraduate training among medical students (10, 22-27). Most of our study population (78.5%) had a role model, similar to the results of an earlier study in which 68.6% of female students reported that the presence of role models was the top factor in choosing a career in surgery (23). This is important as female physicians who have a mentor are more motivated to write articles and participate in research and to show greater career satisfaction (28). These findings highlight the formative influence of a role model in shaping a physician's professional identity, in particular at the level of specialty decision making.
In the eyes of the residents, clinical knowledge, operative skills and demonstrate integrity and honestly, making time to teach and responding to students' needs are the most important characteristics in a role model. This finding is comparable with that reported by Wright et al (29) in which clinical skills were also ranked highly. When we inquired about the role models' teaching skills, this response supports the idea that university hospitals may be the ideal setting for medical role models in Saudi Arabia. Therefore, we can conclude that the surgical residents in our study valued clinical traits above all others. In contrast to the results of our study, the sample in a study by Sternszus et al (18) did not assign as much importance to clinical skills. One explanation for this discrepancy may be that in Saudi Arabian society, competition for general surgery residency spots in the most prestigious centers is high, leading trainees to value the clinical practice skills that they can acquire from a surgeon above all else. In addition to good technical skills and other well-known qualities of good surgeons (such as firmly grounded medical knowledge and clinical and operative skills), trainees may also value more humanistic qualities, including adequate interaction with patients and their families, honesty and integrity, and ethical behavior. Research in positive psychology and moral philosophy suggests that "moral elevation," the experience of positive moral emotions after witnessing an exceptional attitude from a role model, may sustain the influence of role models on the choice of specialty (30).
Family and lifestyle:
Female surgeons placed minimal emphasis on the influence of childcare and their spouse on their decision to pursue a career in GS. Interestingly, it is commonly assumed that these factors are more influential for women. For example, Sanfey et al (4) indicated in their study that concerns about combining a surgical career and surgical training with future lifestyle, family life, and parental responsibilities were more significant for women than for men. On the other hand, some studies suggest that these gender differences are no longer as evident (19, 31). They reported a tendency for both men and women to agree on issues regarding family or lifestyle priorities when considering the pursuit of a surgical career. In another study, more men than women chose practice lifestyle as influencing their career choice. (29). Of our 51 respondents, only 3.9% were married, most being single, as observed in other studies (32, 33). Therefore, it can be assumed that both the demanding nature of surgery and the length of the residency period make it difficult for women to achieve a balance between their surgical career and family life. Another thing to be considered, It was often reported that women prioritise career advancement by delaying starting a family. Female surgeons in the US were twice as likely as male surgeons to delay having children until after postgraduate residency training; women who had children early in their career felt less financially secure and more anxious than women who commenced families later in their career (34). Work hours and residency lifestyle may also be attributed to women’s shifting interest toward medical specialties with more flexible lifestyles that are more suitable to the current generation (35).
Presence of female surgeons
Another area that has been little analyzed in the literature is the impact of the presence of female surgeons on the number of female surgical residents. This number has been slowly growing with each year. Our results show 41.2% of female surgeon residents who pursuit a career in surgery were affected by presence of female surgeons in the field. Some authors have speculated that women may view a specialty as being more attainable and achievable if they see another woman in the same position (36). Other studies have shown similar trends of women choosing surgery as a career when there is a high proportion of female faculty members and female residents (14, 15). Organizational and social psychological research suggests that women might be subjected to greater scrutiny because they are pressured to represent their group, i.e., other women. Furthermore, women face more stereotypical threats in comparison to men. Therefore, women fear being judged more than men do. If that is the case, a more well-balanced gender composition in such a setting may increase women’s self-confidence, encouraging them to take part (37-39).
Working with seniors in the field
Interaction with residents was the most common factor influencing the choice of surgery as a career (28). In addition, our results show that women are more likely to be influenced by other female residents or surgical consultants if they worked directly with them. Interestingly, however, the overall influence of a female resident was more than that of a consultant. This trend also applied to male residents and consultants, but in reverse, with male consultants being more influential than male residents. Regarding differences between consultants and residents, other studies have also shown various patterns. One reported that consultant role models are more important than resident role models (18). This may be because consultants have overall more experience and skills in the surgical field. Other studies claim that residents outscored attending physicians in the eyes of students (40, 41).
We hypothesis that since surgical fields have traditionally been a male-dominated profession, it is not surprising to have male consultants have an influence in female residents more than female consultants did. With time the increased enrollment of female medical students in GS, increased the number of female surgical residents, that being said residents are usually more approachable and thus have an excellent positive influence on younger students. Another hypothesis is that residents are nearer in age to younger students, bringing their teaching methods and skills closer to the students’ level. This opens room for future application of peer training in addition to staff-led training, which may elevate the overall level of the learning experience.
Other influencing factors
In exploring the effect of other factors besides role models, our results show that a positive experience in core rotations highly encouraged residents to choose GS. It has been suggested that clerkship offers interaction with senior residents and attending surgeons who may serve as potential positive future role models (42). The study by Berman et al (42) supported this possibility when they found that surgical clerkship plays a large role in influencing career choice, possibly because actively participating in the operating room and seeing the specialty up close makes students feel more involved.
Our study also shows that work hours and residency lifestyle are the most negative influencing factors. These findings are similar to those from American studies in which work hours and lifestyle were chosen as factors that would discourage one from pursuing GS (4, 26, 43).
There are some limitations to this study. These findings are the opinions of the female surgical residents in Jeddah, KSA and opinions may vary geographically. So, we suggest undertaking studies on a larger scale by repeating the study on a larger group with various backgrounds and in different countries to extend these findings to eliminate selection bias. Secondly, this study has established the importance of surgical role models, but there is further work to be done as to how this can be positively used by the profession to encourage young women to embark on and persist with a surgical career, one way to assess that is by tracking student’s interest via sending a survey to them in their fifth year, then sixth, then the internship, then residency to see how their views and perception changing over time in presence of a surgical role model. Also exploring why medical students avoid surgery.