On the Last Frontier: Tracking the Paths of Women Surgeons
words by Eve Jacobs / photography by John Emerson
Rachana Tyagi, MD,
assistant professor, neurosurgery,
UMDNJ-Robert Wood Johnson Medical School
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omen are entering medicine in droves, making their mark in specialties ranging from rheumatology to dermatology, obstetrics/gynecology to emergency medicine, and from pathology to family practice. In general, women now make up half of all medical school classes, and when it’s time to choose their life’s work, they tend to fan out across a spectrum of specializations, cold-shouldering just a few. You don’t have to be a brain surgeon to figure out which fields they aren’t choosing — namely neurosurgery, orthopedic surgery, cardiothoracic surgery and several other surgical subspecialties — but the question that begs to be answered is: Why? Given the chance to “go to the head of the class” (the median salary for a neurosurgeon in the northeast U.S. is $445,300 and that of an orthopedic surgeon is $395,100), why are there so few women in these specialties? We went to the source — women who have chosen to weather the storms to reach the Alaska of medical specialties — to find out how they got there, and what they encountered enroute.
Role model, role model, role model. When buying a house, the mantra is location, location, location. When choosing a profession, it just might be knowing someone (and even better, admiring someone) who has successfully gone there before. That’s how it worked for Rachana Tyagi. How can you dream of becoming a neurosurgeon if you’ve never met a neurosurgeon, if you cannot visualize what a neurosurgeon does or crack open the door to peek inside his or her life?
With a father who is a surgeon and a family friend who was a neurosurgeon, Tyagi certainly had an inside view. “My father loved his work,” she says. “Since my mother stayed home, this was the only career path I knew as a child.” She also had a fascination with the brain that led her to Stanford University for a major in artificial intelligence, but the computer part bored her and the world of medicine still called.
Her years at the University of Michigan Medical School taught her, among other things, that immediate gratification is high on her list of priorities. “In neurology, there is a lot of diagnosis, but not a lot that you can do,” she says. “With surgery, you see immediately that you helped.”
Add to that Michigan’s “amazing chair of neurosurgery — the best ever,” who was also “very supportive of women,” and you can see how her choice was made. She also loved the “huge scope” of neurosurgical procedures, as compared to “only a small number in such surgical areas as ophthalmology and cardiothoracic.”
The seven year time commitment for residency was daunting, but doable, she decided, and she “matched” with Temple University’s program, which she began in 1998 and where she says her first two years were “VERY challenging, very hard, with really, really long hours. I had no life.”
She openly admits to spending “a lot of time crying” in her second year and says she often thought of quitting and going into radiology or anesthesiology, but “I couldn’t imagine doing anything else.” There were no other women residents or attendings in the neurosurgery program during her entire time there.
What was life like as a neurosurgical resident? A 90-hour work week during year one grew into a 120-hour work week for year two. Her workday started at 5:30 a.m. and she staggered through her apartment door between 10:30 and 11 p.m. seven days a week, ate dinner and fell asleep while studying, only to wake up in the dark the next morning and start the grueling schedule again.
Friends took pity on her, she says, and at the end of her second year, introduced her to a man they had hand-picked. Amazingly, it clicked and they married during her third residency year. “No, not a doctor,” she says. “He’s an engineer — and he made it possible for me to do all this.”
The following years were easier, she explains, and during year four, her research year, she gave birth to her first baby, a son. She used her accumulated vacation and sick time and was able to take four weeks off after giving birth. During year six, she gave birth to a girl — perfectly timed for her six months of research, and then stepped back into high gear as chief resident during the latter part of her sixth and the first part of her seventh year.
But Tyagi didn’t stop her training there. She completed two surgical fellowships — the first in orthopedic/spine at Shriner’s Hospital to become more proficient in scoliosis surgery, and the second in pediatric neurosurgery at Cincinnati Children’s Hospital, during which time she had her third child. “It was crazy for awhile,” she says. “For six months, we had a nanny in Philadelphia and a nanny in Cincinnati.” But Tyagi made it.
Now that she has a “real job,” what is her life like? “Intellectually stimulating and every day is different,” she says happily. “There’s so much we don’t know about the brain and spine. There are lots of research opportunities and you can make such a huge difference in people’s lives.”
So, what is her take on why women aren’t choosing this field?
Tyagi answers quickly: “Long hours, a long residency, the perception that it’s too hard for women — that it’s a macho field, that if you need sleep and don’t like people yelling at you, then you can’t do this.” How did she do it? “I knew it was going to be hard, but I like a challenge,” she says.
Her advice if you’re considering this profession: “You have to sacrifice a lot during your residency but make time for the things that are really important. Training is a defined time period and you’re going to be working for a long time after — 35 to 40 years. I wanted to do something that I really like.”
“A lot of women neurosurgeons don’t get married or have a family,” she continues. “I don’t know if it’s their personalities or if it’s because of their job. There’s still some of that macho stuff. There were some places that had job openings where I didn’t even get an interview.”
But as more female role models — like Tyagi — successfully balance their professions with family life, there will likely be more women who can see themselves doing the same.
Anne Mosenthal, MD, Trauma Surgeon: A Question of Lifestyle
Anne Mosenthal, MD,
associate professor, surgeryc
UMDNJ – New Jersey Medical Schoolc chief of critical care and director, Surgical Intensive Care Unit, UMDNJ-University Hospital
Anne Mosenthal, Dartmouth Medical School class of ’85, has gained perspective in the more than 20 years since she earned her MD. Her response to an email asking her to participate in this article was: “Sure. A topic near and dear to my heart.”
As one of 15 women in a class of 65, and one of less than a handful who chose surgery, she remembers being told: “Surgery is not for women. Well, maybe plastics — that’s OK for women.” But this graduate did not see her future in “plastics.”
“My sense was that women in surgery were pariahs,” she says, “that they were taken less seriously than men, but I was determined to defy the stereotypes.”
Life at Dartmouth was sweet for Mosenthal: “I loved everything about it from its small, nurturing atmosphere to the students, many of whom were older and had done many things, to being in an old world atmosphere where everyone was nice.” And while in snow country, she learned to ski.
But when she looked beyond the bounds of Hanover, NH, at the possibility of training to become a surgeon, she questioned if a quiet, unassuming woman (like her) would be accepted by the “classic surgical personality of the time — confidant, arrogant, never in doubt, usually right.” Lucky for her, the times were already changing.
She matched at the University of Massachusetts Medical Center, where she remembers feeling that “being a woman was not an issue. It was very tough and everyone was in this together.” Rethinking her words, she rephrases them: “At least it wasn’t professionally harder for a woman, but it was personally harder. Many of the men were married, and some had children, but very few of the women were married and none had children.”
With no limits on hours, and being “on call” every other night, Mosenthal says her social life “was my fellow residents — the camaraderie among us was so important.”
Of the eight interns accepted for the five-year surgery program, five were women, she recalls. “But of the five women who started, only two of us finished.” At the time, programs accepted residents on a year-to-year basis and weeded some out, a practice that is no longer allowed.
The two remaining female residents became best friends. Mosenthal says: “It would have been much harder if we didn’t have each other. There was only one woman faculty member in surgery.”
Mosenthal married a fellow surgeon when she was chief resident; and completed two fellowships — one in surgical critical care, the other in surgical endoscopy. She observes that over the years, the culture of medicine has become less macho, although it’s not perfect. “Our general surgical residency is about 40 percent women now,” she says. “But that’s not true for the surgical specialties.”
The issue, she thinks, is primarily a lifestyle one: “Women are not willing to give up their childbearing years.” Also, she says, there is a continuing “perception — that it’s really brutal. What is true is that in the training, all surgical specialties are more demanding in terms of time.”
Does she have regrets? “I think I made a good choice,” she says, “but there were periods when my kids were young that it was very hard to keep up with both my professional and family lives. I would be gone from home for 36 hours of ‘on call.’ If it hadn’t been for my husband, who not only provided a lot of childcare and took care of everything when I wasn’t around, but who believed in my potential and advancement even when I didn’t, I would never have made it. This kind of partnership is so little-talked about, but such a crucial element of success for women in competitive fields.”
The trauma surgeon notes that it’s much lonelier for women. “There are way fewer women than men who are colleagues who have a home life and children. It’s actually tougher after residency. When I was a resident, I threw myself into it. I knew that’s what I would be doing for five years —that’s what surgery demands.”
Mosenthal says she loves doing trauma surgery, caring for very sick people and dealing with the families. “I like all of it — it’s very gratifying.”
Then she recalls an image — or a long series of them — that have remained in her brain for decades. “When I started out, patients always assumed that I was the nurse, or the dietician. They never thought I was a surgeon. Now, that’s changed. It may be because I’m more self-confident and older — amazing what some gray hairs can do. But, perhaps, more importantly, there are far more women surgeons out here and everyone is getting used to that.”
Laurie Kirstein, MD, Breast Cancer Surgeon: The Old Boys’ Network
Is Starting to Break Down
Laurie Kirstein, MD, assistant professor, surgery, UMDNJ–Robert Wood Johnson Medical School
If you have a mental image of a surgeon, it certainly bears no resemblance to breast cancer specialist Laurie Kirstein. In her reception area at The Cancer Institute of New Jersey, women wait anxiously to discuss potentially life-changing surgeries. But what a surprise is in store for them — not only is the surgeon a young woman, but one whose tough training has not extinguished her “heart.” This surgeon has a lovely smile and a vibrant personality, and she feels just fine about showing them.
“Surgery has a reputation for beating you down,” she says. “Historically, women had to be very tough to make it through — no one wanted to be like that.”
A Brandeis University graduate in sociology, Kirstein did not make a beeline for medical school. In fact, she had no clue that doctoring was in her future. She highly valued her “warm and nurturing” undergraduate environment; and following college, her parents encouraged her not to rush into graduate school, but to work for awhile and figure out what she wanted.
Two years post-graduation — after working first in a private psychiatric hospital in Manhattan, then for Memorial Sloan-Kettering Cancer Center on an educational grant teaching doctors about cancer pain — she knew where she was headed, but it took her four more years to get there. Working during the day and going to classes at night, she completed the post-baccalaureate premedical program at Columbia University in three years. She then took her MCAT and spent her “lag year,” before starting medical school, working at the Hospital for Special Surgery.
Accepted to Downstate Medical School, Kirstein, a “people person,” found the third and fourth year clerkships to be “more my strength.” Science, she says, was not her forte, so the first two years were challenging.
What specialty called to her? “Well, I figured I would follow my heart,” she explains, “so I chose to get through my surgery rotation first, since I was so sure I would hate it.”
“But I just loved it!” she laughs. “I figured out I’m a hands-on, procedure-oriented, get-it-done kind-of-person.”
So, she applied to surgical residencies and matched with Albert Einstein. “I wanted to stay near my family. I needed their support,” she states.
The first year was as tough as she had imagined, “but internship is hard for everyone,” she says. “It was the second year that was so grueling.” On top of intensive residency demands, Kirstein helped care for her mother, who was ill and died that year. By her third year, “everything got better.”
When it came time to choose her surgical specialty, Kirstein considered two areas — pediatrics and oncology.
“Fellowships in breast surgery oncology were relatively new,” says the surgeon, and she was interested. What surprised her were the strongly negative responses from some of her male colleagues and advisors.
They said: “Why would you do that?” and “What a waste of training!” For someone less determined to follow her heart, the barbs might have cut too deeply. But Kirstein persisted. “Patients want women breast surgeons — and they need them,” she says.
In her personal life, Kirstein had reached the age of 33 and, still unattached, was questioning “What’s going to happen to me?” A friend encouraged her to sign up with Match.com and within a week, “my husband emailed and we were engaged in four months and married in January of my chief resident year,” she says, looking happily at his picture on her desk.
Fellowship training led her to Harvard, where she spent nine months at Massachusetts General and three at Brigham and Women’s Hospital. Despite having to deal with a long-distance relationship with her new husband, who practices law in Manhattan, “it was the best year of my training” she says.
“It taught me to be a great surgeon. The atmosphere was nurturing and wonderful.
"There were a lot of smart women surgeons with well-rounded lives and people respected them. I learned how to teach and how to make contributions to my field.”
So, when it came time to look for a permanent position, she wanted to be in a place “that cares for patients like Harvard does — it had to be collaborative, provide comprehensive care and offer clinical trials.”
She found that at The Cancer Institute of New Jersey in New Brunswick: “I love operating, love seeing patients, love the intellectual process of working with colleagues,” she says. “I’m the only woman [in the breast oncology surgical practice], but they don’t treat me differently. They respect what I do.”
Why don’t more women pick surgical specialties?
“The training is very grueling — physically and emotionally. The hours are long — although the 80-hour work week limit has made it a little better. A lot of people are not nice to you — it’s not kind and gentle. When you’re in med school, you see a lot of unhappy surgery residents — it’s a deterrent. For certain specialties, you have to do two years of research, so the residency is seven years. A lot of women don’t want that,” she answers.
“Surgery has a reputation for beating you down. Why would you want to go into that?”
Is it changing? “Well, you can’t throw instruments in the OR and get away with it anymore. It’s becoming less and less of an old boys’ network. Surgery is changing as more women go into it.”
Kirstein tells a story of what was allowed during the early years of her surgical training: “At my hospital, there was a surgeon who took away your house keys for two months while you were training there. He locked them in his desk. You lived at the hospital. The men had wives and girlfriends who brought them hot food and clean clothes, but the women…” She doesn’t finish her sentence.
Was it worth it? “I’m thrilled about the choices I’ve made. It’s extremely rewarding. To be able to say to a patient, ‘You have cancer, but we’re going to fix this. We’re going to take it out,’ is wonderful,” she says.
“If you are a woman who is competitive, detail oriented, and can take charge and make decisions, you can do this,” she says. “Your gratification will be delayed, but you just have to commit to it and see it through.”
Kathleen Beebe, MD, Orthopedic Surgeon: Misperceptions Still Abound
Kathleen Beebe, MD, assistant professor, orthopaedics,
UMDNJ-New Jersey Medical School
A competitive runner for most of her life, Kathleen Beebe’s interest in muscles and bones led her first to an undergraduate physical therapy degree from Hunter College in Manhattan, then to a first job at Sloan Kettering Cancer Center, “rehabbing” orthopedic patients with cancer, and on to medical school two years later at Columbia’s College of Physicians and Surgeons.
When choosing her specialty, she considered pediatric oncology, medical oncology and orthopedics. “Musculoskeletal anatomy always interested me,” she says, “as well as doing surgery that makes a difference in people’s function.”
The most interesting aspect of Beebe’s professional journey seems to be the absence of trauma in her personal life. She says her residency in orthopedic surgery and fellowship in orthopedic oncology at UMDNJ-New Jersey Medical School were “tough — a lot of work and a lot of hours. I would be here before 6 a.m. and not get home until 7 or 8 at night. If I was on call, I didn’t get home until 6 p.m. the next day. But I was treated fairly — like we were all on the same team. People were very nice.”
Add to that the fact the Beebe had two children during her residency and fellowship, but never missed a beat. “I was told the rules,” she says, “and we put together a schedule that worked.”
But despite her positive take on her experiences, she says that during her five years, there were 30 orthopedic residents, but only two other females, one in the same year and one two years ahead. So, why does she think more women aren’t choosing this field?
Beebe says one reason is a misperception about the need for physical strength. “Orthopedics is not a required rotation in medical school, so students do not get any exposure to it. There’s a misperception that it’s a bunch of really strong guys — like walking into a weight room. At times, it can be physically demanding, but it’s not about brute force. You need to coax things along.”
“I also think it’s the long hours and the seven year training after med school. A lot of my income went to supporting a full-time nanny, who worked very hard,” she explains. “And when I was on call on weekends, my husband did most of the childcare.”
“When you consider: ‘Do I want children? If so, how can I do all this?’ you just might give up. But I would certainly rather spend 12 hours a day doing what I love than eight hours doing something so-so.”
She also points to the fact that orthopedics is a very competitive match, requiring some background in research (Beebe did this during her summers in medical school), getting a good score on Step 1 of the USMLEs, and being a standout on clinical rotations during medical school.
“If anything, you don’t have fewer opportunities as a woman. Maybe you have a small advantage with so few female applicants.”
In her field of orthopedic oncology, Beebe operates on benign and malignant bone and soft tissue tumors in both children and adults. She works with radiologists, pathologists, medical oncologists and radiation oncologists — a team approach. Up to two of her days are spent in the OR, where one big surgery can last an entire day; two and a half days are spent in the outpatient clinic; and the rest of her time with residents, doing research and completing administrative tasks. She takes trauma call a few days each month.
“All the cases are interesting. It’s always a challenge — a diagnostic dilemma. What kind of tumor are you dealing with? That’s always an interesting part of my work. And the surgeries are complex. We take out large pieces of bone and do surgical reconstructions using metal and cadaver bone.”
Her advice to other women in medicine? “If you do something you’re passionate about — like I do — then it doesn’t seem like work.”
Now an assistant professor in the department where she trained, Beebe says that the residency program at NJMS is getting very good applicants, many of them women; and that the American Academy of Orthopedic Surgeons is trying to attract good female candidates into the field, and raise that 10 percent figure.
Beebe’s two sons, Aidan, now 4, and Casey, now 8, understand that their mother fixes broken bones, and Casey knows that when she’s “on call,” she won’t be home for quite awhile. She thinks that their early introduction to the demands of her field is definitely a positive. “They’re going to see firsthand that it’s OK for women to be in jobs that may be somewhat unique — and that sometimes their father will be there and their mother will be at work.”
So, What’s Keeping Women from Surgery?
Lack of role models and female camaraderie, the old boys’ network, lifestyle issues, and misperceptions about the surgical specialties were among the issues named by our UMDNJ women surgeons as crucial deterrents. Published research on this question agrees with them.
A paper in the September 2008 issue of the Journal of Neurosurgery, commissioned by the American Association of Neurological Surgeons and written by Women in Neurosurgery (WINS), says “long working hours; length of training; risk of litigation; and limited exposure to neurosurgery in the medical school curriculum” deter both men and women from choosing this field. The obstacles that only women name are: inequality in salaries, academic promotion, and leadership positions; lack of role models and “inadequate mentoring” for women; and medical students’ beliefs that women encounter more problems getting accepted into these residencies, and “may face harassment once accepted.”
Identifying a problem is a major step towards solving it. The four women interviewed for this article “made it” despite encountering a fair number of hurdles along the way. With their own experiences fresh in their minds, they — along with their counterparts nationwide — will be pivotal in fixing a gender imbalance that’s way out-of-step with our lives and times.