Soliciting and receiving feedback is an essential component of leadership and professional development, particularly in the context of graduate medical education. For female surgical trainees, obtaining constructive feedback from colleagues and superiors may be more challenging than for their male counterparts. Women in the workplace are 1.4 times as likely to receive critical subjective feedback, instead of either positive feedback or critical objective feedback.1 Female performance is also more likely attributed to personality traits or characteristics rather than actual abilities.1-2
Despite modest progress over the past decade, women in surgery still face substantial gender gaps in academic promotion and financial compensation.4-6 Gender bias in performance reviews may lead to double standards at work and impact opportunities for advancement.1,3 On November 10-11, 2017, the Michigan Women’s Surgical Collaborative organized an inaugural conference to provide dedicated leadership training to female surgeons and trainees. Below is a summary of strategies shared at the conference that may help female surgery residents, like myself, obtain useful feedback and increase their leadership potential.
Understand your personality and how your behaviors are perceived by others
One of the most encouraging things that I learned at this conference was that female surgery leaders come from a broad range of backgrounds, and there is no single personality type that predicts success. Speakers and attendees included a diverse array of female leaders in surgery that were introverted, extroverted, quick/decisive, and slow/deliberate. Leadership training included didactic discussion regarding the strengths, weaknesses, and unique challenges associated with each personality trait.7
Women in surgery must be especially self-aware of their behaviors and how these behaviors are perceived by those around them. In order to improve emotional intelligence, women should strive to understand things that others see about them that they do not see themselves (a.k.a. the “blind self”).8-9 If traditional 360 degree evaluations do not provide enough contextual detail, women may consider performing a reflected best-self exercise, which involves comparing self-narratives of interactions to stories solicited from a network of trusted peers and evaluators.10-11 Finally, in addition to retrospective understanding of behavior and interactions, women should also strive to be more mindful of how psychological expectations and “mental models” influence their perception of other peoples’ behavior during interpersonal interactions and potentially influence their own behavior toward others.7
Identify opportunities for clinical and technical skill development and create a plan for growth
Assessment of competence in surgery is currently ill-defined and subjectively evaluated, lending itself to potential gender bias.12 The development of objective measures of autonomy, such as surgical milestones and entrustable professional activities (EPAs) have the potential to standardize resident experiences and reduce gender disparity among future trainees.13-14 However, many female residents may continue to experience gender related differences in operative autonomy and choose to internalize critical feedback rather than attempt to improve their educational experience.
A survey of 116 attending surgeons evaluated the importance of 13 different subjective and objective factors on resident autonomy in the operating room.15 Among the non-objective items at risk for potential gender bias, 2 were subjective evaluations of competence (recitable knowledge base, observed clinical skill), 2 were subjective assessments of personal characteristics (resident professionalism, resident confidence level), and 1 was an a-priori judgement made without any previous contact with the resident (resident reputation).15 Although female trainees may not be able to influence gender bias in the minds of some evaluators, they should be aware that gender bias in operative training exists and attempt to set objective clinical and technical educational goals within each rotation. Furthermore, by becoming more self-aware and increasing their emotional intelligence, female trainees may also improve their reputation and be seen as more professional and confident.
Conflict is an opportunity to learn and collaborate
Learning how to engage in healthy and constructive conflict is a critical component of leading high-functioning teams. Compared to destructive conflict that causes division among teams and decreases efficiency, constructive conflict encourages the exchange of ideas and builds relationships to solve a problem.16 Throughout surgical training many residents are taught to remain quiet, do as they are told, and avoid confrontation. Although avoiding conflict may improve clinical efficiency among hierarchical surgical teams during busy/stressful situations, this approach does not train surgeons how to become leaders of multidisciplinary teams or manage inevitable conflicts that arise during training and practice.
Research has shown men may be more prepared than women to handle and resolve conflict.17 This may lead to differences in post-conflict perception and disadvantage female satisfaction and reputation among peers in the workplace.18 Because conflict among peers and colleagues is inevitable, women should develop strategies to engage in constructive healthy conflict. The first step to accomplishing this is to embrace conflict and view it as a learning opportunity. Conflicts will rarely resolve themselves and if not dealt with proactively and properly can lead to damaging escalation that could have been prevented.
Strategies to encourage good conflict include listening to the alternate perspective and summarizing/clarifying the issues.16 Avoiding or failing to acknowledge other’s viewpoints will only lead to increased frustration and lack of engagement toward finding a solution. Women should avoid communication distractions and remain focused on the common goal to finding a solution. Finally, once the conflict is over women should quickly reconcile their emotions and embrace repair of the relationship with their colleague.17
Evaluate your core values to improve satisfaction and prevent burnout
Studies have shown that burnout disproportionately affects women, both in surgical practice and during residency.19-20 Potential reasons for this discrepancy include higher levels of work-home conflict and increased gender stereotypes that exact tolls on female psychological well-being.20-21 A recent survey of 566 surgical residents demonstrated that increased dispositional mindfulness was associated with a lower risk of stress, anxiety, depression, burnout, and suicidal ideation.19 Dispositional mindfulness refers to the innate ability to pay attention to one’s thoughts, emotions, and experiences in a non-reactive objective manner. It is a potentially modifiable personal characteristic that may confer resilience to stress.
During the MWSC 2017 conference, each participant took a survey to learn more about the driving forces that motivate their behavior and reaction toward conflict.7 When surrounded by people who share similar driving forces, most individuals will feel as though they fit in and become energized by their work. However, when surrounded by people whose driving forces are significantly different from their own, a person may be perceived as out of the mainstream and this can induce personal stress and conflict. As residents progress through training and make important career choices, they should seek mentorship to critically evaluate their own driving forces and the driving forces of their work environment to improve satisfaction and help prevent burnout.
Over the past 30 years, the feedback process for surgical training has transitioned from one-way critique to more of an active 360 degree dialogue between residents and attendings. Although several studies have explored ways to improve attending feedback to resident trainees, considerably less discussion has focused on ways residents can actively seek better feedback from their evaluators. This review highlights information and strategies shared at the 2017 MWSC conference that may help surgical trainees, like myself, engage their attendings to provide more concrete and constructive feedback. Although leadership training is not a formal part of most surgical residency programs, becoming an effective leader is necessary for everything we do (e.g., leading operating room teams, engaging with clinic staff, performing high level research, etc.). By understanding our mental models, personality, and behaviors we will be better positioned to interact with the world around us and with ourselves.
- Cecchi-Dimeglio P. How Gender Bias Corrupts Performance Reviews, and What to do About it. Harvard Business Review. https://hbr.org/2017/04/how-gender-bias-corrupts-performance-reviews-and-what-to-do-about-it. Published April, 2017. Accessed November 16, 2017.
- Snyder K. The Abrasiveness Trap: High-Achieving Men and Women are Described Differently in Reviews. http://fortune.com/2014/08/26/performance-review-gender-bias/. Published August, 2014. Accessed November 16, 2017.
- Silverman RE . Gender Bias at Work Turns up in Feedback: Research Suggests Women and Men are Assessed Differently, Affecting their Advancement. https://www.wsj.com/articles/gender-bias-at-work-turns-up-in-feedback-1443600759. Published September, 2015. Accessed November 16, 2017.
- Association of American Medical Colleges. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, 2013-2014. Washington, D.C., Association of American Medical Colleges, 2014. https://members.aamc.org/eweb/upload/The%20State%20of%20Women%20in%20Academic%20Medicine%202013-2014%20FINAL.pdf. Published 2014. Accessed November 11, 2017.
- Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H. The Climb to Break the Glass Ceiling in Surgery: Trends in Women Progressing from Medical School to Surgical Training and Academic Leadership from 1994 to 2015. Am J Surg 2016; 212(4): 566-572.
- Jena AB, Olenski AR, Blumenthal DM. Sex Differences in Physician Salary in US Public Medical Schools. JAMA Intern Med 2016; 176(9): 1294-1304.
- Dombrowski, Janet. “Understanding Your Personal Style: Leadership.” Michigan Women’s Surgical Collaborative Women in Surgery Leadership Development Conference, 11 Nov 2017, Graduate Hotel, Ann Arbor, MI.
- Roberts LM, Spreitzer G, Dutton J, Quinn R, Heaphy E, Barker B. How to Play Your Strengths. Harv Bus Rev 2005; 83(1): 74-80.
- Lee, Julia. “Bringing Your Best Self to Work: The Power of seeing Yourself through Others’ Eyes.” Michigan Women’s Surgical Collaborative Women in Surgery Leadership Development Conference, 10 Nov 2017, Graduate Hotel, Ann Arbor, MI.
- Wong, Sandra. “Emotional Intelligence: The X-Factor.” Michigan Women’s Surgical Collaborative Women in Surgery Leadership Development Conference, 11 Nov 2017, Graduate Hotel, Ann Arbor, MI.
- Ramani S, Konings K, Mann KV, van der Vleuten C. Uncovering the Unknown: A Grounded Theory Study Exploring the Impact of Self-Awareness on the Culture of Feedback in Residency Education. Med Teach 2017; 39(10): 1065-1073.
- Meyerson SL, Sternbach JM, Zwischenberger JB, Bender EM. The Effect of Gender on Resident Autonomy in the Operating Room. J Surg Educ 2017; Epub ahead of print.
- Surgery Milestones. The Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/Specialties/Milestones/pfcatid/24/Surgery. Accessed 1/17/18.
- ten Cate O. Nuts and Bolts of Entrustable Professional Activities. J Grad Med Educ 2013; 5(1): 157-158.
- Teman, NR, Gauger PG, Mullan PB, Tarpley JL, Minter RM. Entrustment of General Surgery Residents in the Operating Room: Factors Contributing to Provision of Resident Autonomy. J Am Coll Surg 2014; 219: 778-787.
- Kibbe, Melina. “Not All Conflict is Bad.” Michigan Women’s Surgical Collaborative Women in Surgery Leadership Development Conference, 11 Nov 2017, Graduate Hotel, Ann Arbor, MI.
- Benenson JF, Kuhn MN, Ryan PJ, Ferranti AJ, Blondin R, Shea M, Charpentier C, Thompson ME, Wrangham RW. Human Males Appear More Prepared than Females to Resolve Conflicts with Same Sex Peers. Hum Nat 2014; 25(2): 251-268.
- Women’s Network Australia. Managing Conflict in the Workplace: How Women Do It? http://www.womensnetwork.com.au/blog/managing-conflict-in-the-workplace-how-women-do-it. Published August, 2016. Accessed November 11, 2017.
- Lebares CC, Guvva EV, Ascher NL, O’Sullivan PS, Harris HW, Epel ES. Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience. J Am Coll Surg 2017; Epub ahead of print.
- Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan J, Freischlag J. Relationship Between Work-Home Conflicts and Burnout Among American Surgeons: A Comparison by Sex. Arch Surg 2011; 146(2): 211-217.
- Salles A, Mueller CM, Cohen GL. Exploring the Relationship between Stereotypical Beliefs and Residents’ Well-Being. J Am Coll Surg 2016; 222(1): 52-58.