Another All-Male Conference Panel?

On June 29, 2018, the Society of Surgical Oncology tweeted a photo from the Global Forum of Cancer Surgeons. The image depicted 24 surgeons, every one of them a man—what’s known derisively as a ‘manel,’ an all-male panel. The accompanying tweet said the forum’s mission was to provide a voice for cancer surgeons to improve surgical care for patients with cancer.

Lesley Barron, MD, a general surgeon from Canada, was among the first to reply directly to the tweet. “Are there seriously no female surgical oncologists who could have been added to make this not a #Manel? And a large one at that. #Genderbias,” she wrote.

Dozens of surgeons, most of them women but also many men, added their voices to her criticism, making it one of the larger social media protests against manels in medicine this summer.

On social media, women and men are calling out more organizations across different industries for putting together programs that lack diversity, and for featuring an overwhelming number of male and/or white speakers. The hashtags #manels, #genderbias and #YAMMM (yet another mostly male meeting) are growing in popularity.

Those calling out sex bias aim to increase inclusivity and representation in fields like surgery where women and minorities have historically been greatly underrepresented, and remain so today.

For the first time, a group of researchers in surgery has put some numbers to this pattern at surgical meetings—showing, indeed, a preponderance of men on the program at annual meetings for major surgical societies.

The researchers looked at 14 surgical societies and their annual meetings in 2011 and in 2016. They found a wide variation in inclusion of women in meeting programs, but no statistically significant change in the proportion of women in plenary speaker roles between 2011 and 2016. Four of 14 societies had no women plenary speakers in both 2011 and 2016.

The percentage of manels ranged from 0% to 100% among surgical societies in both 2011 and 2016. Three societies, which were not identified, significantly decreased their percentage of manels over this five-year period, whereas the rest remained unchanged.

Katherine Gerull, an MD candidate for the class of 2020 at Washington University School of Medicine in St. Louis, presented some of the data at this year’s annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Arghavan Salles, MD, PhD, an assistant professor of surgery at Washington University School of Medicine in St. Louis and a senior researcher on the study, said, “For most organizations, there doesn’t seem to be a real difference between the representation of women in 2016 compared to 2011, although there are some exceptions to that.

“The main take-home points of this study are that there are often not very many women, certainly in plenary speaking roles. There are often more women in session speaker roles, and for moderators or panelists. But we have a long way to go in general.”

The study grew out of a Twitter discussion in 2016 among a handful of surgeons, men and women, regarding the poor representation of women and minorities at national meetings in surgery.

The group—which included Amalia Cochran, MD, a professor of surgery at the Ohio State University, in Columbus, and Andrew Wright, MD, the director of the University of Washington’s Hernia Center, in Seattle—set out to compare representation of women at meetings to the percentage of women in each society.

They were surprised at how few organizations tracked sex and the race/ethnicity of their members, making it impossible to know whether or not meetings fairly represent surgeons.

“It would make sense to track gender, race, ethnicity and sexuality at the very least so that programming can be open-minded and relevant to all groups. In addition, tracking can help societies identify whether they are missing a part of their target audience,” Dr. Salles said.

For example, if a particular specialty has 40% women practitioners but only 20% of the society’s membership is women, they are not adequately reaching the population they’re intending to serve.

Despite trying persistently for two years, researchers were unable to get relevant society membership data for 11 of the 28 conferences assessed in this study.

The value of diversity in medicine is well established, with benefits to both the profession and patients. The American Surgical Association, in a report authored by a special task force in the fall of 2018, called for increased diversity in the surgical workforce. Cultural competence, they noted, has been shown to result in better health outcomes for the patient and health system, while providing fair and equitable health care regardless of race/ethnicity, sex or culture (Ann Surg 2018;268[3]:403-407).

Dr. Wright, one of the surgeons behind the study presented at SAGES, said all surgeons ought to have the same opportunities available to them, regardless of sex or ethnicity.

“It’s a matter of fundamental fairness along with the recognition that there’s been some historic discrimination against both women and underrepresented minorities, both implicit and explicit bias that has really created this environment,” he said.

“I actually do think that increasing diversity in medicine is a good thing. When you have a very uniform workforce, you tend to get trapped into sort of traditional ways of practice and ways of thinking. And what we see is that when we increase diversity, we see the entire profession benefit.”

The study also showed that surgical societies vary widely in their commitment to taking on diversity. Although none of the societies in the study were identified, surgeons credited several organizations with leading changes within their representations, particularly SAGES, the Eastern Association for the Surgery of Trauma, the Association for Academic Surgery and the Society of University Surgeons. Recently, the ASA, the country’s oldest surgical association, declared diversity and inclusion a priority, having trailed behind other societies in the promotion of women to positions of leadership.

“I don’t think every society is there yet, but representation of women at meetings is becoming more of a mainstream topic to talk about. People are starting to notice. Just the fact that there’s awareness and people know that it’s going to be scrutinized has led to change and intentionality around it,” said Dana Telem, MD, MPH, an associate professor of surgery, associate chair for clinical affairs and the director of the Comprehensive Hernia Program at the University of Michigan, in Ann Arbor.

Midcareer surgeons and trainees, especially, will benefit from more diversity at meetings, she said. “If you don’t look up at a panel and see yourself or see somebody like you, it becomes hard to envision that you can do it. We all know from all the literature that it’s the accumulation of these small disadvantages that ends up leading to achievement gaps.

“I can tell you something for me personally. I don’t believe I ever saw a pregnant woman on a podium, which is why, when pregnant, I traveled to every conference where I had been invited to give a talk. Just in case there’s one person out there who saw me and thought, ‘She’s pregnant and she’s talking, and they’ve accepted her.’ To me, that’s role modeling.”

Talking about diversity isn’t enough; the culture of surgery won’t change without intentional movements from surgical leadership, which is still predominantly male and white, said Giana H. Davidson, MD, an associate professor of surgery at the University of Washington, in Seattle.

“If we really are going to promote diversity of thought and an equitable invitation to people, it requires an actual checkbox that we’re thoughtful about. The way that I’ve gotten on stages early in my career was credit to more senior and, in many cases, male mentors who said, ‘I’m not able to meet that conference, but let me introduce you to someone who is an expert in this.’”

Dr. Davidson said, “If it’s one person up there, that becomes tokenism. We need to build a culture of inclusion in which you’re being thoughtful and intentional about who you put up there. That’s how you change the culture.”

A 2017 study spanning 20 industries showed the importance of leadership by white men when it comes to changing unofficial limitations for women and ethnic minorities (Acad Manage J 2017;60[2]:771-797). It showed ethnic minority and female leaders who value diversity tend to be negatively stereotyped and receive lower performance ratings. “Somewhat counterintuitively, our findings suggest that organizations seeking to advance the standing of minorities and women might consider having a white male spokesperson for the diversity office.”

Several surgeons who were interviewed said male surgeons could improve diversity by refusing to participate in manels. Dr. Wright said he has participated in some manels, but, in the last two years, he’s declined opportunities to speak on all-male panels. Instead, he provides the names of women who could fill the role.

Keith Lillemoe, MD, the chief of surgery at Massachusetts General Hospital, in Boston, said he wouldn’t refuse to participate in a panel of only men. “But, on the other hand, if I’m picking a panel, I’m certainly going to be conscious of it.”

In 2017, during his presidential address to the ASA, Dr. Lillemoe called for surgeon leaders to do more to support the careers of women in surgery, saying the major challenge for surgical mentoring now and in the future is “advancing the careers of the dramatically increasing number of female surgeons.”

One way to do so, he proposed, was to increase both membership and involvement of women in the leadership of the ASA and other surgical organizations.

In his speech, he called out the ASA for lagging behind other organizations with respect to leadership, having had only one female president in the then 137 years of the association. Its second female president, Robin S. McLeod, MD, from the University of Toronto, will take the helm in 2019.

In an interview, he said the pace of change has picked up in surgery but still falls short. “The number of women who’ve been named chairs of surgery in the last two years has quadrupled almost, and people are starting to say the pendulum has swung fairly dramatically from a vast majority of men to an increasing percentage of women.

“I think that most people realize that all surgical organizations have been a bit slow, and most surgical departments have been slow.”

One area yet unstudied is representation of women and minorities at industry-sponsored meetings. Anecdotally, surgeons say the discrepancy is even more pronounced at industry meetings. Researchers recently reported that, of the 100 physicians receiving the highest compensation from 10 large surgical and medical device companies, 88 were men (JAMA Surg 2018 Aug 15. [Epub ahead of print], doi: 10.1001/jamasurg.2018.2576).

“It’s extraordinarily rare that I see an industry event where there’s a woman speaker as one of the sort of featured persons,” Dr. Telem said.

True diversity will require more than an increase in representation in women and minorities at the highest levels of meetings. It must be accompanied by a change in what they are asked to discuss, said Sareh Parangi, MD, a professor of surgery at Massachusetts General Hospital and the president-elect of the Association of Women Surgeons.

“I do see some women being invited as speakers to only speak about women’s issues, instead of come to a meeting to talk about your spectacular research or how to repair a hernia or the actual medical stuff and surgical stuff that you’re an expert at.

“Diversity is kind of a hot topic, and every meeting wants to have someone talking about these kinds of things so they seem more modern, more equitable and more inclusive, which is a good thing. But I think that that can sometimes backfire because sometimes the male colleagues at these meetings don’t bother going to those talks. And if they do, they say, ‘Oh, this is all the women surgeons want to talk about.’”

Ms. Gerull, the medical student who was a co-author on the study, is considering surgery as a career and said the statistics regarding women in surgery, particularly at the highest levels, can be discouraging.

“As a profession we need to be reflecting on the numbers and asking, ‘Why is this happening?’ That is what drives me toward this field: knowing that I can study these problems and bring about positive data-driven change.”