Why do real-life images of camouflage-clad women soldiers or female surgeons wearing scrubs make us more uncomfortable than the highly sexualized images of fictional women warriors, like Wonder Woman? Are many of us more nervous boarding a plane that will be piloted by a woman than a man? And why hasn’t a woman been elected to the highest office of the land? Does society believe female physicians are less qualified than male physicians?

In the 1960’s, less than 10% of entering medical students were women. Today, the percentage of women entering medical school each year has surpassed men. As a result, medicine is undergoing rapid change, yet vestiges of an antiquated physician code valuing men over women is ever present. Gender bias, discrimination, and even harassment remain deeply embedded in the culture of medical training and practice.

Women surgeons, in particular, who work in a stereotypical male environment, face unique obstacles. Take Karin Muraszko, MD, for instance, who is the first woman to head a neurosurgical department at any medical school in the US. Born with spina bifida, she was also the first neurosurgery resident with a physical disability. I recently had the pleasure of hearing her speak at the inaugural Physicians Moms Group Medical Conference this past weekend.

As any surgeon will attest, having a physical disability can makes a surgical career challenging. However, Dr. Muraszko did not see her physical disability as her largest hurdle. “People often ask me which is harder—being a woman neurosurgeon or having a disability as a surgeon. Being a woman was more difficult.”

Dr Muraszko recounted an anecdote from her first few weeks as an intern that illustrates the experience of blatant gender bias. A supervising attending was teaching a new surgical approach to trainees in her intern class. Wanting to capture their attention, he identified the anatomical landmarks on pictures of women naked from the waist up, an aspect of their bodies which was not essential. About halfway through the lecture, he paused, looked directly at Dr. Muraszko, and said, “Oh I forgot, you guys took a woman at Columbia this year.” As if that was a bad thing.

Dr. Muraszko is certainly not alone.

Research published in the New England Journal of Medicine last October explored the pervasiveness of sexual harassment, bullying and gender discrimination in the field of surgery, surveying more than 7,000 general surgery residents. Researchers found 32% reported gender-based discrimination, 16% reported experiencing racial discrimination, 30% reported verbal or physical abuse, and 10% reported sexual harassment.

And to be sure, discrimination comes in all shapes and sizes. Patients and their families are the most frequent source of gender and racial discrimination. Most retirement-age female surgeons can recount numerous experiences where patients preferred a male surgeon and asked them to leave the room. It turns out we, as a society, are chewing up and spitting out the youngest and freshest among us.

Ironically, statistics indicate that women make better surgeons than men. A large study published in the British Medical Journal compared the effect of surgeon gender on postoperative patient outcomes and found that female surgeons had the edge. Patients operated on by female surgeons had a 4% lower risk of complications and a 12% decrease in 30-day mortality rate. In other research, mortality rates in patients treated by female internal medicine physicians were 4% lower than men. While these differences are statistically significant, they may have less clinical importance. At the very least, statistically, female and male surgeons are equally capable.

Attending surgeons—who supervise resident trainees—were the most frequent sources of sexual harassment and physical or verbal abuse. The fact that medical training is hierarchical by design, leaves female surgeon trainees particularly vulnerable. One anonymous female surgeon shared in the study that a supervising surgeon “can assault you and get away with it since your career is in their hands.” One female surgeon practicing east of the Mississippi reported symptoms of depression to her hospital administration after being raped by a physician colleague and was ultimately forced to take a leave of absence due to developing a “mental health condition.”

Even once training is complete, female surgeons contend with discrimination and bullying and try to avoid receiving any unwanted attention associated with being a woman.  For instance, female surgeons often set ground rules, like “always wear a shirt under your scrubs or else male surgeons will look down at your chest.” How can female surgeons perform at their best when they are hampered by discrimination or abuse that negatively impacts the quality of their care?

Medicine has been described as “one of the loneliest professions,” with good reason. For female surgeons, working in the field can lead to feeling isolated and marginalized on the basis of their gender alone.   Karin Muraszko said, “it is harder to be a woman because we have to deal with what’s going on between someone’s ears, how they perceive me, and it’s something I cannot change. I can overcome a physical disability, but not make them respect me.”

I am reminded of the advertising slogan for Virginia Slims cigarettes: “You’ve Come a Long Way Baby!” Unfortunately, in our society, women physicians still have a long way to go.

If you wish to learn more about gender bias in medicine, I will be writing more about it in my next column.