Women are at least twice as likely to drop out of surgical training programs as men, fuelling concerns the prestigious profession is too patriarchal and in need of a cultural revolution.
Two months after the Royal Australasian College of Surgeons was accused of being an "Anglo Saxon boys club" new data suggests surgery is the last bastion of gender inequality in medicine.
While 52 per cent of medical students in Australia and New Zealand in 2013 were female, women make up just 9 per cent of fully qualified surgeons.
And although women account for 28 per cent of people entering surgical training, they are at least twice as likely to leave the programs compared to men, either for their own reasons or because they were terminated.
Ruth Mitchell, a neurosurgeon registrar at the Royal Melbourne Hospital, presented the data at the Royal Australasian College of Surgeons' annual congress this month, prompting some to question whether the field is biased against women in tests and assessments, does not provide enough flexible part-time work options, or has a culture that is unwelcoming to women at best, and repulsive to them at worst.
Dr Mitchell's presentation also showed that in 2014 women were least likely to be found in training programs for orthopaedic, cardiothoracic, neurosurgery and vascular surgery.
The only sub-specialty in which they were overrepresented was paediatric surgery. Women outnumbered men 17 to 13.
While the reasons for women exiting the program are now being investigated by an expert advisory group convened by the College of Surgeons, Dr Mitchell said about a quarter of 224 trainees surveyed said they would like more flexible working arrangements, which currently exist for only 0.9 per cent of trainees.
She said 20 women said they had been bullied or harassed in their last term compared to 10 men. Only two of these women and four of the men were willing to be contacted to discuss.
Dr Mitchell said it was worth asking whether assessments were biased against women because the University of Queensland had seen a dramatic drop in the number of women getting into medicine when it dropped an interview process to accompany the Graduate Medical School Admissions Test (GAMSAT).
"So is there a bias in what the GAMSAT is testing? How are we testing our junior surgical trainees? And in fact, how are we assessing progress? Are their gender biases in that? Do we have the expertise to know if we're biased? These are big questions and they're kind of scary," she said at the Perth congress.
Over the past three months, more than a dozen female surgeons have told Fairfax Media that they have experienced overt and subtle sexism, harassment and discrimination.
Some have been propositioned for sex by male superiors, some have faced regular comments about their appearance, one had been excluded from a male only golf event, and most were asked about their family plans both before they started their training and on the job.
However, other female surgeons say sexism is no more of an issue in their profession than it is in others. One neurosurgeon, Sarah Olson, said although she had experienced what some women would consider sexism – comments about the fact that she is blonde, for example – it has never bothered her.
She said in reality, surgery was a tough job that required enormous sacrifices, so "if you can't stand the heat, get out of the kitchen".
"If you're going to let things like that get to you maybe you shouldn't be a surgeon," she said.
"In some ways the training has to be hard… we are dealing with life and death every day."
A mother of three, Dr Olson said there were times where she was operating at 2am while heavily pregnant and that she had wondered if two premature births were linked to her excessive work hours. But she never resented these times because she was 100 per cent focused on getting through her training and doing her job properly.
"People choose to have families," said the Brisbane surgeon.
President of the Victorian Medical Women's Society Deb Colville said no matter how jovial or casual sexist remarks and behaviours may seem, they can discourage women from entering surgery or make them feel like imposters. She said orthopaedic surgeons seemed to be the most unwelcoming group for women, with some saying quite seriously that women's brains are "wired differently", making them unsuitable for the job.
Dr Colville, an eye surgeon, said while some male surgeons were making an effort to intervene when male peers exhibit sexism, surgery was a conservative field where the status quo tends to persist.
"We're not social activists," she said.
But Dr Colville said the college should be aiming for equal gender representation on all of its committees to increase female role models for younger women.
Melbourne plastic surgeon and former deputy of the college's women in surgery group, Jill Tomlinson, agreed and said the college could be promoting more women to its committees, board, and council, and telling its members precisely what sexism and discrimination looks like.
Dean of education for the college Stephen Tobin said he had seen no evidence of gender bias in examinations or other reasons why women may not perform well in training or leave the program. But he said it was not a particularly family-friendly medical specialty with its long hours, unpredictable over time and weekend calls to check on patients, and that this may be a factor.
Associate Professor Tobin said the college wanted to examine the reasons why women were leaving training in greater numbers than men, but had paused its work while the expert advisory group examines the culture in surgery and ways to prevent discrimination, bullying and sexual harassment.
In response to calls for more flexible training, he said it was difficult to find hospitals that would accommodate part-time positions and colleagues to job share with.
"Should we push the jurisdictions and hospital networks to create some part-time jobs? You could argue we should do that, but it's probably a discussion going forward," he said.
