Reinventing surgical careers for parents and carers

Women want to work in surgery, but it’s a career ambition many struggle to achieve (doi:10.1136/bmj.p449).1 Those that do start often leave. Surgery is notoriously inhospitable to women (https://www.nuffieldtrust.org.uk/research/future-proof-the-impact-of-parental-and-caring-responsibilities-on-surgical-careers).2 One study found that women made up 50% of newly qualified doctors but only 15% of surgical consultants. Previous reports have detailed the problems women face in surgical careers, with little effect on outcomes. In 2021 a Royal College of Surgeons review admitted its failures in advancing diversity and inclusion (doi:10.1136/bmj.n998).3

This verdict was misaligned with the rhetoric of opening up surgical careers, a verdict better suited to the era of Sir Lancelot Spratt. It was, at least, the beginning of a meaningful conversation. A new Nuffield Trust report finds that there is indeed a “positive commitment to change among stakeholders” (doi:10.1136/bmj.p449) but that problems identified last year by the royal college (doi:10.1136/bmj.02276) remain at every turn.14

Instead of a career that accommodates parenting and caring duties, surgery forces trainees to make difficult compromises in their personal lives. These challenges, from childcare to flexible working, are experienced across the health professions, contributing to working conditions that blight modern healthcare, and surgery remains perhaps the toughest in which to achieve work-life balance.

One disparity in the UK is that although the proportion of doctors in training who work less than full time has doubled in the past seven years, to 27%, surgery remains static at 7%. The Nuffield Trust report also finds that doctors’ requests for training posts during early surgical training were less likely to be accepted if they didn’t want to work full time. Such decision making inevitably discriminates against women, although combining parenthood and a surgical career is also difficult for men. The Nuffield Trust report does make a series of constructive recommendations for improving surgical careers for parents.

The wider issue is one of radical culture change in medicine, including primary care, to make it more compatible with modern working practices while delivering an appropriate level of service (doi:10.1136/bmj.p334).5 The chasm between what is best for patients and what clinicians across the health system are able to offer their patients becomes harder to bridge by the day (doi:10.1136/bmj.p470 doi:10.1136/bmj.p458 doi:10.1136/bmj.p459 doi:10.1136/bmj.p457).6789 Iona Heath and Victor Montori explain how an approach comprising “bread and roses” might form the basis of a better response to the crisis in care (doi:10.1136/bmj.p464).10

This crisis has at least two dimensions, care of patients and care of staff, and the two are inextricably linked. It is a system-wide dysfunction made worse by a chasm between what is best for clinicians and what politicians are willing to offer to improve clinicians’ working conditions and pay (doi:10.1136/bmj.p466 doi:10.1136/bmj.p474).1112 The day-to-day interactions of health systems are complex and are best managed by people who understand those complexities. Politicians’ distance from the realities of the health service—if you are in doubt, the leaks from Matt Hancock’s WhatsApp messages will convince you (https://www.bbc.co.uk/news/uk-politics-64807127)13—is neatly captured by their willingness to pay senior Deloitte staff £6000 a day for a pandemic test and trace system that “largely failed to meet its targets” (doi:10.1136/bmj.p444).14

Achieving diversity in the workforce and fairness in care delivery are fundamental requirements, whose absence manifests in many ways, such as slowing progress on maternal mortality (doi:10.1136/bmj.p454),15 reinforcing inequities in surgical outcomes (doi:10.1136/bmj-2022-073290),16 adopting discriminatory health policies (doi:10.1136/bmj.p341),17 and failing to tackle exploitation of vulnerable individuals by international organisations (doi:10.1136/bmj.p410).18 These are entrenched challenges, among which is the seemingly unbridgeable divide between being a surgeon and a parent— yet, as with all that we face today, we must find our way across.