“He kept yelling at her with the [whole theatre team],” one participant said. “‘No you idiot. Don’t do it like this’ … they just blamed her for everything, even if it wasn’t her fault,” one of 12 former Australian and New Zealand female surgical trainees told the study authors. Loading Another described a male colleague waving his bare chest in front of her face saying “touch my nipples. You know you want to.” Other participants said there was a picture of sex positions pinned to a wall in the workplace, and sexist jokes were widely accepted. The female exodus from surgery was also driven by poor mental health, a lack of interactions with other women in surgery, fear of repercussions and a lack of opportunities for support.

“Ultimately I didn’t see more than two choices: kill myself or leave,” one former trainee said. “I seriously considered driving my car off the road. Twice,” said another. Being discouraged from getting pregnant or derided for having children were also crucial reasons women left training, according to the research, which was published in medical journal The Lancet. One former female trainee told researchers: "Bosses have said to them, to their face, 'I don’t think there’s any point in me training you because you’re going to get married and have kids and then what use are you going to be to this surgical service?'” Women make up roughly 60 per cent of medical students in Australia and New Zealand, yet just 11 per cent of consultant surgeons are female. Women are also leaving mid-surgical training in greater numbers than men, despite evidence that they may be more able applicants.

Lead author Gold Coast general surgeon Dr Rhea Liang said the myriad stresses on female trainees accumulated like a towering stack of blocks that would eventually topple. The reason past interventions had not been successful, she said, was because they focused on just one of those blocks. Dr Yumiko Kadota. “Look at Dr Kadota’s story. There was a combination of fatigue, bullying, and sexism, plus the demands of her physical and mental wellbeing,” Dr Laing said. Kadota, 31, resigned from her unaccredited registrar position at Bankstown Hospital’s plastic and reconstructive surgery department after being made to work up to 24 consecutive days on-call. She was dismissed as an “emotional female” and her pleas for support were ignored. Kadota crashed her car at the end of her last shift and was hospitalised for six weeks for sleep deprivation.

Addressing the inequities is a personal crusade for Liang, who almost quit surgical training for similar reasons. “It’s just abysmal,” she said. “How can this still be happening?” Female trainees also feared reprisal if they spoke up, the study found. And the inability to take leave because their reasons were deemed “invalid”, and the lack of support, opportunities and female role models, were also driving women out of surgical training. General surgeon Dr Rhea Liang said the stressors on trainees were like the blocks of a tower about to topple over. Credit:Gold Coast Health Liang said interventions designed specifically for women could do more harm than good. “They ‘other’ women and give the impression that they didn’t get to where they are on merit, and can make them the target of further discrimination and harassment,” she said. Kadota’s case did more than highlight surgery's gender problem. It exposed the vulnerability of unaccredited trainees, who do not enjoy the protections of specialist colleges. Several unaccredited male registrars who contacted the Herald described being similarly exploited.

Liang said a more sophisticated, multifactorial approach would improve surgical training for both women and men, considering several stressors, such as long working hours (and increasingly child-rearing), affected all trainees. Loading Liang is also deputy chair of the Royal Australasian College of Surgeons’ Operating Respect Committee, an initiative created in the wake of damning reports of sexual harassment in the specialty and an investigation by RACS that exposed an endemic, toxic culture. Some surgeons claim the problem is the “feminisation” of the specialty and believe the new generation of surgeons should “man-up” as previous generations have done. But several senior surgeons - male and female - have rubbished that claim, saying the inclusion of more women in surgery was modernising the profession.

Approximately 96 per cent of RACS fellows completed a mandatory respectful workplace online training modulewithin the past year. “Very few surgeons can argue they don’t know what inappropriate behaviour is,” Liang said. Roughly 600 fellows in leadership positions are also expected to attend face-to-face workshops, which cover advanced training and how to manage testing scenarios. The Herald understands several surgeons have resented being forced to attend the workshops and many are yet to do so. In 2017, RACS received 81 complaints related to discrimination, bullying harassment and sexual harassment. More than one-third of the complaints were about RACS fellows. NSW Health Minister Brad Hazzard has vowed to crack down on hospitals forcing doctors work untenable hours, putting themselves and patients at risk. But Hazzard says RACS and other medical colleges needed to hold their members to account to ensure they did not perpetuate the demand for junior doctors to work themselves into the ground. “Just because it has been done for 40 years doesn’t mean it should continue," he said.