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  Things improved significantly when Bridget took a year out to complete an intercalated degree in neuroscience. She loved the interdisciplinary nature of the field, and her studies spanned neurology, philosophy and physiology. In addition to gaining the top degree in the university, she won a national prize for her research project. At this point she seriously considered leaving medicine and moving straight on to a PhD in neuroscience. But as is often the case, her family and her tutors encouraged her to return to her clinical training, assuring her that her options would be so much greater if she qualified as a doctor. With marked reluctance, she followed their advice.

  Once Bridget had qualified as a doctor and completed the foundation programme, she had to decide on her specialty. With her stellar academic record, the breadth of her interests and the fact that she was highly dextrous, she had the pick of the bunch. In the end she opted for neurosurgery because it built on her earlier degree, required exquisite surgical dexterity, and would also allow her to contribute to interdisciplinary research into questions such as the origins of human consciousness. Given the competitiveness of the application process, Bridget didn’t expect to be selected the first time she applied – but she was. The only problem was that the post she was offered was in the north of England, in a university town where she knew nobody. She accepted the offer, and headed north.

  From the outset, her surgical supervisor made it clear that her face didn’t fit. When other members of the team were present, he personified charm, but when nobody else was around, he constantly reminded Bridget that he hadn’t wanted the position to go to a woman. Frequently he refused to let her join him in the operating theatre, so the only way that she could progress her neurosurgical skills was to approach other consultants and ask if she could ‘scrub in’ with them.

  As Bridget pointed out, you can’t become a surgeon just through studying textbooks in the library, in the same way that you can’t learn how to ice-skate through watching videos of the Winter Olympics. For both you need to practise, practise and practise. With surgery, however, senior surgeons control access to hands-on experience in theatre. Of course this is necessary in terms of safeguarding the patient: the consultant has to assess whether a given trainee has the skills to carry out a particular surgical procedure. But controlling access in theatre isn’t only about safeguarding patients – it’s also about safeguarding a particular conception of who should become a surgeon.

  Everything conspired to make Bridget feel unwelcome. She shared her office with the other trainees, all of whom were male. Sometimes, rather than going to the changing room, they would get undressed and change into theatre scrubs in the office. This made Bridget feel uncomfortable, but she didn’t want to make a fuss so she never complained. At other times she had to push away colleagues’ straying hands in theatre as they attempted to grope her breasts or pinch her bottom. When she attended academic conferences male colleagues phoned her hotel room at night, asking whether she would be willing to join them in bed.

  On one occasion Bridget overheard a senior colleague say, ‘Bridget is a naturally gifted surgeon.’ But she was never given any positive feedback to her face. She stayed in the job because she kept on hoping that things would change. They didn’t. So she was considerably relieved when the opportunity to do a PhD in London presented itself. She left the neurosurgical team and headed south to move into a research phase of her career.

  Bridget’s new research supervisor had recently been awarded a huge grant to carry out an international project across five research centres. With no prior experience of research administration, Bridget was left, with minimal supervision, to get the project off the ground. For the first year or so, although the workload was enormous, Bridget was relieved to escape the toxic harassment she had experienced in her earlier job. But the better she became at running the research project, the more trapped she started to feel.

  ‘If Bridget got pregnant, the whole project would fall apart,’ one of the senior consultants joked in a team meeting. Positive feedback – but not something that Bridget wanted to hear. The previous week she’d just had her first pregnancy confirmed. A month or so later, when she told her consultant, he was incandescent with rage. He would have to find somebody to take her place when she was on maternity leave.

  The day after she gave birth to her first child, Bridget made the mistake of checking her emails. Her supervisor had sent her an academic paper that urgently needed revisions within the next couple of days. Bridget replied that she couldn’t do the editing herself – she had a one-day-old baby. ‘I’ll write to the research funders and tell them about your lack of commitment,’ was how he responded. ‘This will ruin your research career,’ he continued.

  Shortly after her first pregnancy Bridget developed a rare autoimmune disease. She returned to work after four months, and got the research project back on track – but at a considerable cost to her health. A year or so later she became pregnant again and, second time round, she was off for six months after the baby was born. Following her return to work after maternity leave, her health deteriorated significantly. Yet she continued working, determined to see the project through. None of her colleagues (many of whom were doctors) expressed any concern about her. That she was physically exhausted seemed to have escaped their notice. ‘Can I have access to your database in case you die?’ one of them quipped after Bridget had had a brief period of hospitalisation.

  ‘Things got so bad that I felt that I couldn’t be a neurosurgeon and a wife and a mother,’ Bridget told me. ‘It was killing me, and ruining my family. I didn’t think it was worth it.’

  Eventually Bridget met somebody at a conference who worked for a biotechnology start-up. They were looking for a clinician with a background in neuroscience, and asked her to apply. After the interview they were so keen to snap her up that they kept the job open for six months to allow her to finish her PhD.

  ‘Would it have been different if you hadn’t had children?’ I asked. ‘Might you still be training as a neurosurgeon?’

  Bridget said she had allowed herself to leave because of the children. Despite the toll that neurosurgery training was taking on her own health, it was the impact on the children that ultimately proved the decisive factor.

  ‘In my old job I spent every second of the day doing things, but even then there wasn’t enough time for my work and my family. I was constantly exhausted. If I’d loved the work, I would have got two nannies and enough help to muddle through. But ultimately I decided I didn’t love the work enough to go down that route.’

  I asked Bridget what needs to change in order for women like her to survive in a specialty like neurosurgery. I anticipated that she would say something about greater sharing of family responsibilities within the home, or more effective sanctions against sexist bullying, or academic centres having more realistic expectations of the demands they can place on women with young children. But, being Bridget, she came up with something much more interesting:

  ‘We need to broaden our concept of who a surgeon is,’ she said, ‘so that it includes women who have different approaches to work.’

  ‘What do you mean?’

  ‘In both the operating theatre and the lab, I was made to feel that I didn’t fit in – that I didn’t belong. Prior to my surgical training, I was complimented on how I communicated with patients as well as with colleagues. Once I started surgery, nurses and other health professionals said the same. “We need more surgeons like you,” they said. But the surgical consultants told me that I wasn’t sufficiently “surgeon like” – despite the fact that there was never any criticism of my clinical skills in theatre. People wanted me to be somebody else. Somebody who I wasn’t.’

  ‘What did people say when you left?’ I asked.

  ‘Nothing. There was no exit interview. No one bothered to get in touch. I was erased from history.’

  Despite being appointed, against ferocious competition, to one of the most prestigious training programmes in the U
K, nobody was interested in why Bridget left.

  Recently I met up with Bridget, three months after she had started her new job. By most people’s standards she was working extremely hard; in addition to her demanding new role she had a train commute of two hours each way. But she used the commuting time for extra reading (she’s started an online Master’s in computational neuroscience) as well as sorting out family stuff.

  ‘My opinion is valued,’ she said. ‘People are interested in what I have to say. For the first time in years, I can be myself.’

  *

  In 1988 Isobel Allen published a study of women doctors1. Commissioned by the Department of Health, the study was based on face-to-face interviews with doctors (both male and female) who had graduated in 1966, 1976 and 1981. ‘Women were conspicuous by their absence’ in the higher surgical grades, Allen noted. Roll the clock forward to 2009 and the National Working Group on Women in Medicine, also commissioned by the Department of Health, concluded that ‘surgery is an area of particular concern, given the relatively low percentage of women in such a large specialty’2. This report then goes on to make nine recommendations – most of which are entirely predictable (improved access to mentoring, career advice, part-time working, flexible training, adequate childcare). These recommendations sound positive, but you couldn’t say they were forward thinking. Identical suggestions had been made twenty years earlier in Isobel Allen’s report.

  In fact many of these recommendations have been doing the rounds for thirty or forty years. Same old, same old, same old. But we are still in a position where a study published in the British Medical Journal in 2016 reported that3

  Trainees described negative attitudes from seniors towards pregnancy and maternity/paternity leave, and towards trainees – especially women – who wanted to work less than full time … Negative attitudes were most often reported to be from senior male doctors and/or in surgical specialties.

  It’s hard to escape the conclusion that all these government reports and academic papers and working groups are somehow missing the point. To use a medical analogy, if somebody is infected by the rubella virus, they may have a range of symptoms such as a red rash, fever, or swollen lymph nodes. You can treat the symptoms once somebody is infected (give paracetamol, for instance) and it will help the individual patient. But prescribing paracetamol isn’t going to reduce the incidence of rubella in the population. For that you have to tackle the underlying cause – the rubella virus – through population-based immunisation programmes.

  And it’s the same with treating the problem of women in surgery. The lack of role models and mentors, the prejudice against women working part-time, the bullying and sexual harassment are symptoms. They are not the end of the story. Treating the problem at this level is like dishing out paracetamol to patients with rubella. It will probably help a few women surgeons here and there, but to solve the problem you need to deal with the underlying cause – the professional culture of surgery – that, even in the second decade of the twenty-first century, remains hostile to women.

  If you want to understand a virus, ask a virologist. If you want to know how viral infections spread throughout a population, ask an epidemiologist. And if you want to know how the professional culture of surgery damages women’s careers you need to ask somebody who studies cultures – a social anthropologist or sociologist. It’s from their observations of surgery in action that answers can be found.

  Joan Cassell, a social anthropologist, studied the culture of surgery4. She did more than interview female surgeons however – she also scrubbed in and went into operating theatres. In total she observed thirty-three women surgeons over a three-year period. And what did she find? Not simply that the culture of surgery is essentially masculine, but that surgical culture embodies masculinity. In other words, this masculinity is expressed through the body of the surgeon. To understand the difficulties that women face in terms of ‘sexism’ is too abstract, Cassell argues. Too disembodied, in fact. Only by taking account of the embodied nature of surgical practice can you explain the visceral response that female surgeons such as Bridget can encounter – a response that tells them that they are the wrong body in the wrong place.

  Surgery is not the only occupation that embodies masculinity. Cassell mentions test-piloting and racing-car driving, grouping them together as ‘death-haunted’ pursuits. She doesn’t mention the military – but I would certainly add it to the list. It was not until December 2015 that women in the US military were allowed to serve in all front-line combat positions; the UK followed suit the following year, opening up front-line infantry and tank positions to female soldiers. If your line of work (racing-car driver, tank commander, surgeon) embodies what it means to be pre-eminently male in a particular culture, then the presence of a woman will be resisted.

  From my own observations in theatre, I was often struck by how extraordinary it was that one person (the surgeon) cuts into the body of another (the patient). Cassell graphically describes this physical nature of surgery: ‘During an operation the body of the surgeon makes brutal contact with the body of the patient, piercing the envelope of skin, assaulting the flesh, violating body integrity.’

  Of course this ‘brutal contact’ is inflicted for the patient’s benefit (as opposed to such contact by soldiers, where the aim is to benefit one’s country by wounding or killing the enemy). Surgical work (like front-line combat) embodies our cultural view of the characteristics of masculinity – decisiveness, the ability to take command, physical strength.

  This notion that surgery embodies masculinity also explains why female surgeons are treated with particular hostility during pregnancy. Cassell describes one female resident who needed bed rest towards the end of her pregnancy and who was threatened by her Chief Resident, who told her that her salary would be cut. This resident remonstrated with the Chief, pointing out that she had accumulated vacation and sick leave and that anyway the amount of time she was having away from the operating theatre was no greater than the amount taken by military doctors who were training alongside her. As Cassell comments:

  Taking time off for war is such supremely surgical behaviour that it goes almost unnoticed: the iron surgeon is by definition a warrior who engages in hand-to-hand combat with disease and death. Taking time off for pregnancy, on the other hand, is intensely unsurgical: being pregnant and having a baby designates one’s body as that of a patient or a wife.

  Through painstaking observations, Cassell witnessed how dramatic surgical ‘saves’ were valorised over compassionate, clinically informed surgical care. And even when women surgeons did perform dramatic surgical interventions, the male audience assumed that something must have been done wrong. As an example, one female resident told Cassell about a technically demanding surgical procedure she had carried out that had undoubtedly saved the patient’s life. This resident described the case in the weekly M & M (morbidity and mortality) meeting – a forum where adverse or exceptional outcomes get discussed by the whole surgical team. Despite the success of the surgery, she was criticised for tiny details, and her achievement was entirely overlooked. This was in sharp contrast to the response the following week to a male resident, who was widely praised for his role in a far simpler case. In the view of the female resident: ‘If I reported at M & M that I had resurrected Lazarus, they would ask me why I’d waited four days.’

  Unsurprisingly, Cassell concludes that female surgeons are in a ‘double bind’. If they’re not exceptional they probably won’t make it through their training. If they are exceptional they will be ‘the nail that sticks out and gets hammered in’.

  I couldn’t stop thinking how, twenty years after Cassell had carried out her observational research, all the key themes emerged from Bridget’s story: the way in which she was made to feel that she didn’t belong in the operating theatre; the hostility to her pregnancy; how her supervisors overlooked her undoubted surgical competence and instead criticised her compassionate patient care – to list just a f
ew examples.

  Cassell and other authors have shown that even the most exceptional female doctors may struggle against the power of a medical (and particularly surgical) establishment that remains deeply hostile to them. In terms of her achievements, Bridget was exceptional, but sadly in terms of her experiences, she was not. A study published in the American Journal of Surgery in 2016 reached the following conclusion:

  Over half the women in our study stated they felt they had been discriminated against, based on their gender5. Furthermore, the results showed that the perception of gender discrimination seemed to increase as they moved up through the ranks of medical student, to resident, and to staff surgeon.

  Another study, published in 2016 in the British Medical Journal, reported the following responses from trainee female surgeons6:

  The surgical environment is a male bastion, whether or not we like to acknowledge it. If it’s changed, it’s slowly but it’s still very, very male dominated. So maternity leave is a dirty word … I had this very negative reaction from my consultant at the time in the unit when I told them I was pregnant. Very negative. He chastised me for it … It was soul destroying.

  I’ve had people say to me, ‘You’re either a woman or a neurosurgeon, you can’t be both.’

  And according to Jyoti Shah, a consultant urological surgeon in the UK, female surgeons still encounter comments about menstruation in the operating theatre7. If they speak out, male colleagues might enquire ‘Is it the time of the month?’

  Whether the remarks are about periods or pregnancy, their frequency suggests that women are still being told, in one way or another, that they have the wrong body to train as a surgeon.

  *

  Of course it was far far worse for the female medical pioneers. In 1863 Elizabeth Garrett Anderson wrote to the Aberdeen Medical School, requesting permission to attend anatomy classes. This is the response she received8: