- Email: [email protected]
A Questionnaire to Assess the Challenges Faced by Women Who Quit Working as Full-Time Neurosurgeons
Journal Pre-proof A questionnaire to assess the challenges faced by women who quit working as fulltime neurosurgeons Taketoshi Maehara, M.D., Ph.D., Kazuko Kamiya, M.D., Ph.D., Takamitsu Fujimaki, M.D., Ph.D., Akira Matsumura, M.D., Ph.D., Kazuhiro Hongo, M.D., Ph.D., Satoshi Kuroda, M.D., Ph.D., Mitsunori Matsumae, M.D., Ph.D., Hideo Takeshima, M.D., Ph.D., Nobuo Sugo, M.D., Ph.D., Naoyuki Nakao, M.D., Ph.D., Nobuhito Saito, M.D., Ph.D., Fusao Ikawa, M.D., Ph.D., Noriko Tamura, M.D., Ph.D., Kaori Sakurada, M.D., Ph.D., Shoko Shimokawa, M.D., Ph.D., Hajime Arai, M.D., Ph.D., Kaoru Tamura, M.D., Ph.D., Kazutaka Sumita, M.D., Ph.D., Shoko Hara, M.D., Ph.D., Yoko Kato, M.D., Ph.D., On Behalf of The Gender Equality Committee of the Japan Neurosurgical Society PII:
S1878-8750(19)32200-4
DOI:
https://doi.org/10.1016/j.wneu.2019.08.045
Reference:
WNEU 13081
To appear in:
World Neurosurgery
Received Date: 3 July 2019 Revised Date:
31 July 2019
Accepted Date: 1 August 2019
Please cite this article as: Maehara T, Kamiya K, Fujimaki T, Matsumura A, Hongo K, Kuroda S, Matsumae M, Takeshima H, Sugo N, Nakao N, Saito N, Ikawa F, Tamura N, Sakurada K, Shimokawa S, Arai H, Tamura K, Sumita K, Hara S, Kato Y, On Behalf of The Gender Equality Committee of the Japan Neurosurgical Society, A questionnaire to assess the challenges faced by women who quit working as full-time neurosurgeons, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.08.045. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier Inc.
A questionnaire to assess the challenges faced by women who quit working as full-time neurosurgeons Taketoshi Maehara, M.D., Ph.D.*a, Kazuko Kamiya, M.D., Ph.D.b, Takamitsu Fujimaki, M.D., Ph.D.c, Akira Matsumura, M.D., Ph.D.d, Kazuhiro Hongo, M.D., Ph.D.e, Satoshi Kuroda, M.D., Ph.D.f, Mitsunori Matsumae, M.D., Ph.D.g, Hideo Takeshima, M.D., Ph.D.h, Nobuo Sugo, M.D., Ph.D.i, Naoyuki Nakao, M.D., Ph.D.j, Nobuhito Saito, M.D., Ph.D.k, Fusao Ikawa, M.D., Ph.D.l, Noriko Tamura, M.D., Ph.D.m, Kaori Sakurada, M.D., Ph.D.n, Shoko Shimokawa, M.D., Ph.D.o, Hajime Arai, M.D., Ph.D.p, Kaoru Tamura, M.D., Ph.D.a, Kazutaka Sumita, M.D., Ph.D.a, Shoko Hara, M.D., Ph.D. *a, Yoko Kato, M.D., Ph.D.q On Behalf of The Gender Equality Committee of the Japan Neurosurgical Society a
Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45
Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Japan Medical Association Research Institute, 2-28-16 Honkomagome Bunkyo-ku, Tokyo 113-8621 Japan c Department of Neurosurgery, Saitama Medical University Hospital, 1397-1, b
Yamane, Hidaka-City, Saitama, Japan Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan e Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 d
Asahi, Matsumoto, Nagano 390-8621, Japan Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama 930-0194, Japan g Department of Neurosurgery, Tokai University School of Medicine, 143 f
Shimokasuya, Isehara-shi, Kanagawa 259-1193, Japan Department of Neurosurgery, Miyazaki University, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan h
i
Department of Neurosurgery (Omori), School of Medicine, Toho University,6-11-1, Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan j Department of Neurological Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama 6411-8509, Japan k Department of Neurological Surgery, Tokyo University, 7-3-1 Hongo, Tokyo 1
113-8654, Japan l Department of Neurological Surgery, Shimane Prefectural Central Hospital, 4-1-1 Himehara, Izumo, Shimane 693-8555, Japan m Department of Neurological Surgery, Tokyo Women’s Medical University, 8-1, Kawadacho, Shinjyuku-ku, Tokyo 162-8666, Japan n Department of Neurosurgery, Yamagata University Faculty of Medicine, 1-41-12 Kojirakawa-machi, Yamagata-shi, Yamagata 990-8560, Japan o Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga-shi, Saga 849-8501, Japan p Department of Neurosurgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan q Department of Neurosurgery, Fujita Health University BANTANE Hospital,3-6-10, Otobashi, Nakagawa-ward, Nagoya city, Aichi 454-8509, Japan *Authors with equal contribution to this work. Corresponding author: T. Maehara, MD, Department of Neurosurgery, Tokyo Medical and Dental University 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Telephone: 81-3-5803-5266 Fax: 81-3-5803-0140 e-mail address: [email protected]
Key words: balancing career and family, full-time neurosurgeon, physical burden, reinstatement, woman neurosurgeon, work-life balance Running title: Women Neurosurgeons in Japan
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Abstract Objective: To analyze why women quit full-time employment as neurosurgeons and to discuss the conditions required for their reinstatement. Methods: We asked 94 core hospitals providing training programs in the board certification system adopted by the Japan Neurosurgical Society, to indicate the total number and present status of women in their department, and to send our anonymous questionnaire to women who had formerly worked as full-time neurosurgeons. The questionnaire consisted of closed and open questions on their reasons for quitting as full-time neurosurgeons. Results: Among 427 women evaluated, 72 (17%) had quit full-time employment as neurosurgeons. Twenty-one women who had quit three to 21 years after starting their neurosurgery careers responded to the questionnaire, including 17 board-certified neurosurgeons, 11 individuals with master’s degrees and 16 mothers. Their main reasons for quitting full-time work were difficulty in balancing their neurosurgical career and motherhood (52%) and the physical burden (38%). At the time of quitting, only two (5%) units had a career counseling system for women. Two-thirds of participants might resume full-time work as neurosurgeons in the future. Their support system during pregnancy and the child-raising period, and understanding of male bosses and colleagues were identified as the key themes. Conclusion: The Japan Neurosurgical Society could facilitate supportive environments for women in neurosurgery by enhancing adequate childcare services, change the workstyle of full-time neurosurgeons to incorporate diverse working styles, shorter working hours, understanding of their bosses and colleagues, and career counseling system.
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Introduction Many people find it challenging to balance their career and family needs,1 especially women in medicine.2,3 The Japanese medical system is reported to be one of the best in the world4, but it is ranked very low among other countries in terms of the Gender Gap Index.5 The low Gender Gap Index ranking attributed Japanese women’s employment rate, with its M-shaped curve, indicating that many women in the child-bearing age range of 25-45 years quit their jobs because of marriage, pregnancy and childbirth, and motherhood.6 This tendency is similar among all women in medicine, regardless of their specialties.7,8 Although the majority of medical students in the United States in 2016 were women, sexism and maternal discrimination were still reported.2,9 In Japan, the number of women in medical schools has increased to 30%, but this is still lower than that reported in other countries.10 The number of women in the Japan Neurosurgical Society has increased to as many as 600 around 2018, with 12% of new members being women; however, the total number of women in the society remains below 5%. The Japan Neurosurgical Society established the Gender Equality Committee to address various gender-related problems in 2015. As a first step, we have previously reported on the working conditions and lifestyle of women affiliated with the Japan Neurosurgical Society;11 we administered questionnaires to 224 women and 496 departmental heads and concluded that women neurosurgeons appreciated a more understanding attitude from their peers and departmental heads. As the next step, we aimed to analyze the reasons that women neurosurgeons quit full-time employment and to discuss the conditions required for their reinstatement. We specifically focused on women who had quit their full-time employment as neurosurgeons following a number of reported gender-related problems12-15 that might interfere with their neurosurgical careers. In addition to closed questions, our new questionnaire included open-ended questions to allow for more vivid, detailed and understandable responses.
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Methods This work was approved by the ethical committee of The Japanese Neurosurgical Society. Questionnaires were sent to 94 core hospitals providing training programs in the board certification system adopted by the Japan Neurosurgical Society, to determine the number and present work-status of women in their departments. In the questionnaire, the hospital manager was required to provide the number of women neurosurgeons in full-time and non-full-time/part-time work. Full-time neurosurgeons in this study were defined as those working in the neurosurgical hospital every weekday; women engaging only in the outpatient clinic and those who were pregnant or on maternal leave for less than one year were also included as full-time neurosurgeons. Non-full-time/part-time neurosurgeons were defined as women who had quit employment as neurosurgeons as well as those who chose short working hours in neurosurgical hospitals. Continuing the survey, we requested the participating hospitals to distribute an anonymous questionnaire to women categorized as non-full-time/ part-time neurosurgeons. The questionnaire consisted of seven sections with closed and open questions as in Table 1: I) About yourself, II) At the time you started your career as a neurosurgeon, III) Career plan and a counseling system, IV) The time you decided to quit being a full-time neurosurgeon, V) Your career after you quit working as a full-time neurosurgeon, VI) To be a full-time neurosurgeon again, VII) For future women in neurosurgery (Table 1). Participants were informed that their participation was voluntary, anonymous, and confidential. The working group was guaranteed that the data would be used solely for the purpose of this study, and would never be presented or published in a manner that could reveal individuals’ identities. The completed questionnaires were returned to the Japanese Neurosurgical Society by e-mail, and receipt of the completed questionnaire was considered to demonstrate consent to participate. The data were first gathered and collected in the office of the Japan Neurosurgical Society, and members of the working group evaluated the aggregated data. The answers to the closed questions were counted and percentages calculated. The free-text responses to the open questions were collected and categorized according to the main concepts contained in the answers. 3
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Results
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Among the 94 training hospitals, 75 provided the number of women working as neurosurgeons in their department. Ten board training hospitals had registered more than 10 women, 25 had registered five to nine women, and 33 had registered one to four women. There were no women neurosurgeons in
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seven of the hospitals (Fig. 1). Among the 427 women covered in this study, 72 (17%) had quit their jobs as full-time neurosurgeons. The questionnaire was sent to 60 women who had quit working as full-time neurosurgeons, who could be contacted through e-mail or letters via the hospital they work or used to work at; we obtained 21 responses and 39 did not respond (Fig. 2).
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Analysis of closed questions In terms of background, 17 (81%) participants were board-certified neurosurgeons and 11 (52%) had M.D. and Ph.D. degrees. They had quit full-time work within three to 21 (mean 10) years of becoming neurosurgeons. At the time of answering the questionnaire, 16 (76%) had children, including 13 infants under the age of one year (Fig. 3A-C). Fig. 4A shows the reasons that participants chose to be neurosurgeons. Sixty-three percent (13/21) thought that working as a neurosurgeon would be worthwhile and that they wanted to perform surgeries (63%, 13/21) when they started their neurosurgical careers. However, at the time they chose their career, they had worried that neurosurgeons might have little personal and/or family time (52%, 11/21), carry heavy physical burdens (52%, 11/21), and that they would have few women neurosurgeons as colleagues (38%, 8/21) (Fig. 4B). Their main reasons for quitting full-time work were the difficulty in balancing between one’s neurosurgical career with motherhood (52%, 11/21) and physical burden (38%, 8/21) (Fig. 5). Most quit to prioritize another aspect of their lives, such as family or other work (62%, 13/21). Only two (5%) centers had a proper career counseling system for women working as neurosurgeons (Fig. 6A), but in those centers male superiors and colleagues managed the counselling units. This fact indirectly reflected a lack of approachability (Fig. 6B). In the concluding part of the questionnaire, the respondents were asked about their future plans and desirable conditions for their reinstatement to 4
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full-time work. Among twenty-one women, three (14%) had a concrete plan to return to full-time work as neurosurgeons, nine (41%) answered that they would someday return to full-time work, and two (9%) hoped that they would return if possible. Thus, two-thirds of the women neurosurgeons considered the possibility of neurosurgical reinstatement (Fig. 7A). They suggested the reinstatement conditions include shorter working hours, understanding of their working style by their colleagues and bosses, and sufficient childcare services (Fig. 7B)
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Answers to the open questions Twenty-one respondents were interested in various neurosurgical subspecialties, including emergency surgery for cerebrovascular diseases, pathophysiology of brain tumors, endovascular surgery, epilepsy, and functional neurosurgery. Most of these women had wanted to work as full-time neurosurgeons until their retirement (Table 2). However, they encountered many difficulties, including physical burden, overwork, difficulty balancing their career and family lives, and lack of support during women-specific situations to continue their career as full-time neurosurgeons (Table 3). Some of them viewed a career counseling system to be necessary, while others remarked that the career counseling system alone is insufficient (Table 4). The majority quit working as full-time neurosurgeons to achieve a better work-life balance (Table 5). According to their responses, a change in the workstyle of full-time neurosurgeons, support from colleagues and bosses, diverse working styles, and adequate childcare services would allow them to continue working as full-time neurosurgeons, and would be necessary for their reinstatement (Table 6). Additionally, some of them hoped for an improved situation for future women working as neurosurgeons, while others were interested in the results of this questionnaire (Table 7).
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Discussion Our survey results demonstrate that our participants were highly motivated neurosurgeons who chose their careers purely based on their interest, were initially willing to work full-time, with only a few planning to quit full-time neurosurgery eventually. Generally, Japanese women in neurosurgery are highly motivated and willing to work hard, although women are often initially discouraged from choosing a surgical career – a phenomenon that has also 5
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been observed elsewhere.15 Most women in our study had obtained board certification requiring at least four years of neurosurgical training, and half of them had master’s degrees that usually requires an additional four years of research experience. The mean duration for quitting full-time work was 10 years after neurosurgical training, when participants were approximately 35 years old. Although most of them had obtained important qualifications and reached the prime of their neurosurgical careers, they chose to quit full-time work and gave up their careers. Our findings show the primordial reason of quitting to be the lack of support during pregnancy and the child-bearing period, similar to findings in the United States.12-15 Among the respondents, 16 (76%) had children, including 13 infants. Half of them revealed that the difficulty in balancing their neurosurgical careers and motherhood was an important reason for leaving full-time work. In Japan, although the number of women leaving their jobs is decreasing, many women still resign after marriage or having children to become “professional housewives” who exclusively perform unpaid housekeeping tasks and raise children, similar to the cultural norms of the 1960s, during the high economic growth period after World War II.6,16 Because of this Japanese culture of “professional housewives”, child-raising and housekeeping are still considered to be women’s duties, even if the women are employed full-time, as suggested by low paternity leave (only 5%17) and the short time husbands spend on children and unpaid housekeeping work (49 minutes for children and 69 minutes for unpaid work per day, respectively, compared to the world averages of 61 and 141 minutes18,19). As one participant mentioned (Table 7), Japanese women in full-time employment do not have “plenty of private time”’ even when they are exempted from overtime work, and experience guilt and stress related to the high demand of unpaid housekeeping and child-raising tasks, and they are under pressure to manage these unpaid tasks as efficiently as “professional housewives”, to be seen as “good mothers”16. Past studies also reported that American physicians who were mothers experienced hostile treatment from colleagues related to their maternity leave,2,20,21 and we are concerned that Japanese women in neurosurgery may face a similar maternal penalty. We should therefore focus on modifying the factors that eventually lead mother-physicians to leave full-time work as neurosurgeons and to stimulate career success among these women.
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Another big reason was the unbearable excessive physical burden that characterizes full-time neurosurgical employment in Japan. As one participant indicated, current working conditions of full-time neurosurgeons are tough, even for those who did not raise their children (Table 2). More than one third of Japanese neurosurgeons work more than 60 to 80 hours per week22,23, nearly one in five have more than five night shifts per month23, while the reported average working hours were 51.9±24.5 hours per week (women only11) or 59.5±23.7 hours per week (women and men22) owing to the mixture of full-time workers and part-time workers. The number of night shifts varied from 0 to 15 times11 as well. In addition to emergent cases and long technical operations that neurosurgeons should be able to cope with, Japanese neurosurgeons have to perform postoperative intensive care, manage patients who did not require surgery such as those with ischemic and hemorrhagic strokes, and to treat patients in outpatient clinics, none of which forms part of American neurosurgeons’ job description24. The universal insurance system that allows patients to visit hospitals any time they want, and the increasing number of the elderly population and, concomitantly, the increasing number of sick patients, adds to the increasing burden of Japanese neurosurgeons. As one third of neurosurgical institutes reported the number of neurosurgeons in their facilities to be insufficient22, the near future may see an insufficient number of surgeons for the provision of adequate care in Japan25. Considering that women’s abilities as physicians and surgeons are on par with that of men26,27, it is of the utmost importance that women who wish to work as neurosurgeons can do so to provide sufficient medical care to Japanese society. Further, regulating bodies should consider decreasing the physical burden of all Japanese neurosurgeons, through work-sharing to secure off-duty times and days among each other, the consolidation of neurosurgical institutes to increase the total number of neurosurgeons per institute, and task-shifting to other medical staff. As our participants described, support from colleagues and bosses, who were almost always men,28 is critical for their careers. Even in the United States, where more than 50% of graduating medical students are women, gender-based discrimination remains common, particularly in surgical departments.12 Women account for only 6% of the American Board of Neurosurgical Surgery-certified practicing neurosurgeons, and only 4% of full-time professors of neurosurgery in the United States28,30; some women in neurosurgery have described neurosurgery as the “final frontier of the women’s 7
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career movement.”31 In Japan, women account for around 30% of students in medical schools,10 and less than 5% of members of the Japan Neurosurgical Society, while there were only two women professors of neurosurgery after the establishment of the Japan Neurosurgical Society. Therefore, it is crucial that men in neurosurgery become more understanding of the career needs of their female colleagues, and create a supportive environment for allowing women neurosurgeons to achieve their career goals. However, as our previous survey showed, a quarter of departmental chiefs indicated their reluctance to appoint women to their departments11. This reluctance can be partially explained by the overworked status of Japanese neurosurgeons that makes it difficult for colleagues and bosses to support women surgeons raising children, as described by our participants (Table 6). To support women, as suggested by our participants, men in neurosurgery need to have the strength or time to cover their work; therefore, the working style of full-time neurosurgeons among both men and women is essential to consider for the career achievement of women in neurosurgery. Most of our participants agreed that a career-counseling system is important to talk with bosses and to consult with others while planning their careers; however, the results of our survey showed only 5% of the units had a career counseling system in place. Past studies suggested that workers with mentors feel more satisfied with their jobs compared to those without mentors22, that women placed more importance on receiving support from peers and having a mentor,33 and that same-gender relationships were more effective compared to cross-gender relationships.34 Because the number of women in neurosurgery is small, only a few women neurosurgeons can find a same-gender mentor. By establishing a career counseling system to match women neurosurgeons with their counterparts in other facilities, the Japan Neurosurgical Society may facilitate conversations between women neurosurgeons, which may enable them to think more concretely and prepare for their future. At the same time, a support system that can allow communication between employers and managers may be desirable, as one of our participants indicated that a career counseling system alone would not provide sufficient support for women neurosurgeons (Table 4). Our participants reported the achievement of a better work-life balance through the modification of the factors discussed above might allow them to continue working as full-time neurosurgeons and that these would be necessary 8
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for their reinstatement. While almost half of women neurosurgeons in Japan were not satisfied with their work-life balance,11 American physicians who were also mothers ranked “more flexible weekday schedule” as the most important workplace change they desired29. Maternal discrimination might be mitigated by flexible schedules, including shift work, on-site high-quality childcare, and longer, paid maternal leave.2,35 Although our participants were initially worried about having little personal and/or family time, as well as the physical burden of being a neurosurgeon, they committed to their decision of becoming a neurosurgeon as they thought the work was worthwhile and had a keen interest to learn neurosurgical techniques; however, they quit full-time work after a sudden change of working conditions, including pregnancy and childbearing, while they had little chance to seek consultation and resolve the problems. Currently, fourteen percent of the respondents had a concrete plan for reinstatement, and 50% were willing to return to full-time work if working conditions were what they hoped for. The Japan Neurosurgical Society may work with each hospital to allow women to continue their work as full-time neurosurgeons, by allowing them diverse working styles or support systems such as childcare services. Our study has limitations in ascertaining the true opinions of women who quit full-time neurosurgery. We could not contact 12 of the 72 doctors of interest and only 35% (21/60) completed the questionnaire. Although there were few differences between responders and non-responders in physician surveys,36 we require further opinions from non-full-time workers. We are also concerned that the definition of full-time neurosurgeons might be different for each physician and may have caused bias during candidates’ selection, as one of our participants pointed out (Table 7). If women neurosurgeons who thought that they engaged in full-time neurosurgical work or other worthwhile duties received our questionnaires, they might not have completed the questionnaires. We also did not include the voices of women who currently work as full-time neurosurgeons, or men who had quit full-time neurosurgery. Not all women quit because of work-life imbalance or physical burden but because they lost interest in neurosurgery (Table 5); several women will never return, even if the modifiable factors, such as diverse working styles, were adjusted (Table 6). However, the present study revealed that only one-third of the respondents decided to leave full-time work forever and half hoped to return to full-time work if working conditions suited their lifestyle. To achieve this, the Japan Neurosurgical Society needs to develop policies to support these surgeons. 9
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Conclusion Through this survey, we could obtain vivid voices from women who quit working as full-time neurosurgeons. We found several factors – adequate childcare services, a change in the workstyle of a full-time neurosurgeon, diverse working styles including shortening of working hours, understanding of their bosses and colleagues, and career counseling system – to achieve their reinstatement. This study is the first step to recruiting these women as full-time neurosurgeons again; the Japan Neurosurgical Society may create supportive environments for future women neurosurgeons by encouraging each hospital to support childcare, to modify the working styles of all neurosurgeons in Japan, and to create career counseling system to connect women in different hospitals and to allow communication between employers and managers.
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Acknowledgments The authors thank Ms. Junko Kikuchi and Ms. Yukari Murano for their technical
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support with the survey and data analysis.
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Funding This research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors.
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https://www.med.or.jp/joseiishi/wp-content/uploads/2018/10/h29wd_survey.pdf 2018 Accessed 22 July 2019. 24. Shinohara S. Is it true that “the number of Board-certified Neurosurgeon in Japan is too much”? Discussion in the Panel Forum of The Japanese Neurosurgical Society. https://medical-tribune.co.jp/mtpronews/1002/1002027.html; 2010 Accessed 22 July 2019. 25. Ministry of Health, Labor and Welfare. Sectional meeting: the supply and the demand of physicians. https://www.mhlw.go.jp/stf/shingi2/0000208863_00010.html; 2019 Accessed 12 March 2019 26. Tsugawa Y, Jena AB, Orav EJ, et al. Age and sex of surgeons and mortality of older surgical patients: observational study. BMJ 2018;361:k1343. https://doi.org/10.1136/bmj.k1343. 27. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for medicare patients treated by male vs female physicians. JAMA Internal Medicine 2017;177:206–213. https://doi.org/10.1001/jamainternmed.2016.7875. 28. Aviva A, James TR. Women in neurosurgery: inequality redux. J Neurosurg 2018;129:277–281. https://doi.org/10.3171/2018.4.JNS172878. 29. Adesoye T, Mangurian C, Choo EK, et al. Perceived discrimination experienced by physician mothers and desired workplace changes: a cross-sectional survey. JAMA Internal Medicine 2017;177:1033–1036. https://doi.org/10.1001/jamainternmed.2017.1394. 30. Renfrow JJ, Rodriguez A, Wilson TA, et al. Tracking career paths of women in neurosurgery. Neurosurgery 2018;82:576–582. https://doi.org/10.1093/neuros/nyx251. 31. Corley J, Williamson T. Women in neurosurgery: final frontier of career women’s movement. World Neurosurg 2018;111:130–131. https://doi.org/10.1016/j.wneu.2017.12.086. 32. Wronski L. Nine in 10 workers who have a career mentor say they are happy in their jobs. https://www.cnbc.com/2019/07/16/nine-in-10-workers-who-have-a-mentor-say-t hey-are-happy-in-their-jobs.html; 2019 Accessed 22 July 2019. 33. Thoreson RW, Kardash CM, Leuthold DA, et al. Gender differences in the academic career. Res High Educ 1990;31:193–209. 14
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https://doi.org/10.1007/BF00992262. 34. Ragins BR, McFarlin DB. Perceptions of mentor roles in cross-gender mentoring relationships. J Vocat Behav 1990;37:321–339. https://doi.org/10.1016/0001-8791(90)90048-7. 35. Riano NS, Linos E, Accurso EC, et al. Paid family and childbearing leave policies at top US medical schools. JAMA 2018;319:611–614.
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https://doi.org/10.1001/jama.2017.19519. 36. James KM, Ziegenfuss JY, Tilburt JC, Harris AM, Beebe TJ. Getting physicians to respond: the impact of incentive type and timing on physician survey response rates. Health Serv Res 2011;46:232–242.
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https://doi.org/10.1111/j.1475-6773.2010.01181.x.
7 8 9
12 13
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Figure legends Fig. 1 Women neurosurgeons in Japanese board training hospitals. Fig. 2 Women neurosurgeons who answered the questionnaires. Fig. 3 Background of women neurosurgeons in non-full-time work. Fig. 4 Reason they chose to be neurosurgeons and concerns regarding that choice. Fig. 5 Reason they quit full-time work. Fig. 6 Career counseling system. Fig. 7 Reinstatement to full-time work.
16
Table 1. 1 Questionnaire to women neurosurgeons who formerly worked as full-time neurosurgeons
I. About yourself Q1-1 How many years have passed since you graduated from medical school? Q1-2 Do you have a master’s degree? Q1-3 Are you a board-certified neurosurgeon of the Japan Neurosurgical Society? Q1-4 Do you have a child? How many, and how old are they? Q1-5 Do you have an elderly person that you need to take care of? II. At the time you started your career as a neurosurgeon Q2-1 Why did you choose neurosurgery as your specialty? Q2-2 What worried you when you chose neurosurgery as your specialty? Q2-3 Tell us about your career plans when you chose neurosurgery as your specialty. (Open question) Q2-4 What were you interested in, when you chose to be a neurosurgeon? Q2-5 Tell us why you chose to be a neurosurgeon. (Open question) III. Career plan and counseling system Q3-1 What challenges and difficulties did you face during your career as a full-time neurosurgeon? (Open question) Q3-2 Did your office have a career counseling system? Who did you consult before you decided to quit being a full-time neurosurgeon? Q3-3 Do you think a career counseling system is necessary? Q3-4 Tell us why you think a career counseling system is necessary or not. (Open question) IV. The time you decided to quit being a full-time neurosurgeon Q4-1 When did you quit being a full-time neurosurgeon? Q4-2 Why did you quit being a full-time neurosurgeon? (Closed + open questions) Q4-3 Did you willingly quit, or did you quit to prioritize something else (e.g. interest in other fields. family time)?
Q4-4 Is there anything that might have prevented you from quitting your job as a full-time neurosurgeon? (Closed + open questions) V. Your career after you quit working as a full-time neurosurgeon Q5-1 What is your current working style and working field? Q5-2 Did your career as a full-time neurosurgeon benefit your current practice? VI To be a full-time neurosurgeon again Q6-1 Do you want to work as a full-time neurosurgeon again someday? Q6-2 What would be necessary for you to resume working as a full-time neurosurgeon again? (Closed + Open question) VII For future women in neurosurgery Q7 What do you think is necessary for neurosurgeons to enhance their careers during the child-raising period or while nursing the elderly? Q8 Tell me anything you felt about this questionnaire. (Open question)
Table 2. The initial career plan
Q2Q2-3. Tell us about your career plan, when you chose neurosurgery as your specialty. Work as a fullfull-time neurosurgeon until retirement
"To work in the hospital until retirement" "Get board-certification; get a master’s degree, and work as a full-time neurosurgeon until retirement in the general hospital" "To be a specialized neurosurgeon to perform surgery; get a master’s degree, and study abroad" "After getting board-certification and a master’s degree, I wanted to be a subspecialized neurosurgeon (such as, brain tumors) and work in a highly specialized hospital" "To be able to perform any emergency operation to help the patients (hemorrhage, brain injury, stroke, etc) who present to me" "I just wanted to be a professional neurosurgeon" "Get board-certification and do basic research"
Work as a fullfull-time neurosurgeon while balancing career and family
“I planned to give birth to a child while researching during the master’s course. I believed it would be not difficult to balance my career and family." "Get board-certification; get a master’s degree; to conduct research abroad with my husband, and perform operations as a specialized neurosurgeon"
Others
"Work for a decade in a hospital, and work afterwards in a neurosurgical clinic"
"Nothing special. I just wanted to do what I can do"
Table 3. 3. Challenges and difficulties faced as a full-time neurosurgeon
Q3Q3-1 What challenges and difficulties did you face during your career as a fullfull-time neurosurgeon? "Although the physical burden was as heavy as I presumed, I felt it was worthwhile to work as a
Physical burden
neurosurgeon. However, after the age of 30 years, my working ability deteriorated to below an acceptable limit after an overnight surgery. Moreover, I was too busy to find my future husband. The thought of being at a childbearing age also embarrassed me." "Although it was physically demanding, I felt it was worthwhile to work as a full-time neurosurgeon. However, I gradually wondered whether I would be able to continue my current workstyle until
“
retirement. Thus, I decided to spend more time with my family rather than working in the hospital after marriage." "Right after maternity leave, I went back to the hospital as a full-time neurosurgeon. However, some
“
of my former colleagues had left the hospital, which increased my job burden. It became impossible to manage it." "I noticed that it was difficult for me to go back to a full-time career without family support (such as
Overworking
from my parents). If my child got sick, I had to suddenly take a day off to take care of my child. However, it was impossible, as I was the only neurosurgeon in the hospital." "It was satisfactory to work as a neurosurgeon in the emergency room and performing many
“
emergency operations. However, at the same time, I thought it would be impossible to continue my current workstyle after my marriage, pregnancy, or during the child-raising period."
"It was difficult to continue neurosurgical work as a part-timer because the number of neurosurgeons “
was not sufficient."
Difficulty balancing the career and family
"My husband's transfer and pregnancy made me unable to work, not only as a neurosurgeon, but also as a medical doctor."
“
"Child-raising was extremely tough and time-consuming; it was far beyond my expectations."
Lack of support for women--specific situations women
Male bosses and colleagues seemed emotionally distant after my maternity leave."
“
"My ex-boss told me that if I got pregnant, my career as a surgeon would end."
“There were fewer female neurosurgeons and less support from males, compared to other specialties.
"My boss did not give me his blessing when I Informed him about my pregnancy; instead, he seemed “
annoyed and asked me whether I would quit or continue. It was shocking, but my university pushed and supported me to continue working." "There was no support from the hospital when my parents, who took care of my child, suddenly got
“
sick. Thus, I could not work in the hospital as a full-time worker. I was warned to come back within one week as a full-time worker or else lose my position." "Around me, there were no female neurosurgeons who worked during their childraising period.
“
Therefore, I am currently struggling to build my career." "After I became pregnant, I lost many opportunities performing surgery (partly because, I should
“
avoid radiation exposure). The feeling of embarrassment overtook my motivation to achieve improvement in my career." Only a few doctors around me achieved an ideal career. The chance to perform surgery was only
Others
offered to a few talented doctors. Because I am a woman and not talented, I felt I would be just busy working without achieving an ideal career."
“ Nothing
"Just because I found other things to be more interesting." "There were no unexpected events during my career. Many doctors (both men and women) felt like leaving the hospital after around seven years of being a post-graduate." "My real career was almost the same as I had presumed; however, I noticed there were many
“
differences among the training programs."
“
"I achieved my career roughly as much as I had expected."
“
"I achieved my expected career."
“
"I felt no difference between expectations and reality."
Table 4. The importance of a career counseling system
Q3Q3-4 Tell us the reason that you think that a career counseling system is necessary or not.
The system is important for career planning.
"Luckily, I personally have someone to consult about my career. However, if there is no one around, a career counselling system to meet someone would be important to cope with the challenges and difficulties." "The hospital or the boss should know the employee’s concerns, even if they would finally quit." "If you can talk with your boss, it would be easier to achieve your career goals." "It would be important to know what the hospital requires from you and what you want." "If there is some system, maybe we can keep our dream or career plan alive." "I did not get a chance to talk or consult about my career plan at all. I wish there was a system to talk about your career or your achievement during your career."
It is worthwhile to talk with other women physicians.
"I'm interested in knowing how other women cope with these difficult situations" "I could not imagine any situation that I would encounter after childbirth, because there were no such women neurosurgeons around me. If I knew how women physicians work, I might have planned my working style after maternity leave. Although a career counseling system would help a person like me, how much you can work depends on personal situations."
It is worthwhile to talk with in other neurosurgeons
"I couldn't consult other doctors in my university, because I decided to quit."
places places/fields /fields. "It is worthwhile, if you can ask another's opinion." "Most neurosurgeons work in the hospital, but I did want to seek the opinion of doctors working in the research field." “You decide your career yourself; however, it is important to know how others are doing."
Career counseling system is not sufficient.
"It is better to have it, but it is not sufficient" "What is important is the real support system, and not a career-counseling system" "Even if you know what is ideal for your career, it depends on how much physical burden you can endure or how much time you want to spend at home." "It depends on the person."
Table 5. The reason for quitting Q4Q4-2, 44-3 Why did you quit being a fullfull-time neurosurgeon?
To have a better workwork-life balance
"I wanted to change my working time from 80% to 50% of my lifetime." "I didn't have sufficient private time."
As a part of career plan (± to have better workwork-life balance)
"To give priority to family, I entered a master’s course." "When my child was young (<2 yo), thanks to my university, I was offered work as a neuroradiologist, as well as a job in the hospital with few operations." "To have research experience abroad"
Others Others
"I lost my interest in neurosurgical practice" "I felt it was natural to quit."
Table 6. The requirements to continue/resume working as a full-time neurosurgeon Q4Q4-4 Is there anything that might have prevented you from quitting your job as fullfull-time neurosurgeon? Q6Q6-2 What is necessary for you to be a fullfull-time neurosurgeon again?
Change in workstyle full--time neurosurgeons of full
"Clear on-duty and off-duty time periods, including work shifts instead of 24h/365d duties." "No hospital should have a small number of neurosurgeons, to reduce the burden on one doctor. I can be a full-time worker again, if there was a sufficient number of neurosurgeons in the hospital, and if I could regularly have off-time." "When other doctors are significantly overworked without any extra fees, it was embarrassing for me to go home on time. I hope everyone can be paid for overworking."
Support of colleagues bosses and boss es
"Support from my bosses and colleagues, including their understanding when I need to take care of my sick child," "Bosses and male colleagues, who are not very busy and have the emotional resources to support women doctors." "If I had a boss I could respect and wanted to work for."
Diversity in working style
"Diversity in working style, and the atmosphere in which anyone can work in any style with satisfaction." "Social support for diversity in working style." "If you have time to work in a subspecialty, while working as a neurosurgeon in the hospital." "If you can keep board-certification even after you become a part-time worker." "Working mainly in the outpatient clinic (no operations, no overwork time)." "If I could work in the regional area where I wanted to (because of family matters)."
Childcare services
"Nursery in the hospital, and sufficient after-school services." “Sick child-care inside the hospital." "If my parents were alive and could raise my child."
Others Others
"My husband is planning to be a part-time worker for a certain period, while I work as a full-time neurosurgeon to improve my career." "After I finish a graduate-school course and achieve a doctor’s degree." "I want to work as a part-time worker while my child is very young. My boss understands me. " "I will be glad to work with neurosurgeons if my current work could be useful for them." "I did not quit because of dissatisfaction. When I get sufficient results from my current research, and if I am motivated to, I will work in the hospital again." "Nothing, I would never go back."
Table 7. What the participants felt about our questionnaire
Q8 Tell me anything you felt about this questionnaire. "I hope male doctors would understand that women are not ‘having plenty of private time’ or
Wishes Wishes for future neurosurgery
‘having an easy and comfortable life’ as part-time workers or as full-time workers without night-shifts." "I believe communication among bosses and coworkers is important for women to continue their careers as neurosurgeons." "I hope women neurosurgeons can improve their career, even as a part-time workers or without overworking."
Others
"Please show me the results of the questionnaire in some way." "I feel that my current career is based on my experience as a neurosurgeon, even though I did not work as a neurosurgeon now." "The definition of a full-time neurosurgeon in this questionnaire is rather ambiguous." "This questionnaire did not include those who were interested in research instead of a career in the hospital."
Fig. 1 35
30
Full-time worker 25
Non-full-time worker 20
15
10
5
0 1 2 3 4 5 6 7 8 9 1011 12 1314 15 1617 18 1920 21 2223 24 2526 27 2829 30 3132 33 3435 36 3738 39 4041 42 4344 45 4647 48 4950 515253 54 5556 57 5859 60 6162 63 6465 6667 68 6970 71 7273 74 75
Fig. 2
All women neurosurgeons in 75/94 core hospitals of training programs 427
Full-time workers 355
Unable to send the questionnaire 12
Did not answer the questionnaire 39
Non-full-time workers 72
Sent the questionnaire 60
Answered the questionnaire 21
Fig. 3 A
Board-Certified Neurosurgeons of The Japan Neurosurgical Society
B
Academic Degree M.D., Ph.D. 52%
No 39%
Yes 61%
C
M.D. 48%
Child None 24% Infants 33%
Adult 9% School age 5%
Toddlers 29%
Fig. 4 Q2-1 Why did you choose Neurosurgery?
A
It is worthwhile I want to perform operations It is professional I have respected doctors I am interested in it It seems promising It suits me 0
2
4
6
8
10
12
14
(No. of answers)
B
Q2-2 What did you worry at that time? Little private and/or family time Physical burden Few woman colleagues around Mental burden Difficult to have a future plan Negative opinion from the family 0
2
4
6
8
10
12
(No. of answers)
Fig. 5 Q4 Why did you quit Neurosurgery? Difficulty balancing my career and motherhood Physical burden Decline in interest Mental burden Marriage Family opinion Study abroad Difficulty having a future plan Health problems To start an outpatient clinic 0
2
4
6
8
10
12
(No. of answers)
Fig. 6 B
A Q3-2 Did your office have a career counseling system? 2 (5%)
Q3-2 Who did you consult before you decided to quit being a full-time neurosurgeon? None (I wanted someone) 5%
None (I did not need anyone) 5%
Both 21% Boss and/or colleagues 53% 19 (95%)
Someone unrelated to work 12%
Fig. 7 B
A Q6-1 Do you want to work as a fulltime neurosurgeon again someday? No 36%
Yes (if it s become possible) 9%
Yes (I have a concrete plan) 14%
Yes (someday) 41%
Q6-2 What is necessary for you to return to Neurosurgical regular work again? Shortening of my working hours
5
Understanding of bosses/colleagues
4
Chance to improve skills
4
Sufficient childcare services
3
Reviewing of everyone's work style
3 0
1
2
3
4
(No. of answers)
5
Abbreviations (This manuscript do not include any abbreviations should be listed here.)
S1878-8750(19)32200-4
DOI:
https://doi.org/10.1016/j.wneu.2019.08.045
Reference:
WNEU 13081
To appear in:
World Neurosurgery
Received Date: 3 July 2019 Revised Date:
31 July 2019
Accepted Date: 1 August 2019
Please cite this article as: Maehara T, Kamiya K, Fujimaki T, Matsumura A, Hongo K, Kuroda S, Matsumae M, Takeshima H, Sugo N, Nakao N, Saito N, Ikawa F, Tamura N, Sakurada K, Shimokawa S, Arai H, Tamura K, Sumita K, Hara S, Kato Y, On Behalf of The Gender Equality Committee of the Japan Neurosurgical Society, A questionnaire to assess the challenges faced by women who quit working as full-time neurosurgeons, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.08.045. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier Inc.
A questionnaire to assess the challenges faced by women who quit working as full-time neurosurgeons Taketoshi Maehara, M.D., Ph.D.*a, Kazuko Kamiya, M.D., Ph.D.b, Takamitsu Fujimaki, M.D., Ph.D.c, Akira Matsumura, M.D., Ph.D.d, Kazuhiro Hongo, M.D., Ph.D.e, Satoshi Kuroda, M.D., Ph.D.f, Mitsunori Matsumae, M.D., Ph.D.g, Hideo Takeshima, M.D., Ph.D.h, Nobuo Sugo, M.D., Ph.D.i, Naoyuki Nakao, M.D., Ph.D.j, Nobuhito Saito, M.D., Ph.D.k, Fusao Ikawa, M.D., Ph.D.l, Noriko Tamura, M.D., Ph.D.m, Kaori Sakurada, M.D., Ph.D.n, Shoko Shimokawa, M.D., Ph.D.o, Hajime Arai, M.D., Ph.D.p, Kaoru Tamura, M.D., Ph.D.a, Kazutaka Sumita, M.D., Ph.D.a, Shoko Hara, M.D., Ph.D. *a, Yoko Kato, M.D., Ph.D.q On Behalf of The Gender Equality Committee of the Japan Neurosurgical Society a
Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45
Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Japan Medical Association Research Institute, 2-28-16 Honkomagome Bunkyo-ku, Tokyo 113-8621 Japan c Department of Neurosurgery, Saitama Medical University Hospital, 1397-1, b
Yamane, Hidaka-City, Saitama, Japan Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan e Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 d
Asahi, Matsumoto, Nagano 390-8621, Japan Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama 930-0194, Japan g Department of Neurosurgery, Tokai University School of Medicine, 143 f
Shimokasuya, Isehara-shi, Kanagawa 259-1193, Japan Department of Neurosurgery, Miyazaki University, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan h
i
Department of Neurosurgery (Omori), School of Medicine, Toho University,6-11-1, Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan j Department of Neurological Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama 6411-8509, Japan k Department of Neurological Surgery, Tokyo University, 7-3-1 Hongo, Tokyo 1
113-8654, Japan l Department of Neurological Surgery, Shimane Prefectural Central Hospital, 4-1-1 Himehara, Izumo, Shimane 693-8555, Japan m Department of Neurological Surgery, Tokyo Women’s Medical University, 8-1, Kawadacho, Shinjyuku-ku, Tokyo 162-8666, Japan n Department of Neurosurgery, Yamagata University Faculty of Medicine, 1-41-12 Kojirakawa-machi, Yamagata-shi, Yamagata 990-8560, Japan o Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga-shi, Saga 849-8501, Japan p Department of Neurosurgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan q Department of Neurosurgery, Fujita Health University BANTANE Hospital,3-6-10, Otobashi, Nakagawa-ward, Nagoya city, Aichi 454-8509, Japan *Authors with equal contribution to this work. Corresponding author: T. Maehara, MD, Department of Neurosurgery, Tokyo Medical and Dental University 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Telephone: 81-3-5803-5266 Fax: 81-3-5803-0140 e-mail address: [email protected]
Key words: balancing career and family, full-time neurosurgeon, physical burden, reinstatement, woman neurosurgeon, work-life balance Running title: Women Neurosurgeons in Japan
2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Abstract Objective: To analyze why women quit full-time employment as neurosurgeons and to discuss the conditions required for their reinstatement. Methods: We asked 94 core hospitals providing training programs in the board certification system adopted by the Japan Neurosurgical Society, to indicate the total number and present status of women in their department, and to send our anonymous questionnaire to women who had formerly worked as full-time neurosurgeons. The questionnaire consisted of closed and open questions on their reasons for quitting as full-time neurosurgeons. Results: Among 427 women evaluated, 72 (17%) had quit full-time employment as neurosurgeons. Twenty-one women who had quit three to 21 years after starting their neurosurgery careers responded to the questionnaire, including 17 board-certified neurosurgeons, 11 individuals with master’s degrees and 16 mothers. Their main reasons for quitting full-time work were difficulty in balancing their neurosurgical career and motherhood (52%) and the physical burden (38%). At the time of quitting, only two (5%) units had a career counseling system for women. Two-thirds of participants might resume full-time work as neurosurgeons in the future. Their support system during pregnancy and the child-raising period, and understanding of male bosses and colleagues were identified as the key themes. Conclusion: The Japan Neurosurgical Society could facilitate supportive environments for women in neurosurgery by enhancing adequate childcare services, change the workstyle of full-time neurosurgeons to incorporate diverse working styles, shorter working hours, understanding of their bosses and colleagues, and career counseling system.
26
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Introduction Many people find it challenging to balance their career and family needs,1 especially women in medicine.2,3 The Japanese medical system is reported to be one of the best in the world4, but it is ranked very low among other countries in terms of the Gender Gap Index.5 The low Gender Gap Index ranking attributed Japanese women’s employment rate, with its M-shaped curve, indicating that many women in the child-bearing age range of 25-45 years quit their jobs because of marriage, pregnancy and childbirth, and motherhood.6 This tendency is similar among all women in medicine, regardless of their specialties.7,8 Although the majority of medical students in the United States in 2016 were women, sexism and maternal discrimination were still reported.2,9 In Japan, the number of women in medical schools has increased to 30%, but this is still lower than that reported in other countries.10 The number of women in the Japan Neurosurgical Society has increased to as many as 600 around 2018, with 12% of new members being women; however, the total number of women in the society remains below 5%. The Japan Neurosurgical Society established the Gender Equality Committee to address various gender-related problems in 2015. As a first step, we have previously reported on the working conditions and lifestyle of women affiliated with the Japan Neurosurgical Society;11 we administered questionnaires to 224 women and 496 departmental heads and concluded that women neurosurgeons appreciated a more understanding attitude from their peers and departmental heads. As the next step, we aimed to analyze the reasons that women neurosurgeons quit full-time employment and to discuss the conditions required for their reinstatement. We specifically focused on women who had quit their full-time employment as neurosurgeons following a number of reported gender-related problems12-15 that might interfere with their neurosurgical careers. In addition to closed questions, our new questionnaire included open-ended questions to allow for more vivid, detailed and understandable responses.
31
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Methods This work was approved by the ethical committee of The Japanese Neurosurgical Society. Questionnaires were sent to 94 core hospitals providing training programs in the board certification system adopted by the Japan Neurosurgical Society, to determine the number and present work-status of women in their departments. In the questionnaire, the hospital manager was required to provide the number of women neurosurgeons in full-time and non-full-time/part-time work. Full-time neurosurgeons in this study were defined as those working in the neurosurgical hospital every weekday; women engaging only in the outpatient clinic and those who were pregnant or on maternal leave for less than one year were also included as full-time neurosurgeons. Non-full-time/part-time neurosurgeons were defined as women who had quit employment as neurosurgeons as well as those who chose short working hours in neurosurgical hospitals. Continuing the survey, we requested the participating hospitals to distribute an anonymous questionnaire to women categorized as non-full-time/ part-time neurosurgeons. The questionnaire consisted of seven sections with closed and open questions as in Table 1: I) About yourself, II) At the time you started your career as a neurosurgeon, III) Career plan and a counseling system, IV) The time you decided to quit being a full-time neurosurgeon, V) Your career after you quit working as a full-time neurosurgeon, VI) To be a full-time neurosurgeon again, VII) For future women in neurosurgery (Table 1). Participants were informed that their participation was voluntary, anonymous, and confidential. The working group was guaranteed that the data would be used solely for the purpose of this study, and would never be presented or published in a manner that could reveal individuals’ identities. The completed questionnaires were returned to the Japanese Neurosurgical Society by e-mail, and receipt of the completed questionnaire was considered to demonstrate consent to participate. The data were first gathered and collected in the office of the Japan Neurosurgical Society, and members of the working group evaluated the aggregated data. The answers to the closed questions were counted and percentages calculated. The free-text responses to the open questions were collected and categorized according to the main concepts contained in the answers. 3
1 2
Results
3
Among the 94 training hospitals, 75 provided the number of women working as neurosurgeons in their department. Ten board training hospitals had registered more than 10 women, 25 had registered five to nine women, and 33 had registered one to four women. There were no women neurosurgeons in
4 5 6 7 8 9 10 11 12
seven of the hospitals (Fig. 1). Among the 427 women covered in this study, 72 (17%) had quit their jobs as full-time neurosurgeons. The questionnaire was sent to 60 women who had quit working as full-time neurosurgeons, who could be contacted through e-mail or letters via the hospital they work or used to work at; we obtained 21 responses and 39 did not respond (Fig. 2).
13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Analysis of closed questions In terms of background, 17 (81%) participants were board-certified neurosurgeons and 11 (52%) had M.D. and Ph.D. degrees. They had quit full-time work within three to 21 (mean 10) years of becoming neurosurgeons. At the time of answering the questionnaire, 16 (76%) had children, including 13 infants under the age of one year (Fig. 3A-C). Fig. 4A shows the reasons that participants chose to be neurosurgeons. Sixty-three percent (13/21) thought that working as a neurosurgeon would be worthwhile and that they wanted to perform surgeries (63%, 13/21) when they started their neurosurgical careers. However, at the time they chose their career, they had worried that neurosurgeons might have little personal and/or family time (52%, 11/21), carry heavy physical burdens (52%, 11/21), and that they would have few women neurosurgeons as colleagues (38%, 8/21) (Fig. 4B). Their main reasons for quitting full-time work were the difficulty in balancing between one’s neurosurgical career with motherhood (52%, 11/21) and physical burden (38%, 8/21) (Fig. 5). Most quit to prioritize another aspect of their lives, such as family or other work (62%, 13/21). Only two (5%) centers had a proper career counseling system for women working as neurosurgeons (Fig. 6A), but in those centers male superiors and colleagues managed the counselling units. This fact indirectly reflected a lack of approachability (Fig. 6B). In the concluding part of the questionnaire, the respondents were asked about their future plans and desirable conditions for their reinstatement to 4
1 2 3 4 5 6 7 8
full-time work. Among twenty-one women, three (14%) had a concrete plan to return to full-time work as neurosurgeons, nine (41%) answered that they would someday return to full-time work, and two (9%) hoped that they would return if possible. Thus, two-thirds of the women neurosurgeons considered the possibility of neurosurgical reinstatement (Fig. 7A). They suggested the reinstatement conditions include shorter working hours, understanding of their working style by their colleagues and bosses, and sufficient childcare services (Fig. 7B)
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Answers to the open questions Twenty-one respondents were interested in various neurosurgical subspecialties, including emergency surgery for cerebrovascular diseases, pathophysiology of brain tumors, endovascular surgery, epilepsy, and functional neurosurgery. Most of these women had wanted to work as full-time neurosurgeons until their retirement (Table 2). However, they encountered many difficulties, including physical burden, overwork, difficulty balancing their career and family lives, and lack of support during women-specific situations to continue their career as full-time neurosurgeons (Table 3). Some of them viewed a career counseling system to be necessary, while others remarked that the career counseling system alone is insufficient (Table 4). The majority quit working as full-time neurosurgeons to achieve a better work-life balance (Table 5). According to their responses, a change in the workstyle of full-time neurosurgeons, support from colleagues and bosses, diverse working styles, and adequate childcare services would allow them to continue working as full-time neurosurgeons, and would be necessary for their reinstatement (Table 6). Additionally, some of them hoped for an improved situation for future women working as neurosurgeons, while others were interested in the results of this questionnaire (Table 7).
29 30 31 32 33 34 35 36
Discussion Our survey results demonstrate that our participants were highly motivated neurosurgeons who chose their careers purely based on their interest, were initially willing to work full-time, with only a few planning to quit full-time neurosurgery eventually. Generally, Japanese women in neurosurgery are highly motivated and willing to work hard, although women are often initially discouraged from choosing a surgical career – a phenomenon that has also 5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
been observed elsewhere.15 Most women in our study had obtained board certification requiring at least four years of neurosurgical training, and half of them had master’s degrees that usually requires an additional four years of research experience. The mean duration for quitting full-time work was 10 years after neurosurgical training, when participants were approximately 35 years old. Although most of them had obtained important qualifications and reached the prime of their neurosurgical careers, they chose to quit full-time work and gave up their careers. Our findings show the primordial reason of quitting to be the lack of support during pregnancy and the child-bearing period, similar to findings in the United States.12-15 Among the respondents, 16 (76%) had children, including 13 infants. Half of them revealed that the difficulty in balancing their neurosurgical careers and motherhood was an important reason for leaving full-time work. In Japan, although the number of women leaving their jobs is decreasing, many women still resign after marriage or having children to become “professional housewives” who exclusively perform unpaid housekeeping tasks and raise children, similar to the cultural norms of the 1960s, during the high economic growth period after World War II.6,16 Because of this Japanese culture of “professional housewives”, child-raising and housekeeping are still considered to be women’s duties, even if the women are employed full-time, as suggested by low paternity leave (only 5%17) and the short time husbands spend on children and unpaid housekeeping work (49 minutes for children and 69 minutes for unpaid work per day, respectively, compared to the world averages of 61 and 141 minutes18,19). As one participant mentioned (Table 7), Japanese women in full-time employment do not have “plenty of private time”’ even when they are exempted from overtime work, and experience guilt and stress related to the high demand of unpaid housekeeping and child-raising tasks, and they are under pressure to manage these unpaid tasks as efficiently as “professional housewives”, to be seen as “good mothers”16. Past studies also reported that American physicians who were mothers experienced hostile treatment from colleagues related to their maternity leave,2,20,21 and we are concerned that Japanese women in neurosurgery may face a similar maternal penalty. We should therefore focus on modifying the factors that eventually lead mother-physicians to leave full-time work as neurosurgeons and to stimulate career success among these women.
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Another big reason was the unbearable excessive physical burden that characterizes full-time neurosurgical employment in Japan. As one participant indicated, current working conditions of full-time neurosurgeons are tough, even for those who did not raise their children (Table 2). More than one third of Japanese neurosurgeons work more than 60 to 80 hours per week22,23, nearly one in five have more than five night shifts per month23, while the reported average working hours were 51.9±24.5 hours per week (women only11) or 59.5±23.7 hours per week (women and men22) owing to the mixture of full-time workers and part-time workers. The number of night shifts varied from 0 to 15 times11 as well. In addition to emergent cases and long technical operations that neurosurgeons should be able to cope with, Japanese neurosurgeons have to perform postoperative intensive care, manage patients who did not require surgery such as those with ischemic and hemorrhagic strokes, and to treat patients in outpatient clinics, none of which forms part of American neurosurgeons’ job description24. The universal insurance system that allows patients to visit hospitals any time they want, and the increasing number of the elderly population and, concomitantly, the increasing number of sick patients, adds to the increasing burden of Japanese neurosurgeons. As one third of neurosurgical institutes reported the number of neurosurgeons in their facilities to be insufficient22, the near future may see an insufficient number of surgeons for the provision of adequate care in Japan25. Considering that women’s abilities as physicians and surgeons are on par with that of men26,27, it is of the utmost importance that women who wish to work as neurosurgeons can do so to provide sufficient medical care to Japanese society. Further, regulating bodies should consider decreasing the physical burden of all Japanese neurosurgeons, through work-sharing to secure off-duty times and days among each other, the consolidation of neurosurgical institutes to increase the total number of neurosurgeons per institute, and task-shifting to other medical staff. As our participants described, support from colleagues and bosses, who were almost always men,28 is critical for their careers. Even in the United States, where more than 50% of graduating medical students are women, gender-based discrimination remains common, particularly in surgical departments.12 Women account for only 6% of the American Board of Neurosurgical Surgery-certified practicing neurosurgeons, and only 4% of full-time professors of neurosurgery in the United States28,30; some women in neurosurgery have described neurosurgery as the “final frontier of the women’s 7
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
career movement.”31 In Japan, women account for around 30% of students in medical schools,10 and less than 5% of members of the Japan Neurosurgical Society, while there were only two women professors of neurosurgery after the establishment of the Japan Neurosurgical Society. Therefore, it is crucial that men in neurosurgery become more understanding of the career needs of their female colleagues, and create a supportive environment for allowing women neurosurgeons to achieve their career goals. However, as our previous survey showed, a quarter of departmental chiefs indicated their reluctance to appoint women to their departments11. This reluctance can be partially explained by the overworked status of Japanese neurosurgeons that makes it difficult for colleagues and bosses to support women surgeons raising children, as described by our participants (Table 6). To support women, as suggested by our participants, men in neurosurgery need to have the strength or time to cover their work; therefore, the working style of full-time neurosurgeons among both men and women is essential to consider for the career achievement of women in neurosurgery. Most of our participants agreed that a career-counseling system is important to talk with bosses and to consult with others while planning their careers; however, the results of our survey showed only 5% of the units had a career counseling system in place. Past studies suggested that workers with mentors feel more satisfied with their jobs compared to those without mentors22, that women placed more importance on receiving support from peers and having a mentor,33 and that same-gender relationships were more effective compared to cross-gender relationships.34 Because the number of women in neurosurgery is small, only a few women neurosurgeons can find a same-gender mentor. By establishing a career counseling system to match women neurosurgeons with their counterparts in other facilities, the Japan Neurosurgical Society may facilitate conversations between women neurosurgeons, which may enable them to think more concretely and prepare for their future. At the same time, a support system that can allow communication between employers and managers may be desirable, as one of our participants indicated that a career counseling system alone would not provide sufficient support for women neurosurgeons (Table 4). Our participants reported the achievement of a better work-life balance through the modification of the factors discussed above might allow them to continue working as full-time neurosurgeons and that these would be necessary 8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
for their reinstatement. While almost half of women neurosurgeons in Japan were not satisfied with their work-life balance,11 American physicians who were also mothers ranked “more flexible weekday schedule” as the most important workplace change they desired29. Maternal discrimination might be mitigated by flexible schedules, including shift work, on-site high-quality childcare, and longer, paid maternal leave.2,35 Although our participants were initially worried about having little personal and/or family time, as well as the physical burden of being a neurosurgeon, they committed to their decision of becoming a neurosurgeon as they thought the work was worthwhile and had a keen interest to learn neurosurgical techniques; however, they quit full-time work after a sudden change of working conditions, including pregnancy and childbearing, while they had little chance to seek consultation and resolve the problems. Currently, fourteen percent of the respondents had a concrete plan for reinstatement, and 50% were willing to return to full-time work if working conditions were what they hoped for. The Japan Neurosurgical Society may work with each hospital to allow women to continue their work as full-time neurosurgeons, by allowing them diverse working styles or support systems such as childcare services. Our study has limitations in ascertaining the true opinions of women who quit full-time neurosurgery. We could not contact 12 of the 72 doctors of interest and only 35% (21/60) completed the questionnaire. Although there were few differences between responders and non-responders in physician surveys,36 we require further opinions from non-full-time workers. We are also concerned that the definition of full-time neurosurgeons might be different for each physician and may have caused bias during candidates’ selection, as one of our participants pointed out (Table 7). If women neurosurgeons who thought that they engaged in full-time neurosurgical work or other worthwhile duties received our questionnaires, they might not have completed the questionnaires. We also did not include the voices of women who currently work as full-time neurosurgeons, or men who had quit full-time neurosurgery. Not all women quit because of work-life imbalance or physical burden but because they lost interest in neurosurgery (Table 5); several women will never return, even if the modifiable factors, such as diverse working styles, were adjusted (Table 6). However, the present study revealed that only one-third of the respondents decided to leave full-time work forever and half hoped to return to full-time work if working conditions suited their lifestyle. To achieve this, the Japan Neurosurgical Society needs to develop policies to support these surgeons. 9
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Conclusion Through this survey, we could obtain vivid voices from women who quit working as full-time neurosurgeons. We found several factors – adequate childcare services, a change in the workstyle of a full-time neurosurgeon, diverse working styles including shortening of working hours, understanding of their bosses and colleagues, and career counseling system – to achieve their reinstatement. This study is the first step to recruiting these women as full-time neurosurgeons again; the Japan Neurosurgical Society may create supportive environments for future women neurosurgeons by encouraging each hospital to support childcare, to modify the working styles of all neurosurgeons in Japan, and to create career counseling system to connect women in different hospitals and to allow communication between employers and managers.
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Acknowledgments The authors thank Ms. Junko Kikuchi and Ms. Yukari Murano for their technical
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support with the survey and data analysis.
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Funding This research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors.
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Figure legends Fig. 1 Women neurosurgeons in Japanese board training hospitals. Fig. 2 Women neurosurgeons who answered the questionnaires. Fig. 3 Background of women neurosurgeons in non-full-time work. Fig. 4 Reason they chose to be neurosurgeons and concerns regarding that choice. Fig. 5 Reason they quit full-time work. Fig. 6 Career counseling system. Fig. 7 Reinstatement to full-time work.
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Table 1. 1 Questionnaire to women neurosurgeons who formerly worked as full-time neurosurgeons
I. About yourself Q1-1 How many years have passed since you graduated from medical school? Q1-2 Do you have a master’s degree? Q1-3 Are you a board-certified neurosurgeon of the Japan Neurosurgical Society? Q1-4 Do you have a child? How many, and how old are they? Q1-5 Do you have an elderly person that you need to take care of? II. At the time you started your career as a neurosurgeon Q2-1 Why did you choose neurosurgery as your specialty? Q2-2 What worried you when you chose neurosurgery as your specialty? Q2-3 Tell us about your career plans when you chose neurosurgery as your specialty. (Open question) Q2-4 What were you interested in, when you chose to be a neurosurgeon? Q2-5 Tell us why you chose to be a neurosurgeon. (Open question) III. Career plan and counseling system Q3-1 What challenges and difficulties did you face during your career as a full-time neurosurgeon? (Open question) Q3-2 Did your office have a career counseling system? Who did you consult before you decided to quit being a full-time neurosurgeon? Q3-3 Do you think a career counseling system is necessary? Q3-4 Tell us why you think a career counseling system is necessary or not. (Open question) IV. The time you decided to quit being a full-time neurosurgeon Q4-1 When did you quit being a full-time neurosurgeon? Q4-2 Why did you quit being a full-time neurosurgeon? (Closed + open questions) Q4-3 Did you willingly quit, or did you quit to prioritize something else (e.g. interest in other fields. family time)?
Q4-4 Is there anything that might have prevented you from quitting your job as a full-time neurosurgeon? (Closed + open questions) V. Your career after you quit working as a full-time neurosurgeon Q5-1 What is your current working style and working field? Q5-2 Did your career as a full-time neurosurgeon benefit your current practice? VI To be a full-time neurosurgeon again Q6-1 Do you want to work as a full-time neurosurgeon again someday? Q6-2 What would be necessary for you to resume working as a full-time neurosurgeon again? (Closed + Open question) VII For future women in neurosurgery Q7 What do you think is necessary for neurosurgeons to enhance their careers during the child-raising period or while nursing the elderly? Q8 Tell me anything you felt about this questionnaire. (Open question)
Table 2. The initial career plan
Q2Q2-3. Tell us about your career plan, when you chose neurosurgery as your specialty. Work as a fullfull-time neurosurgeon until retirement
"To work in the hospital until retirement" "Get board-certification; get a master’s degree, and work as a full-time neurosurgeon until retirement in the general hospital" "To be a specialized neurosurgeon to perform surgery; get a master’s degree, and study abroad" "After getting board-certification and a master’s degree, I wanted to be a subspecialized neurosurgeon (such as, brain tumors) and work in a highly specialized hospital" "To be able to perform any emergency operation to help the patients (hemorrhage, brain injury, stroke, etc) who present to me" "I just wanted to be a professional neurosurgeon" "Get board-certification and do basic research"
Work as a fullfull-time neurosurgeon while balancing career and family
“I planned to give birth to a child while researching during the master’s course. I believed it would be not difficult to balance my career and family." "Get board-certification; get a master’s degree; to conduct research abroad with my husband, and perform operations as a specialized neurosurgeon"
Others
"Work for a decade in a hospital, and work afterwards in a neurosurgical clinic"
"Nothing special. I just wanted to do what I can do"
Table 3. 3. Challenges and difficulties faced as a full-time neurosurgeon
Q3Q3-1 What challenges and difficulties did you face during your career as a fullfull-time neurosurgeon? "Although the physical burden was as heavy as I presumed, I felt it was worthwhile to work as a
Physical burden
neurosurgeon. However, after the age of 30 years, my working ability deteriorated to below an acceptable limit after an overnight surgery. Moreover, I was too busy to find my future husband. The thought of being at a childbearing age also embarrassed me." "Although it was physically demanding, I felt it was worthwhile to work as a full-time neurosurgeon. However, I gradually wondered whether I would be able to continue my current workstyle until
“
retirement. Thus, I decided to spend more time with my family rather than working in the hospital after marriage." "Right after maternity leave, I went back to the hospital as a full-time neurosurgeon. However, some
“
of my former colleagues had left the hospital, which increased my job burden. It became impossible to manage it." "I noticed that it was difficult for me to go back to a full-time career without family support (such as
Overworking
from my parents). If my child got sick, I had to suddenly take a day off to take care of my child. However, it was impossible, as I was the only neurosurgeon in the hospital." "It was satisfactory to work as a neurosurgeon in the emergency room and performing many
“
emergency operations. However, at the same time, I thought it would be impossible to continue my current workstyle after my marriage, pregnancy, or during the child-raising period."
"It was difficult to continue neurosurgical work as a part-timer because the number of neurosurgeons “
was not sufficient."
Difficulty balancing the career and family
"My husband's transfer and pregnancy made me unable to work, not only as a neurosurgeon, but also as a medical doctor."
“
"Child-raising was extremely tough and time-consuming; it was far beyond my expectations."
Lack of support for women--specific situations women
Male bosses and colleagues seemed emotionally distant after my maternity leave."
“
"My ex-boss told me that if I got pregnant, my career as a surgeon would end."
“There were fewer female neurosurgeons and less support from males, compared to other specialties.
"My boss did not give me his blessing when I Informed him about my pregnancy; instead, he seemed “
annoyed and asked me whether I would quit or continue. It was shocking, but my university pushed and supported me to continue working." "There was no support from the hospital when my parents, who took care of my child, suddenly got
“
sick. Thus, I could not work in the hospital as a full-time worker. I was warned to come back within one week as a full-time worker or else lose my position." "Around me, there were no female neurosurgeons who worked during their childraising period.
“
Therefore, I am currently struggling to build my career." "After I became pregnant, I lost many opportunities performing surgery (partly because, I should
“
avoid radiation exposure). The feeling of embarrassment overtook my motivation to achieve improvement in my career." Only a few doctors around me achieved an ideal career. The chance to perform surgery was only
Others
offered to a few talented doctors. Because I am a woman and not talented, I felt I would be just busy working without achieving an ideal career."
“ Nothing
"Just because I found other things to be more interesting." "There were no unexpected events during my career. Many doctors (both men and women) felt like leaving the hospital after around seven years of being a post-graduate." "My real career was almost the same as I had presumed; however, I noticed there were many
“
differences among the training programs."
“
"I achieved my career roughly as much as I had expected."
“
"I achieved my expected career."
“
"I felt no difference between expectations and reality."
Table 4. The importance of a career counseling system
Q3Q3-4 Tell us the reason that you think that a career counseling system is necessary or not.
The system is important for career planning.
"Luckily, I personally have someone to consult about my career. However, if there is no one around, a career counselling system to meet someone would be important to cope with the challenges and difficulties." "The hospital or the boss should know the employee’s concerns, even if they would finally quit." "If you can talk with your boss, it would be easier to achieve your career goals." "It would be important to know what the hospital requires from you and what you want." "If there is some system, maybe we can keep our dream or career plan alive." "I did not get a chance to talk or consult about my career plan at all. I wish there was a system to talk about your career or your achievement during your career."
It is worthwhile to talk with other women physicians.
"I'm interested in knowing how other women cope with these difficult situations" "I could not imagine any situation that I would encounter after childbirth, because there were no such women neurosurgeons around me. If I knew how women physicians work, I might have planned my working style after maternity leave. Although a career counseling system would help a person like me, how much you can work depends on personal situations."
It is worthwhile to talk with in other neurosurgeons
"I couldn't consult other doctors in my university, because I decided to quit."
places places/fields /fields. "It is worthwhile, if you can ask another's opinion." "Most neurosurgeons work in the hospital, but I did want to seek the opinion of doctors working in the research field." “You decide your career yourself; however, it is important to know how others are doing."
Career counseling system is not sufficient.
"It is better to have it, but it is not sufficient" "What is important is the real support system, and not a career-counseling system" "Even if you know what is ideal for your career, it depends on how much physical burden you can endure or how much time you want to spend at home." "It depends on the person."
Table 5. The reason for quitting Q4Q4-2, 44-3 Why did you quit being a fullfull-time neurosurgeon?
To have a better workwork-life balance
"I wanted to change my working time from 80% to 50% of my lifetime." "I didn't have sufficient private time."
As a part of career plan (± to have better workwork-life balance)
"To give priority to family, I entered a master’s course." "When my child was young (<2 yo), thanks to my university, I was offered work as a neuroradiologist, as well as a job in the hospital with few operations." "To have research experience abroad"
Others Others
"I lost my interest in neurosurgical practice" "I felt it was natural to quit."
Table 6. The requirements to continue/resume working as a full-time neurosurgeon Q4Q4-4 Is there anything that might have prevented you from quitting your job as fullfull-time neurosurgeon? Q6Q6-2 What is necessary for you to be a fullfull-time neurosurgeon again?
Change in workstyle full--time neurosurgeons of full
"Clear on-duty and off-duty time periods, including work shifts instead of 24h/365d duties." "No hospital should have a small number of neurosurgeons, to reduce the burden on one doctor. I can be a full-time worker again, if there was a sufficient number of neurosurgeons in the hospital, and if I could regularly have off-time." "When other doctors are significantly overworked without any extra fees, it was embarrassing for me to go home on time. I hope everyone can be paid for overworking."
Support of colleagues bosses and boss es
"Support from my bosses and colleagues, including their understanding when I need to take care of my sick child," "Bosses and male colleagues, who are not very busy and have the emotional resources to support women doctors." "If I had a boss I could respect and wanted to work for."
Diversity in working style
"Diversity in working style, and the atmosphere in which anyone can work in any style with satisfaction." "Social support for diversity in working style." "If you have time to work in a subspecialty, while working as a neurosurgeon in the hospital." "If you can keep board-certification even after you become a part-time worker." "Working mainly in the outpatient clinic (no operations, no overwork time)." "If I could work in the regional area where I wanted to (because of family matters)."
Childcare services
"Nursery in the hospital, and sufficient after-school services." “Sick child-care inside the hospital." "If my parents were alive and could raise my child."
Others Others
"My husband is planning to be a part-time worker for a certain period, while I work as a full-time neurosurgeon to improve my career." "After I finish a graduate-school course and achieve a doctor’s degree." "I want to work as a part-time worker while my child is very young. My boss understands me. " "I will be glad to work with neurosurgeons if my current work could be useful for them." "I did not quit because of dissatisfaction. When I get sufficient results from my current research, and if I am motivated to, I will work in the hospital again." "Nothing, I would never go back."
Table 7. What the participants felt about our questionnaire
Q8 Tell me anything you felt about this questionnaire. "I hope male doctors would understand that women are not ‘having plenty of private time’ or
Wishes Wishes for future neurosurgery
‘having an easy and comfortable life’ as part-time workers or as full-time workers without night-shifts." "I believe communication among bosses and coworkers is important for women to continue their careers as neurosurgeons." "I hope women neurosurgeons can improve their career, even as a part-time workers or without overworking."
Others
"Please show me the results of the questionnaire in some way." "I feel that my current career is based on my experience as a neurosurgeon, even though I did not work as a neurosurgeon now." "The definition of a full-time neurosurgeon in this questionnaire is rather ambiguous." "This questionnaire did not include those who were interested in research instead of a career in the hospital."
Fig. 1 35
30
Full-time worker 25
Non-full-time worker 20
15
10
5
0 1 2 3 4 5 6 7 8 9 1011 12 1314 15 1617 18 1920 21 2223 24 2526 27 2829 30 3132 33 3435 36 3738 39 4041 42 4344 45 4647 48 4950 515253 54 5556 57 5859 60 6162 63 6465 6667 68 6970 71 7273 74 75
Fig. 2
All women neurosurgeons in 75/94 core hospitals of training programs 427
Full-time workers 355
Unable to send the questionnaire 12
Did not answer the questionnaire 39
Non-full-time workers 72
Sent the questionnaire 60
Answered the questionnaire 21
Fig. 3 A
Board-Certified Neurosurgeons of The Japan Neurosurgical Society
B
Academic Degree M.D., Ph.D. 52%
No 39%
Yes 61%
C
M.D. 48%
Child None 24% Infants 33%
Adult 9% School age 5%
Toddlers 29%
Fig. 4 Q2-1 Why did you choose Neurosurgery?
A
It is worthwhile I want to perform operations It is professional I have respected doctors I am interested in it It seems promising It suits me 0
2
4
6
8
10
12
14
(No. of answers)
B
Q2-2 What did you worry at that time? Little private and/or family time Physical burden Few woman colleagues around Mental burden Difficult to have a future plan Negative opinion from the family 0
2
4
6
8
10
12
(No. of answers)
Fig. 5 Q4 Why did you quit Neurosurgery? Difficulty balancing my career and motherhood Physical burden Decline in interest Mental burden Marriage Family opinion Study abroad Difficulty having a future plan Health problems To start an outpatient clinic 0
2
4
6
8
10
12
(No. of answers)
Fig. 6 B
A Q3-2 Did your office have a career counseling system? 2 (5%)
Q3-2 Who did you consult before you decided to quit being a full-time neurosurgeon? None (I wanted someone) 5%
None (I did not need anyone) 5%
Both 21% Boss and/or colleagues 53% 19 (95%)
Someone unrelated to work 12%
Fig. 7 B
A Q6-1 Do you want to work as a fulltime neurosurgeon again someday? No 36%
Yes (if it s become possible) 9%
Yes (I have a concrete plan) 14%
Yes (someday) 41%
Q6-2 What is necessary for you to return to Neurosurgical regular work again? Shortening of my working hours
5
Understanding of bosses/colleagues
4
Chance to improve skills
4
Sufficient childcare services
3
Reviewing of everyone's work style
3 0
1
2
3
4
(No. of answers)
5
Abbreviations (This manuscript do not include any abbreviations should be listed here.)