Moustapha Abousamra
Ventura, California, United States

Last spring, I spent three months in the Texas Hill Country. It is a place that at once can be beautiful and hostile. The fields of blue bonnets in full bloom are breathtaking. The cacti that abound around barbed wire fences at first glance appear ominous with their threatening thorns, but also dazzle with a multitude of flowers on every paddle, mostly pure bright yellow, but occasionally speckled with orange or red.

In looking at these images, I reflected on the beautiful work that has been done by women surgeons in an often-hostile environment. During my career as a neurosurgeon, I have mentored many talented surgeons, including two exceptional and accomplished neurosurgeons who are women. I also work with several amazing women neurosurgeons as colleagues. Our profession is better because of each of them.

My female colleagues have had to work harder to reach their well-deserved positions in our medical practices, academic institutions, and professional societies. The inimitable former governor of Texas, Ann Richards, expressed it accurately and with humor when she said, “After all, Ginger Rogers did everything that Fred Astaire did. She just did it backwards and in high heels.” But they have persisted and the number of women in surgery and surgical subspecialties is increasing.

Historically, women were not encouraged to become physicians and their work in the healing professions was not even recognized. Most people are familiar with Hippocrates’ role in establishing medicine as a profession, but few are familiar with Metrodora, a Greek woman of Egyptian origin who was born between 200 and 400 A.D. and is credited for establishing obstetrics and gynecology as a specialty. She wrote a comprehensive two-volume book—sixty-three chapters—called On the Diseases and Cures of Women. Some of the book’s content is still relevant today, and she also invented the speculum to conduct pelvic examinations.

Even though the oldest medical school in the world, the Schola Medica Salernitana in Salerno, Italy was established in the eleventh century, it was not until 1754 that Dorothea Christiane Erxleben in Germany became the first female physician to be credentialed by a licensing body to practice medicine. The delay was certainly not because women lacked talent.

It has been difficult for women to work and advance in the profession of medicine, perhaps especially in surgery. Society still expects women to be in charge of the bulk of home responsibilities, including child-rearing, even when also working outside the home. This is getting better but has not been resolved equitably. While more fathers are becoming intimately involved in taking care of their children’s daily needs, the bulk of responsibility still remains on the shoulders of women.

There are many stereotypes faced by women in the workplace and in society. A 2017 Pew Research article titled “On Gender Differences, No Consensus on Nature vs. Nurture” described a few of these: men are tough; women are in touch with their feelings. Men are providers; women are nurturers. Men should punch back when provoked; women should be physically attractive.

Yet Lord Berkley Moynihan (1865–1936), the famous English surgeon and teacher, said: “The perfect surgeon must have the heart of a lion and the hands of a lady, not the claws of a lion and the heart of a sheep.”³ Women are absolutely capable of accomplishment at the highest levels in surgery, as suggested by Lord Moynihan. Among the women surgeons I have worked with, I have personally experienced not only excellent technical abilities but also heightened skills in empathy, flexibility, and listening, which I believe to be an advantage for both their patients and our profession.

The history of medicine is replete with examples of discrimination against women and minorities. Muslim women healers in the fourteenth century, in the early days of the Ottoman Empire, practiced folk medicine, midwifery, and gynecology. They were referred to as “tabiba,” the feminine form of “tabib,” the Arabic word for physician. They had an important role in the medical establishment, and although appreciated by the public, they were not formally recognized. They had no access to formal medical education and had to practice in the shadows of their male colleagues, who commanded the respect and stature.

Margaret Ann Bulkley was born in 1789 in Cork, Ireland. She decided to disguise herself as a male in order to be accepted to medical school at the University of Edinburgh. She lived the rest of her private and professional life as a male under the pseudonym of Dr. James Miranda Stuart Barry and became a successful military surgeon. Dr. Barry rose to the rank of Inspector General in charge of military hospitals, the second-highest medical office in the British Army. The fact that Dr. Barry was born female was not discovered until a post-mortem examination was performed.

But the history of female physicians has been one of only sporadic inclusion. Progress has been made, but we still need to recruit more women into our ranks, or we will deprive our profession and our specialty of an amazing pool of talent.

Women in surgery continue to do beautiful work, even when they are surrounded by thorns in their work environment, much like these images of cactus flowers in the Texas Hill Country. They have demonstrated an amazing ability to focus, persevere, and succeed. They model for many of us how a surgeon can be both gentle and tough when required, and our profession is better because of it.