Sareh Parangi, MD: Making Surgery a More Sustainable Career for Women

The number of women entering medical schools has been steadily rising, and today women make up half of U.S. graduates. But even so, the number of young women entering surgery still reveals large disparities. Just one-third of applicants to general surgery are women. And a recent study found that over one-third of women consider leaving residency due to the challenges of balancing the demands of residency with those of pregnancy and motherhood. Post training, the challenges continue. Women surgeons still have higher attrition rates than men, with one-quarter leaving the specialty.

Dr. Sareh Parangi views this as serious problem. Sareh, who directs the thyroid cancer research laboratory at Mass General, was inspired to enter health care by her mother, who was admitted to medical school in Iran, but ultimately didn't go because she thought it might complicate raising a family.

Sareh was only the second woman to become a full professor of surgery at Mass General. She is currently the president of the Association of Women Surgeons and has become a vocal advocate, encouraging women to join the field. Today, she is leading efforts to make surgery a more sustainable career for working mothers.

Welcome, Sareh.

A:  Thank you very much.

Q:  I wanted to start off by talking about some research that's been done. There was a study published out of Brigham & Women’s Hospital last year that found that over one-third of female surgery trainees have considered leaving the specialty, and some have even changed their fellowship plans as a result of these perceived difficulties. And I know you were quoted in the Globe commenting on that research, so I wanted to start there.

A:  Unfortunately, that's very true. Right now the numbers you quoted are very accurate. Fifty percent of medical students are women, and the truth of the matter is that we need the brightest and the best to go into surgery. And therefore, we need to make sure to recruit women who want to become surgeons and stay in surgery.

There are definitely barriers that seem to stop women from the very first steps of medical school. Definitely what we see is that raising a family and being able to balance career with family needs is very important for women medical students, and for women residents. So as a specialty, when we don’t pay attention to that, we're unable to recruit the very best to come into our specialty.

And keep in mind that while in general surgery we have made great strides, and now some 23% of general surgeons across this country as faculty member are women, in certain specialties like urology, it’s only 8%. Thoracic surgery, orthopedics, it’s 5 and 6%. The same for neurosurgery. So those specialties are really being left behind because they're really not able to recruit the best.

And that's not good for patients. Patients need to have a balanced group of doctors. We have to really do things to improve it.

We've definitely seen in many studies, unfortunately, when students come into surgery about a quarter are interested in surgery; it’s equal between men and women. But by the time they finish, way more women are dissuaded from going into surgery, and men are actually encouraged to go into surgery. And so the number goes up for men who go into surgery and goes way down for women who go into surgery.

Q:  Is that happening because of implicit messages or explicit messages?

A:  We recently looked at some of the data. And it’s both. So some of it is implicit messages, but some of them are just explicit comments. You know, “Why would you want to go into surgery? You won't be able to have a family.”

I definitely heard that when I was a medical student. But that was, you know, 25 years ago. To think that it’s happening right now is sad. I just had a recent experience, one of the medical oncologists at MGH told me a sad story. His daughter, according to him, is a born surgeon. He thought for sure she would choose surgery. And his wife thought for sure she would choose surgery.

When she did her surgery rotation, she loved it. But at the end of the day she decided not to do it because she was constantly told, “You won't be able to have a family.” So she went into emergency medicine instead. That's a big loss.

Q:  Yeah. Can you talk a little bit about, as far as I understand, there's some barriers in the structure of the field that can be challenging for women.

A:  One is obviously the length of the training. So the training to become a surgeon can take five to eight years, depending on which program you choose and if you want to do a fellowship, if you want to do research. And certain ones, like cardiac surgery, almost take ten years. So some medical students who are women look at that and say, “I'm going to give away the prime of my life and my childbearing years to do this specialty. And at the end of the day, is that worth it?”

The other thing that's a barrier is childbearing. So it used to be that being pregnant was just not going to happen during surgery residency. In fact, the first women surgery resident I knew who was pregnant who was in my class in residency was fired when she was pregnant.

Q:  Really?

A:  Yeah, really.

Q:  Was it explicit?

A:  Yeah. It was pretty explicit. She was a single mom. She was an MD/PhD student. She got pregnant. They kept shifting to her, let's say, less desirable rotations where she wouldn’t be operating, because the operating rotations didn't want her. And at the end of the year, they fired her.

So we've come a long way from there. I think we've definitely put in place protection for residents who want to get pregnant during residency. I think we have petitioned the American Board of Surgery to make the training more flexible, so you can take off anywhere from six to eight weeks now as maternity leave. Many surgical residents take time off for research, and during the research time, they’ll have kids. So sometimes they overcome that barrier that way.

And then there's physical barriers. Sometimes, people may experience complications with pregnancy, and definitely there's data that women surgeons experience complications at a higher rate around pregnancy. And so that can delay training and throw you off.

So all these things add up a little bit at a time--discouragement, the length of the training, the bias in perception that it’s not for women.

People used to not be able to see role models. So that's one of the reasons we have organizations like Association of Women Surgeons, to show people that there are women surgeons. They have families, they can become leaders in American surgery. And that seems to have a positive influence.

Q:  Can you talk a little bit more about that bias piece? I imagine you can set up new structures that might be a little more friendly, but fighting bias is a little more nebulous?

A:  Yeah. I think, unfortunately, that's true. And I think maybe surgery’s perception has been, “Well, women shouldn’t come and train here if they're not willing to be as rigorous as everyone else,” let’s say. Why should they be able to take time off for having a child if the male resident is not taking time off? for example.

So we are trying to combat some of those through professionalism training. And I think in the long term, those kinds of things will be much better for our profession on a whole. We are already better now than we were 10 or 20 years ago, and we are going to be better in another 10 years. It’s just a matter of getting there completely.

So I think there is bias, unfortunately. There are ways to combat it. We're all working on it. And I think the key is that the chairs of surgery have to buy in. And we're lucky, at Mass General we have an amazing chair of surgery who talks about this issue all the time and has a daughter who’s training in surgery. And that's really, I think, brought it home for him. And it’s people like him who will make the biggest change, I think.

Even though I’d love to think it’s people like in the Association of Women Surgeons who are doing all the groundwork. But I think if the leaders at the top, at the highest level, make those changes, it’ll just go faster.

Q:  Yeah, kind of in combination, working from both ends.

A:  Bottom and the top, that's right. Like if you imagine the glass ceiling,  if you're picking at it from the bottom, it’s harder to shatter. But if you're cracking it from the top, well that's a bit easier.

Q:  Just smash it.

A:  Just Just smash it. [laughter] I like that idea.

Q:  What has your experience been like? I know you've come up through the ranks and been able to have a family, raise children.

A:  I've had a great experience. I mean, I have to say I'm thankful, obviously, to my own family. When I decided to go into surgery and I was asking around, I was in medical school and really fascinated by surgery. And everybody pretty much, including the one single woman surgeon who was at my medical school, told me, “Don’t go into surgery. You won't be able to get married or have kids.”

And my mom was the one who said, “Why would that be? Of course you're going to get married. Of course you're going to have kids. It’s totally normal.”

And that normalized it for me. So that was the first barrier, I’d say, just kind of making the decision. After that, I had all the support in the world. I had a very supportive husband. I did a great residency. Everybody there was super caring and really invested in me becoming the best surgeon I could be.

And I was interested in research, so they invested in that for me. And so, I’d say all the way until I reached mid-career, I didn't experience any barriers. But I’d say progress slowed for a little while, and that was definitely a learning experience for me. And it was something I had to overcome to be able to get to the next step and become a professor.

Q:  How did you end up in the field? You mentioned you didn't necessarily expect to land where you did?

A:  Yeah. I mean, I had no interest in surgery, I had never thought about surgery. And the rotation I did during medical school was just really excellent. It was a lot of team oriented work. And as a medical student, you really felt part of the team. In fact, I don't know if you guys know Dr. Oz, Mehmet Oz, he’s on TV. He was my senior resident. And so he was a very engaging guy and he ran a very nice team and really made me feel part of the team.

And the first operation I saw, it was like magic. Like I could not believe you could open a real live person and put them back together. That was so weird to me. And so mind boggling that--I was like, “I have to do that. That just seems amazing.” I’d actually never seen anyone be put to sleep, either, so that whole thing was very amazing. Putting someone to sleep, cutting into them, removing something and sewing them back up and waking them up was fascinating.

Q:  In the beginning is it scary when you have that scalpel for the first time.

A:  Yeah, I do think it’s really scary. I remember a very distinct time in my training when I was a second year resident and the attending said to me, “Well, I'm here in the room. I'm just putting my gown on. You go ahead and get started.” And it was gallbladder surgery, and I knew exactly where to put the incision. But I swear to God, I measured like ten times and marked it and re-marked it hoping he would already be on with his gown and so I could make it when he was watching. But, I think he was doing it on purpose because he waited until I made it. And it was pretty scary, yeah.

Q:  Little bit of tough love.

A:  Little bit of tough love. Under supervision, always a good thing. [laughter]

Q:  So then going forward, you said mid-career you hit some of these barriers. What it was it like to, in the middle of success, reach these barriers?

A: So this is something I pretty much never talk about. So, it’s a little bit hard to talk about it, because no one wants to talk about hard parts of their life. But for me at first, it was I guess like that saying, they say if you have a frog in hot water, it’s very, very slowly getting hot, they may not notice. That's kind of how things happened for me. I didn't really notice at first, at all. Little things put in my way, and then bigger things put in my way and then real obvious things that were said that were inappropriate.

And honestly, I still didn't get it. I still didn’t get it. And sometimes, I would ask myself, why am I not able to move past this barrier? I wanted to get promoted; that was one of the things. And I just couldn’t understand why it wasn’t happening. And I'm grateful that one of my really good friend’s husband, who was a cardiologist, actually explained it to me. He said, “You don’t seem to be getting it, but this is gender discrimination and they're discriminating against you.”

And only when he said it, it was like a little light bulb. It all was like, “Oh, that's what's happening.” That was very helpful because once I could kind of get what was happening, I could try to figure out how to overcome it, because I knew it wasn't me. Because before, I was thinking, “Well, I'm not getting promoted because I'm not good enough.” Or, “What I have accomplished is not good enough.” “Or, I just need to click off ten more boxes, and then it’s going to happen.”  Or, “I need to get one more grant.”

But once I realized that in that situation that I was, which was not at Mass General, it was never going to happen. I could click off a hundred boxes, and it wasn't going to happen because they were discriminating against me.

Q:  Were there ever times where you felt like giving up?

A:  Not for me, although the particular group of people who were trying to kind of, let's say, torpedo my career, sort of suggested that, weirdly. They suggested maybe I should just go into private practice because, you know, academics wasn't going to be for me.

And I had to sit back and think about it. And I decided that just wasn't me. I didn't want to do that. I loved my research, and I really wanted to continue that. And like while I love taking care of patients and I still operate a ton and I love doing surgery, I didn't want to only do surgery. I wanted to do the research. So I realized I couldn’t cop out that way.

Q:  I think it’s really interesting to hear that, as you said, sometimes when you're in a situation it’s hard to see what's going on around you. But then once you have someone hold the mirror and reflect back to you, is that a skill that you’ve used since then moving forward?

A:  I've tried to be the mirror for some other people who can't see their own situation, or who minimize their own situation and think they’ll be able to solve, again, some barriers that are obviously not going to be solvable, let's say. I don't know if I'm great at doing it for myself. But I am better at seeking out, maybe, opinions from other people. And weirdly, I use my husband as a little mirror for myself because basically as medical students, we both went into surgery. He’s a urologist. Then we both did residencies, we both did research, we both started our careers, we both got grants around the same time. We've done so many things that are similar. So when something seems off, I kind of compare myself in some weird way to him.

Not in a competitive way, but I try to figure out how he would view it and get his opinion. And it’s super valuable.

Q:  I like that idea of you’ve kind of got this alternate personality, almost, that you can pick from.

A:  Yeah, compare and learn from. I've learned a lot from him and how he manages situations and how he views things.

Q:  You have become a very strong leader and advocate for women in the field. I wonder if you can talk a little bit more about your advocacy work?

A:  I think that all together, I've sort of got two hats on right now, which are very, very interrelated. So I am definitely president of the Association of Women Surgeons, and in that role the vision really is to help women surgeons achieve equity in their training, in their lives and to help them reach a great point in their career where It's sustainable and fulfilling for them.

So last year, for example, we ran the Association of Women Surgeons meeting in Boston. We almost doubled the number of attendees. And really, it was very successful, I think. And through these kind of venues, we are trying to make sure to get our message out and partner up with chairs of surgery, as well as other societies.

My other hat, recently I was appointed the inaugural diversity and inclusion director, within the department of surgery. So that really, I'm doing in conjunction with Dr. Oseni, who’s another surgeon. She's African American and she's a breast surgeon. And it’s great to partner with her and work together to really increase the diversity and inclusion efforts of our department.

So those are my two hats. They're very interrelated in my opinion, because what we do for women makes everything better for everyone. And the same is for underrepresented minorities. The more we recruit them and bring them into MGH and the Department of Surgery, the better it’ll be for everyone; our patients, our organization, our initiatives that happen.

Q:  How are you approaching those efforts to increase diversity?

A:  Part of it is just setting our mind to it, looking at the data and seeing where we are. That's really hard to do because sometimes we're not in a great place, and it's hard to look at ourselves and say, “Where are we?”

And then we have a diversity and inclusion committee with representatives from the residents’ community, so patients, as well as a representative from every division in our department.

And then we're going to work on a lot of initiatives. We have now gone through one resident recruiting season. We made a lot of efforts to encourage underrepresented minorities to come and interview. And so hopefully, we’ll see if that will yield results.

We're doing an “I am MGH Surgery” campaign, which focuses on interviewing the diversity we have in our department. So not just underrepresented minorities, but what is the diversity and why did these particular people come to MGH and what's the sense of belonging they have at MGH? And we want to show the world that MGH is not just, let's say, a hospital that encourages people from Harvard or Yale or Ivy League schools or the white ivory tower schools to come and train here. We encourage everyone in the country to come; the best and the brightest and we want them to serve their communities after they leave MGH.

Q:  Yeah. How has it been received internally?

A:  People are super excited, and I'm excited that they are excited.

I think clearly Mass General has heard the message from its patients, its community, and its physicians that we need to be more diverse and to better serve our entire city’s and region’s population. So I think that message is clear.

Q:  So sounds like actively working to build community among this group of people?

A:  It's important, it’s really important. I've done some one on one interviews with the underrepresented minorities in our department. And that's really important to them. That's one of the barriers they face.

They feel like if they train in a city with a high African American community, let’s say like Atlanta, there's an instant community. They don’t have to think about it, it’s already happening. But here, they have to think about it. So the easier we make it for them, the better it’ll be in the long term, I think.

And again, when we say inclusive and welcoming, we mean for everybody. We want to make sure the gay and lesbian community is included. We want to make sure physicians with disabilities are included. All that diversity has to be included. We're not just thinking necessarily underrepresented minorities only, of course. But everybody.

Q: And are there changes that have been made here around the motherhood piece to make that, not just doable, but sustainable?

A:  So there's been a lot of efforts. I’d say some of them are broad, like at the American Board of Surgery level, to make sure that the training eventually becomes competency-based and not necessarily time-based. So right now, if a woman resident wants to take off multiple times during a residency and become pregnant, it’s almost impossible to finish training on time, because you can only get six weeks off. So if you can only get six weeks off, what if you also get ill? What if you need your gallbladder out or what if you break your ankle? All those things can happen to people. So, part of it is on our part advocacy for those kind of things.

Unfortunately, another big barrier is childcare, of course. And the cost of childcare for faculty and residents, is very high. So that, hopefully, would be something to tackle in the future to try to see how to overcome that.

Q:  Another thing I always wonder about in these conversations is we focus so much on-- particularly when it comes to women, what women should do and how the system can support them. But, half of the population is men. So, what role do they play in these issues?

A:  I definitely think that we need to see men as allies and listen to them and how they perceive the situation as well. I think that's really important, because otherwise it’s like a little echo chamber and they have to listen to us, but we also have to listen to them.

So I think lot of national organizations have taken note of that. So for example, in our Association of Women Surgeons, we had a big push last year to have a whole task force called “He For She.” And these are men that we recruited who, I’d say, are very progressive and are great voices for advancing issues centered around women in surgery.

Now this year, I'm taking it a step further and really just opening the conversation to all the chairs of surgery. Naturally, they're not all progressive, but I think we still need to hear what are their needs. What's happening in their departments? What do they see as the important next steps that their departments need to take? And it may not be the same thing that the very progressive people see. So I think we need to get their input. And then see what tools we could provide them and work through them.

We need to have men as allies. And it’s really critical for moving the needle forward faster.

Q:  How have you gone about finding those people who can be allies, for yourself or in the organizations?

A:  Well, last year, for example, when I ran the Association of Women Surgeons meeting, I decided that I was just going to email all the chairs of surgery. And bizarrely, no one had ever done that before.

Q:  In the whole country?

A:  Yeah, in the Association of Women Surgeons, no one had ever thought to do that. Kind of strange. So, I just emailed every single person with a very personal email saying, “We are doing these initiatives and we want you to help us and we want you to be involved, and we want you to send residents and we want you to send your faculty. And by the way, we want you to give us money.”

And a huge number of them responded. A lot of them sent members of their department. And a lot of them just communicated with us. They said, “We don’t have money right now, but we think this is valuable.” So it started a dialogue. But I think that because the numbers were high, it generated a lot of buzz, and even the ones who were, let's say, latecomers to the party, are very interested now.

Q:  I love hearing that there is this power and value in just asking questions and speaking up.

A:  Communication. Yeah, I think that's really important, and I was the first to be surprised, I have to say. When I sent out that email I thought the few people I know, really know, will answer. But, by 6:00 the next morning, two chairs who I’d say I kind of know well, maybe, one of them I haven’t spoken to in 20 years, said, “Oh yeah, we’ll send people and we’ll give you $10,000.” So, that was a good sign to me.

Q:  When I was in graduate school, that was one of the best pieces of advice that I got, was it never hurts to ask. The worst that happens is someone says no.

A:  I think it’s hard sometimes for a woman, right? We don’t ask for promotions, we don’t ask for increase in pay. We can't play shy.

Q:  What do we do about that? I struggle with that all the time.

A:  Well, I think some of it is a gender schema, right? Like how you were raised as a child and what was emphasized to you and your family. Girls are quiet and girls are shy and boys are active and loud, et cetera. Those kind of things. So I think slowly, those schema will change. But it’s something we have to, I think, learn for now. And, like you say, the sooner you learn it, the better, right?

I always recommend people read that book, Women Don’t Ask. I don't know if you’ve ever read that?

Q:  No, I’ll look it up.

A:  It's a little bit older now, but it’s a great book. It’s a woman who is a professor-- I forget exactly at which university-- and she notices that all of her graduate students are male are always in her office asking for things. And the women graduate students never come in her office and never ask for anything. So she decides to study this for real and just do research on it and eventually publishes this book. And she gives a lot of advice about why aren't women asking and what should they do to ask.

Q:  Are there other things that either people or books or studies you encountered on the way that have helped you to learn these skills?

A:  Yeah. I’d say actually-- so Mass General’s Center for Faculty Development puts on a negotiation course by a professor of law at Harvard Law School called Bob Bordone. I have found that course invaluable. I always thought of negotiation of I'm going to go in my chair’s office and ask for a raise.

But he really tells you how much in your life you use negotiation. It’s not about money, it’s about power and getting what you want and getting initiatives you want done, et cetera. And through that course and learning more about negotiations, I've been reading some books. So for example, one of my favorite is called Never Split the Difference. It’s written by this guy who’s an FBI hostage negotiator. Every chapter starts with a little anecdote about some hostage negotiation that he’s been part of, and then he tells you the story through that. But generally speaking, it’s just about negotiations. So I've learned a lot through there. It’s been fascinating.

Q:  That sounds like a lot of fun.

A:  Yeah, read it. You'll like it.

Q:  And you're the mother of boys, correct?

A:  Yes.

Q:  So as you've been talking about learning these skills yourself and other women learning them, how are you thinking about that when you're raising young men?

A:  So I do have two boys; one is 23 and one is 19. I guess until they were teenagers, I don't know that I thought about it a lot, to be honest with you. But when they became teenagers, and they could really think and express themselves, and I could see the difficulties with the concepts of dating and racism and equity and all these things formulating in their heads. It’s been interesting watching it because I would say that I've learned a lot more from them and the way that they are so open-minded. And so not bogged down by many of these issues, that it gives me a lot of hope for the future because I actually don’t see them too mired in a lot of these things. But I think the new generation is going to be in a much better place. And I think they are much more open-minded.

But I think it’s hard for men. The same gender schema as we suffer under as women, they definitely suffer under and have to find their way. I don’t have any solution for that, unfortunately. Talking a lot to them has been helpful, and listening to them and learning from them.

Q:  Yeah. And we're in this moment when it’s kind of tumultuous.

A:  Yes. Yes. Yes. And they sense that. They sense that. The whole last election was very interesting to them. The current #metoo movement, they think about that stuff all the time. They talk about it among their friends. A lot of times when their friends are over, I try to just listen and see what the conversation is like. It’s interesting.

It’s on their social media radar super heavily. And they worry about it. Both my sons have mentioned to me that they have, both of them actually already even though my youngest is just a freshman, kind of intervened in separating a young woman in college, from bad situations when there's been alcohol involved.

And they were grateful that they could think about it and intervene. But I don't think they would have known about it, or any of these things, if there hadn’t been all these movements and talk about it.

Q:  And I'm wondering, when young women who want to enter the field of surgery come to you, what counsel do you give to them?

A:  Oh, I say go for it. I mean, I think you just got to do what you love. So if they love it, I think they should go for it. They shouldn’t think of it as barriers or anything. They should just do what they love. I'm very saddened when I hear that some women surgeons tell students, “Oh, don’t do surgery. I wouldn’t do it if I were doing it again.”

I definitely don’t tell them that. I love operating. And I love all the opportunities it’s given me all over the world to visit and give talks and mentor people and meet people and the patients I've helped. I totally encourage them to do it. I just think they have to do it for the right reasons and they have to really understand the road ahead. And I think as long as they understand the road ahead, they can totally do it. So I'm, I guess, all encouragement.

Q:  I love it. All right, well that concludes our discussion. But before you go, I have my final five questions. Number one, what's the best advice you've ever gotten?

A:  Focus on your family. I think it just permeated through my culture, that your family’s your most important thing. I don't know exactly who, particularly, may have given me that advice. It was probably my parents and my ten aunts and uncles at some point [laughter] but I think that that's clear to me.

Q:  The name of this podcast is Charged. What does that word mean to you?

A:  Electricity and sort of excitement and spark.

Q:  How do you recharge?

A:  I spend time with my family. That's the number one way I recharge. But I also read books, lots and lots of books. I garden a lot, and I bake a lot of bread.

Q:  Why bread?

A:  Bread? Because it was kind of scary. I don’t come from a family of bakers and I never thought you could actually make bread. I’d never known anyone to make bread. So I think I read it somewhere and I decided it was like a chemistry experiment and I was going to try it. And so now I make a lot of different kinds of bread.

Q:  When and where are you happiest?

A:  I am definitely happiest in the summers in my vacation home on the water waterskiing or wake boarding.

Q: And what rituals help you have a successful day?

A:  Sleeping well. I think if I sleep well, then the next day is great.

Q:  Well, thank you, Sareh. It's been such a pleasure.