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neglect. Worse, our current culture of medicine and healthcare assigns physician wellness a low priority, with many physicians fearing repercussions when help is finally requested.42,44 Physician burnout ultimately leads to lower job satisfaction, less productivity, less willingness to help colleagues, and higher attrition rates.42,45 Surgical specialists have been shown to be more likely to reduce work hours or retire early as a result of burnout.45 Given that females experience higher rates of these contributors to burnout at baseline, one might suppose that females have higher rates of burnout than their male counterparts. Although specific studies have not yet been carried out, it stands to reason that the global impact of career-long obstacles, personal sacrifice, and burnout combined have resulted in lower female representation in medicine, surgery, and plastic surgery alike. Evidence of Growth in Modern-Day Plastic Surgery Despite the many challenges that women have faced throughout their journey in medicine, female presence in plastic surgery is growing. Female representation has increased from 21.84% to 37.31% in both independent and integrated plastic surgery residency training programs over the last decade.46 From 2008 to 2018, female representation in plastic surgery residency programs increased by 16.7%, second only to vascular surgery which saw an increase of 17.3% in female residents.47 Of all surgical residency training programs in 2018, plastic surgery was the closest to approaching gender parity with a female-to-male ratio of 38.9% to 61.1%. Orthopedic surgery had the lowest percentage of female residents at only 15.3% female, although this was still a 2.9% growth in female representation compared with 2008 data.47 On the other end of the spectrum lies obstetrics and gynecology with residency programs dominated by female representation at 82.9%.47 It is worth noting that this finding represents the opposite form of gender disparity, which is also less than ideal. Overall, female presence is rising in all surgical residency programs, with plastic surgery most closely approaching gender parity. In addition, female residents in plastic surgery have been shown to be happy with their careers and report increasing support for simultaneous personal life progression, including pregnancy, during training.31,48 Similarly, the percentage of females in plastic surgery academia is increasing with a nearly 10% rise in practicing female surgeons over the age of 55, indicating not only a greater number of females graduating from plastic surgery training programs but also long-term retention of active surgeons.47 These practicing female surgeons are also increasingly taking on national roles as evidenced by an Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz299/5609346 by guest on 14 February 2020 Moak et al 5 increase in societal female membership and participation. The ASPS has seen a growth of 120% in female membership since 2000.15 The ASAPS has seen an increase to 14% female representation, up 2% from last year alone.46 Further, female leadership in these national societies has expanded from 6.78% to 20.29% over the past decade.46 Female plastic surgeons in training and in practice are also gaining voice and recognition within the plastic surgery literature. Although previous studies have found that women tend to publish fewer articles than men, publications by female surgical faculty authors are increasing exponentially in all areas of plastic surgery and are more likely to be cited soon after publication, suggesting higher-quality work.15,33 Further, although women publish fewer articles than their male colleagues in early career years, scholarly productivity for female surgeons has been shown to increase over time, peaking at 15 to 30 years in practice.15,16 These senior female plastic surgeons are generating more articles and are receiving more grants and greater overall funding than their male counterparts, suggesting that women who remain in academic plastic surgery do overcome gender disparity experienced in career infancy.17 Thus, at all levels of career development, plastic surgery is growing in diversity and quality with continual movement towards gender parity. From medical school to residency training, from early to later career years, females continue to join the field of plastic surgery at ever-increasing rates and are demonstrating a lifelong commitment to furthering the specialty in all facets of the profession. More excitingly, this current trend is still in its infancy and will undoubtedly lead to an overall increase in female presence and leadership within our profession over the coming years. We’re Not There Yet: Leadership, Mentorship, and Sponsorship How Can Women Compete in a Male-Dominated Field Such as Plastic Surgery? For a woman to compete in any male-dominated arena, she must first believe she can compete. That is, she must have the confidence to pursue her passion and demonstrate her competence. There is a growing body of evidence that outlines just how important confidence is for not only achieving success but simply asking for the opportunity, an attribute that most women do not adequately harness.49,50 Women have been shown to underestimate both their abilities and performance, and routinely pass up
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