Gynecologic oncologist Sarah Temkin has observed and experienced sexism in many venues: in hospital inpatient units, in the clinic infusion site, in the emergency room, but nothing is more blatant than sexism in the operating room.
“My personal experiences as a woman, a surgeon, a gynecologic oncologist—and how the way that our physician workforce is structured impacts our lives as physicians—but also, it downstream impacts the quality of patient care that we’re able to give, and also equity in cancer care,” Temkin, a gender equity advocate, said to The Cancer Letter.
Last fall, Temkin decided to tell the story of sexism in the workplace through a documentary. The film, “1001cuts,” has a mission to improve surgical care by seeing the OR through the eyes of women surgeons.
The documentary is being completed, and the trailer is available here. The goal is for the film to be released in early 2022. Temkin is raising funds for the production costs here.
“When I thought about it, telling a story about the OR made the most sense, and the stories of women and their personal experiences as surgeons in the operating room seemed like the highest impact place to tell the story of gender bias in our healthcare system,” Temkin said.
“We wanted to tell the story of the operating room through the eyes of surgeons who are women in order to really showcase how, by creating equity in the physician workforce, we can improve patient care for everybody,” she said. “The OR is a closed environment where teamwork is required and small disruptions can reverberate.”
In the film, Temkin interviews women who practice surgery across specialties.
“It’s been difficult for some people to talk about their experiences—almost everyone has cried during their interview, just reliving the experiences of being dismissed or diminished because of their gender,” she said. “Every single woman who’s a surgeon who has come forward to talk to me has some version of the same story.
“There are things like having comments made about their body, smile, or mood. All of the women that we have interviewed have experienced walking into the operating room, being told that your voice isn’t loud enough, and then raising the volume of your voice, and being reprimanded for yelling.”
Temkin’s interviews have documented much of what are common experiences for women surgeons. For instance, that every woman surgeon has an OR voice, “where she tries to find the right pitch and timbre and volume to be able to be assertive, but not threatening,” she said.
“We’re training women to be assertive and decisive as surgeons, and then turning around and expecting them to not be perceived as aggressive while they are leading a surgical team, because it’s outside of our expectations for behavior from women,” she said. “This is a classic double bind faced by women in leadership.”
Their experiences are ubiquitous, Temkin said. It doesn’t matter if the surgeon practices in oncology, plastic surgery, or podiatry.
“Even though we’re not specifically interviewing surgeons who have oncology as the sole focus of their practice, each and every one of these surgeons impacts cancer patients in some way—even the hand surgeon is involved in reconstructive procedures for patients with sarcomas,” she said. “The plastic surgeon whom we’ve included in the film has decided not to ever enter a hospital again, because the environment is too sexist, which means that patients with breast cancer will not have her expertise if they want reconstructive surgery.”
Ultimately, gender harassment and bullying they experience has a great impact on the care of cancer patients, she said.
“The orthopedic surgeon we interviewed does primarily oncologic procedures. For the colorectal surgeon—20% of her practice or more is cancer,” she said. “This message from the operating room can be extended to every specialty.”
Over the years, several people have tried to assure Temkin that “sexism doesn’t exist in healthcare anymore.” In this documentary, she is collecting evidence to the contrary.
“There’s this accumulation of evidence that demonstrates that sexism is very present. So, telling these stories through narratives and through anecdotes is really important,” she said. “The practice of oncology, for example, is very stressful, obviously. It’s the high-reward, high-stress work environment where we absorb a lot of the emotional components of what our patients go through.
“To think about the added stress of being discriminated against in the workplace or bullied or harassed, it just seems unacceptable. And if we cared about our patients, we would care about this issue,” she said.
Alexandria Carolan: How did you get the idea for a documentary about women in the OR? When did this all begin?
Sarah Temkin: Throughout my career, I have been an advocate and champion for equity in cancer care, and I had recently over the last few years really started writing about my experiences, not just with patient care, but also my personal experiences as a woman, a surgeon, a gynecologic oncologist—and how the way that our physician workforce is structured impacts our lives as physicians—but also, it downstream impacts the quality of patient care that we’re able to give, and also equity in cancer care.
The idea for “1001cuts” really began last fall. I was talking to an old friend of mine, Richard Chisolm, who had been reading some of my writing on gender equity in the physician workforce. Richard has been a cameraman in Baltimore for his whole career.
He has spent a huge amount of time in hospitals and operating rooms. His response to my writing was that it’s very good, but no one reads anymore.
And so, he encouraged me to make a film. He introduced me to Jill Yesko, who’s my director and producer, and we thought a lot about how we could impact health care the most through a documentary film.
When I thought about it, telling a story about the OR made the most sense, and the stories of women and their personal experiences as surgeons in the operating room seemed like the highest impact place to tell the story of gender bias in our healthcare system.
We wanted to tell the story of the operating room through the eyes of surgeons who are women in order to really showcase how, by creating equity in the physician workforce, we can improve patient care for everybody.
The OR is a closed environment where teamwork is required and small disruptions can reverberate.
I know that your background is in gynecologic oncology. How have your observations and your experiences in the field informed the documentary?
ST: Being a gynecologic oncologist gives you a lot of very unique perspectives on the healthcare system. We are cancer surgeons that prescribe chemotherapy, and because of that very broad set of responsibilities that we have, we inhabit so many different spaces in the healthcare system every day.
In just one day, we might go to the operating room, the hospital inpatient units, the clinic infusion suite, emergency room, ICU—and we’re housed typically in the OB/GYN department and the cancer center. We have a variety of experiences witnessing how much culture in a clinical space matters for patient care.
As a woman, physician, surgeon in all of these places, I’ve seen some very good and person-centered cultures and some less good and even, frankly, toxic cultures. In different institutions the culture might be good in the cancer center or the infusion suite, but difficult in the inpatient ward—or good in the operating room, but bad in the infusion center.
Having to navigate all these spaces as a gynecologic oncologist, I think has given me a very unique viewpoint on discrimination and harassment in the physician workforce.
And on that note, what are some of the most important messages that “1001cuts” gets across?
ST: I really hope to bring the message to the general population and healthcare consumers, that gender bias discrimination and harassment in the physician workforce is not just a one-individual-institution or a one-individual-healthcare-provider problem.
It’s really a public health issue, and I think the operating room, because it’s a closed environment, it’s just the ideal way to demonstrate how preconceptions we as physicians, or our staff or nursing in the operating room have about what we’re capable of based upon the way we look, can really be detrimental to patient care.
There are more and more women entering surgical specialties. So, this year over 40% of the general surgery residents are women, and we’re training a huge number of women in surgical fields.
Historically, over 20% of women have dropped out or been forced or fired from surgical residencies—and so that didn’t really strain the system when women were five or 10 or 15% of general surgery residents.
But at some point, as women make up more and more of our surgical trainees, this really starts to add up and impact patient care. There are easy ways to fix these things and keep women in the workforce.
It sounds like women surgeons from different specialties tell their stories in this documentary. That being said, what does oncology have to learn from them?
ST: From my understanding from talking to other surgeons and reading about this topic extensively for the past few years, the problem is ubiquitous. Gender discrimination and harassment is not a problem just of one type of surgeon or surgeons. It extends into every single specialty.
In gynecologic oncology, we’ve become a majority-women subspecialty, yet almost 60% of our gynecologic oncologists experience bullying or harassment, and up to 20% of them change jobs because of that—just in one recent survey. We want these highly specialized, highly trained physicians to stay in our workforce and to be supported.
If gynecologic oncologists are experiencing gender discrimination despite the large numbers of women in our field, inclusion of women needs to be coupled with culture change to allow women to succeed in surgical spaces.
This message from the operating room can be extended to every specialty. The practice of oncology, for example, is very stressful, obviously. It’s the high-reward, high-stress work environment where we absorb a lot of the emotional components of what our patients go through.
To think about the added stress of being discriminated against in the workplace or bullied or harassed, it just seems unacceptable. And if we cared about our patients, we would care about this issue.
How does the treatment of women surgeons in oncology compare to other specialties? You mentioned that this is ubiquitous.
ST: The thing that I have found the most fascinating is that in OB/GYN and gynecologic oncology specifically, which are the two things that I’ve dedicated my life to, we’re surrounded by women all day—we’ve specifically chosen to care for women as our passion and our mission.
Yet, the rates of gender discrimination and harassment are identical to those of other surgical fields. That really belies structural problems in the healthcare system leading to the negative experiences that women are reporting.
Even though we’re not specifically interviewing surgeons who have oncology as the sole focus of their practice, each and every one of these surgeons impacts cancer patients in some way—even the hand surgeon is involved in reconstructive procedures for patients with sarcomas.
The plastic surgeon whom we’ve included in the film has decided not to ever enter a hospital again, because the environment is too sexist, which means that patients with breast cancer will not have her expertise if they want reconstructive surgery. Even if gender bias and discrimination is not directly related to oncology care, it impacts the care that every cancer patient gets.
The orthopedic surgeon we interviewed does primarily oncologic procedures. For the colorectal surgeon—20% of her practice or more is cancer.
You’ve spoken with a lot of women surgeons for this documentary. What have you learned?
ST: The most powerful lesson for me and the other people involved in this film is how incredibly uniform our experience has been. The film is about the collective story that women experience in the operating room.
I’ve interviewed at this point dozens of women across surgical specialties, across age groups, across racial and ethnic groups. Everybody basically had the same story, and there are everyday events that seem like small events, but they add up over time.
Every single one of the women that we’ve talked to has a story, either about some part of the equipment of the operating room being mismatched to them—whether it’s the gloves or the tables that are made typically for people that are 5’8” or taller, or the staplers that we use in colon surgery (the handles are not typically made for a woman’s hand), or even the scrubs that we wear don’t have a waist.
There are things like having comments made about their body, smile, or mood. All of the women that we have interviewed have experienced walking into the operating room, being told that your voice isn’t loud enough, and then raising the volume of your voice, and being reprimanded for yelling.
Every single woman that we’ve interviewed has described having an OR voice that she uses—where she tries to find the right pitch and timbre and volume to be able to be assertive, but not threatening.
We’re training women to be assertive and decisive as surgeons, and then turning around and expecting them to not be perceived as aggressive while they are leading a surgical team, because it’s outside of our expectations for behavior from women. This is a classic double bind faced by women in leadership.
Every single woman who’s a surgeon who has come forward to talk to me has some version of the same story. These are experiences that they don’t perceive impacting the workplace for their male colleagues.
It seems your documentary is a good place to bring all of these stories together and show that it’s not just an isolated incident.
ST: Throughout my life I’ve had various people tell me that, “Oh, sexism doesn’t exist in healthcare anymore.” But there’s this accumulation of evidence that demonstrates that sexism is very present. So, telling these stories through narratives and through anecdotes is really important.
It’s been difficult for some people to talk about their experiences—almost everyone has cried during their interview, just reliving the experiences of being dismissed or diminished because of their gender.
It sounds extremely powerful, and I’m glad you’re able to document that. Could you describe the significance of the documentary title? Why “1001cuts”?
ST: Initially, we talked about calling the film “1000cuts,” because historically, death by a thousand cuts is a form of torture where 1,000 cuts are used to methodically remove portions of a body, resulting in extraordinary pain and ultimate death. However, we all felt very very strongly that the message needs to be positive.
We’re all surgeons, and so we’re very data-driven and solution oriented. We ended up adding an extra cut to make it “1001cuts,” as sort of a nod toward Scheherazade from “One Thousand and One Nights,” because she saved her own life, essentially, through storytelling. That’s what we hope to do, to provide solutions and a positive light to what has historically been a very difficult subject.
Ultimately, the reason for making this documentary is to lead to positive change; right?
ST: Yes. It’s really incredible, people have volunteered so many creative solutions to begin correcting the problem of gender bias and discrimination in the operating room.
We really hope to end on a positive note, because one of the other very striking things that I’ve learned is how much all of these women love their job. They love being surgeons, they love taking care of patients, and they all have ideas about how to improve the work environment.
Is there anything else you’d like to add?
ST: If we really want to create solutions to equity in our patients’ experiences, we have to address equity in our workforce.
