Access to surgical care in low- and middle-income countries (LMICs) remains deficient without an adequate workforce. There is limited understanding of the gender gap in surgical trainees in LMICs. In Rwanda, females fill only one of 20 positions available. Understanding surgeons’ experiences and perceptions of surgical careers may help facilitate support for females to contribute to the global surgical workforce. We performed qualitative analysis on perceptions of surgical careers through semi-structured interviews of all female surgeons (n = 6) and corresponding male surgeons (n = 6) who are training or have trained at University of Rwanda. Transcripts were analyzed with code structure formed through an integrated approach. Question categories formed the deductive framework, while theoretical saturation was reached through inductive grounded theory. Themes were organized within two key points of the career timeline. First, for developing interest in surgery, three main themes were identified: role models, patient case encounters, and exposure to surgery. Second, for selecting and sustaining surgical careers, four main themes emerged: social expectations about roles within the family, physical and mental challenges, professional and personal support, and finances. All female surgeons emphasized gender assumptions and surgical working culture as obstacles, with a corresponding strong sense of self-confidence and internal motivation that drew them to select and maintain careers in surgery. Family, time, and physical endurance were cited as persistent challenges for female participants. Our study reveals concepts for further exploration about gendered perceptions of surgical careers. Efforts to improve support for female surgical careers as a strategy for shaping surgical work culture and professional development in Rwanda should be considered. Such strategies may be beneficial for improving the global surgical workforce.
This study is a cross-sectional qualitative survey of all female surgeons in Rwanda and their corresponding male surgeon colleagues. An integrated approach was used to explore the contextual variables involved in selecting and building a surgical career in Rwanda: a deductive organizing framework was built for the interview guide, and an inductive, constructivist grounded theory approach was applied to the data to develop new theoretical constructs from the “ground up”[14]. We adhered to the consolidated criteria for reporting qualitative research (COREQ).[15] Rwanda is a low-income country in East Africa,[6] where tremendous recent investment in health care has improved life expectancy and infant/maternal health indicators.[16] In 2012, the Rwandan Ministry of Health partnered with a consortium of US academic institutions to create the Human Resources for Health (HRH) Program to increase the quantity and quality of providers in Rwanda.[17] The number of surgical residents increased from 15 in 2012 to 50 in 2016. Despite such progress, significant challenges in infrastructure, staff, and clinical processes remain for delivering safe, effective, and timely surgical care.[18] It is in this context that Rwanda provides an ideal background for understanding perceptions about entering and building surgical careers amidst growing yet still resource-limited settings. Using a purposive sampling technique, we interviewed all female surgeons who had been trained in Rwanda (n = 6), as well as male surgeons at corresponding career points (n = 6), for a total of 12 surgeons. After matching the number of years in training or practice to their female counterparts, male surgeons were selected randomly from a list of providers through the Department of Surgery at the University of Rwanda. Of note, there are female and male surgeons in Rwanda who have trained in other countries or work temporarily in Rwanda; however, our objective was to understand the perceptions of those who had trained in Rwanda. All participants were approached in person or via mobile phone and provided informed oral consent to take part in the study. Participants were also offered a written statement describing the project and their rights to withdraw themselves from the study. No individuals approached declined to participate. The research team included a surgeon, two surgical residents, and one medical student- all of whom are female. The primary interviewer (SY) is a US medical student with experience in qualitative methodology. The data collection and analysis process were managed by SY and a US surgical resident with training and experience in qualitative methodology (YL). The surgeon (ACC) and surgical resident (GK) who have been living and working in Rwanda provided counsel with contextual insight during the analysis phase, as GK participated in the study as well. Prior to the study, SY worked in Rwanda for 5 months and met with Rwandan surgical residents and surgeons to explain the goals of the study. The interviews were semi-structured with evolving open-ended questions.[19] Our interview guide consisted of questions on the chronological process of selecting and building a career in surgery. This structure enabled the interviewer to collect information about how participants became interested in surgery, how they perceive the specialty, and which aspects continue to motivate them, while still giving informants the opportunity to report on their own thoughts, gender assumptions, and feelings. Two pilot interviews were conducted on a surgeon and surgical resident in Rwanda, but only minimal changes for clarifying the wording in the interview guide were made. Interviews were conducted in private and performed in English. No repeat interviews were conducted. Interviews and informed oral consent were audio-taped when permission was given, then transcribed verbatim. Per the IRB protocol approved by the University of Rwanda College of Medicine and Health Sciences, all electronic recordings and documents were appropriately secured to preserve participants’ desired anonymity. All interviews were conducted from December 2016 to January 2017. Analysis occurred in two phases. In the first phase, two members of the research team (SY, YL) read the transcripts and inductively created a code structure. Transcripts were assigned in ATLAS.ti (version 1.01.50; Scientific Software Development GmbH, Berlin), and open coding was used to assign and generate themes and subthemes for a final code structure. The categories of questions from the interview guide represented key conceptual domains for the deductive framework. An inductive grounded theory approach was then taken to develop the codes and code structure until the point of theoretical saturation,[20] which was defined as the point at which no new concepts emerge from reviewing of successive data from a diverse sample set. Theoretical saturation was reached after four interviews. Two researchers independently applied the codes from the finalized code structure, reviewed discrepancies, and resolved differences through in-depth discussion and negotiated consensus. In the second phase of analysis, the coded transcript was explored to describe and form relationships within the content. The results provided insight into the nature of selecting specialties, as well as participants’ perceptions about gender-based roles and their influence on surgical careers. Contextual validity was sought through sharing preliminary study findings to Rwandan surgeons and residents so that they could respond to and advise on the validity of the emerging themes. The process of “member checking” facilitated a feedback mechanism on the interpretation of our results from individuals who are living and working daily in the context of this study.[21] Ethical approval for the study was obtained from the Institutional Review Board at the University of Rwanda College of Medicine and Health Sciences: Approval Notice No. 362/CMHSIRB/2016. The informed oral consent procedure was reviewed and approved by the Institutional Review Board at the University of Rwanda College of Medicine and Health Sciences. Consent for participation was recorded, and no subjects refused participation. Written consent from the participants was not pursued or stipulated by the Institutional Review Board in order to minimize the physical supervision and security needed to store identifying information. Limited data from this study is only available upon request, as there are ethical restrictions on sharing the de-identified data set publicly. First, the interview transcriptions are inextricably linked to the participants, as the content reflects their experience training in Rwanda so far and cannot be de-identified appropriately without removing most of the data. Second, the Institutional Review Board approved a data collection, security, and storage procedure in which the original transcriptions must be erased and destroyed upon completion of the written work for this research. The contact point for accessing the de-identified data is the corresponding author.
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