Gabrielle Van Ramshorst ^1* Barbora East ² Nadia Henriksen ³

• ¹ Ghent University Hospital, Ghent, Belgium
• ² Charles University, Prague, Prague, Czechia
• ³ Herlev Hospital, Herlev, Denmark

The CanMeds roles state that as physicians, we need to demonstrate a commitment to patients by applying best practices. (3) Christoffersen and Henriksen found that more than half of the women with epigastric hernias in the Danish national database underwent suture-based repairs, even though mesh-based repairs reduce the rate of recurrence. (4) Most groin hernias are found in men, therefore the article by Dahlstrand et al on groin repairs in Swedish women adds to solving a knowledge gap. (5) Only 19 out of 52 studies that included female patients showed separate results for women, highlighting an important focus for future study reporting. Following changes in guidelines, the proportion of endolaparoscopic surgery for groin hernia repairs (vs. open repair) has steadily risen over time in women, indicating growing adherence to guideline recommendations. Holland et al explored racial and socioeconomic disparities in complex abdominal wall reconstruction referrals, as the equal access to minimally invasive surgery based on racial disparities has been a concern. (6) Some research questions will never be asked if female surgeons are not growing into principal investigators. And in order for them to climb the academic ladder, they need to be provided with opportunities for growth, mentoring and promoting from the early beginning of their careers. During training, female residents are perceived as needing more guidance and are offered less intraoperative autonomy. (7-9) Once in independent practice, women receive fewer referrals than men, especially from male colleagues. (10) This often results in less focused practices with fewer opportunities to build experience of performing complex procedures. (11,12) Female surgeons least commonly performed the most lucrative surgical procedures. (13). Over a simulated 40 year career, female surgical specialists earn $2.5 million less than males after adjustment for factors such as hours worked, clinical revenue, type of practice and subspecialty, resulting in lower savings for retirement. (14-16) An American survey among over 25,000 academia, industry and government showed that all marginalised social groups earned less than white heterosexual males, with the latter granted more career opportunities, feeling more respected at work, experiencing less harassment and less likely to leave science. (17) A report from the Australian National Health Medical Research Council found that men were disproportionately awarded 23% more grants than women and received an additional $95 million in funding. (18) Women are less likely to be promoted even after adjusting for number of publications, amount of grant support, tenure vs other career track, number of hours worked and specialty. (19), and are less likely to become department chairs, as are specialists from non-white backgrounds. (20) In a randomised double blind study, applications with invented male names were rated as more competent and hirable by science faculty, given higher starter salaries and offered more mentoring whilst applications with invented female names were viewed as less competent. (21) Changing practice for the better requires a working culture that recognizes, supports and responds effectively to colleagues in need. Some barriers that women experience are invisible to others. In the operation room, if the surgeon's gender differs from the primary gender composition of the rest of the surgical team, cooperation is higher, and conflict is lower. (22) Attending a (social event at a) conference can be a barrier to women and other minorities if they witnessed or experienced harassment inside and outside the hospital. Gender and racial based discrimination, verbal and physical abuse, and sexual harassment are reported at higher rates by women, with up to 65.1% of women reporting gender discrimination and 19.9% reporting sexual harassment. ( 23) A systematic review by our research group describes the (additional) challenges that female surgeons face during pregnancy and early motherhood, soon to be published in Surgery. As members of the surgical community, we need to recognize and respond to unprofessional and unethical behaviours and some institutions have started to offer bystander training for developing this skill.Creating an environment where females and underrepresented minorities are recognised as experts (not only as moderators) is an open opportunity for anyone who organises an educational event. If you are an invited speaker and the programme's speakers are a poor representation of society: this is the time for you to speak up and promote others. The pharmaceutical and medical device industry is far behind, creating an industry payment gap -again in favour of male experts. (24) In 2023 I was awarded the American College of Surgeons Dr. Abdol and Mrs. Joan Islami International Guest Scholarship. One session at the annual meeting was dedicated to promoting women in leadership positions. and the following statement was shared: "A female leader must be competent, fearless and authentic". I never heard a better description to fit Agneta Montgomery, a role model for so many female surgeons of my generation. (25) If you wish to be part of the solution: please find, mentor and promote more Agnetas to inspire the future generations of surgeons. Arrange a seat for them at the table where decisions are being made, as well as speaking time.