LAUSR

We read with great interest the article by Inam et al. discussing the cultural barriers for women in surgery in lowand middle-income countries (LMIC), namely Pakistan [1]. Their survey highlights roadblocks unique to female students and trainees in pursuing a surgical career, as a result of societal expectations and stereotypes associated with women in their country. The study also emphasizes that perceived barriers to pursuing a career in surgery are felt not only by women but also men, with 22% of men having been told they cannot be a surgeon (vs. 47% of women) and feeling that a surgical career would hinder them from getting married 33% (vs. 56% of women) [1]. Aside from gender inequity, existing disparities within the surgical ecosystem in LMICs adds another layer of complexity in pursuing a career in surgery. At baseline, trained surgical personnel in LMICs are scarce: many postgraduate programs in surgery in LMICs have only recently been established with variable structures while others are non-existent [2]. This situation implies that training opportunities in surgery are often few for both men and women to begin with. Although many seek opportunities beyond their home country, the significant costs are deterrent to choosing surgery [2]. This creates a vicious circle where the lack of human resources in surgical care in LMICs restricts the number of training spots, which will eventually limit the number of those graduating into the workforce unless effective intervention can break the loop. Moreover, while surgical ecosystems in high-income countries (HIC) face less resources insecurity and personnel shortage, gender equity remains an issue [3]. Although the number of female trainees in medicine is increasing worldwide, mentorship, and consequently gender representation in certain surgical specialties, continue to favour a higher proportion of men in surgery [4]. Just like their colleagues in LMICs, the prime time of surgical training often coincides with the optimal time for building their family, which can be a considerable challenge if support infrastructures are lacking [4]. Mentorship styles also vary depending on the gender of both the mentor and the mentee: which skews the overrepresentation of male trainees in ‘‘traditionally male’’ surgical specialties such as orthopaedics, thoracic surgery or urology [5]. Gender equity in HICs also shows through the underrepresentation of women surgeons at leadership positions within hospitals or professional societies [5]. Policies aimed to change the status quo ought to not only empower women trainees through access to mentorship and sponsorship but also create opportunities, support and resources, to level the playing field for men and women to pursue a surgical career. We need environments that actively foster diversity and inclusion to ensure that any aspiring surgeon feels supported in the recruitment process as well as in retention and promotion. Furthermore, by overcoming existing gender disparities and cultural barriers in surgical education, we can expand the capacity of LMICs in surgical education to bridge the gaps in LMICs in terms of access to surgical care. This mindset will ensure that we continue to attract the best candidates to meet surgical demands worldwide.