I was sitting next to two of my co-residents during a break in conference this morning, answering emails on autopilot and half-listening to the buzz of conversations around me, when their muffled laughter caught my attention.

“What’s so funny, guys?” I asked them, thinking that a good joke or funny story might break up the monotony of hours of lecture. The reply I got stunned me.

“It’s man talk,” one of them said, and they both laughed before turning away and changing the topic. While it wasn’t intended to be hurtful, it felt like a slap in the face. Sure, you’re entitled to have a private conversation at work, although having it in a public room within two feet of several other people may not be the best choice. But saying it’s “man talk” is saying that we’re excluding you for one reason and one reason only, and it’s because you don’t have a penis.

Medicine, and surgery in particular, has long been a male-dominated field, and is still a dinosaur in terms of gender equality when compared to other professions. While women now make up approximately 50 percent of incoming medical students, by the time they enter residency they gravitate overwhelmingly to certain specialties. In 2013, 82.6 percent of OB/GYN residents were female, along with 70.6 percent of pediatrics residents, 62.4 percent of dermatology residents, and 54.9 percent of family medicine residents.

By comparison, women made up only 37.9 percent of general surgery residents, 32.1 percent of plastic surgery residents, 15.8 percent of neurosurgery residents, and 13.4 percent of orthopedic surgery residents. The reasons behind these choices are multifactorial, including the training and work environment, perceived work-life balance, gender distribution of senior physicians and mentors, and opportunities for career advancement.

While progress towards equality has been made (albeit at a glacial pace), gender discrimination has gone underground. Residents today have to deal with a more subtle form of sexism than in the past, which makes it more difficult to recognize and much harder to push back against.

Department chairs and senior faculty will swear up and down that medicine is now an equal playing field, but the visible evidence is very much to the contrary. In my training program, 100 percent of our 7-person faculty is male. We’ve had several surgeons visit recently to interview for jobs, and they’ve all been male too. Our residency is only 25 percent female. When female residents go to national meetings, they are more likely to be mistaken for a surgeon’s wife or a sales rep than to be recognized as a surgeon. At a specialized society meeting last year I watched a group of about 100 surgeons congregate at the front of the room for the annual photo. The entire group was male, and except for two people, the entire group was white. While at the medical student level things may be equalizing, in the upper echelons of our profession we really haven’t come that far since the 1950s.

This lack of prominent female mentors plays an important role in shaping the perspectives and career choices of female medical students and residents as they choose their specialties and progress through their training. While many of us have been lucky enough to benefit from supportive male mentors, looking at the top people in your profession and seeing absolutely no one who looks like you takes a definite psychological toll. The “old boys club” is still alive and kicking, with people who are being promoted in academic medicine often looking a whole lot like the generation before them. Some of this is biologic programming — there’s even a different part of our brain that’s involved when we think about people who are similar to us compared to people who we perceive as different — whether that’s a difference in opinions, interests, or simply a difference in the way we look. Women are fighting an uphill battle to break the glass ceiling in medicine, and that’s far from our only challenge.

Among both patients and health care workers, gender biases are still deeply entrenched; I’ve lost track of the number of times I’ve been called a nurse. This gets even worse if you happen to be ethnic as well as female. An African-American co-resident of mine went to check on her patient one day and was asked by their nurse whether she was there to deliver the patient’s pudding.

Sometimes I feel like my work as a senior female surgical resident is like walking an invisible tightrope. While my male counterparts have the benefit of having a group of “the guys” both as co-residents and attendings, when a female resident is around a group of women it’s usually a group of nurses, and trying to be “one of the girls” introduces a whole other set of problems. At the end of the day there’s still an unspoken power dynamic between doctors and nurses, and you need to strike a delicate balance between being nice but not a pushover; firm in your decisions but not aggressive (or you risk being labeled a bitch or worse). To top it off, you have to be twice as good as your male counterparts to get half the amount of respect.

We spend a lot of time with our fellow residents in high-stress environments, times when we’re frustrated, sleep deprived, burnt out, and finding common ground is just another coping mechanism. But when the small talk in the call room sounds like a frat house, it’s just one more example of how subtle sexism is isolating female residents. We don’t feel we can say anything because it would lead to further isolation and exclusion from the group. So while “man talk” may be something my generation of female surgeons has to deal with because gender equality is a theory instead of a reality, hopefully one day it’s place will be definitively outside the hospital workplace.

And hey, at least they didn’t call me a nurse and ask me to get the coffee.

The author is an anonymous surgeon.

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