Role models.

Most participants reported that observing surgeons was important to piquing their interest in surgery as a specialty. This opportunity to observe and gain hands-on experience in the operating room is built-in as a required clinical rotation for all medical students in Rwanda. All female participants defined important role models as each other, as well as select male colleagues who encouraged them. One female surgeon recalled, “it was important that [she] was there… At that time, I didn’t know that I could do it too. That alone couldn’t have helped me decide, but [she] really made me say, let me try” (F5). The male figures commonly cited by the female participants as “encouraging” qualified by promoting the idea that females could also train in surgery despite it being a male-dominated field. Multiple female surgeons recalled that even this initial act of “thinking about it, considering the career” (F6) involved a role model who demonstrated or verbally supported the feasibility of this career path for women.

In contrast, male participants cited attending surgeons who expressed confidence in the trainees’ technical ability to succeed. Many participants mentioned having foreign surgeons “find” them (M2). A role model often acknowledged an innate talent for a surgical skill that then motivated the male participant to develop an interest in surgery: “good at tying”(M4), “good at cesarean sections”(M5), “good at anastomoses”(M6).

Patient encounters.

The importance of interpersonal influences on female participants was also apparent in their descriptions of surgical patients. All females shared some critical aspect of surgical patient care that influenced their selection of surgical careers. Some described being drawn to the brief intensity of caring for surgical patients, because there is an operation and solution to offer, instead of the often intangible or long-term care needed in other specialties. As students, they could observe the immediate benefits of surgery on their patients, in contrast to the slow or lack of visible improvement of patients on their brief pediatrics or internal medicine rotations. Being able to provide a tangible service engendered a sense of accomplishment and affinity for surgery.

Alleviating suffering for patients was another appealing aspect of surgery for some females. Limited pain relief options for children or for mothers during childbirth appeared to have left negative impressions. Surgery, with its anesthesia and lasting potential benefits, represented a type of patient care that could be done without pain to alleviate pain. Not being able to manage the suffering of their patients evoked feelings such as “fear,” “shame,” “discomfort,” and “not be satisfied” in these female participants (F2, F3, F4, F5)

In contrast, no male participants mentioned the impact of their care on patients as factoring into their decision for selecting surgery. Instead, many described the appeal of patient care from an intellectual perspective, using terms such as “straightforward,” “straight,” or “clear” to describe the clinical pathways involved in patient cases. Only one female cited this intellectual clarity as a significant factor in her decision. A male participant explained, “I like surgery because it is clear… you make a diagnosis and then there is a clear plan and then you can do it. This is different than internal medicine, where you may have a patient, not know the diagnosis. And even if you have diagnosis… you can have mixed results” (M1). Rather than focusing on how they may feel from personally affecting patients, many male participants emphasized how they felt from the clinical thinking process stimulated by patient cases.

Exposure to surgery.

Participants reported exposure to surgery through rotations during medical school, or while working as general practitioners in rural district hospitals. Only two female participants explicitly cited the hands-on experience of operating as a factor in their interest in surgery: “I think I have good hands-on skills [to do surgery]” (F1), “I like being in the OR just operating, doing something that you see the result of. I can wash out an abdomen, do a resection, make anastomoses, and the patient goes out. You are satisfied” (F3).

All male participants cited exposure as a main factor in the development of their interest. They offered other reasons as well, but the time spent in the operating room directly observing the surgeries appeared to help solidify their decision to enter the specialty. One surgeon emphasized this experiential bias: “Everyone had something that happened to them to select their specialty. I changed my mind during my 5th year… It came abruptly, [after] seeing cases during rotations” (M2). Another surgeon described regular interaction with international surgeons who were “helping people in the district, and I saw that it [surgery] was good. I started operating on patients too, doing hernias… And this is when I chose” (M5). While this participant alluded to the beneficial impact of surgeries on helping people at the district hospital, he continues on to clarify, “even minor surgeries, excising lipomas, cysts…it was just from there that I starting liking surgery,” shifting the focus from patient care to the operative exposure.

Social expectations about roles within the family.

Gender assumptions played a significant part in participants’ perceptions about building careers and particularly careers in surgery. All participants acknowledged that “surgery takes time” (F5), with each gender citing different competing interests for their time.

For the female surgeons, expectations about what it means to inhabit a female role within the family or societal structure often felt at odds with the demands of a surgical career. Females discussed social challenges of getting married or, if they were already married, having children. These concerns were described in terms of the social pressure that women should fulfill certain roles, and the physical accommodations during pregnancy and child-rearing. One surgeon summarized this conflict as: “When you want to join surgery, you know how demanding it is, but if you like it, you tend to sacrifice other things. You can choose another [specialty] for the sake of family and other social responsibilities” (F6). They observed, however, that they alone could not overcome this gender stereotype, as “the fact is marriage has a very big effect. Even if there are some who have [an] open mind, there are very few [and] they cannot determine the society” (F3). They insisted that it would take conscientious effort from both male and other female colleagues to address these biases.

Male participants offered mixed views on social responsibilities, with some volunteering that limited time with their families may present a challenge, while some stating that they do not anticipate any personal concerns for their surgical career. One male surgeon responded that “I’ve managed to balance the two things: too much work load but also having time with social pattern. I have never abandoned my social life” (M1). Another male participant framed the gender expectation as “time for your family is not the primary thing that men think about, but for women they would think about that before anything else” (M6).

Physical and mental challenges.

In addition to these social pressures, the physical demands of surgery were framed in terms of gender expectations. All female participants recalled physical stereotypes, such as “women are less strong than men” (F4), being imposed upon them. They all defied these assumptions, acknowledging the physical challenges of the work but refusing to concede that being female must be a limitation. One surgeon’s statement captured this attitude: “Women may be physically, emotionally less strong than men. But me, I am not that way, because I feel that I am strong as men” (F4).

Moreover, some females reported that there were limitations in mindsets within personal relationships, where male figures may seek to exert control over female activities. This control was described both in marital relationships and at a societal level: “We are in Africa. [The husbands] say you can do this, you cannot do this” (F3), and “in Rwanda, they say there are some jobs that are made for males and other jobs made for women, culturally… In sciences, people think it was made for males not for females” (F3). Even after overcoming such gender expectations to become a surgeon, one female participant shared that “patients still hesitate a bit with me and other people ask me, why [surgery]? And I say to them, 99% of [surgeons] are male. Do you ask them the same question?” (F1).

In the process of overcoming this mentality about not belonging, female participants often mentioned fear in terms of self-doubt as a possible factor contributing to the gender divide in surgeons. Only female participants mentioned feeling personally responsible for the outcome of their patients as a significant challenge of surgical practice. A negative outcome, such as complications from surgery or even mortality, was internalized, expressed in phrases such as “I feel responsible” (F3), or “maybe the patient has even died because of me” (F4). One surgeon explained, “Some women just can’t make it to surgery. People got scared in undergraduate; they showed us that surgery is like a fight” (F3). Another even drew on biological roots, with “testosterone. Men do not fear, and female do fear. So, when in surgery, gynecology, anesthesia, you need a high level of androgen to do it, self-confidence” (F1). In response to this perceived need for fearlessness in surgery, female participants rejected the gender stereotype: “I am judged, but not because I’m a woman, but because I’m like everyone else. I don’t consider myself as female” (F6). Others shared their experiences of overcoming fear through perseverance, “I think I am quite persistent with what I do. I will not really fail to do something" (F5).

When asked why more men enter surgery than women in Rwanda, male participants speculated that it was female mindsets that shaped their preference, rather than any systemic gender-based bias. One surgeon summarized this difference in genders: “surgery requires brain, requires physical work, [and] working hard. Males… in our culture and all over the world, they are stronger so they have been doing stronger things” (M2). Instead of recognizing this gender assumption, many male surgeons placed the onus on their female colleagues: “There really is no sex selection criteria for doing surgery. It is all ‘mentality-driven’” (M1), “factors that push women away from surgery are in their minds” (M2), “what a man can do, a woman can do it” (M3), “women don’t like blood” (M6). Beyond this mental barrier, male participants described that females may not feel fit for the physical demands of surgical careers. While this preference is admissible for any provider, the descriptions were contextualized in terms of gender: “[women] think that job for women should be easier, that they don’t have to work hard” (M4), and “females do not like stress. They like easy life, like pediatrics, radiology, something in which they are not stressed and can just sit down” (M4).

Despite the demands and risks of surgical careers, the hands-on nature of operating seemed to sustain all participants, as they described how rewarding it felt for their work to translate into outcomes for patients. All interviewees cited the importance of developing a tactile skillset of operating. One surgeon explained, “That is the special thing about surgery … You can touch it, it is palpable … you can do it, you can do you right things. You can expect your outcomes” (M1). Another compared surgery to other specialties such as “internal medicine: they work like a witch! You just give many, many medications, you never know which one is treating the patient, which one is killing him… In surgery, you always know what is happening” (F5).

Professional and personal support.

All surgeons also described the difficulty of working in an environment that lacks the proper infrastructure, materials, equipment, and surgical staff to learn and operate effectively. Also, given limited opportunities for further training in Rwanda, some surgeons, both male and female, remained hopeful that pursuing surgical careers could lead to more international opportunities.

Navigating the work place includes negotiating relationships with peers, mentors, and institutional hierarchies. All surgeons regardless of gender described challenges in managing expectations of others and seeking positive learning experiences. All participants also described a professional mentor in the form of an attending surgeon or surgical resident who had been critical to supporting their careers. The definition of what this professional support looks like varied widely, from technical guidance and responding to questions during operations to spiritual counsel and motivation during difficult cases. All females described the importance of “respect” and “independence” in both personal and mentor relationships, which were not mentioned explicitly by males. A few females further clarified independence as feeling they were making decisions and operating without an overbearing presence. Only female participants shared an explicit desire to support and mentor future generations.

Most male and female surgeons appeared to find support from their colleagues, their nuclear families, and their own families.

Finances.

All males cited inadequate financial compensation as their main concern for sustaining surgical careers. They explained that financial restructuring would need to occur at a larger institutional or national level to retain surgeons and to offer higher-level training. Many surgeons described their concern for the mismatch in compensation and time: “when I see consultants (surgery, anesthesiology) leave, I begin to worry. You train someone for that long, for 10 years, you should be training others. But they leave for themselves. [they] need money, and they leave for NGOs, private” (M5), and “when you spend 15 years in training, at some point you need something back, and that thing should be money” (M6).

In contrast, most females mentioned financial stability and job prospects as advantages of surgical careers, because there are “no concerns about job prospects. We have like 100 years of need for surgeons in Rwanda. The future is bright; I have no concern about financial prospects” (F5).