Feminization of medicine

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http://careerfocus.bmjjournals.com/cgi/con...l/330/7482/13-a

Over the past 40 years the number of women entering medicine has increased dramatically. It is predicted that by 2012 women doctors will outnumber men

What does this mean for the profession and for patients?

Firstly, it's worth considering why this demographic trend might have happened. Some likely explanations for this sort of societal change and trend include:

Economic factors

Equality legislation

Changing position of women in society and possibly feminism (once defined by the author Carol Shields as "the belief that women are people")

Altered structures of families (Britain has the highest divorce rate in Europe).

Perhaps the continued academic success of girls has also contributed to the increasing number of women in medicine, along with the changing nature of the profession itself. Changes in medical education to a problem based, outcome oriented curriculum with a wider set of skills may have increased its appeal to women (box 1).

What are the implications?

When considering the implications of more women than men entering medicine we need to look at the roles women have adopted in medicine, traditionally and now.

(1) Within clinical medicine women and men have traditionally taken on different roles. Specialties that have a high degree of technical expertise and procedural roles (and which are often the more lucrative specialties) have attracted men in greater proportions than women. Conversely, women continue to be over-represented in the lower paid, less technically focused specialties, which are often more patient centred (box 2).

Box 1

"Female students now perform as well as, or better, than male students in every science examination between age 11-18."

Source: Griffiths E. Just who are tomorrow's doctors? BMJ Careers 2003;326: 4.

Box 2

"It is easy with so many women entering medicine in some countries to think that there is no longer an issue about being a woman doctor, and that medicine is just as challenging for men as women. But it is interesting that having a high proportion of women in a particular specialty is often associated with that specialty losing its high status and popularity. Why? Why is `being attractive to women' apparently unattractive for men? Most women work hard, are well organised, humane, and sociable. The facts of gender inequalities are not caused by social relationships, but by systematic discrimination and disadvantage."

Amanda Howe, professor of primary care, University of East Anglia

How does the profile look today? We are seeing a marked decline in interest in general practice among male medical graduates,2 and only 4% of today's consultant surgeons are women.3 Although the number of women consultants has increased by 50% in the past 10 years,4 only 25% of the total are female, so there is still a long way to go before the numbers begin to level out.

(2) Within academic medicine there continues to be a marked under-representation of women. Currently, there is only one female head of a medical school, Professor Yvonne Carter at Warwick, although the increasing number of female vice chancellors shows that this pattern is likely to change (box 3).

The dismal position of women in academic medicine has been publicised by the BMA, which issued a comprehensive report in September 2004, "Women in academic medicine: challenges and issues." The report discusses not only the barriers that exist to progression (commonly referred to as the glass ceiling) but also describes suggestions for good practice. The academic medicine campaign recently launched by the BMJ (see further information box) has taken a clear stance on gender affirmative action by declaring that all advisory group convenors to the central working party will include at least one woman (out of a maximum of three).

Box 3

"Women make up 26% of the full time clinical academic workforce."

Source: Higher Education Statistics Agency, 2002

Box 4

"Men make up the majority of employees in the five highest paid occupations. Women predominate in four out of the five lowest paid."

Source: Equal Opportunities Commission. Pay and Income. Manchester: EOC, 2003.

(3) Within medical politics women still have a backstage role in terms of their profile. Six of the 19 elected doctors on the General Medical Council governing council are women, and there has never been a women president.

Why is this happening?

Top

Introduction

What does this mean...

What are the implications?

Why is this happening?

Achieving equal opportunities

The reasons behind the current position of women in medicine are complex. They derive from a much broader sociopolitical-economic axis which has historically determined the position of women in society. A recent BMJ editorial by Iona Heath5 contrasted the progress Scandinavian countries have made with regard to sexual equality and women's empowerment with the depressing situation in Britain (box 4).

Women and families

The position of women is also linked to the value a society places on families and the raising of small children, a critical but relatively short time in a woman's working life. British society and the profession of medicine itself have paid lip service to the choices made by those women doctors (and students) who are lucky enough to have children (box 5).

Women's priorities

Women doctors make different choices about their personal and professional lives. The slavish devotion to a career in medicine, often achieved at the expense of a rich and satisfying home life, has often not been the priority for women doctors.

Box 5

"Nothing in my life is remotely as important as my three children. Female doctors who don't have children, or have only one child, can devote themselves largely to their careers. They deserve success in proportion to their effort and focus, while doctors who are also mothers with families need to set their own criteria for success and to pace their medical careers over a lifetime, taking advantage of their longevity compared with men! I have seen too many doctor-mothers as unhappy patients because they are simply trying to do too much, all at once". I'm with Robert Louis Stevenson: "It is better to travel hopefully than to arrive, and the success is in the labour."

Jill Gordon, professor of medical humanities, University of Sydney

Traditionally, medicine has allowed for few compromises. "Success" entails not just putting in the endless hours at work but a commitment to informal networking and a participation in tacit power structures. These demand hours of one's life that women often choose to invest elsewhere—in family and personal relationships. The result of differing priorities, however, has been seen in the distribution of power within the profession (box 6).

Social conditions and flexible working

Social conditions may explain why, despite increasing numbers of women in medicine, there is not an equal distribution of genders across the specialties, within academic medicine or in the positions of greatest power and influence.

In addition, there is a growing desire for both sexes to work flexibly (less than full time), seen as part of a wider societal trend and supported by the Department of Health through initiatives such as Improving Working Lives for staff working in the NHS. Flexible training unequivocally requires an increase in the total number of doctors, and this has been recognised by the government (box 7).

Box 6

"I think there is a difference between the way men work and think and the way women work and think, and I don't think that that can change. I mean there are obviously women who think like men, Mrs Thatcher being the best example."

Source: Women in academic medicine: challenges and issues. A report by the Health Policy and Economic Research Unit, 2004

Box 7

"Medical student numbers have increased from 3749 in 1998 to a projected 5894 in 2005."

Source: Higher Education Funding Council for England (report 01/31). Bristol: HEFCE, 2001

Achieving equal opportunities

Top

Introduction

What does this mean...

What are the implications?

Why is this happening?

Achieving equal opportunities

As the body of this article has sought to show, increasing the number of women has not yet resulted in equity within medicine. How else might this be achieved?

Restructuring training

Changes in postgraduate training have been put forward as a fairer method of postgraduate training, allowing progress towards a certain number of posts. The Royal College of Surgeons has recently unveiled its radical overhaul of postgraduate surgical training, which is to be launched in 2007 with pilots across England and Wales from next summer (box 8).6

Box 8

"Modernising Medical Careers is competency based assessments rather than the more modular type of training and will be to the advantage of women (and some men). Unless we make surgery a more attractive career option, we will be in disciplines selecting from relatively small numbers of males."

Hugh Phillips, president of the Royal College of Surgeons

"If females continue to reject surgery as a career choice, we will be forced to fill our posts from a (small) pool of men, who may not have the skills or aptitude to make good surgeons. One factor which I think (and have shown through published research) is very important in this discussion is role models—the lack of female surgical role models may result in fewer women going into surgery, which becomes a self perpetuating argument."

Helen Richardson, consultant ear, nose and throat surgeon

Box 9

"Access to flexible training at specialist registrar level, which is highly variable by region and specialty, needs to be improved."

Selena Gray, president of the Medical Women's Federation. BMJ 2004;329: 742-3[Free Full Text]

Flexible training

Administered by postgraduate deaneries and advocated by organisations supportive to the professional and personal development of women in medicine, such as the Medical Women's Federation (see further information box), flexible training schemes are vulnerable to short term decisions and are not "protected." A recent letter in the BMJ by the president of the Medical Women's Federation laments the iniquitous situation in which the provision of flexible training has been compromised in some deaneries by cuts in postgraduate budgets (box 9).

Credit: PHOTOALTO/PHOTONICA

Structural changes

An example of an external factor that impacts directly on medicine is the European Working Time Directive to promote family friendly working. Launched in August 2004, the directive imposed an upper limit of 58 hours for a junior doctor's working week, with further limits to be introduced in 2009. Again, this will have a considerable impact on staffing.

Broadening our view of success in medicine

Aside from the legislative and structural changes occurring within medicine, perhaps another dimension of change is required: how we view "success" in a medical career. Could there be more options than the single track, linear progression traditionally favoured (but not exclusively) by men?

Box 10

"The profession must wake up to the needs of women medical graduates."

Professor Rudy Bilous, Regional Chair in Clinical Medicine, Academic Sub-Dean for Teesside

Further information

www.medicalwomensfederation.co.uk: an independent charity which supports the professional development of women in medicine

BMA Medical Academic Staff Committee

Two recent reports (www.bma.org): "Encouraging women to work in academic medicine" Dec 2003

"Women in academic medicine: challenges and issues" Sept 2004 www.bma.org

BMJ: bmjjournals.com/academinmedicine/progress_report.shtml. The international campaign to promote academic medicine

European Working Time Directive: www.dh.gov.uk/ HumanResourcesAndTraining

Modernising Medical Careers: www.dh.gov.uk/ PublicationsPolicyAndGuidance

One of the clear challenges for women in medicine (as in other professions) is to receive recognition for career journeys that may appear unorthodox but which demonstrate motivation and commitment, along with a sensitivity to other needs in their lives which change over time. This includes the recognition of part time work, which for many women is not translated as part time commitment. As Dr Selena Gray recently commented on part time working: "Male consultants frequently work part time, dividing their work between the NHS and private work. It's not a practical problem, it's a cultural one." (Observer, 21 Nov 2004).

Valuing the richness of diversity, both within our society and within medicine itself, is likely to contribute to more fulfilling personal and professional lives for doctors of both sexes, with a happier workforce likely to result in better patient care and satisfaction

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