Women in medicine—whatever next?

By Reema Fatima Subia

The Changing Face of Medicine: Women Doctors and the Evolution of Health Care in America

One afternoon at the Royal College of Physicians, I expressed mild interest in the fact that in the election for my successor as Academic Vice President, there had been no female candidates. My (senior and male) colleague looked at me in astonishment and said “haven't there been enough women already?” An interesting perspective given that in around 500 years there have been only two female presidents and only three female vice presidents of the Royal College of Physicians of London. What is this all about?

Historically, caring for the sick was seen as women's work. The baton was taken back by the men when it secured professional status with the creation of the first medical royal colleges and societies. Since then, medicine has been dominated by men. But times are changing—just more than 500 years later—and women now make up the majority of medical school entrants, and are likely to become the dominant gender in the medical workforce in the next 10—15 years. Is this a triumph for those seeking gender equality, or is it a problem for the profession?

In the UK, this issue first hit the media spotlight in 2005, following which the Royal College of Physicians of London developed proposals for a research project to find the evidence base for a number of developing issues related to the increase in the number of women in the medical workforce. As the newest appointed female College Officer, I was asked to chair the research steering group. We appointed a researcher, and set off on an interesting journey to produce an unbiased and accurate evidence base. The research, done by Mary Ann Elston, will be published by the Royal College of Physicians next month. Perhaps I should have anticipated the potential controversy around the interpretation of those facts, given that each participant in the project was either a man or a woman, and came to it with their own values and experiences on the subject.

Ann Boulis and Jerry Jacobs' book about women doctors and their relation to the evolution of health care in the USA is timely and discusses these issues from a perspective that is pleasantly sympathetic to women. They have collated and analysed an impressive dossier of qualitative and quantitative data and put forward some suggestions as to why the “gender gap” still exists in the USA and how to address it. Not surprisingly, most of the challenges facing women doctors in the USA echo those being experienced in the UK, but interestingly, the UK seems to be doing better.

One explanation for why there has been this increase in women in medical schools is the depressing thought that it has come from the decline in status of the medical profession overall. Boulis and Jacobs have posed convincing arguments to show us how it is not a simple as that. The status of medicine was apparently declining before the rise in female applicants, and has been influenced by complex societal changes that reflect current general sociological trends in the USA. Moreover, American women are now better educated so provide a better pool of applicants and have access to impressive female role models.

There have also been government initiatives to reduce barriers and discrimination affecting women in the professional workforce. The authors describe a positive feedback loop of declining discrimination, expanding opportunities, women's early success, and continued women's interest in medicine over time. There was concern in the USA that the number of male applicants to medical school was declining, but the research in this book has shown that this is also not really the case. The percentage of male applicants has declined, but actual total numbers are still rising, although at a slower rate than the numbers of female applicants.

This is also the case in the UK. An interesting aside is the effect of the Vietnam War Draft in the USA, which encouraged men into the medical profession to avoid being called up, although this levelled off and then declined in the 1980s.
Another observation that also holds true for the UK is the so-called gender segregation within medicine: that women tend to aggregate in specialties with particular characteristics. These have been described as the more planable and less technical specialties, and those with a higher emphasis on the caring aspects of medicine. For example, there are more women in general practice and palliative care, and fewer in surgery or clinical research.

Why is this? The evidence presented in the book suggests that women and men have a similar approach to patient care, and practise in very similar ways, so segregation is not only caused by women's choice of career, there are other factors. What is interesting is that those in favour of better equality for women refer to these factors as “barriers”, whereas those who think there is no problem with gender equality attribute the career differences to choice. A choice becomes a barrier when it is influenced by external factors that make women decide not to choose that specialty. Examples include: gender stereotypes about appropriate roles for women; lack of flexibility in the structure of the working day; and out of hours work at times when child care is hard to find. All these become barriers that influence the choice about whether to enter that specialty.

Part-time working is a continuing source of controversy in medicine. With the increased number of women coming into the workforce, and their likelihood of working less than full time to complete their families, there will need to be alterations in the current pattern of the working day, and more opportunity for part-time work. It is essential to maintain the workforce, which means keeping women in the workplace. But this means that more people (jobs) will be required to fill the same number of working hours. An alternative approach would be to encourage women to work longer hours, but this would need to be supported by more flexible and accessible child care. Either way, an increase in part-time working will be more expensive.

Here in the UK, a 2006 report called for action in taking steps to increase the number of women in the most senior positions in medicine. A working party chaired by Baroness Deech has been set up and will report later this year. Although women will soon be the majority of medical school entrants, the numbers at the top do not reflect those going in at the lower levels. One of the arguments here is that it is not possible to become a part-time leader, and it is difficult to reach leadership status if you have not invested in the necessary extra activities along the way. The barriers to this—or the “choice” not to do these activities—is influenced by a number of issues. The working week has become longer, and societal expectations still presume that women will continue with the majority of the household chores and the child care. This makes it difficult for women with family responsibilities to participate in the “extras”, which involve going to meetings before or after the working day and participating in international travel.

The gender gap in medicine is narrowing. Gender equality is slowly filtering into the medical workplace, but there is still a way to go. The situation in the UK is better than the USA, with better pay equality, maternity leave provision, and opportunity for part-time working at consultant level, but organisational and cultural barriers continue to inhibit true equality in the medical workplace. Books like this, together with the research completed by the Royal College of Physicians, have presented the data in a usable form. It is now up to the profession to interpret it and act on it.

When I first became interested in women in medicine, I thought that I personally had not come across any discrimination in the workplace, but I now think that it was there, but subtle. It is only when you look carefully that you notice problems with the perceived normality around you.