Also Human

by Caroline Elton

  I have so strong a conviction that the entrance of ladies into dissecting-rooms and anatomical theatres is so undesirable in every respect, and highly unbecoming that I could not do anything to promote your end … It is indeed necessary for the purpose of Surgery and Medicine that these matters should be studied, but fortunately it is not necessary that fair ladies should be brought into contact with such foul scenes … Ladies would make bad doctors at the best, and they do so many things excellently, that I for one should be sorry to see them trying to do this one.

  Undeterred, Garrett Anderson followed other routes, and eventually found her way on to the medical register. Together with Sophia Jex-Blake, she later founded the London School of Medicine for Women in 1874. Three years later, female medical students were able to gain access to clinical experience through the London Free Hospital, and two years after that, an Act of Parliament granted relevant institutions the authority to let women qualify as doctors.

  American women faced similar obstacles. The influential Canadian physician William Osler, first Professor of Medicine at the newly founded Johns Hopkins Medical School in Baltimore and later Regius Professor of Medicine at Oxford University, opposed opening up the profession to women9. Osler argued that the professional demeanour of the doctor should be characterised by equanimity – the capacity to remain cool, calm and collected in all situations. According to Osler, women lacked this essential capacity, and thus would never make good doctors. In the 1890s Osler joked with his (male) students that ‘humankind might be divided into three categories – men, women and women physicians’. A light-hearted quip perhaps, but giving voice to a similar sentiment to the writer from Aberdeen Medical School: real women don’t become doctors.

  Yet women continued to demand access to the medical profession – despite facing considerable obstacles. In the UK opportunities for women expanded during the First World War, but most of the places made available during this period were subsequently withdrawn after the war. In 1921 women still made up only 5.4% of the total medical workforce. By the end of the Second World War, 25% of medical students were female, although their student numbers were decreased after the war as ex-servicemen returned to claim university places10. One step forward, one step back. In 1962, just over 20% of UK medical students were women, but twenty years later the proportion had risen to 45.3%11. By 1992, female students outnumbered their male colleagues, and that is the way it has stayed ever since. Latest figures for the UK show that 55% of medical students are women12.

  The feminisation of the US medical workforce has consistently lagged behind. Whilst women were admitted to Oxford Medical School from 1916, they were denied this option at Harvard and Yale until after the Second World War. In fact, it was only after a significant change in legislation in 1972 (Title IX of the Education Amendments) that discriminatory admissions policies were outlawed in institutions receiving federal funds. As a result, between 1970 and 1980, the proportion of female medical students more than doubled, from 12.3 to 28%13. And the latest figures, for 2016 entry, indicate that for the first time ever, parity has almost been achieved: 49.8% women compared to 50.2% men14. Almost, but not quite.

  Yet these figures on access to the profession can be deceptive. Underneath a thin veneer of equity lie significant differences in the career trajectories of male and female doctors. This becomes clear when one looks at the particular specialties that women doctors end up pursuing.

  Olivia, a married doctor with three young children, came to see me because she felt she had ended up in the wrong specialty. In our first session she told me that she had volunteered in an orphanage in India before starting medical school, and the country had got under her skin. Her love of the country pulled her back during her elective period in medical school, when she returned to work in the hospital attached to the orphanage, and she returned again once she qualified. From the time of her elective, when she had encountered patients suffering from a wide range of infections, Olivia decided that infectious diseases was the specialty for her. She loved the fact that some of the conditions were extremely rare and tricky to diagnose; the specialty demanded ‘detective work’. She also found it hugely satisfying that many patients with an infectious disease could make remarkable recoveries once the disease had been correctly diagnosed and treated. And she sensed that the specialty attracted kindred spirits – people like her, who were committed to working in the developing world.

  But in the UK, infectious diseases is a highly competitive specialty. It’s difficult to get a place on a training scheme and, as with other competitive specialties, studying for a PhD, on top of completing the clinical aspects of training, has become the norm. To make matters worse, whereas in the past infectious disease trainees would often have had a reasonably light out-of-hours schedule, nowadays this has all changed. The shift isn’t due to pedagogical demands; you can learn how to be a first-class infectious disease specialist without staffing the hospital at night or at weekends. Instead, it is entirely due to staff shortages.

  Olivia didn’t want to study for a PhD alongside her clinical work. She didn’t want to have to worry about churning out publications or meeting funding application deadlines and she didn’t want to work lots of evenings and weekends. With three children, she decided that training in the specialty would be unmanageable, so after a lot of soul searching, she opted instead for general practice.

  As soon as she started working as a GP she realised she had made a dreadful mistake. Olivia enjoyed treating very sick patients whom she could make better. Quickly. She liked diagnostic challenges, with clear definable outcomes. Now if patients presented with serious, puzzling symptoms she referred them to hospital specialists. From her point of view, it was her hospital colleagues who were doing all the detective work, and having all the fun.

  There’s also evidence that patients bring different problems to male and female GPs. Women GPs see a higher proportion of female-specific and psychosocial problems. In contrast, male GPs are more frequently consulted about musculoskeletal and respiratory problems, as well as male genital problems. Not surprisingly, given that patients are more likely to consult female GPs about complex psychosocial issues, they tend to have a significantly higher proportion of lengthy consultations than their male GP colleagues15. It wasn’t that Olivia was uncaring – she just liked to be presented with well-defined clinical problems that could be quickly cured. Long-term depression, or anxiety, or alcoholism, coupled with a whole host of social and financial difficulties, don’t fall into this category. But these were the sorts of patients who came knocking on Olivia’s surgery door asking for help.

  Olivia was not alone in choosing general practice over a hospital specialty in order to give priority to her family life. A 2015 study asked over 15,000 doctors in the UK about the factors that had influenced their specialty choices16. GPs were much more likely to attribute their decision to ‘wanting a career with acceptable working hours’ and ‘wanting a career that fits in with my domestic situation’ than doctors in any other specialty. This isn’t necessarily a problem, and many GPs enjoy their work enormously. But doctors who select their specialty on the basis of a shorter working day, or less time on call, are in effect choosing their job because it gives them more time not doing the job. This is just like teachers who go into the profession solely because of the long holidays. Of course evenings, weekends and holidays are all crucially important for one’s well-being. In the longer run, however, people in demanding professions such as teaching or medicine also need to derive satisfaction from the time they spend at work, rather than staying in their jobs because it allows them more time to be away from work.

  Olivia knew nothing about general practice before she chose it as her lifelong specialty. From our discussions, she has come to the conclusion that she is better suited to hospital medicine. She has also accepted that the research demands of infectious disease, coupled with the hours of work, mean that it probably wouldn’t work for her either. But she is exploring
whether a specialty such as sexual medicine might be a good alternative. This specialty includes a lot of infectious diseases work (treating patients suffering from sexually transmitted infections), is largely outpatient based, and would also allow her to do stints working in HIV clinics in India. That’s the good news. The bad news is that leaving general practice and qualifying as a consultant will require at least four more years of full-time training – and she might find it difficult to get accepted on to a scheme in the part of the country where she currently lives with her husband and three young children. Her problems are not yet over.

  *

  As many female doctors choose general practice because of the flexibility it offers, women are over-represented amongst GPs, and under-represented amongst hospital consultants. Two hospital specialties, however, buck this trend and have a majority of female consultants. Just two. Not surprisingly these two specialties are obstetrics/gynaecology and paediatrics; women doctors flourish, as long as they are dealing with ‘womanly’ problems such as pregnancy, childbirth and children17.

  And the hospital specialty with the lowest proportion of female consultants? Surgery. In 2016 just 12% of surgical consultants were women. This difference can’t be explained away in terms of women not being interested in or good at surgical procedures, as obstetrics/gynaecology could technically be defined as a surgical specialty. And with acute obstetrics, unlike every other surgical specialty, the surgeon has to safeguard the well-being of two patients (mother and baby) rather than just one. Yet in the UK, the proportion of female consultants in obstetrics/gynaecology is over four times greater (51%) than the proportion of female consultants in other surgical specialties.

  Women doctors don’t only cluster in different specialties; they are also much more likely to work part-time. So for example, a 2016 survey of over 10,000 doctors in the UK found that whilst 42% of women worked part-time, the comparable figure amongst men was 7%18. The proportion of part-time medics was also skewed by specialty; amongst female GPs, 40% worked part-time whilst amongst female surgeons, the figure was 10%. Women in surgical specialties are still very much in the minority – and when they do choose these specialties, they are highly unlikely to work part-time. This study also showed clearly that the critical factor was children. In fact female doctors without children were no more likely to work part-time than male doctors with, or without, children.

  Family considerations also impact on the proportion of female doctors choosing to go down an academic clinical pathway. Doctors who choose this type of career have to complete the same demanding clinical training but on top of this have to carry out research, write academic papers and complete complex applications for continued research funding. Given that doctors in the US have clinical schedules of eighty hours per week, it’s clear why opting for a chunky additional set of tasks might put women off – particularly if they go home to equally chunky domestic responsibilities. Even in the UK, where working hours are constrained by the European Working Time Directive and integrated academic training pathways have been devised, a significant gender imbalance remains in academic medicine – particularly at senior levels.

  As in so many other professions, within medicine women are paid less than their male counterparts19. In part this discrepancy is due to the fact that across the consultant workforce as a whole women consultants tend to be younger, are more likely to have had career breaks, and are less likely to hold high-profile administrative or research posts. These factors account for about 60% of the pay gap between male and female consultants. The remaining 40% is caused by the fact that women get different financial rewards for the same achievements. For example, a premium for being a professor adds 22% to a man’s salary, but only 8% to a woman’s. Men who have been in their consultant post for ten years earn 34% more than a recently appointed consultant, yet for women this difference is only 13%. And it’s not just in the UK; similar salary discrepancies between male and female doctors doing exactly the same work have been reported in the US20.

  As Sir Liam Donaldson, the then UK Chief Medical Officer, wrote in 2009: ‘the problem is not access to medical school, but rather how we ensure that the female medical workforce is able to fulfil its potential once in employment’21. The step on the bottom rung of the medical ladder may be equally accessible to men and women. But it’s a long ladder. Once women climb up the first few steps, the notion of gender parity looks less convincing. The particular pathway chosen, how high up someone is able to climb, and even the amount they will get paid for their labours differ between the two sexes.

  An email pings into my inbox:

  Dear Caroline

  I went into medicine as a postgraduate so unlike my colleagues I am a little older and am married with two wee girls. At this point my priorities lie far less with my career progression and much more with preserving a happy family life … I feel that I have hit a junction in my medical career with some stark choices to make and I feel a lot of responsibility in making this choice – I just want to get it right. I’ve begun to suffer from insomnia which is new for me and though I don’t lie awake ruminating nor feel low in mood I know that this is a sign that I cannot plough ahead as I have been.

  I get emails like this all the time and many of the doctors who come to see me bring stories about the impossibility of balancing work and family life. Typically these stories are told by women, but sometimes (as with the email above) it’s men who agonise about the toll that their medical work is having on their children.

  Specialty training in the UK can last for more than ten years after leaving medical school. That’s ten years of full-time work. Or twenty years, if you are working part-time. During this period you will change job, with little choice as to where you get sent, every six to twelve months. As one doctor put it – ‘the system moves you around like a piece of equipment rather than a person’. And if the constant moving isn’t bad enough, some of these jobs may involve a considerable commute. From a logistical point of view, trying to arrange childcare can be a nightmare. But that’s not all.

  With each move you will need to get to know new colleagues and work in different hospitals, so you quickly have to learn how things are done in your new place of work. For the first few years there is the relentless pressure of postgraduate exams, and throughout the whole of your training you are constantly being assessed by your seniors. Now some specialties have introduced exit exams as well, at the end of training. And on top of all of this, there is an ever-increasing load of extraneous tasks that every doctor needs to complete each year in order to get through their annual review and be allowed to progress to the next step of training. Imagine trying to do all of this stuff to keep one’s training on track, for ten to twenty years alongside looking after one’s family.

  The bottom line is that medicine is not an accommodating profession when it comes to supporting doctors with childcare (or indeed any other caring) responsibilities. Some of this lack of accommodation comes with the territory; sick patients need care twenty-four hours a day. Typically an accountancy or architecture problem can wait till the following morning. Acutely unwell patients cannot. But it’s not only the clinical needs of patients that make medicine a challenging career choice for women. The profession as a whole has not yet fully adapted to a feminised workforce, many of whom are attempting to combine their medical training with looking after a family for years and years on end.

  The responses to a survey of women doctors carried out by the BMA in 2009 give a good sense of the career challenges that these individuals face22:

  ‘I was offered but had to turn down a clinical senior lecturer post because I cannot work as few hours as I need to and the responsibilities are too great to juggle with new motherhood.’

  ‘A female colleague who was childless was promoted over my head despite much lower experience, but I applied for promotion through an appeal process and got it.’

  ‘Senior female staff exist in our organisation but they do not have children and take t
he view that we should be “flexible” and prepared to relocate if necessary.’

  ‘Being part-time, still regarded as inferior to full-time male colleagues.’

  ‘I had to wait 8 years for a part-time consultant post.’

  ‘It is still a man’s world – especially at the top.’

  In the US, it’s even worse. Part-time work may hamper one’s career prospects, but in the UK the official guidance states that all doctors can apply for flexible training, and that every application will be treated ‘positively’. In contrast, in America, maternity leave following the birth of a child is far shorter (twelve weeks as opposed to six months), and opportunities for training part-time are often scarce. Studies are replete with horror stories that women faced when they attempted to continue training with a young family23:

  When at age 37, I delivered my firstborn 1 week to the day after beginning a fellowship in high-risk pregnancy, I was devastated to have him admitted to the neonatal intensive care unit. On my way out the door, I ran into the senior fellow who said to me, ‘Too bad about what happened. When can I put you back on the call schedule?’

  With all these difficulties, it’s hardly surprising that many women, and some men too, leave hospital medicine to work as a GP. It’s not that this is an easy option. Far from it. But with general practice in the UK or primary care options in the US, the postgraduate training is shorter than in hospital specialties, part-time schedules can be more easily accommodated, and there are few or no compulsory night shifts. In both the UK and the US there are also shortages of primary care physicians, so finding a training scheme and later a job in the right part of the country tends to be easier. Yet sometimes these doctors, like Olivia, become haunted by the path not taken. They constantly ask themselves whether things would have been better if they had followed their heart and tried to complete their training in a hospital specialty.