BMJ  2008;336:748 (5 April), doi:10.1136/bmj.39505.491065.94

Head to Head

Are there too many female medical graduates? Yes

¹ Community Health Sciences: General Practice Section, University of Edinburgh, Edinburgh EH8 9DX

UK universities are now producing more female doctors than male. Brian McKinstry argues we are risking future staffing problems, but Jane Dacre (doi: 10.1136/bmj.39505.566701.94) thinks there is still some way to go before we reach true equality

Too many female graduates are bad for medicine, just as too many male ones have been in the past. The numbers of men and women entering medical school should roughly reflect the numbers in society. The case for this is simply on grounds of equal opportunity. But there are also strong economic and workforce planning reasons. I will argue this largely from the perspective of my own specialty, general practice, which illustrates most strongly the impact of the feminisation of medicine.

Over the past 30 years the proportion of women attending medical schools has steadily risen in many countries including the UK, US, Canada, and Australia.^{1 2} In 2002-3, all UK medical schools had more female students than male, with the percentage of women exceeding 65% in some.³ This partly reflects the increasing number of women applying for medical courses and their increasing examination success in science. For many years the relative lack of female doctors was bemoaned, but the tables are turning and soon male doctors will be in a minority. This is already the case in primary care in many parts of the UK.

Workforce implications

Why does this matter? The main concerns centre on the work patterns of women doctors and also around the development of the profession. Women doctors concentrate in a few specialties regarded as family friendly (for example, primary care⁴ and psychiatry⁵) and tend not to take up some specialties such as surgery.⁴ This unequal distribution means that some specialties feel the implications of part time working and maternity leave, such as lack of continuity of care and resource use disproportionately.

Female doctors are more likely to work part time than their male colleagues.⁶ Despite many years of feminist discourse society still expects women rather than men to reduce work commitments to look after children and not to return to full time work until the children are older. However, research among general practitioners has shown that many women in their 50s, when their children are relatively independent, continue to work part time, often because of other caring demands.^{7 8} In addition, more female general practitioners plan to retire before the age of 60 than men, shortening their working life further.⁷ In psychiatry, one study found that nearly twice as many female consultants (41%) as male planned to finish work on or before their 55th birthday.⁹ Fewer women than men choose to work out of hours,⁸ and the increase in women doctors may have partly influenced the recent abdication of out of hours work by general practitioners in the UK. Although some research suggests that younger male doctors are also seeking part time careers,¹⁰ there is little evidence that they are actually opting for this lifestyle.

Time bomb

We are yet to feel the full effect of the feminisation of primary care in the UK and elsewhere. Above the age of 45 years men, mostly working full time, are still the majority, whereas most general practitioners younger than 45 years are female and mainly working part time.¹¹ As older mainly full time doctors retire, unless employment behaviour changes from past patterns, there will be a major shortfall in primary care provision.

This demographic change may also affect education, research, and development. In an American study of women in internal medicine,¹² the researchers found that compared with men with children, women with children had fewer publications (18.3 v 29.3; P < 0.001). However, no significant differences between the sexes were seen for doctors without children. In our study in primary care we found that women were contributing about 60% of the activity of men in development aspects of general practice such as training, teaching, research, and committee work.⁷ It is not clear to what extent this is through choice or lack of opportunity.

Some have argued that the future feminisation of medicine is justified on the grounds that women perform better than men in undergraduate and postgraduate examinations. Although several large studies have shown differences, these differences are very small and of little practical importance.¹³ Men and women may bring different, complementary skills to medicine. There is some evidence that women engage in more patient centred communication.¹⁴ However, women consult for longer with patients,¹⁴ and in one UK study of out of hours consultations they were 30% more likely to refer to hospital increasing pressure on hospital services.¹⁵ Moreover, recent UK research shows that even full time female consultants see fewer patients than their male colleagues.¹⁶ Empathy and communication skills are important, but so are efficiency and the ability to live with risk.

For years women have been unfairly discriminated against in medicine. I fully support their role and the strengths they bring to modern medicine. However, in the absence of a profound change in our society in terms of responsibility for child care, we need to take a balanced approach to recruitment in the interests of both equity and future delivery of services.

---

I thank Iain Colthart for his help with the literature review. BMcK is funded by the Chief Scientist Office of the Scottish Government.

Competing interests: None declared.

References

1. Burton KR, Wong IK. A force to contend with: the gender gap closes in Canadian medical schools. CMAJ 2004;170:1385-6.[Free Full Text]
2. Barzansky B, Etzel SI. Medical schools in the United States, 2006-2007. JAMA 2007;298:1071-7.[Free Full Text]
3. BMA Board of Medical Education. The demography of medical schools: a discussion document. London: BMA, 2004.
4. Lambert TW, Goldacre MJ, Turner G. Career choices of United Kingdom medical graduates of 1999 and 2000: questionnaire surveys. BMJ 2003;326:194-5.[Free Full Text]
5. Goldacre M, Turner G, Fazel S, Lambert T. Career choices for psychiatry: national surveys of graduates of 1974-2000 from UK medical schools. Br J Psychiatry 2005;186:158-64.[Abstract/Free Full Text]
6. Davidson JM, Lambert TW, Goldacre MJ. Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey. BMJ 1998;317:1425-8.[Abstract/Free Full Text]
7. McKinstry B, Colthart I, Elliott K, Hunter C. The feminization of the medical work force, implications for Scottish primary care: a survey of Scottish general practitioners BMC Health Serv Res 2006;6:56.[CrossRef][Medline]
8. Gravelle H, Hole A. The work hours of general practitioners: survey of English GPs. Br J Gen Pract 2007;57:96-100.[ISI][Medline]
9. Eagles JM, Addie K, Brown T. Retirement intentions of consultant psychiatrists. Psychiatric Bull 2005;29:374-6.[CrossRef]
10. Mather H. Specialist registrars’ plans for working part time as consultants in medical specialties: questionnaire study. BMJ 2001;322:1578-9.[Free Full Text]
11. Royal College of General Practitioners. Key demographic statistics from UK general practice 2006. www.rcgp.org.uk/pdf/ISS_FACT_06_KeyStats.pdf.
12. Carr PL, Ash AS, Friedman RH, Scaramucci A, Barnett RC, Szalacha L, et al. Relation of family responsibilities and gender to the productivity and career satisfaction of medical faculty. Ann Intern Med 1998;129:532-8.[Abstract/Free Full Text]
13. Kilminster S, Downes J, Gough B, Murdoch-Eaton D, Roberts T. Women in medicine –is there a problem? A literature review of the changing gender, structures and occupational cultures in medicine. Med Educ 2007;41:39-49.[CrossRef][ISI][Medline]
14. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA 2002;288:756-64.[Abstract/Free Full Text]
15. Rossdale M, Kemple T, Payne S, Calnan M, Greenwood R. An observational study of variation in general practitioners’ out-of-hours emergency referrals. Br J Gen Pract 2007;57:152-4.[ISI][Medline]
16. Bloor K, Freemantle N, Maynard A. Gender and variation in activity rates of hospital consultants. J R Soc Med 2008;101:27-33.[Abstract/Free Full Text]

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