Are there too many female medical graduates? Yes
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39505.491065.94 (Published 03 April 2008) Cite this as: BMJ 2008;336:748All rapid responses
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Dear Editor,
The proportion of women as students at the medical school and residency programs for medical specialisation has risen dramatically over the three past decades in the developed world. A recent Head to Head under “Are there too many female medical graduates?” was controversial. Brian McKinstry - senior research fellow, Community Health Sciences: General Practice section, University of Edinburgh - said yes (1). He argued women are more likely to choose less pressurized disciplines, work part time, take career breaks, and leave medicine early. Jane Dacre – vice dean, Faculty of Biomedical Sciences, University of London; and academic vice president, Royal College of Physicians, London - replied medicine needs and want to attract the best and brightest people, whatever their sex (2). Whereas women now outnumber men at entry to medical workforce, they are still under-represented in some specialities and in the higher career stages, as it has been noted by Allen in United Kingdom, and Arrizabalaga, Moreno, Merino and Estrach in Spain (http://bmj.bmjjournals.com/cgi/eletters/331/7516/569).
McKinstry and his colleagues Colthart, Elliot and Hunter - NHS Education for Scotland – previously have expressed their pessimism about the feminization in medicine (3). It’s unlike to the tradition of the University of Edinburgh, where Sheila Sherlock (SS) (1918-2001) was fortunately accepted in medical school, after she was rejected as student in three universities. SS would hold the first European Women Professor in Medicine.
Underlying the debate about feminisation in medicine: what sort of medicine do we want? Because adequate service delivery is a basic requirement of workforce.
Women are changing the profession itself. The tendency for women in medicine to provide patient-centred care has interesting implications for the profession. Women are likely to be sensitive not only to patients’ biomedical concerns but also to their emotional concerns. Studies have demonstrated effective communication skills can enhance outcomes of care, including patient adherence to treatment recommendations, biological outcomes in chronic disease, and patient satisfaction.
Models of health care delivery at the local level are changing rapidly toward a multidisciplinary team approach to patient care. Studies of leadership style indicate that women empower other team members to develop their potential, act as role models by gaining confidence of colleagues, and take an interest in the personal needs. Some authors point out that the M-shaped distribution of women’s careers has been recognized for a long time: a peak in the early years, a dip in the middle and then the potential for a peak in later years. The careers of women do not fall after childbirth, as many people believed (4), and for that reason, the potential contribution of women in the second half of their careers has not been fully recognized. There is, however, the hope that more women gain positions of power and high rank, and that the institutions will be able to warrant equivalent opportunities to women and men.
References 1. Mc Kinstry B. Are there too many female medical graduates? Yes. BMJ 2008; 336: 748.
2. Dacre J. Are there too many female medical graduates? No. BMJ 2008; 336: 749.
3. McKinstry B, Colthart I, Elliot K, Hunter C. Women's contribute less than men to non-clinical care as general practitioners in Scotland. BMJ 2005; 331: 696-97.
4. Allen I. Women doctors and their careers: what now?. BMJ 2005; 331: 569-72.
Competing interests: None declared
Competing interests: No competing interests
Dr McKinstry is to be congratulated for making an important observation and cogently presenting the potential consequences of a greater proportion of female medical graduates compared to male. The question that is not answered is why more females than males are admitted to medical schools and the issue that is not addressed is that perhaps the answer lies, at least partly, in the fact that the education system fails more boys than girls. There is a disturbing spread of feminisation across society leading to mistaken beliefs that boys, and the men that they become, are worse at communicating, cannot show empathy and consequently are not as good at caring. This, of course, is all seen from a female perspective with no recognition that a male manner of communicating, showing empathy and care may differ from that of a female but it is no less acceptable. Women are not better at being doctors than men are but with more women in the profession, the talents and skills of male students and eventually male doctors stand the risk of being eroded.
As academics and educators in the clinical and medical professions we have seen and heard of excellent male students chided and even insulted by female clinicians for being poor communicators because they do not behave in a certain way that is more characteristic of females. Unlike the female student who can complain of sexist behaviour if a male tutor were imposing his viewpoint on her communication skills, the male who is unfairly treated by a female tutor is unlikely to make such a complaint.
The chatty, touchy feely manner may be favoured by some, but not by others. One can only wonder whether the gradual loss of public respect in the medical profession, the increasing input, in medical courses, of sociological topics and the over emphasis on communication skills at the expense of the science of medicine, are not all correlated with a feminisation of the profession.
The solution lies in keeping the numbers of male and female students equal and in ensuring that the equality begins years before applications to medical courses are made: by providing schooling that is as fair to boys as it is to girls.
Professor Barbara Pierscionek Dr Patricia Hart
Competing interests: None declared
Competing interests: No competing interests
interesting but rather offensive article... i suspect people like Brian will next be advocating that we also limit or stop older students from studying medicine as they also will have a shorter active working life...
i disagree with him. if there's a shortage, let's have more students and train more postgraduates rather than prejudging female applicants who may or may not individually work less.
we should wholeheartedly reject any proposal that calls for gender discrimination. a more positive step would be to look at why medical graduates stop working and what can be done to persuade them back to work.
Competing interests: None declared
Competing interests: No competing interests
What is the reason for the best male applicants to universities to choose other subjects over medicine?
Male students would traditionally choose careers which are lucrative, stable, and with a high professional reputation. If the proportion of male to female students is shifting, is the reason not just the doubtless better academic achievements of female students, but also a choice away from medicine? Does it reflect the reduction in job security, lower pay than the private sector and 'doctor bashing' in the media?
Commenting on 'efficiency': To see as many patients as possible in a clinic can backfire and lead to a high number of follow-up appointments and reduced patient satisfaction. Having worked for male consultants, some very 'efficient' and others taking more time, I know that a little more time spent at each appointment lead to less follow-up and better patient self-management, surely a desirable outcome (and nothing to do with male/female working patterns).
Competing interests: None declared
Competing interests: No competing interests
Dr Brian McKinstry (BMJ April 4th 2008 “Are there too many female medical graduates?”) accepts that for many years women have faced unfair discrimination and that he supports their role and the strengths they bring to medicine. However he goes on to suggest that “in the absence of profound change in our society in terms of responsibility for childcare we need to change approaches to recruitment in the interests of equity and future delivery of service.” This suggests a position which would see women discriminated against because of their reproductive capability, a position which is illegal and irresponsible.
There have been obvious changes in societal attitudes towards women and the role of women, and as with many cultural shifts the medical arena has been perhaps slower to adopt these changes, but long gone are the days of suffragettes and the concept of the female gender as a second class in terms of autonomy or productivity. It is sad that Dr McKinstry’s arguments seem to reflect a tenuous evidence base recently rehearsed in the Journal of the Royal Society of Medicine (JRSM), instead of arguing for more robust exploration of gender comparisons with transparent methodology and like for like comparisons, he proposes discrimination that could disable the healthcare profession and alienate the majority of the workforce.
Childcare is no doubt a significant challenge for the NHS, for all healthcare professional groups. As the proportion of women in medical schools moves to reflect the national demographic (1) the NHS will need to make true the commitments of the 2000 Labour NHS Plan to a flexible, accommodating and productive workforce. It is also worth noting that as the general population grow older, the burden of caring may not be restricted to those with children.
We would suggest that although arguments about gender productivity provoke extreme reactions and can prompt a new onslaught of sexist humour, the global evidence base and legislative framework suggest that where women are given equality of opportunity, resource and infrastructure, they achieve at least equal productivity. (2,3,4)
The reality is that the NHS has not evolved to meet the needs of the 2008 workforce. The argument should not be about women taking time to support their children, because the evidence base is that men value the opportunity just as much,(5) but rather be about the way the NHS can maximise productivity alongside maximising workforce well being, moral and loyalty.
‘1.2 Our vision is of an NHS where staff are not rushed off their feet and constantly exhausted; where careers are developed not stagnant; where staff are paid properly for good performance; and where childcare is provided in every hospital. Ours is a vision of a renewed public service ethos, a system that values the dedication of staff and believes that trust is still the glue that binds the NHS together.’(6)
The 2005 NHS Staff survey found that 4 times as many women experienced bullying or harassment from colleagues compared with men in the survey.(7) This reflection of the experience of women in the NHS is shocking and illustrates the poor interpersonal relationships between men and women in the NHS which can be perpetuated by the mythologies and discrimination promulgated by Dr McKinstry. We hope that his article prompts all of us to consider our own prejudices and practice and lobby for an NHS which is truly a gold standard employer for a diverse, exciting and challenging workforce at all levels.
Yours sincerely,
Professor Bhupinder Sandhu MBBS, MD, FRCP, FRCPCH & Dr Justin Varney MBBS, MSc, MFPH.
Equal Opportunities Committee Co-Chairs British Medical Association
1 The demography of medical schools: a discussion document. BMA. June 2004. P59.
2 A fair deal for women in the workplace – an interim statement. Women & Work Commission. March 2005.
3 Towards A Fairer Future: Implementing the Women and Work Commission recommendations. Department for Communities and Local Government. April 2007.
4 Gender Differences in Agricultural Productivity: a Survey of Empirical Evidence Discussion Paper Quisumbing Agnes R. June 1995.
5 Mather H. Specialist registrar’s plans for working part time as consultants in medical specialities; questionnaire study. BMJ 2001;322:1578-9.
6 The NHS Plan. Secretary of State for Health. July 2000. section 1.2. p17.
7 NHS Staff Survey 2005. Healthcare Commission. Q30d.
Competing interests: British Medical Association Equal Opportunities Committee Co-Chairs
Competing interests: No competing interests
Has the question been asked as to why fewer males are applying to study medicine? Is it possible that some of the reasons to consider are that there is no job security, training costs are high (eg exams, self- funding of courses), the work is intense, with pay that does not reflect time spent, and medicine is seen as a professional job and not a career?
In the imminent future the European Working Time Directive will ensure that both male and female trainees work a 48hr week. 'Less-than- full-time' working will become the norm from trainee to consultant level and therefore job patterns will change.
Women generally only work part time for some of their working lives, when their children are young. This gives a bimodal working pattern with subsequent return to full time employment. There should therefore not be any anxiety as to loss of "woman power" in the NHS but rather innovative ideas for job creation and job-sharing as part of workforce planning.
The Medical Women's Federation, which is over 90 years old, strives to encourage and support our medical students and juniors to achieve their career goals. We listen to our members and the problems of trying to combine family and careers and facing barriers. The career choices that women make in medicine after graduating reflect the opportunities available and we continue to lobby for equal opportunities. If it means less than full time training is needed for equal opportunity towards career progression, then this should be available. The results of our study “Making Part-time Work” are to be launched in June and will provide useful data on less than full time working experiences of both male and female doctors.
Beryl De Souza
Joint Honorary Secretary
Medical Women's Federation
www.medicalwomensfederation.org.uk
Competing interests: Joint Honorary Secretary Medical Women's Federation
Competing interests: No competing interests
There are 3 important points I would like to make
1- Maternal Instincts:
Nowadays, many women are asking men to take similar responsibilities of raising the kids, but none would ask the kids, what they want and whom they prefer? Talking from my point of view, when I was a child, I surely preferred my mother to look after me, rather than my father, what a child look for is affect, compassion, care, love, and tenderness, many of these gifts are naturally and inherently present in women, in fact that what maternal instinct is all about. The majority of kinder garden and preliminary school teachers are females, this secret bonding between female gender and kids is written in the book of nature and it cannot be changed or substituted… you are asking men to give something they don’t possess, I’m not saying men don’t love their children, they do, but they can’t substitute women even in million years. The same instincts can be found in animals; mothers always support, defend and care for their cubs until they become independent. Asking men to assume the role of mothers or equally share that role is going against nature, and I believe they will fail miserably.
2- Physical/physiological differences:
Talking medically, Male dominant specialties are the toughest specialties, and tough specialties require devoted people. In the current extremely competitive world, to be successful in a career like surgery or an academic career, you should be extremely committed, you should be overzealous, hardworking, devoted and you have to show good career progress. Being a female and wanting surgery for example, means that you have no time to get pregnant, at least in the first few years of the specialty, as having frequent career breaks would not help career’s progression, let alone the involvement with children care which is inevitably distracting and hindering many potentials for excellence. By the time a female surgeon becomes a consultant and considers getting married or having children if already married, the crucial physical difference between men and women sets in; We can’t deny the fact that Women age quicker than men, a 35 year old male consultant surgeon, is at his peak and is attractive for many women including younger women, with a huge potential to get married, in the same take, a 35 year old female consultant surgeon is not as attractive, and If she didn’t get married until this age, which is a likely scenario given the nature of her job, then her chances of getting married are less and her physical attractiveness is withering by the day, and even if she already got married she has only few years left to have children safely.
Some would argue, that there are very successful female consultant surgeons who were married at an early age, had many kids and led a happy life, I am not saying it’s impossible, it can be achieved, but such examples are exceptional, it’s not common and thinking otherwise is simply not true.
3- Women’s rights defenders
Most women who defend the idea of equality, and the competency of women to work in demanding careers, are in fact not a representative voice of the majority of women, they are themselves excellent women and they managed to strike a very difficult balance between their careers and their families, but not all women are exceptional, and asking all women to be the same, or putting women under the illusion that they can do it, is not to the best thing to do.
If women want to deny their maternal instincts, if they want to devote themselves to their careers the same way men do, if they don’t care about how years bear on their bodies and looks, if they don’t care about getting married and have kids at an early age, then I have absolutely noting to say, but to me, the first victim of such approach would be women themselves.
P.S. I am only talking about women who choose to work in demanding specialties or careers, I have nothing against women who choose to work in family friendly specialties, which I always believe is the best of wisdom.
Apologies to all women who find my comments offensive.
Competing interests: None declared
Competing interests: No competing interests
The gender distribution in medical specialties need not reflect the population. For instance, look at nursing, dentistry, construction: gender roles are defined in these professions. The choice of medicine or a sub- specialty should be a function of competence, not gender, race etc. It is interesting that despite having >50% medical school graduates as women, less than 20% choose general surgery, and 14% of all surgeons are women in the US. Thus, female medical graduates self select themselves to specialties that meet their needs. We must avoid trying to equalize the distribution, rather, we must provide opportunities and remove barriers to this choice.
Competing interests: None declared
Competing interests: No competing interests
In response to Dr McKinstry’s letter I have to say that I feel as if I have been assaulted, and devalued, and I believe it will now be hard for doctors like me to recover from this attack. It will also deflect attention from the main cause of the very real problem, which is that many (or even most), new doctors, regardless of gender, have very different hopes and expectations of what a career in medicine will offer them.
I have worked for 25 years as a full-time partner and GP trainer in a deprived area, and I have never stopped doing my share of out of hours (I am currently contracted to do 10 hours per week on top of my practice commitment). In addition I have been a GP appraiser, summative assessment audit assessor, audit facilitator for the trust, associate advisor for the development of practice based learning, served on the GP quality development committee for the LHCC, have been involved in the development of the PEP, led my practice twice through Practice Accreditation, obtained the Certificate in Medical Education, and have been nominated as a fellow of the College. I have had three children and took 16 weeks off work after the birth of each of them. I never took any time off for child care reasons, nor for my children’s illnesses.
Until now, when I am recovering from major abdominal surgery, (not gynaecological in nature) I have never had any sick leave. My plan has always been to work until I am 65. So far none of my male partners, male salaried GPs, male locums, or male interviewees have done, nor have had any intention to do, all of this.
Admittedly one partner, who reduced his sessional commitment, works elsewhere (outwith the NHS) in the time liberated, but that is scarcely relevant to the NHS commitment. I respect the right of all of these doctors to make these choices.I do not think it means we should have fewer male graduates.
When we advertised recently for a new partner (full time) every single applicant, male and female, including married men who had children and non-working wives, asked if we would consider offering fewer sessions. Two years ago we did a straw poll of our then registrar group of 14 (8 men, 6 women) if they were going to look for partnerships and 100% of them said no. Course organisers told me that this pattern was reflected in the bigger group of over 80 bright young men and women.
In conclusion, the truth is that I used to agree with Dr McKinstry; I believed that general practice was sitting on a demographic time bomb with the preponderance of women coming through. What changed my mind was the discovery that it was not the just the women graduates who wanted a reduced commitment, but all of the graduates. It made me feel better as a woman but obviously did not make me very hopeful for the future of general practice.
I meet many of our future GPs in the out of hours service. They are highly personable, educated, intelligent, and talented. They know what they want to do and it is not what I do. They tell me explicitly "no-one wants to work like that any more", I have met quite a few young men who tell me they want to "do locums for a few years, then find a part time salaried post, perhaps taking a few months off each year in the ski season". I tell them that we always had room for a few eccentrics who wanted that sort of career (indeed we welcomed them), but that these people were completely reliant on a majority who were willing to run the service and provide the practices where they were going to do locums and work part-time. I point out that if they all want to do it the whole system will collapse within a few years. This might please the government, as they rush in with their polyclinics. This might also suit the young doctors who can then choose their hours. I think something very valuable will then be lost forever, but perhaps no-one cares about that (except the patients?)
I fail to see how anyone inside or outside the profession can argue with the idea that we should all give time back to the NHS in the country which trained us. And if they cannot or will not give enough time then we need more doctors.
I believe that despite my gender I have given as much to the NHS as most people, and will continue to do so. I have probably not given as much as Dr McKinstry, but I would defy him to find any evidence that this is because I am a woman
Competing interests: I am a female medical graduate
Competing interests: No competing interests
We rest our case
Dr Patricia Hart and I wrote in support of Dr McKinstry (1) and pointed out the misguided arguments, about women being better carers and communicators that are used, mainly by females, to make the case for women being better doctors (2). We did not have to wait too long for the evidence. Pilar Arrizabalaga (3) makes the sort of unjustified statements: “Women are likely to be sensitive not only to patients’ biomedical concerns but also to their emotional concerns” and “Studies of leadership style indicate that women empower other team members to develop their potential, act as role models by gaining confidence of colleagues, and take an interest in the personal needs” that are not backed by any proper scientific analysis and only serve to perpetrate the myth that women are better carers, better communicators and hence better doctors than are men.
Yes Pilar, women may be ‘changing the profession itself’ but not necessarily and in all aspects for the better.
1. Mc Kinstry B. Are there too many female medical graduates? Yes. BMJ 2008; 336: 748.
2. Pierscionek B. and Hart P. Feminisation of medicine begins before medical school. Rapid response 11th April 2008
3. Arrizabalaga P. Are there still barriers to women in Medicine? Rapid response 28th April 2008
Competing interests: None declared
Competing interests: No competing interests