Gender and academic medicine: impacts on the health workforce

Enrolment

Around the world there is an increasing trend to consider gender in the recruitment and enrolment of medical students. As a result, in many countries women are enrolling in medical schools in increasing numbers, and in some countries gender equality has been achieved. This “feminisation of medicine,” has resulted in increased numbers of female doctors entering the health system. In Russia in 1990, 69% of doctors were women,3 and in the United Kingdom women doctors are expected to outnumber men doctors within 10 years.7 These steps toward gender equality raise important challenges for academic medicine. A recent statement by Carol Black, president of the Royal College of Physicians, that the medical profession becomes less powerful and influential as it becomes increasingly feminised is testament to this.8

Data describing the gender dimensions of medical school enrolment in developing countries are less available. However, recent data from Mexico and Bangladesh indicate that the numbers of women entering medical school in these countries are increasing. In Mexico women's enrolment rates increased by 6.5% between 1990 and 2001, and in 1999 women surpassed men in enrolment figures.9 Currently in Bangladesh, of the 9391 students in government-run medical schools, 46% are women (S Hussain, director medical education and health, Bangladesh, personal communication, 2004). Although such improvements in gender equality of medical school enrolment are encouraging, experiences in developed countries suggest that gender inequities persist despite improvements in gender equality. These gender inequities can affect men and women in terms of their selection of specialty and promotion opportunities. Analyses from developing countries may show similar patterns as in developed countries In Mexico in 2000, 46% of registered women doctors were not employed in medicine, compared with 35% of men doctors (N Gustavo, FUNSALUD, Mexico, personal communication, 2004). Gender inequities often occur early in the academic training process and affect career trajectory and, ultimately, the extent, distribution, and skill mix of the health workforce.10 11

Credit: BURNER/PHANIE/REX

Curriculum

Disregard for gender in the medical curriculum affects the health workforce. The medical curriculum reflects a common set of standards that guide achievement and success during and beyond medical training.2 Gender based critiques argue that training materials in academic medicine endorse a patriarchal view that neglects women's healthcare needs.12 Physicians will provide higher quality care to their female patients if the medical school curriculum better reflects the female patient's perspective.13 Kerala state in India has led a recent effort to examine gender issues in medical school training. This effort started with a gender based review of the curriculum and produced a three year programme that includes training modules on gender sensitisation for medical college teachers and is used in several Indian states.14 Such efforts have as their ultimate goal the removal of gender biases in how providers deliver health services.

Making medical training curriculum more gender sensitive can also affect the career trajectory of health providers and the management of human resources for health. Adapting the curriculum to reflect gender prepares providers to address a range of health issues that better meet the needs of a diverse group of patients. Ultimately, this may allow the provider greater flexibility in choice of specialty and location of practice. For example, better preparing men to address women's health needs may increase patient demand for their services, leading to greater job satisfaction. It may also open up medical specialties often seen as the domain of female providers, such as paediatrics, to men.

Promotion practices

Research in the developed world has documented gender inequities in the promotion practices of academic medicine.10 15 Studies show that women in the medical profession advance more slowly than men, particularly in academic medicine, and that there are far fewer women in leadership positions.11 In the United States, women accounted for only 6% of medical school departmental chairs in 1998; in 1999, only six of 125 medical schools had female deans.3 Several studies have shown that it takes women longer to be promoted from assistant to associate professor and to full professor.11 Among explanations for this gender inequity in promotion is that women, because of family obligations, work fewer hours and are less productive than men. However, a survey of physician faculty in US medical schools found that even after work schedule, specialty, and productivity differences were accounted for, women remained less likely to be promoted than men.11

Another explanation for gender inequity in promotion is the institutional and cultural structure of academic medicine, which relies heavily on sponsorship and patronage. Medical school faculty and practitioners serve as informal and formal gatekeepers; they influence students' selection of specialty and serve as mentors, grooming students for careers in clinical or academic settings. A plausible explanation for gender disparities in promotion is that women have fewer mentors and professional networks and less collegial support while in the academic medical system. This suggests the need for gender equity in mentoring during the education process and throughout the academic medical career. Specific suggestions include using visiting professorships to increase the presence of female professional role models and encouraging female students to develop multiple mentoring relationships with men and women to foster greater understanding of the gender-specific challenges facing academic professionals.10

Building an evidence base

The first change needed is a commitment to collect evidence related to gender and academic medicine. This should include data on gender and promotion practices, mentoring systems, and how gender is valued in academic medicine. Constructing an evidence base will raise awareness about the utility of incorporating gender into academic medicine; illuminate new interventions; help decision making; and generate systematic analyses. It will allow questions such as “do women tend to practice particular medical specialities because of individual choice or due to gender biases?” to be addressed. Finally, an evidence base will make it possible to track progress in achieving gender equity in academic medicine. While creating indicators is not a straightforward process, it will generate debate about the best measures for gender equity in academic medicine.

Gender equality versus gender equity

The second change requires leaders in academic medicine to recognise the distinction between gender equality and gender equity. Gender equality refers to men and women having equal opportunity and access to resources, whereas gender equity strives for fairness and justice for men and women in the professional opportunity structure. In the past, academic medicine has addressed gender primarily through recruitment policies for enrolment in medical education. This has increased the number of female physicians, but they are more likely to be unemployed or less likely to practice in highly specialised areas of medicine than their male counterparts. Gender equity addresses underlying injustices in the professional opportunity structure and offers a more complete approach to addressing gender and academic medicine.

Challenging traditional values

The final change requires a fundamental shift in values and expectations among leaders of academic medicine. Expectations about what represents measures of success and performance may need to be reconsidered. For example, number of hours worked may not be an accurate measure of productivity without also taking into account some measure of the quality of care provided. Traditional expectations about who is best equipped to practise a particular specialty must also be revised. Students should not be pressured, directly or indirectly, to enter particular specialties because of social expectations about the professional strengths or weaknesses of men and women.

Gender presents challenging issues and critical questions for decision makers at all levels of academic medicine. As a conservative, male dominated institution, academic medicine may not easily examine the gender dimensions of its operations and values. However, it is critical to view the issues raised by gender as an opportunity to help revitalise academic medicine and strengthen its contributions to the health system rather than as a threat to the profession. Improving gender equity is essential to the future of academic medicine; ensuring the health system's most effective response to the public health challenges of the future may well depend on it.