Women doctors and their careers: what now?

Introduction

Many people in the medical profession still view women doctors with scepticism despite their increasing numbers. It is nearly 20 years since I was commissioned by the Department of Health to help them assess the implications of the fact that women would soon account for half of medical graduates.1 That research and its follow-up2 found that both men and women experienced similar problems and constraints in their careers, suffering from what they regarded as a rigid and conservative career structure. They overwhelmingly supported the provision of more flexible working patterns so that all doctors could lead a normal life. How far have women doctors progressed and what do they feel about the profession?

Change in culture

In 1986, many trainees had to work 120 hours a week and move to different locations every few months. Women were asked the most outrageous questions at interviews, the old boy network and behind the scenes telephone calls were dominant factors in the selection process, and women who wanted to reduce their hours to spend time with their children were not regarded as proper doctors. Things have changed in medicine, but perhaps not as fast as in the outside world. Powerful and influential doctors continue to express fears that the increasing proportion of women in medicine will lead to a loss of power and influence and professional status.3 4 But even if their fears were well founded, the progress of women in medicine is less than many people imagine.

Entry to medical school

Women are indeed accounting for a larger proportion of medical graduates. All through the 1960s women accounted for about 25% of those entering medical school. By 1975 the proportion was 35%, rising to 46% by 1985. In the early 1990s the proportion was around 50% but has since increased each year and is now 61%.5

But just because the proportion of women has increased over the past few years, it does not necessarily mean that it will go on increasing. We should be careful before saying that on present trends women doctors will outnumber men doctors by 2012.6 In neither hospital medicine nor general practice have women reached even 40% of the medical workforce.

Hospital medicine

Women accounted for 23% of all grades in hospital medicine in 1983, rising to 35% in 2003, hardly swamping the medical workforce (fig 1).7 8 The proportion of women consultants doubled from 12% in 1983 to 24% in 2003 and reached 25% in 2004. Women account for 39% of specialist registrars (the consultants of tomorrow) and for 44% of senior house officers. It is only among preregistration house officers that women are now in the majority, but still only just over 50%.

Fig 1

Percentage of female hospital doctors by grade

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One of the reasons for the relatively low representation of women in postgraduate training grades is that as many as 42% of senior house officers and 38% of specialist registrars qualified outside the UK, and most of these are men.8 Traditionally, most overseas qualified trainees return to their home countries when they complete their training and do not take consultant posts. If we look at UK qualifiers, women account for 50% of senior house officers and 44% of specialist registrars.

Women doctors still account for less than half of the UK medical workforce

Credit: MARK THOMAS

The specialties with the largest proportions of women consultants in 1983 were psychiatry, pathology, and paediatrics (fig 2). Today paediatrics is now well in the lead with 40% women consultants. It is interesting that paediatrics with its on-call and out of hours commitment—things that women are supposed to shun—is the leading specialty. The number of women consultants has also increased greatly in acute specialties like obstetrics and gynaecology and accident and emergency. Surgery, however, remains a male preserve, with only 7% of consultants being female in 2003.7 8 Around 30% of women consultants now work less than full time.8 Women account for a higher proportion of specialist registrars, but the overall pattern is similar to that for consultants (see bmj.com).

Fig 2

Proportion of female consultants by specialty

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Women in general practice

The proportion of women working in general practice has doubled from 19% in 1983 to 38% (see bmj.com). The proportion of women principals has more than doubled from 17% to 35%, but the biggest increase is among general practice registrars: from 37% to 60%.9 10

Between 1993 and 2003 the proportion of male principals working full time remained over 90% but the proportion of women fell sharply from 73% to 53%.9 10 If only just over half of women principals are working full time, it is unsurprising that we urgently need to increase numbers entering general practice. These figures reflect the age profile of women in general practice, with high proportions of younger women with child care responsibilities. These women may increase their hours when their children are older.

Views of women doctors

I recently conducted a series of five focus groups in a London hospital with women consultants and specialist registrars in their late 20s and 30s. I asked many of the questions asked in my earlier research, with particular reference to the work-life balance. I focus here on the views of consultants. The women came from a mixture of specialties and all had small children. Some had done flexible training; some were working full time and others part time. What were the biggest constraints on their careers and what stresses did they experience?

Stress at work has been consistently related to lack of control over the working environment.11 But it was striking how these women consultants felt that they were actually “in control,” “calmer” at work than at home. The things that male consultants found particularly stressful—perceived loss of consultant autonomy, loss of control over their work environment, concern about targets, conflicts with managers, poor support services, and inefficient back-up systems12—paled into insignificance for the women. “I think you just factor that in as a normal background source of irritation,” one commented.

These women consultants stressed the importance of time management in their lives. All of them considered proximity to the workplace to be crucial. Certainly the stability of a fixed job in one place as a consultant and the removal of the geographical mobility required of most specialist registrars was a great relief.

The importance of role models or mentors for women doctors cannot be underestimated. Both consultants and specialist registrars spoke of the advantage of having people in the department who shared the stresses of juggling work and family, not only other women consultants. An anaesthetist spoke of her department being “Run by people who have other lives. It's not just the surgeons and the anaesthetists, it's the theatre staff, ward staff. It's a whole department of people saying the operating session has to stop at half past five.”

Those who had done flexible training said they had been regarded as very desirable, not only because they were supernumerary but because they came with funding attached. But times (and funding) had changed, and they thought that it was much more difficult now for potential flexible trainees.

The women thought it better to start full time as a consultant and then negotiate to less than full time. They often dropped just one or two sessions, and they regretted the loss of time for developing services that resulted. Women registrars and consultants still had problems in some male dominated specialties.

One consultant had considered an academic career but had abandoned the idea. She had done a PhD at a prestigious teaching hospital and could have gone on to a senior lectureship, but had settled for a consultant post elsewhere: “I decided I would not be able to juggle everything—to be a good clinician, plus do the research, plus have a social life and a family life. I couldn't do a senior lecturer job part time. I'd get kicked out.”

The problem of recruitment to academic medicine, which has been highlighted by the chief medical officer,13 seems likely to become more acute unless women's needs can be accommodated in more flexible career pathways.14 Attention also needs to be paid to the particular importance of mentors and role models for women in academic medicine.13 15

The consultants emphasised that women may have different career paths from men. This M shaped distribution of women's careers has been recognised for a long time: the peak in the early years, the dip in the middle, and then the potential for a peak in the later years. My earlier research showed clearly that women doctors did not drop out after childbirth, as many people had thought, but continued working, often part time in general practice or community health. There are far more opportunities for women now and their potential contribution in the second half of their careers should be fully exploited.

Adapting to change

The profile of the medical profession is changing—not only with increasing proportions of women doctors but also with increasing proportions of UK qualifiers from ethnic minorities. The days of the white male dominated medical profession are numbered. In 2003, among UK qualified doctors, white men accounted for 68% of consultants but only 33% of senior house officers and 29% of house officers.8 In 2002, white men accounted for 26% of entrants to UK medical schools.16 But does this matter? Great care should be taken before attributing any potential loss of professional status to the changing profile of the medical profession.

We need to take a fresh look at the ingredients of professional status. I don't believe that patients value women doctors any less than men doctors. Much more damage is likely to have been done to the status of the medical profession by costly public inquiries into professional misdemeanours, mostly resulting from actions by white male doctors, than by the failure of women doctors to flock into committees.

It is time to reconsider some of the entrenched values and attitudes that reinforce the traditional pecking order in medicine and remain a source of implicit discrimination against women. Should certain specialties be more highly regarded than others and remain largely male preserves? Why are all consultants expected to take on so many different duties, particularly if they want clinical excellence awards? Are there no measures of quality other than long hours, committee membership, and research papers?

Some progress has been made. The profession has realised that long hours and lengthy, unstructured training periods do not necessarily ensure a well equipped and well balanced workforce. But perhaps the most important recent change to benefit women doctors—the reduction in hours—has been imposed from outside the profession with the implementation of the European working time directive. There has been some belated recognition that the straight full time career path so engrained in the mindset of the medical hierarchy could be open to change. But suspicion remains of those who have more unconventional career paths or who have not reached a certain grade by a certain age. Let us hope that the government's plans for reform of postgraduate training will allow more flexibility.17

It is pointless to hanker after some golden age in which medical careers and working practices were organised in such a way that nobody who wanted to lead a “normal” life, whether male or female, could hope to reach the top of the profession. It was not a golden age and will never return. The most important thing for the medical profession to concentrate on now is how best to use the resources it has and will have in the foreseeable future. It should be a matter of great pride that so many brilliant young women are choosing to enhance the profession, and every effort should be made to throw out old fashioned practices and attitudes that inhibit the contribution they can make both in the early and later stages of their careers.