By Victoria Cook and Josephine de Costa
— ElliottHaut (@elliotthaut) August 13, 2015
In 2015 I started my first year of medical school and for the first time in my (very privileged) life I was confronted with a setting where being a woman was quite openly considered a factor in my future career. Perhaps I was naïve, but I wasn’t expecting that.
Women have made up the majority of medical students since 2001. Yet, despite what people hoped or expected, gender norms in medicine have not evolved at a similar rate.
I was surprised, amused and then frustrated as well-intentioned friends and strangers reminded me to consider family-friendly specialties like dermatology, or general practice. They cited their predictable hours and flexibility making them ‘good careers for women’. Didn’t I want to specialise in paediatrics?
I listened as female friends considering a career in a specialty such as surgery were consistently reminded to consider how they would fit in family, and that ‘it would be hard for them.’ People, with the best intentions at heart, warned them of a ‘boy’s club’ culture.
Yet nobody questioned why, in 2015, medicine still had a place for ‘boy’s clubs’?
If you ask a female medical student she will tell you that at some point or other she has been mistaken for a nurse or referred to by a patient as a ‘lady doctor.’ As trivial as this may seem, these messages are pertinent reminders that gender is still very relevant and very visible in medicine.
And all this, in the context of a year full of revelations about sexual harassment of female surgical trainees by male surgeons, aggravated by a lack of consequences for perpetrators and the silence of bystanders and leaders.
This cultural environment where the challenges for women are viewed with resignation as simply ‘the way things are’ is a symptom of a powerful cultural concept at work in medical school- its called the ‘hidden curriculum’.
The hidden curriculum refers to the undercurrents of information, not formally part of the medical curriculum, that filter through from peers, patients and lecturers to budding doctors. It is particularly powerful in medicine. Students, keen to fit into the medical profession they idolise, rapidly adopt many of these tacit lessons. And thus outdated views propagate unchallenged.
The hidden curriculum perpetuates stereotypical representations of the qualities required for success in particular specialties. For example, the surgical stereotype is deeply ‘masculine, competitive, confident’. These embedded perceptions of specialties, combined with the scarcity of female role models, preclude female students from envisaging a ‘successful self’- the ability to imagine a successful career in surgery.
Although these messages won’t deter the most certain, committed female students from pursuing a career in a male-dominated specialty, like surgery, it is the students who are less set upon a particular specialty who are subtly influenced.
Studies consistently show that the most significant factor influencing a medical students career choice is gender. Intelligent, ambitious female students reconsider their career options, favoring the paths where their gender does not represent a significant obstacle. These include specialties with more accessible maternity leave or job share options, more flexible training programs and a higher proportion of women in leadership.
Such findings go some way to explaining the deeply gendered pattern of medical specialisation in Australia today.
Women represent 44% of GPs and 36% of specialists yet only 13% of general surgeons, 3% of orthopaedic surgeons, 8% or urologists and 16% of cardiologists. In comparison, 52% of geriatricians, 44% of GPs, and 72% of palliative care specialists are women. Women are concentrated in lower paid, less prestigious specialties.
Historically, female absence from some specialties was considered a reflection of differing professional and personal priorities including a lack of interest in ‘technical skills’, a preference for ‘patient contact’, and a desire for a career with more family friendly hours. Others argued that the disparity would simply correct itself with time.
Given the enduring nature of the problem, and the predominance of women in paediatrics, or obstetrics and gynaecology; two specialties that are both procedural and unpredictable, these hypotheses have been discarded for a more nuanced view of a structural barriers deterring women from selecting or succeeding in male-dominated specialties. This approach returns the onus for increasing gender diversity from individual women to the professional and educational institutions they belong to.
Medical schools have a role to play in countering the ‘hidden curricula’ to foster a more gender-neutral pattern of specialisation in their graduating students.
This includes ensuring exposure to female role models as lecturers or clinical tutors, as well as monitoring and addressing instances of gender discrimination in clinical rotations. It means training teaching staff to avoid subtle and overt patterns of gender discrimination and unconscious bias. It also includes an open and public commitment from leaders to improving gender equality in medicine, in order to counter the message that such disparity is inevitable or intractable.
It must be noted that confronting gender bias at medical school requires a simultaneous commitment by the medical profession to address the very real barriers faced by female doctors after medical school. Chiefly, measures to improve gender equality in medicine are futile without a simultaneous commitment to increasing flexibility of training programs and access to parental leave.
No strategy to increase the participation and progression of women in male-dominated specialties will be successful as long as female trainees are required to choose between delaying or foregoing children in order to pursue an ambitious specialty.
In 2016 there aren’t a lot of female firsts left in medicine, women achieve incredible success in all aspects of medicine- and so they should. But in applauding these ‘exceptional’ women it is easy to neglect a conversation about the way in which the majority of women experience a career in medicine.
Differential patterns of specialisation, pay, publication, promotion and leadership clearly indicate that gender inequality persists in medicine. We must have a frank conversation about women in medicine. This conversation can focus on barriers, or it can focus on solutions. And it begins at medical school.
Disclosure: Victoria Cook and Josephine de Costa are founding members of the group Level Medicine, a group that aims to start a positive discussion about gender in medicine.
The views and opinions expressed in this article are those of the author and do not necessarily represent those of SUMS.