Aneka Larsen has some medicinal book recommendations for those idle holiday minds…
Two common ailments among medical students are:
The desire to run away and hide, just for a little bit, please
Constantly asking yourself why you are putting yourself through this
To cure you of these truly debilitating conditions, I offer you two very important prescriptions.
PRESCRIPTION ONE: A BOOK TO HELP YOU ESCAPE MEDICINE
The World Without Us – Mireille Juchau
This is a book that feels like Australia. The Australia of my childhood, tucked away in a neat little bundle of memories, sacrosanct and intangible. What a treat to dive back in, to explore the muddy riverbanks, bush land and tight-knit community of a rural town that is infused with its own unique history and culture. The Big Smoke is a whirlwind of excitement, but it sure feels nice to momentarily escape, nestle into the cosy, green tableau of the Ghost Mountains and dream for a while.
The Müller family are a made-up family in a made-up town somewhere in a northern rainforest. Their family is complex. A distant mother heals herself with painting and secret sojourns to the woods. A gentle, eccentric father tends to bees and his two young girls, Tess and Meg. The girls try to make sense of their world, their mother, and the ever-changing emotional landmine that is growing up.
Juchau offers up a plethora of and touching and nostalgic insights into life and adolescence in rural Australia. They are a community of strange yet jarringly familiar characters; A doomsday fanatic, a wily family friend, busybodies, cult members, farmers, merchants and criminals. As well, the imagery is familiar and comforting; sections of the book are demarcated with odes to flowers, the rain, and the bees. There are narratives I remember from my own past; Silly competitions with my sister, a refusal to speak, running away from home, riding silently in the passenger seat through the dirt roads of my hometown. The knowledge that members of your community do not like your family for reasons you are too young to understand. The special attention proffered by a favourite teacher who encourages your curiosity and offers you books to devour. The feeling of being home.
If you come from somewhere else; somewhere quieter, somewhere that flickers behind your eyes as you fall asleep, a place far from flashing, beeping, bustling Sydney, then I hope you read this book. It was a pleasure to fall into, a pleasure to be carried away by, and a truly dream-like dance through the warming nostalgia of an Australian childhood.
PRESCRIPTION TWO: A BOOK TO REMIND YOU OF WHY YOU’RE DOING MEDICINE
The Man Who Mistook His Wife For A Hat – Oliver Sacks
As someone who today listened to six lectures in the library, came home to read a chapter on the GIT exam, and then fall asleep across the table from my dinner, I have a deep understanding of what it feels like to question one’s life choices. Luckily for me, there are those in the world who act as beacons of inspiration, guiding the way from out behind my bowl of soup, into the wider world of real medicine making a real difference to real patients. The first of such beacons was, for me, Oliver Sacks. A brilliant neurologist and author, whose books emanate a profoundly sincere respect for his patients, and a humbling acknowledgment that the people we care for can be our most important teachers.
The Man Who Mistook His Wife For A Hat is a series of case studies that detail the intriguing and bizarre neurological phenomena Sacks encounters throughout his career. Such cases include a man suffering from agnosia who is compensated with a gift for music, a woman who can no longer feel her own body, an elderly man seemingly stuck in his past, a man who cannot believe that his leg is his own, and a ninety year old woman who has started to feel “frisky”. Sacks regales these stories with deep consideration not just for the neurological pathology, but for the character and substance of the patient before him. Each case study illuminates a special individual and reminds us of the privilege studying medicine affords us – the ability to play a significant role in the lives of significant individuals.
Anatomy atlases, ankis and academia abound can make anyone feel apathetic from time to time. Admonish these unwelcome feelings by reminding yourself of the people you will meet, the stories you will hear, and the difference you can make. There is no better way to do that than with the tried and true, evidence-based method of immersing yourself in an Oliver Sacks novel. This is one of his best. NNT = 1.
Josh Druery reflects on #auspol’s abysmal year on climate change, reminding us of the sobering reality of rising temperatures for small island nations like Kiribati.
The rise of One Nation has been a frightening, surprising and simultaneously entertaining development for Australian politics. Already Pauline Hanson has refused to partake of the Halal Snack Pack with Sam Dastyari and has slammed the ATO for installing squatting toilets as part of an inclusive workplace (despite Squatty Potty’s assertion that squatting actually helps relax the puborectalis muscle while you do your business – but I digress). Worryingly, Hanson has also recently called for the complete ban on Muslim immigration to Australia, a call for a regression to the White Australia policy that blighted our nation’s history over 100 years ago.
Malcolm Roberts, another of the four senators elected under the One Nation banner, has been making headlines of his own. On an August episode of “Q and A” Roberts more or less dismissed over 2000 reports of abuse in Nauru’s offshore detention centre because Hanson talked to a single security guard that used to work there. He also spent the majority of that program arguing that climate change was a myth fabricated by the UN and NASA. Roberts would not even be assuaged after distinguished scientist Brian Cox pulled out two graphs and a report from the Australian Academy of Science – he needed to be shown “the empirical data”.
While climate change skepticism is thankfully becoming a rarity among mainstream media, government policy is nowhere close to reflecting the depth of the problem we face as an international community. Part of the problem with the climate change debate is that it’s an inaccessible discussion for most people. It’s clear that many politicians also can’t see the relevance of these environmental changes. The Lancet has published two commissions on climate change and its impact on health to address this particular problem and put a human face on an often complicated science, informing both medical professionals and politicians in order to drive a more effective policy change.
One change that has become evident with a rise in global temperatures is an increase in the frequency, severity and duration of heatwaves worldwide. The less a country is prepared for a heatwave the more people it can affect, most often causing fatalities among the elderly. Somewhat less intuitively is the link between climate change and ocean acidification – both contribute to a reduction in agricultural produce as well as fishing. This increases the price and availability of food, a phenomenon known as food insecurity, and causes the greatest harm to the poorest and most vulnerable. Climate change will also increase the number of natural disasters around the world, including droughts, floods and long-term desertification in some countries. All of these factors push people out of their homes and the number of displaced people in the world will continue to increase.
To put this in perspective, the number of people who have been displaced from their homes and have nowhere safe to live is at an all-time high of 65.3 million.
Migrants moving because of environmental changes will most likely travel to poor neighbouring countries that are themselves struggling with climate change. Displacement also increases the spread of communicable diseases and malnutrition through overcrowded housing and limited access to safe food and water. Resources will no doubt be overwhelmed in these areas and access to healthcare will be little or nonexistent. Currently these environmental refugees have not been designated as “refugees” under the 1951 UN Refugee Convention and are therefore given no legal long-term protection under international law.
These trends are best explained by looking at some island nations in the Pacific as examples. Climate change is an immediate threat to Tuvalu, the average height of its islands just two metres above sea-level. It’s estimated that the island of Fongafale, which houses Tuvalu’s capital city Funafuti, will lose 20% of its land to temporary or permanent flooding by 2040. Successive Tuvaluan Prime Ministers have pleaded with the UN for action on climate change but have achieved little traction, in 2007 John Howard refused to meet with the Tuvaluan Prime Minister to discuss climate change at all. This is despite the fact that Australian institutions such as the CSIRO are currently doing climate change research alongside Tuvaluan centres. Cyclones are a semi-regular event in Tuvalu and between 1969 and 2010 a total of 33 tropical cyclones passed within 400 km of Funafuti causing flooding and storm surges that ruined crops and disturbed daily life. These cyclones are set to become less frequent but more intense with climate changes.
In addition to directly causing fatalities, large storms can also destroy fresh water supplies. Low-lying islands (atolls) such as those found in Tuvalu, Kiribati and the Republic of Marshall Islands rely on freshwater lenses, collections of freshwater that sit on top of denser seawater, for clean drinking water. When cyclones strike they can disturb these delicate freshwater lenses which take many months to recover.
A permanent loss of many water sources in Kiribati is now certain and the construction of desalination plants is one possibility the government is considering to increase its water supplies.
It’s estimated that the cost of desalination, to increase water supply by 1700kL a day in Kiribati, would be around 2.2 million USD per year between now and 2050. The funding for these plants would have to be donated by other countries as the current government is unable to afford to pay for these projects. If this funding isn’t found then all 110,000 inhabitants of Kiribati will have to consider resettlement and the country and culture of Kiribati will be all but lost.
It’s baffling that these problems are not more widely discussed in Australia given our proximity to and scientific collaboration with these nations. Climate change is often depicted as a concern of radical young people, a problem that isn’t severe or immediate. Unfortunately, this is clearly untrue. Climate change has already caused damage to many other countries but it poses little immediate threat to ours. The difficult truth in this debate is that climate change is a challenge of inequalities. Developed countries produce the overwhelming majority of greenhouse gas emissions and developing countries have to deal with the brunt of the consequences. When natural disasters hit these countries the most disenfranchised are hit the hardest. The world is not sticking up for the little guy.
To quote UN Secretary-General Ban Ki-Moon “there is no Plan B because there is no planet B”.
It’s high-time the Australian government took responsibility for the footprint that we leave and acknowledge that the problems it’s causing are enormous for other nations. In the meantime, we might chuckle at Pauline Hanson’s antics on the Australian political scene but she has real influence among the Australian public. The major parties will have to play ball with Hanson on a whole host of issues but entertaining the possibility that climate change does not exist is an inexcusable way to treat the largest global health problem of the century.
Referenced by this article and for further reading:
Dr Zeshan Qureshi is a paediatrician based at King’s College in London, with a special interest in Medical Education. Dr Qureshi founded the successful Unofficial Guide to Medicine textbook series, which is regularly among Amazon’s best selling medical textbooks. Imogen Thompson was fortunate to be able to sit down with Dr Qureshi when he visited Sydney as part of a trip to learn more about how medicine is taught outside of the UK. They discussed med school, a life in paeds, the art of getting published and resuscitating zombies, here is the transcript of their chat:
I: What first sparked your interest in medical education?
Z: It’s one of those things, that just seem to just happen. I guess the most powerful stimulus was that when I teach, students are always very receptive and grateful. I remember starting a s a junior doctor, and I felt like – oh I’ve been given overwhelming amounts of work to do. A lot of it was quite mundane, a lot of it was following orders and I didn’t really have ownership or control over any of it. But when I taught, it was something that I could prepare, I could do what I thought is best for students, and it was a very worthwhile experience – literally every time that it happened. And then after that experience, I thought how can I expand teaching further, how can I have more of an impact and create something more positive. And so I went from teaching at the bedside to helping implement teaching programs to helping implement teacher training programs so we reached even more people. And then to writing medical books, which meant that although even more work had to go into preparation, all it took was one click on amazon for people to buy them.
I: So you’re visiting Australia to learn about how medical school is taught here. What have you found to be the biggest differences between the way that medicine is taught in the UK compared to Australia so far?
Z: The biggest difference that’s been most immediately noticeable is the relationship between the students and the faculty. I feel that although there’s hierarchy, it isn’t anywhere near as embedded. I see students asking way more questions in lectures, I see them refer to their professors by their first names, I see teachers in the same bars as students and it’s a very positive relationship, which ultimately can only be a good thing. Another thing that is very obvious compared to the UK, is that there is a much greater culture of advocacy amongst students, a much great culture of organisation and engagement. I’ve seen medical student societies which have 70 plus members with their own legal advisors that are intimately involved in developing curriculum. Not just on the basis of the opinions of a few individuals, but actually gathering organised data from the student body and looking at the long term improvement for the medical school.
The biggest difference that’s been most immediately noticeable is the relationship between the students and the faculty. I feel that although there’s hierarchy, it isn’t anywhere near as embedded.
I: That actually links really well with my next question, our medical school is currently in the process of developing a new curriculum. What aspects of medical education do you see as being the most important for the training of good doctors?
Z: I think it’s difficult to say. The most important thing actually is not what is in the curriculum, but the process by which the curriculum is arrived at. Two groups of people that I think are very important – one is the patients themselves and what they perceive is important, even in paediatrics where we increasingly consult children who are teenagers or even younger about what they want in hospitals and what they want from their doctors. And they say very simple things, like having unisex bays, having a play area, having Wi-Fi access in the hospitals. And you know even just informally speaking to my friends that have had medical experiences as patients, they speak of wanting communication to be better, wanting to be listened to when they have ideas of what needs to be changed. And so yeah, I think patients are a very important group to be listened to. And then the other group is the students. Academics, professors, consultants, they have the learned experience of treating and managing disease. But the student body know their own methods of learning, and their own knowledge gaps. And I think curricula should be as sensitive and responsive to that as possible. Particularly considering it’s the students that pay for their education. So what sort of things does that mean? I really value the use of comedy or drama in medical education. One thing that I saw in a conference in Edinburgh a few months ago, was an alternative way of teaching resuscitation, instead of using standardised scenarios, for example “Stephen gets hit by a car driving 90mph”, fantasy scenarios are used. The scenario was Stephan gets bitten by a zombie and has his blood drained – and it was all run in a SimLab. Everyone had lots of makeup on, and it was made fun and interesting but with all the same principles behind it. And then when the group studied outcomes comparing the zombie apocalypse stimulated scenarios with the standardised ones – students had greater retention of knowledge and more fun when it was associated with the comedy. It’s non-traditional but it’s something that works and is effective.
But the student body know their own methods of learning, and their own knowledge gaps. And I think curricula should be as sensitive and responsive to that as possible.
I: Given that you have a successful book series, undertake research and are a practising clinician, how do you go about maintaining a good life balance considering all of these different demands?
Z: In everything I do, I work in teams and I make sure that I recruit people and work with people that share the same values and the same vision as me. And I found that increasingly as my work grows, more people are aware of it and more people want to do similar things. I think one of the greatest things that I have achieved is creating pathways for people to be successful that wouldn’t have otherwise existed. So for example the last book that I published: “The Unofficial Guide to Medial Research, Audit and Teaching”. I worked with a really bright young student from Oxford University, who I rapidly promoted to chief editor for the book, despite her only being a final year medical student. After months of hard work, it was published before she graduated and she won a “BMA Medical Book of the Year” award. And that all happened because of pathways that wouldn’t have existed without the work of the “Unofficial Guide to Medicine” textbook series. So I find that very valuable – helping other people be the best they can be, giving them opportunities and helping to achieve outcomes that I really believe in at the same time.
I: I think it’s a sign of a good leader as well
Z: And then the second thing is, I put a lot more thought into my personal wellbeing than I used to. I really value and invest in my friends and I know that they’re people I can always talk to when things go wrong. I do simple things, like making sure that I eat three meals a day, I sleep, I exercise, I reflect on things even when they don’t go particularly badly, just so I know that I am being the best version of myself that I can be.
I: Onto your research – what role do you see research as playing in a medical career?
Z:One of the big problems with research to me is that lots of people feel obliged to get involved in research despite it not being important for them in their career.
And there are whole sways of research done that is technically not very good, that crowds the literature and makes it hard to discern what is good and what is bad. And this all stems from a desperate desire to get published.
Because you need to get published to get ahead. In terms of what the true value of what research is in a curriculum, I think the most important thing that people need to know is how to apply research into their clinical practice. How much of the curriculum this requires I don’t think is very much. Particularly as we move away from a very strongly basic science based curriculum, to one that is more integrated and clinical.
I: What has been the most rewarding aspect of your life as a paediatrician?
Z:I remember my first shift as a registrar, I was working in the new born baby unit. I was covering the labour ward and a 33-week mum developed pre-eclampsia and she was being monitored. She then developed eclampsia, she started fitting, and her blood pressure went up to over 200 mmHg. I remember going to theatre because they’d called a category one caesarean section. And then whilst in theatre, I was there with my team of nurses and junior doctor, and then all of the sudden, this lady’s heart stopped pumping – she arrested. Then everything changed, chest compressions were started, mum was given adrenalin (she eventually got 8 rounds of adrenalin) and the baby was carved out of her stomach in about 20 seconds with no anaesthetic. And I was handed a blue, floppy baby, with no signs of life, I thought that they were dead, that they were stillborn. But then with my team we stimulated the baby, we applied basic resuscitation measures to them, and by about 8 minutes the baby had started breathing for itself. We took them across to intensive care, within a week both the mum and the baby had gone home. Mum’s biggest complaint about the baby was that it had the sniffles! And this is the greatest personal thing I get in paediatrics – where you know that there are simple things you can do, that make a really big difference. That baby would have been stillborn in most parts of the world. But what we were able to do as a team, was save that baby’s life so that for all intents and purposes they are going to have a normal life.
I: On the flip-side of that, what do you think has been the greatest challenge of your career so far?
Z: The hardest thing for me has been when things aren’t going well, when I see that things might be able to get done in a better manner. And I raise concerns or ask questions and it doesn’t go anywhere. And that process has always been extremely frustrating. And sometimes me raising the concerns has made things worse, because it’s forced people to become more defensive and maybe even try and silence me because I’m questioning authority. What I’ve learnt as I’ve gotten older and more experienced with healthcare services is that everyone has the same shared vision of wanting to provide extra patient care but you just have to work out the appropriate pathways to voice concerns and to make a change.
So you don’t immediately shout out the first thing that comes into your head when it appears that things aren’t going as they should be.
But you take time to reflect on it, to collect information to objectively quantify the problem. And then go through the pathways that are there already to raise it appropriately so that a proper long term solution can be implemented.
I: You’ve spoken about the importance of mental health and self-care, something that is particularly important to medical students. Do you have any advice regarding this?
Z: I think that the first thing to note is that if you have a problem don’t blame yourself, don’t think it’s a weakness on your part.
In the UK the suicide rates of doctors are double that of the normal population. Depression is rife, anxiety is rife, post-traumatic stress disorder is rife. It’s a problem with the system, rather than you as an individual.
Be honest with yourself as soon as the problem arises, as early as possible. Work out what you can do to genuinely improve things, the day-to-day challenge is preventing mental health problems and the solution is very individual. Simple things like making sure that you eat well, spending time with your friends, and you sleep well are often easier said than done but important to be aware of – in the same way that you are aware of deadlines for essays. Put personal wellbeing in the same league as academic commitments. I’d say also be honest with yourself, really try and think about how things are, the challenges you have on a day to basis and reflect on them. Keeping a diary is a wonderful that you can do. Remember the experiences you have at medical school: they are nothing like what normal human beings do, you could easily have a shift where one or two babies die – and most people never see a baby die in their whole life. And the trauma that comes with that is important to recognise.
I: Just on that note, this is a particularly pertinent issue in the UK at the moment with the changes that have been made to NHS junior doctor contracts. In an ideal world what provisions what you like to see put in place to protect the mental health of junior doctors and create a safe working environment for both staff and patients?
Z: I think that the difficulty in the UK has been that the government are felt to be completely out of touch with junior doctors and the problems on the frontline
One of my colleagues, Professor Clare Gerada, she said that if the NHS was a coal mine, it would have been shut down years ago because of how awful the conditions are, and that’s just the implementation of the NHS.
I think that the job itself needs to give people time to spend with their family and with their loved ones, it needs to give them time to rest between shifts and within shifts so that doctors can be healthy themselves. And then if things do go wrong, the culture has to be one of I want you to speak out, I will support you if you speak out. And there will be something meaningful we can do about it if a problem has been identified. Rather than now, when people feel ashamed to talk about mental health problems, because its seen as a weakness, a weakness that you as a doctor who has learnt about depression should know how to overcome, and should be clever enough to overcome. Mental health doesn’t work that way, and back in London, we have anonymous specialist services for doctors with mental health problems to help deal with this unnecessary dilemma.
I: Do you have any last pieces of advice or words of wisdom for our medical students?
Z:One thing that medical students forget is how special they are. I remember when I started at Southampton, a guy called Professor Norman Carr stood up and said that you are the brightest of the bright, the majority of you are going to sail through medical school, you are going to enter into them top tiers of society and will have a long term fulfilling career, that you will be very proud of. I think that being drowned in assessments, being told what to learn and what to do, can often drain that spirit out of you. But just remember you’ve got another 60 years to contribute to medicine and you can start that contribution as a medical student, right now. With the medical books that I do, I have over 500 students across the world working on various titles, but it doesn’t have to be medical textbooks that is your passion. You can get involved in global health, local community action, you can get involved in education. You have the intelligence to do it. Keep the drive alive that got you to apply to medical school in the first place and do what you want, so that you can be the type of doctor that you want be. You don’t have to wait until you graduate to do this, you can start doing this now.
I: Excellent advice, thank you so much for your time.
More women are entering medicine than ever before, and yet men are still earning a lot more money. What is the go with that? Leah Ginnivan looks at the evidence.
According to last year’s tax returns, the average male gynaecologist/obstetrician earned $446,500 in that year. His female counterpart made $264,600, around 40% less. The average employed female GP earns about $840 less per week before tax than the average male employed GP.
So, what’s going on? Is some guy sitting in payroll doing a heap of Ctrl + F for female names and marking their payscales down?
Sounds unlikely, hey! And yet, it’s true that female doctors earn quite a lot less than male doctors. Across the profession, this gap is currently estimated at around 17-23% *depending on the data you’re using and whether you consider employees only or people who are self-employed or run a medical business.
While these kind of statistics are eye-catching (that’s why some people put them at the beginnings of articles), they are often presented without much explanation. It turns out the reasons behind this pay gap are a complex mix of policy, culture, gender roles, and personal desires that all combine to create a lot of missing money. In this article, I’m going to step through the factors contributing to the pay gap in medicine.
Yet, these factors alone fail to explain the size and persistence of the gap.
In this article, I’ll mainly be focussing on the issues that affect female doctors, though many of these are applicable to other professionals.
Firstly, though, note that this article isn’t about how much doctors should be making, or about whether being motivated primarily by money is a good thing. We know that doctors are well-compensated. The average employed GP, for instance, earned more than twice ($2618) the weekly wage of the average employee ($1182), so I am hesitant to label doctors as battlers at this point. I also want to flag this article refers mainly to male/female couples with kids, simply because that’s the kind of analysis that current data allows. We know very little about doctors of any gender who are single parents, or how queer doctor couples choose to balance work/family time.
More female doctors are junior (and more junior doctors are female)
This first reason is pretty straightforward. Since 1996 female medical students are in the majority and the proportion of women in the medical workforce has been rising for some time (currently 40%) the additional female doctors are more junior (and therefore earn less). Most doctors under 35 are women, but this proportion declines when considering older groups of doctors. The more senior, and more highly compensated, generation of doctors is predominantly male.
For instance, check out the numbers of male and female doctors by age group in 2014.
Many professional women will leave full-time work in their late 20s or 30s, and doctors are not an exception to this. When women take ‘time off’ under most current policies, it becomes more difficult to advance to senior positions. This is one reason that it shouldn’t be assumed gender equality will be attained solely through more women beginning med school. The hope that more senior women will undo aspects of bro-y culture can only be realised when there actually are a lot of senior women.
Female doctors work fewer hours, especially if they have children, and do lots of unpaid care work
Another straightforward partial explanation for the pay gap is the number of hours worked. Male doctors worked 6.4 more hours per week than female doctors in 2015. Female doctors also work part time much more frequently than men, with about a third going part-time compared to 13% of men.
Why such indolence? Well, it’s babies, isn’t it. Babies, which many people have. Children are very costly, and it’s women who bear both the time and pay implications of having them. For instance, female GPs with children earn $30k less per year than similar female GPs without kids, mainly due to being the primary carer for these children. Many female GPs stop working altogether, or work part-time (female GPs make up 80% of all GPs who work less than 30 hours a week.).
The implications of having children, under current policy and workplace culture, are essentially less money for women and no change (or more money) for men.
This has negative implications for women’s long-term career prospects and earnings, as well as their retirement income. It should also be noted that pregnant women also have a difficult time of it, with their commitment and ability called into question, and barriers put up on their return to work.
Across Australia, only 24% of working men took leave for more than two weeks when their partner had a baby. And male GPs with children work more hours than their childless counterparts, working an extra 328 hours and earning $45,000 more per year on average. This is called the ‘breadwinner effect’ by some economists, where men are motivated to spend less time with their families and more time making money, once they have kids.
All this adds up to the pretty gnarly reality that female GPs with kids earn 53% less than male GPs with kids.
The differences in earnings between female GPs with and without kids will persist long past the age that the children are in school and the doctor goes back to work, because they may still work less hours, and work in practices as employees rather than as bo$$es. Meanwhile, male doctors do out-of-hours work, and are more likely to own their own businesses, do consulting, and other work that makes money.
Female doctors are not working in highly-paid specialties
This is another major reason why male doctors make more money. Overall, only 25% of female doctors are specialists, compared to 41% of male doctors. By comparison, women are more evenly represented in lower-paid jobs — 42% of GPs, for instance, are women.
Surgical specialties, which are generally the most profitable, have very few women, and women also earn less in these specialties (probably mainly due to the seniority/part time issues discussed earlier). We all know that the proportion of women in surgery is ultra-low — there were 11 female cardiothoracic surgeons in Australia last year compared to 191 male ones, and overall there are nine times as many male surgeons as female ones.
The reasons as to why this is the case are often cited as an inhospitable (pun) culture of macho exclusivity, sexism, and a work environment not compatible with having a life unless you already have someone taking care of your meals, family, and life admin. It’s difficult to estimate how much this is changing in very recent years, however, as a bit of un-rigorous anecdote, a glance at my hospital’s photo board reveals that 3 out of the 30 surgical registrars are women. One in ten!
Female doctors do work that isn’t rewarded by current incentives
More research has been done on GP remuneration than other medical specialties. Here, studies have shown that female GPs have longer and more complex consultations. These consultations pay less per minute than the short consultations, so female GPs earn about 6% less per hour as a result.
The time/cost divide is more stark with young female GPs, who are more likely to have unbillable time where they were, for instance, arranging patient care or communicating with patients. This time would be worth between $10,000 and $23,000 per year if it was billed through Medicare, but it is instead borne disproportionately by younger and female GPs.
In primary care, moves towards capitation-based payment models (where doctors receive a fixed payment for taking care of a patient with chronic conditions for a fixed period, rather than charging them for each visit) may alter the way GPs are remunerated, potentially meaning the current underpaid additional work female GPs do is better recognised and rewarded. Yet this is far from certain.
There is still an unexplained gap
After adjusting for the factors above – hours worked, specialty choice, having children, and seniority, up to half the pay gap is still unexplained (though again, estimates of this gap vary).
That is, while we know that all these things contribute, there is something more we can’t account for. For instance, In the GP study I discussed earlier, childless female GPs under 40 earned $6 less an hour than their childless male peers, while this gap widened to about $14 an hour when comparing childless older GPs.
The reasons behind the ~extra~ gap in pay in medicine are not well understood, but it’s worth noting here that the medical training system has been historically built around training and promoting male doctors. Regardless of what you consider to be innate or socialised differences between genders, it stands to reason that the qualities, skills and abilities that the broad group of individuals known as women bring may not be fully recognised by a system that wasn’t designed by them or for them.
There is some evidence that male doctors are more confident, more prone to overestimate their competence and have fewer reservations about putting their hand up for things they aren’t qualified for, where female students shied away out of concern about doing the wrong thing. Regardless of skill, apparent confidence makes people more likely to see you as competent, which then may be reflected in more opportunities for learning and promotions.
It’s also worth noting that women who do present as ‘confident’ are often seen as being ‘full of themselves’ in a way that men are not — so telling women to be more confident is both kind of wrong from a patient safety perspective and also because it probably won’t help.
Interestingly, male doctors are twice as likely to be ‘complaint-prone’ (with more than four complaints against them) than female doctors, and surgeons are nine times more likely than GPs to be at a swirling epicentre of patient complaints. I’m not saying there’s a connection between overconfidence, machismo, and being a doctor who is ‘not good’, but I’m not not saying it, either. Just something to ponder if someone queries whether women are a good fit for surgical careers.
There are many reasons why women earn less money as doctors. This isn’t to say that any particular female doctor can’t be absolutely making a stack of cash, if that truly is her #lifegoal, but rather that the average one earns less than her male counterpart. A large part of this phenomenon can be explained by a large proportion of women doctors taking time out from work to raise children, while male doctors do not do this, and indeed may spend less time with their family in this critical period.
And this is the next frontier in the fight for equal pay — not just in our work lives, but in our life-lives.
It’s about the way that we view gender roles, what commitment to a profession looks like, and how families make choices about who will care for whom. Parental leave policies, job-sharing, part-time training positions and less insane work hours are all good ideas, but they should be available and accessible for all genders.
Men and women report similar desires for having children (or not having children) and men and women also agree that both partners should share parenting and housework responsibilities especially if both parents work. Yet, gendered assumptions about equality persist, with some research showing male/female couples perceive an equal amount of work is being done when a male partner is contributing only a third of unpaid labour (i.e half that of his female partner).
Even the couples that most want to equally share parenting and household responsibilities have the female partner doing between 60-73% of both. Partnered women report they are doing their ‘fair share’ of childcare when they are caring for a child 67% of the time. For some people, this may well be a fair share. However, we should consider the possibility that if both partners have similar levels of education, ambition, health, and so on, then an equal partnership may involve men doing 50% or greater of the unpaid work.
I’m not here to say anyone should run their household in any particular way ¯\_(ツ)_/¯, but I assume most female medical graduates, having put in the effort of going through medical education, actually do want to be doctors, and should be supported to continue with it past the putative birth of a child.
Some people (men) have suggested that the ‘feminisation’ of the medical workforce is bad and inefficient, because it means hospitals and medical schools are having to adapt their culture and practices to the grim reality that women in heterosexual partnerships are generally less supported at home than men are, so cannot simply palm off their childrearing / life admin responsibilities to Bae.
In some ways, you can see their point: medicine is a difficult profession and it is certainly more administratively simple to hold everyone to the same crushing, 100-hour week standards and say you’re being gender-blind. However, what’s easy isn’t always right; there are many reasons to expect that a more diverse workforce will be one that’s able to respond to patient needs, but this is an argument for another day.
A lot has changed for women in medicine in recent years. The recent recognition, and condemnation, of the prevalence of disgusting, male idiots harassing their female colleagues for blow jobs was an important step. Many hospitals have pro-active policies on job-sharing. Colleges are developing policies on recruitment and retention of women. Yet it will take ongoing generations of doctors to use these policies, keep advocating and keep changing the culture to one that celebrates and promotes competent and caring medical professionals of all genders.
The views and opinions expressed in this article are those of the author and do not necessarily represent those of SUMS.
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.