Problems with women in medicine begin at medical school

By Victoria Cook and Josephine de Costa

 

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 And thus outdated views propagate unchallenged.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. 

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And Bid the Sickness Cease by Amelia Welch

And bid the sickness cease
~ Pears’ Soap, “The White Man’s Burden” (1899).

The saying goes ‘those who do not learn history are doomed to repeat it’ – Amelia Welch reflects on two particularly shameful chapters in the history of medicine. 

The practice of medicine, by nature and necessity, lays claim to our bodies, professing to know us intimately while seeking to cure ills and aches. In the right hands, we can consider it a noble endeavour. However, history is littered with stories of how medicine was used as both justification for, and a tool of control. Its diverse victims include the mentally ill, women, colonial subjects, Jewish populations and slaves. Some of these stories we know. Some I’ll share with you now.

Manila, 1906

Let us begin in Manila, November 1906, when an American surgeon visiting Bilibid Prison asked twenty-four prisoners to form a line. A month later, thirteen of them were dead.

Unbeknownst to them at the time, the American surgeon, Dr Richard Strong, was testing a potential cholera vaccine. Administered to each prisoner in turn, the vaccine was later found to contain traces of the plague, a sample of which had gone missing from Strong’s office.  None of the test subjects knew about, nor had the opportunity to consent, to the procedure. Strong, head of the Philippine Biological Laboratory, was not punished for his negligence. In fact, there were no notable outcomes from an incident in which 13 men were unintentionally put to their death.

This anecdote is merely a small fragment from America’s foray into the Philippines. A strategic outpost in the Spanish-American war, the United States assumed control of the colony in 1898, and retained power in some form until 1946. However, it was not solely military might that allowed the United States to maintain control over the colony, but rather a particular brand of ‘benevolence’ popular with colonialists at the time, which sought to save or improve the lives of the natives. Their mission was justified by mainstream-media theory, and medicine itself was used as a tool to maintain widespread and invasive regulation and control of Filipino life.

The amalgamation of germ theory and tropical medicine was crucial to justify the American intervention. Tropical medicine divided the globe into temperate and torrid zones, and germ theory was used to describe how overcrowding, uncleanliness, and the lack of sanitation and drainage, combined with tropical heat, caused putrefaction and disease. It was believed that hot climates robbed the ‘native’ of the will to improve these conditions, leading to a vicious circle in which decomposing materials amassed, promoting the spread of parasitic insects, which then infected the native, further reducing their vitality and efficiency. The only way out of this vicious circle is for a third party to intervene, master the environment, and save the natives from their hopeless circumstance. And in 1898, the Americans were more than willing to assume the guise of benevolent tutor, enabling and legitimising their subjugation of a foreign people.

Colonial health programs in the Philippines and elsewhere made habit of assuming a rigid and intimate control of indigenous bodies, homes and societies. Prevention of disease warranted constant inspection and mass vaccination, forced, if necessary. These campaigns were conducted with military rigor – vaccinators often relied on soldiers for protection and enforcement – and served to feed the triumphant celebrations of the wonders and wisdom of western medicine. By 1914, American authorities had performed almost 18 million vaccinations.  By 1929-1930, smallpox ceased to be endemic in the Philippines.

Methods of public health regulation were diverse, involving the imposition of quarantines and forced isolations, burning and disinfecting homes and clothes, changes to diet. American authorities established a health bureaucracy, a registration of marriages, death and births, and a licensing system for physicians, pharmacists and dentists. They policed the sale of food and drink. Filipinos were relocated to sanitary barrios, and the number of habitants in dwellings were monitored. The military, American health officials, and appointed local sanitation inspectors were instructed to examine Filipinos at random, and to disinfect, fumigate and medicate at will.

The role of these medical interventions in maintaining and encompassing complete control over the colony and its subjects cannot be understated. Although justified by germ theory and a benevolent desire to control the spread of infectious diseases, the sanitary codes, vaccinations, regulations and bureaucracy amounted to a network of surveillance, maintained by the watchful eye of municipal officers and sanitary police. Physicians were required to report any suspected case of disease, and subject the individual to mandatory isolation. These efforts not only ensured the establishment of a healthy native workforce and protection for American bureaucrats and military, but it ensured the transformation of the Filipino people into surveyed colonial subjects, securing the United States’ foothold in the Pacific.

Puerto Rico, that same year

The United States assumed control of Puerto Rico from the Spanish in the same year as the Philippines, and for similar reasons. Although historically an isolationist power, in the late 19th century the United States began to push for greater influence abroad. Establishing a powerful navy and attaining strategic overseas outposts was crucial to this endeavour. The acquisition of Puerto Rico promised a commanding naval position between two continents and vast potential for commercial gain.

The methods of maintaining control over the island and populace were similar to other colonial interventions, balancing military might with the appearance of beneficence. It was an expensive endeavour, made worse by the 1918 Great Depression and several natural disasters to hit the island. However, the United States was determined to extract as much economic gain as possible, which eventually lead to the passage of Law 116 in 1937.

Justified by the need for a productive workforce, concerns about overpopulation and squalid conditions and influenced by eugenic theory, Law 116 made tubal ligation legal and free for all Puerto Rican women. No alternative methods of birth control were offered.

Misinformation about the permanence of tubal ligation was rife. Many women believed it was reversible. This belief, along with employer discrimination incentivised women to undergo the procedure.

It was common practice in hospitals to sterilise women post-partum. This policy, funded by the United States government, effectively institutionalised a program of population control on the island of Puerto Rico- by 1965, one-third of Puerto Rican women aged 20-49 were sterilised.

Imperial medicine

Through medical intervention and military might, the imperial grasp was both rigid and intimate, holding power over the colonial subject’s environment, home, freedom and fertility.

Although heralded as missions of benevolence, the overriding purpose was undoubtedly to serve the imperial powers’ own military and economic interests.

The United States may have eradicated smallpox in the Philippines, but the legacy of medicine as a military tool hangs over modern foreign policy. We need only look to the recent targeting of polio vaccinators by the Taliban in Pakistan, the purposeful bombing of the Médecins Sans Frontières compound in Kunduz, the kidnapping of doctors in Burkina Faso and elsewhere.

This distrust of medical profession exists because of the immense power and intimate reach medicine has into people’s lives. However, these are also the very things which endow it with its capacity for good.

As we venture out into this world as medical professionals, we must be aware of the legacies past, and the legacies we are helping to create.

The views and opinions expressed in this article are those of the author and do not necessarily represent those of SUMS. 



There Is No Such Thing as Fair-trade Cocaine

Joel Selby recently travelled to South America where he witnessed first-hand the thriving cocaine-trade. He reflects on the trail of damage left by pleasure seeking ‘gringos’. 

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Photo source: http://www.wsj.com/ad/cocainenomics

“Yeah I knew Tommy, Rusty, if you’ve read the book, I knew all of them”

In a piazza outside San Pedro prison in La Paz, Bolivia, an ex-inmate regales tourists with stories from his time spent inside one of the world’s most notorious prisons, and the subject of the book Marching Powder by Australian Rusty Young.

‘Crazy Dave’, as he is known, looks like a caricature of a gangster from GTA San Andreas, complete with bandana, singlet, sleeves of tats, but with a broad Long-Island accent. Once he reveals that he was sentenced to 14 years for trying to smuggle cocaine into Bolivia, which seems like a bad idea at the best of times, a nagging bit of doubt starts to form about the authenticity of Crazy Dave’s stories, and his motives on this so-called ‘prison tour’.

“How much is coke at home? Brits tell me 200 pounds. Aussies tell me 300, 350 dollars. This stuff, this will cost you 20 dollars, straight from the prison.“

San Pedro must be the most ironic prison in the world; the inmates relocate with their families, the children go to school across the road, the rich come and go as they please, and the whole system pulls together so that the inmates, many of whom who were put away for drug offences, spend their sentence making cocaine.

“I see most of y’all have the wristband for Wild Rover Hostel – I know the Aussie bar guy there he’s cool. I know all the staff there, they’re cool. Make sure you hit us up before New Year’s tonight.”

At this point Crazy Dave hands over to ‘Magic Mike’, a compadre he met on the inside.

Mike looks a little like the dad from Matilda, sporting a silky red tie, slicked back hair, and an over-sized three-piece suit. Mike tells us a few stories, explaining that he grew up in LA, joined a gang of Mexicans for which the entry condition was that he kill somebody, and ended up extradited back to Bolivia to serve his sentence. He hands out a piece of paper with his phone number on it. I am less than thrilled about accepting it.

“Make sure you call before 6pm.”

Back at the hostel, it looks as though Crazy Dave is right. Despite the signs in the bathrooms with catchy phrases such as ‘We are all equal before the law’ and ‘the following substances are prohibited’, it seems as if you are handed a bag of white stuff on arrival. As we arrive home our Aussie and Kiwi roommates are racking up at three in the afternoon, and later when a group of Aussie blokes fresh from Death Road arrive, their first question is ‘How’s the rack here?’


There are lots of ways to travel, and there are lots of ways to spend your money.

Of course, there is also legal dimension to trying something illicit that you wouldn’t normally do at home. But importantly, it’s worth considering that the way you travel affects the society that you are visiting.

Every year people from affluent Western countries (gringos) travel to South America and dabble in as much coke as they can squeeze into their backpacking budgets.

And it seems fairly harmless. After all, this is Bolivia, where prisoners can make cocaine, and drug-dealers can hand out their business cards in the square, because that’s just how it works here. Similarly back home in Australia, our cocaine usage per capita is one of the highest in the world. However, the real cost of cocaine is not covered by you at the tourist discount price of $20, but by the local people.

Regardless of how many grams you buy, the local people suffer to get you that little bump.

There has been much written about the mass murder, extortion and intimidation inflicted upon the local populations by the drug industry- decapitations, faces sewn onto soccer balls, lines of innocent people executed by a single sledgehammer. And this is a problem that spans the continent. Peruvian kids (mochileros) are sacrificed to make dangerous journeys trafficking backpacks of drugs across the Andes, during which they are often killed, die of disease, or are betrayed and imprisoned for life. In Mexico tens of thousands of people simply disappear or are killed each year in a civil war between the cartels and the state, and although that little white bag that Crazy Dave is plugging seems a far cry from things like torture and unmarked graves, as long as we keep buying, locals will keep suffering.

As medical students it is interesting to consider that the issues that cause the most mortality are often logistical and social problems rather than medical – for example malnutrition kills three-hundred thousand annually, and causes a third of all the deaths in young children worldwide. This is obviously also the case for war, displacement, oppression and, it seems, for the cocaine trade.

Prominent surgeon and writer Atul Gawande claims that being a doctor is as much about enabling wellbeing as it is about Medicine. If this holds true, then it is up to us to consider our engagement with society broadly, and consider the consequences of choices we make both at home and overseas.

If we care about where we source our eggs, our sneakers or our jeans, then we owe the same consideration to the impact of industries like cocaine. I’m not writing this op-ed due to any strong ideological stance against drugs per se- everyone is free to make up their own mind. But, the choice should be an informed one.

And also because Crazy Dave and Magic Mike bothered me, and I think it’s important to write about the things that bother us.

As described here, you can drink ethically sourced coffee and eat free-range eggs all year but for cocaine, there’s no such thing as fair-trade.

The views and opinions expressed in this article are those of the author and do not necessarily represent those of SUMS.