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October 2011 What is it about women doctors?Ann K. Boulis and Jerry A. Jacobs The Changing Face of Medicine: Women Doctors and the Evolution of Health Care in America, New York, ILR Press, 2010 (280 pp). ISBN 9-78080147-662-4 (paperback) RRP $31.95.
What do women do with their feminine when they become doctors? Fitting women into a male defined profession is a slow and painful process. In the case of medicine, the medical woman is both recent and ancient. Women have always practised medicine, they have always tended to bodies and been present at those great transitions of birth and death. That we even need to think at a policy level about how women are included in the practice of medicine is a result of the systematic exclusion of women from licensed practice as healers when modern medicine was being established in Europe from the 15th–19th centuries.
The book about women doctors, The Changing Face of Medicine: Women Doctors and the Evolution of Health Care in America by Ann Boulis and Jerry Jacobs is a detailed study of the way women have moved into medicine in the United States, and their position within the profession. It is a high quality sociological study using multiple sources of data to chart the increasing presence of women as doctors and compare their patterns of practice, remuneration, hours, specialty and leadership roles with those of their male colleagues. If it is data you are after, this book is likely to provide it. However, the story about women doctors is not that simple. The book does not challenge the assumption that standards of practice and norms set by men are those women must be assessed against. Cohen (1998) describes how medicine has regarded women as ‘a special case—a deviation from the norm presented by the male’ and Quadrio (2001) laments the continual identification of what women doctors ‘lack’ in comparison with men. The presence of women as doctors is much more interesting than comparisons with men about where they practise. WOMEN AS KNOWERSWestern scientific medicine reflects the culture in which it is embedded. Australian culture, like that of Canada, the United States, the United Kingdom and to a lesser extent European nations, has strong processes of gender identity formation that form the frame for internal thoughts, feelings and possibilities for women and men, and those with other gender identities. These possibilities are more or less strictly patrolled in different eras, and individuals who deviate from them are severely punished. Over the past forty or so years some women have been challenging the naturalisation of masculine privilege, seeking to gain for themselves privileges previously reserved for men. Among them are women who become doctors. This apparently recent phenomenon poses unique challenges for women. Where will they find the thought structures and internal dialogue that allow them to hold inner authority in their own lives, and outer authority in the lives of their patients – a necessary requirement to practise medicine? How do individual women hold authority in the public sphere if women in general are seen to have none? We see the Australian Prime Minister dealing with this challenge under a relentless bombardment of criticism directed toward her every day.
Talking about ‘women doctors’ as a discrete group is both necessary and problematic, as Quadrio (2001) has pointed out. Necessary because, as the half of humanity that has been excluded from the development of medicine, women, as a group, have something to say. And problematic because the underlying assumption that women are either homogeneous or have common experiences because they are born female, the ‘essentialism’ argument, has worried feminist theoreticians for decades (Stone 2004; Butler 1999). However there is ‘a womanly capacity that men do not possess’ that in part is related to women’s relationship with their bodies (Pateman & Gross 1986, p. 7; Cohen 1998; Quadrio 2001, p. 79). A consideration of women in medicine must include this ‘womanly capacity’ and how it influences the experience of medicine, and medical practice as women practise it. An unchallenged and continuing assumption of science has been that the authority to define what constitutes knowledge belongs with men. Women were systematically and thoroughly excluded from the process—so thoroughly that the fact of the exclusion is not considered problematic. The absence of women narrowed the possibilities in the philosophy of science, and left women untrained and unpractised in articulating their own natural philosophy. This leaves medical women with no choice but to work within the linguistic and philosophical frameworks established by men. The Gender Medicine movement is one current response to challenging the masculinist bias of science. Driven from the United States, Canada and Europe, and in which Australia is a small player, the movement seeks to include women and women’s experience in the generation of medical scientific knowledge. The Engender project in Europe and the Centre for Gender Medicine at the Karolinska Institute are doing the science that demonstrates the clinical importance of gender (Engender 2011; Centre for Gender Medicine 2011). The inclusion of women will help protect science from the unreflective acceptance of its own assumptions, but only if those women have not had to absorb those same assumptions in order to be recognised as capable of creating truth. This process of being identified as part of the scientific community, a process that requires absorption and reflecting back of agreed norms and values as well as technical skills (Kuhn 1970), is part of what makes medicine problematic for women when those agreed norms and values do not include norms and values that women may hold differently. Women must either give up their particular perspectives or risk being excluded from the scientific project. Women doctors do both, sometimes at the same time. Some wear a mask of acceptance in order to be included in the community of doctors, others are more challenging and often suffer the consequences (Quadrio 2001).
To avoid this women must ‘change the subject’ so that the fantasy of the mind that has no gendered body is replaced by sciences in which body, culture, history and values are made transparent rather than made to disappear (Haraway 1996; Harding 1998). When women insist on being knowers too, as doctors are, they disturb the homogeneity of the elite, and if they are powerful enough, cause confusion and conflict. This capacity is alluded to in the concluding chapter of The Changing Face of Medicine, when the authors finally relax and begin to speak in their own voice. It is possible to trace the process of the exclusion of women from science and medicine in the European culture that we have inherited. This can be done through the study of mythology and the history of science. Part of the process of eliminating women resulted from the Inquisition, in which women who were not under the control of a man, and who dared to heal, were accused of consorting with the devil, tortured and often killed (Daly 1979; Barstow 1994; Heinemann 2000; Bever 2002). That modern science and with it, modern medicine, rose from the ashes of the witches pyre makes the relationship between women and medicine highly problematic (Easlea 1981, p. 64; Wainer 2005). An aspect of the feminine has ever since been contaminated by association with the projection of the female as witch. Rational thought contains within it a horror of magic, nature, chaos, intuition and the feminine. Women doctors are taught the same horror, and quickly learn to hide their female ways of knowing behind a mask, or reject the feminine, as part of the trial of fire that comprises induction into the profession. The medical profession was developed in part to distinguish itself from the activities of others who claimed to heal, at a time when women and the feminine had been rendered silent. It is essential to come to grips with this engendering of the profession if we are to understand how women draw on their own agency to subvert, circumvent, invert and overcome the symbols, structures and content of a profession that systematically refuses to engage with the way many women doctors live their lives and how this differs from that of men. WOMEN IN MEDICINEWomen struggled in Australia for acceptance into the profession, firstly into medical school and then for the right to practise. The University of Melbourne graduated Australia’s first women doctors, Clara Stone and Margaret Whyte, in 1891 (Allen 1995). Increased numbers of women began entering medical school in Australia in the 1980s, and The Changing Face of Medicine documents a similar process in the United States. By the 1990s women were well established as part of the medical student body in Australia (45 per cent of students in 1992) and by 2000 were equally represented with their male colleagues in the study of medicine. This is similar to data reported by Boulis and Jacobs for the United States, where gender parity among graduates was close by 2003, the last year reported. The authors speculate that the faltering economy in the 1990s increased the attraction of medicine for men who might otherwise have gone into business, and that this changed as the economy rebounded in the late 1990s with a resulting reduction in male applications for medicine that was also spurred by the constraints on medical autonomy of managed care. Whether this is true in Australia is unclear but the pattern of equal proportions of men and women among graduating medical students is similar in Australia and the United States.
Women and men are attracted to medicine for similar reasons. Doctors are held in high regard within our society and are generally thought to be well paid. This, however, provides a dilemma for women. The men who established the profession were uniquely successful in negotiating high reward and high status in return for long and unsociable working hours, which depended on having a wife. This may be a social contract which cannot be cherry-picked. Yet the contract does not work well for a lot of women, and probably for a lot of men too, as wives become scarcer. If women attempt to unpick this contract they risk losing the status and the rewards of being a doctor. Women manage this conundrum is in their decisions about how to practise as a doctor. Places in medicine where the hours can be contained and predicted, or where training takes place outside the hierarchy and trial by fire of hospital medicine, are attractive to women who are mothers too. In Australia these include general practice (39 per cent women), emergency medicine (29 per cent), psychiatry (33 per cent), pathology (38 per cent) and hospital non-specialists (47 per cent), (Australian Institute of Health and Welfare 2011). (Women are attracted to emergency medicine, which is practiced in hospitals, because they can work defined and predictable shifts.) Others go into specialties where having a female body can be an asset, such as paediatrics (41 per cent) and obstetrics and gynaecology (36 per cent). Women are less likely to be surgeons (10 per cent) although they make up 25 per cent of surgical trainees, and this is true in the United States as well. In 2009 doctors in Australia worked an average of 43 hours. Boulis and Jacobs document clinician hours in the United States at an average of 53 hours (in 2001). They explore the relationship between family status, the presence of children, and working hours over time in insightful refutation of the ‘retreat from work’ of professional women that is part of the American debate. Women doctors in Australia work fewer hours (38) than men (45) if work is defined as not including family work. This discrepancy in hours emerges at age 35 and older, the ages of child bearing and rearing for most doctors. The lengthy training required for medical practice, which varies from five years of post-graduate training for general practice, to eight years and more for sub-specialist training, combined with graduate entry to medical courses and, in some cases, time taken for research degrees that have become a hurdle to get into specialty training courses, mean women are in their thirties before they have completed their education and have some control over their lives. This has been called ‘training induced infertility’ (Wainer 2005). In Australia the greatest gap in hours is among primary care doctors (32 for women, 43 for men), and the least gap is among specialists in training (47 for women, 49 for men) and hospital non-specialists (45 for women, 47 for men) (Australian Institute of Health and Welfare 2011). Surgical trainees in Australia, whether male or female, work the hardest, with an average of 61 hours at work plus 28 hours on call (O’Grady et al. 2010). On the whole doctors in the United States work longer hours, although no definition of work was provided by Boulis and Jacobs and this is a critical gap.
The Changing Face of Medicine provides data about the interaction of student and young doctor preference and experience in influencing where doctors practise, while acknowledging that gender segregation is influenced by more than decisions that doctors make. They identify other factors such as gender stereotyping, the willingness of specialties and sub-specialties to accept women, the hyper-masculine culture of some work environments, and the availability of flexible training places. They note that harassment and intimidation are common techniques for keeping women doctors in their place and this is true in Australia as well (Wainer 2005). Boulis and Jacobs document studies about whether men and women practise medicine differently, concluding that if they do it is because of differences in experience and patient preference rather than the values of doctors. What is missing in this analysis is a description of the process by which doctors are trained to practise in ways that exclude the feminine. They demonstrate, correctly, that structural factors such as funding and workplace culture override the capacity of individual doctors to have a lot of influence on how they practice. However, women are changing more than working hours. They are changing medicine with every small act of resistance in face of the requirement that they adopt masculine culture. They may not be conscious of what is happening, they may instead be fighting for survival, yet every act of resistance demonstrates that it is possible to be a woman and be a doctor. Changes are easier to implement close to the margins of the profession, and much more difficult close to the sources of power, authority, prestige, and particularly, resources, and this is also described in The Changing Face of Medicine. Boulis and Jacobs conclude that women in the United States are changing clinical practice, supported by women and some men in Congress and science, particularly through the Women’s Health Initiative of the National Institutes of Health. Women doctors in Australia too contest the structure of medical knowledge, the structure of training programs, the culture of patronage and hierarchy, the culture of overwork. In some specialties, such as general practice, it is now possible to interrupt training to have a child, although this is still strongly resisted in surgical training. Women have established ‘women in medicine’ groups within their medical colleges, there is an international women in family practice network that has changed the way international family doctor meetings are held, and women have moved into undergraduate teaching and use this opportunity to teach about sex, gender and medicine, even though attempts to change the formal curriculum have foundered (Australian College of Rural and Remote Medicine n.d.; Royal Australasian College of Surgeons 2011; Working Party on Women in Family Medicine 2011; Gender and Health Collaborative Curriculum n.d.; Monash University Faculty of Medicine, Nursing and Health Sciences n.d.). The structure of the profession is constantly changing, in part in response to changes in medical technology, but also in response to the evolving heterogeneity of the medical workforce. Some of these changes make it even more difficult for women. One example is increasing sub-specialisation, which reduces the community of peers for each sub-specialty and magnifies the impact of personalities. For example there were 129 heart and lung surgeons in Australia in 2009, including five women, and 305 urological surgeons, 31 of whom were women (Australian Institute of Health and Welfare 2011). The peer group in an individual hospital is small and the competition to be accepted into training is intense. The more rarefied the environment the more difficult it is for women to be there because the requirements for belonging are so coded, the codes are so dense and embedded and so naturalised as masculine (Wainer 2005).
The Changing Face of Medicine identifies how the work to change medicine to accommodate women is left to individuals rather than being dealt with by the medical college training programs and hospitals. There have been few attempts at organisational or structural levels to make it possible live a female life course and practise as a doctor in either Australia or the United States. Examples do exist, partly because men need it too, and it will be the policy work of the future to embed these in all training and practice environments to make the most of the medical workforce. Over the centuries women have endured many trials in order to claim/reclaim their own lives. Women doctors today continue this tradition as they twist and weave their way through the labyrinth of the medical profession, skirting pathways guarded by minotaurs, following Ariadne’s web to safe places, being bruised and bloodied in battles of unequal power, comforting and healing each other away from supervisory eyes determined to prevent suspicious and murky things from going on. The changed sex ratio of doctors is a worldwide phenomenon attracting the interest of policy makers at the highest level. The primary motive for this interest is the impact on the medical workforce of women’s ways of practising. In Australia, workforce planners did not predict the changes in doctor working hours that are occurring as a result of the presence of women. Women have complex lives and multiple sources of satisfaction and often resist working the extended hours that have been the norm in medicine. Younger men are increasingly working the way the women do rather than the way older men have, and this has an important impact on the number of doctors required. When doctors were men with wives they worked the hours of two doctors. Now that doctors are wives as well, there is resistance to this double shift and a consequent requirement to train more doctors. Boulis and Jacobs agree that women are now embedded in medicine in sufficient numbers that the profession will have to engage with the feminine and the culture of women in a more subtle way than either marginalising individual women or requiring all women to behave like men. The inclusion of women in the canons of medicine is likely to cause a revolution in medical science and practice of parallel significance to the revolution in the 15th and 16th centuries that saw them excluded. The inclusion of women and the feminine in the creation of scientific knowledge is the next paradigm shift, the next scientific revolution. REFERENCESAustralian College of Rural and Remote Medicine n.d. Women in Rural Practice [Online], Available: https://www.acrrm.org.au/women-in-rural-practice [2011, Oct 12]. Australian Institute of Health and Welfare 2011, Medical Labour Force 2009 [Online], Available: http://www.aihw.gov.au/publication-detail/?id=10737419680 [2011, Sep 20]. Allen F. 1995, ‘Women and the profession of medicine’, in The Politics of Health: The Australian Experience, ed. H. Gardiner, Churchill Livingstone, UK, pp. 323–343. Barstow, A.L. 1994, Witchcraze: A New History of the European Witch Hunts, Pandora, San Francisco. Bever, E. 2002, ‘Witchcraft, female aggression, and power in the early modern community’, Journal of Social History, vol. 35, no. 4, pp. 955–988. Butler, J. 1999, Gender Trouble: Feminism and the Subversion of Identity, Routledge, New York. Centre for Gender Medicine 2011, About the Center for Gender Medicine [Online], Available: http://ki.se/ki/jsp/polopoly.jsp?d=38840&l=en [2011, Sep 20]. Cohen, M. 1998, ‘Towards a framework for women’s health’, Patient Education and Counseling, vol. 33, no. 3, pp. 87–196. Daly, M. 1979, Gyn/Ecology: The Metaethics of Radical Feminism, The Women’s Press Limited, London. Easlea, B. 1981, Science and Sexual Oppression: Patriarchy’s Confrontation with Woman and Nature, Weidenfeld and Nicolson, London. Engender n.d. About the Engender Project [Online], Available: http://engender.eurohealth.ie [2011, Oct 12]. Haraway, D. 1996, ‘Situated knowledges: The science question in feminism and the privilege of partial perspective’, in Feminism and Science, ed. E.F. Keller & H.E. Longino, Oxford University Press, Oxford. Harding, S. 1998, Is Science Multi-cultural ? Postcolonialisms, Feminisms, and Epistemologies, Indiana University Press, Bloomington. Kuhn, T. 1970, The Structure of Scientific Revolutions, The University of Chicago Press, Chicago. Lovejoy, E. 1957, Women Doctors of the World, Macmillan, New York. Monash University Faculty of Medicine n.d. Nursing and Health Sciences, Gender and Medicine [Online], Available: http://www.med.monash.edu.au/gendermed [2011, Oct 12]. O’Grady, G., Loveday, B., Harper, S., Adams, B., Civil, I. & Peters, M. 2010, ‘Working hours and roster structures of surgical trainees in Australia and New Zealand’, Australian and New Zealand Journal of Surgery, vol. 80, no. 12, pp. 890–895. Pateman, C. & Gross, E. 1986, Feminist Challenges: Social and Political Theory, Allen & Unwin, Sydney. Quadrio, C. 2001, Women Working and Training in Australian Psychiatry, Book House, Glebe NSW. Royal Australasian College of Surgeons 2011, Women in Surgery [Online], Available: http://www.surgeons.org/racs/fellows/interest-groups-and-sections/women-in-surgery [2011, Oct 12]. Stone, A. 2004, ‘Essentialism and anti-essentialism in feminist philosophy’ Journal of Moral Philosophy, vol. 1, no. 2, pp. 135–153. Wainer J. 2005, Athena’s Journey: The Feminine and Medicine, PhD thesis, Monash University, Melbourne. Working Party on Women in Family Medicine 2011, Women and Family Medicine [Online], Available: http://www.womenandfamilymedicine.com [2011, Oct 12]. Gender and Health Collaborative Curriculum n.d. Gender and Health Collaborative Curriculum [Online], Available: http://genderandhealth.ca [2011, Oct 12]. Associate Professor Wainer is a social scientist. She worked with the medical faculty at Monash University for fifteen years to understand how women doctors fit into the profession, and how medical knowledge was constructed in the absence of women. Her doctoral dissertation was on medicine and the feminine. She is the author of Lost, Illegal Abortion Stories (Melbourne University Publishing, 2006), based on interviews with Australian women about their experience of abortion when it was illegal. |
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