Women in medicine continue to experience professional barriers in their medical careers, because of their practice styles and life courses, that differ to those faced by their male colleagues.  This discussion paper was funded by the Australian Government Office of the Status of Women under the Women’s Development Program Project Grants 2003-04 to look at the current status of women in medicine. As part of this study, we will be proposing ways of incorporating the diversity of medical men and women within medical practice and outlining discriminatory practices that are still occurring.

Glossary

  • AFMW Australian Federation of Medical Women
  • AIHW Australian Institute of Health and Welfare
  • AMA Australian Medical Association
  • AMC Australian Medical Council
  • AMWAC Australian Medical Workforce Advisory Committee
  • Direct Discrimination Treating someone less favourably on the basis of an attribute they possess or by an act involving a distinction,
  • exclusion or preference.
  • DoH Department of Health
  • HREOC The Commonwealth Human Rights and Equal Opportunities Commission
  • Indirect Discrimination Constitutes a policy or practice that appears to operate in a neutral or non-discriminatory manner, however, the application of the policies or practices leads to a result which disadvantages a particular group or nominated persons, for example, women.
  • GAD Gender and Development
  • Gender Refers to women’s and men’s roles and responsibilities that are socially determined. Gender is related to how we are perceived and expected to think and act as women and men because of the way society is organised, not because of our biological differences. (http://www.who.int). Gender can be seen as the full range of personality traits, attitudes, feelings, values, behaviours and activities that society ascribes to the sexes on a differential basis. It is a social construct, which varies from society to society and over time. (MWIA 2001).
  • Gender Equality The absence of discrimination on the basis of a person’s sex in authority, opportunities, allocation of resources or benefits, access to services. It is therefore, the equal valuing by society of both the similarities and differences between men and women, and the varying roles that they play. (MWIA 2001).
  • Gender Equity The process of being fair to women and men. To ensure fairness, this may necessitate measures to compensate for historical and social disadvantages that prevent women and men from otherwise operating on a ‘level playing field’. (MWIA 2001).
  • Gender Mainstreaming The process of assessing the implications for women and men of any planned action, including legislation, policies and programs, in all areas and at all levels. It is a strategy for making women’s as well as men’s concerns and experiences an integral dimension of the design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated. The ultimate goal is gender equality. The UN Economic and Social Council (ECOSOC) agreed conclusions (1997:2).
  • MTRP Medical Training Review Panel
  • OSW The Australian Government Office of the Status of Women Sex A biological description determined by an individual’s biology.
  • WID Women in Development

Executive Summary

Background

Women in medicine continue to experience professional barriers in their medical careers, because of their practice styles and lifecourses, that differ to those faced by their male colleagues.

This discussion paper was funded by the Australian Government Office of the Status of Women under the Women’s Development Program Project Grants 2003-04 to look at the current status of women in medicine. As part of this study, we will be proposing ways of incorporating the diversity of medical men and women within medical practice and outlining discriminatory practices that are still occurring.

Does One Size Fit All?

Women In Medicine

Although women in medicine today have greater options than our predecessors, we continue to attempt to fit a male defined structure that does not truly value or accommodate our professional, societal and biological differences. Women acknowledge less professional progression because of this situation and attribute this to a sacrifices made because of a paucity of realistic alternative options that are construed by the profession as ‘choices’.

Even though medicine of today practices in an increasingly egalitarian society, we often continue to ‘put on men’s clothing’ in order to succeed in medicine and conform to the historically defined, male norm. This continues to be professionally beneficial as organisational barriers are reduced when our female lifecourse is altered to accommodate this male defined system.

Moving On From Equality To Equal Opportunity

It was assumed in early ideals of equality that if we treated people in the same way then similar individuals would have the same opportunities. This premise relies on a comparative assumption that two individuals are the same, that group characteristics such as sex, culture and religion can be considered separately from the individual and promotes conformity to a pre-defined ‘normal’ criteria that may be inherently biased towards one sex or culture.

It is now acknowledged that the premise of treating individuals similarly does not facilitate equal opportunity. It is apparent that to offer individuals the same opportunity to proceed through systems, their individual and group differences need to be embraced and incorporated into mainstream policy development. It is not enough for individuals to be judged the same at an entry point, each individual must have the same capacity to proceed past the same point with similar ease.

Moving On From Women To Gender

Over the last decade, the United Nations has progressed from a ‘Women in Development’ approach to a ‘Gender and Development’ as the approach to realise gender equality in society. To understand this paradigm shift, it is important to reflect on the terminology used as ‘gender’ in a sociological sense differs from its surrogate use for ‘sex’ in the medical field.

Sex can be described as a biological description, while gender can be seen as the full range of personality traits, attitudes, feelings, values, behaviours and activities that society ascribes to the two sexes on a differential basis. Gender is a social construct, which varies from society to society and over time.

It is the concept of gender that explains why gender neutral situations impact on individuals in different ways and why implementing gender neutral policies will not adequately represent the varying social and professional needs of diverse populations over time.

Moving On From Denial To Inclusion

There are four phases Amanda Sinclair describes the progressive phases of executive culture in dealing with women. The first stage is the stage of denial when the absence of women from the culture is not regarded as a problem or a core business issue. In the second stage, organisations define women’s difference as the problem and propose the solution as women adapting to the predefined (usually male) norms. The third stage allows incremental adjustments to existing structures to incorporate women and the final stage is the organisation’s commitment to a new culture. In this last phase, the exclusion of women is seen as a symptom of deeper problems requiring solutions focused on the existing culture.

The Australian Federation of Medical Women (AFMW) believes that medicine needs to move quickly from earlier stages through to stage four where we value and incorporate men’s and women’s professional and personal diversity and allow each to progress through medicine in the way their lifecourses require.

National Policy Settings Requiring Equality

Australian Medical Council And The Medical Training Review Panel

The Australian Medical Council (AMC) has recently paid attention to the particular needs of women in the provision of part-time and interrupted training as part of their accreditation process. In a recent accreditation review, the AMC suggested a review of training regulations to ensure that they fulfil necessary discrimination legislation and that guidelines relating to these issues should be disseminated to trainees. Medical Training Review Panel reports reflect that women still encounter inappropriate questioning and harassment in the workplace. It described these behaviours as contravening legislation and unprofessional. It suggested increased awareness was needed and the incorporation of legislative requirements into best practice frameworks.

Federal And State Legislation

Current federal and state legislation have provisions to safeguard against discrimination. This includes both direct and indirect discrimination. The concept of direct discrimination is well accepted and can be defined as treating someone less favourably on the basis of an attribute they possess. The concept of indirect discrimination however, is less acknowledged and understood.

Indirect discrimination occurs when a policy or practice that appears to operate in a neutral or non-discriminatory manner in practice leads to a result which disadvantages one particular group or nominated persons. This type of discrimination is of particular concern to women in medicine, as issues such as child bearing and rearing, breastfeeding and family responsibilities tend to have a disproportionate effect on women during their medical training and early consultant years.

There is also federal and state legislation in industrial relations acts that allows parents and mothers certain rights within the workplace and outlines workplace provisions that are necessary during pregnancy, child birth, child rearing and breastfeeding.

Colleges and hospitals must comply with anti-discrimination legislation in both their workplaces and in the provision of training. Hospitals, with the added role of employer must also comply with workplace legislation. Colleges may be wise to also incorporate the provisions of the workplace legislation to ensure employers may provide the necessary workplace entitlements and ensure trainees are not disadvantaged in the process.

The Diversity Dividend

While there are many external forces ensuring equality, the organisational benefits are becoming increasingly clear.

War For Talent

It is necessary for industries to attract talented people for continued business success. By identifying and addressing the specific concerns of both sexes, organisations can become ‘Employers or Trainers of Choice’ and as a result attract a greater variety of highly talented individuals.

Retention Of A Skilled Workforce

The human resources and training costs associated with the loss of an employee can be expensive and has been estimated as high as $48,000 in an Australian company for a general staff member. A United States study has shown that participants in work-family programs had resignation rates of 2% compared with 7% of non-participants.

Maximising Effectiveness Of Doctors With Family Responsibilities

The expense of lost productivity due to family issues has been estimated in the United States at $11.4 billion a year. Current estimates of business savings by investing in work-family programmes have been approximated at between $2 and $6 for every $1 spent.

Diversity And Productivity

Poorly managed diversity produces an organisation with poorer productivity. A US study of top American businesses showed more than a 50% decrease in profits in organisations with poorly managed diversity when compared with excellent diversity performers.

Litigation Risk

Many discrimination and industrial relations cases place the onus on the organisation to demonstrate their consideration of all possible realistic options taken to identify and accommodate the needs of the individual. Consequently, organisations would benefit from an informed and detailed method of addressing these issues if such a case should arise.

Professional Responsiveness

A characteristic of a profession is its professional accountability. In order for the medical profession to retain its highly regarded professional status, it needs to be continually accountable to not only to its clients but to the entirety of its professional constituents both male and female, in a legally sound, responsive and dynamic way.

The Concerns Of Women’s Families And Partners

Women are now not only the colleagues of professionals, but also their life partners. Trends indicate both sexes are now making career changes for marriage and children. Medical workplaces and training environments must realise that unless we keep pace and continue to adapt ahead of this sociological change, we will be unable to provide a trained and equitably distributed workforce in the near future. The impact of women’s work practices is not segmental but global, in the present and requires urgent attention.

Women In Medicine –The Research

Rhetoric regarding the ‘waste of women in medicine’ still abounds today. However, when research regarding women in the workforce is considered in detail, it is seen that women’s decrease in hours is not proportional to their increased role in the home. When the current workforce percentages are converted to real numbers, the urgency in identifying realistic solutions to current workforce issues is clear.

Workforce

a) General Workforce

The increase of females in the medical workforce doubled the increase in males between 1998 and 2001 (variously termed "feminisation of the workforce", or "normalisation of the workforce"). The increase in females under 45 was approximately one and a half times the decrease in males under 45. The entire medical population is ageing.

b) Trainee Workforce

The number of females in specialty training continues to rise and they are skewed in multiple specialties. This sex skew may dramatically effect practitioner supply in specialties with few practitioners if workplaces do not accommodate female doctors having children after attaining fellowship. Areas with significant skew include forensic pathology (100% female trainees), paediatric surgery (92%), clinical immunology (91%), anatomical pathology (75%), gastroenterology (21%), thoracic medicine (20%), plastic surgery (17%), cardiology (13%), otolaryngology (12%), orthopaedics (8%) and urology (4%).

c) Specialist And General Practice Workforces

Between 1998 and 2001, significant changes in the numbers of female and male practitioners occurred. There was a numerical increase of 1,000 female specialists with a decrease of approximately 40 male specialists. There was an increase of 650 female general practitioners with a decrease of 200 males. The increase of 100 female surgeons offset a decrease of 130 surgical males and there was an increase in both sexes in internal medicine of 338 females and 229 males.

d) Practice Characteristics

Women are less likely to have autonomy over their work environment both locally and federally, they are considered less ‘productive’ because of an hourly rate rewarded by short consultations and procedures and are less likely to benefit from and participate in continuing medical education because of the timing and focus of these opportunities.

e) Work Hours

The average lifetime contribution of women in medicine was estimated almost a decade ago. It may be inconsistent with the changes of the current work profiles of men and women given the change in men’s work hours and the greater proportions of women entering age groups with traditionally less child care responsibilities. This estimation is limited by generational effects and also gives no indication of work contributions in relation to an average Australian working week.

f) Trends In Work Hours

The average medical working week continues to decrease with males decreasing their work hours at a faster rate than women. One of the fastest growing sectors of the workforce are women with dependent children. The provision of appropriate child care and family programs for female medical practitioners with dependent children may be one of the few ways of increasing the work hours of medical practitioners.

g) Specialist Work Hours

The variability between male and female doctors in the following groups is less than 4-7%: all specialists under 35 years of age and between 45-54 working 35-64 hours per week, in surgeons working 35-80+ hours per week and in internal medicine specialists working 35-64 hours per week show less than 4-7% variability. The age group of 35-44 years of age showed a 16% difference between male and female specialists working between 35-64 hours per week. Considering that up to 85% of medical females carry the main responsibility for child care of dependent children, this decrease is certainly not proportional to their non-medical commitments.

h) General Practice Work Hours

Work hours in general practice demonstrate the greatest variance between male and female doctors with 82% of female general practitioners working less than 49 hours per week compared with 41% of males.

i) Intern And Registered Medical Officer (Rmo) And Vocational Trainee Work Hours

There are no appreciable differences in work hours between male and female interns or RMOs in all brackets or in vocational specialist trainees in the 35-64 hours per week brackets. General practice trainees showed greater variability between the sexes in work hours.

Part-Time Work

a) Relationship Of Children To Part-Time Work

Medical women have more children under the age of five than other professional women. Dependent children continues to have a differential impact on men’s and women’s clinical hours that decreases with the increasing age of the children.

b) TRAINEES

The number of trainees (not disaggregated by sex) undertaking part-time training in Australia increased by 22.3% in six years. Although the provision of part-time work can be related to a woman’s choice of career, part-time trainees do not necessarily work as part-time consultants. The decision to undertake part-time training depends on various factors such as the method of part-time work provided. These factors have significant implications for future workforce planning, sex distribution among specialties and the practical implementation of any part-time training programs.

Geographical Distribution

a) Rural Practice

Men are more likely to work in RRMA 3-7 but this difference decreases with increasing remoteness. Access to female practitioners has significant implications for young rural women. Rural women have identified workforce matters, isolation, networks and child care as important in retaining and attracting rural female practitioners.

b) Urban Practice

Female doctors are more likely to practice urban areas. Within these areas they were more likely to practise in under-serviced sectors and treat lower income families.

c) Career Choice

Women doctors are more likely to consider training requirements and domestic considerations rather than true occupational preference in their career choice and be less certain of this decision. They are more likely to make career changes because of children. Similar trends are beginning to emerge in male populations. Consideration of these factors when developing training and workforce programs will affect the distribution of male and female practitioners in the workforce of the future.

d) Mental Health

Compared to the general population, female doctors have a three to four times increased risk of suicide compared to a one to one and a half increased risk for medical men. This has been attributed to increased role-strain experienced by women as their role as primary care giver is not considered consistent with their professional choice. Men’s roles did not demonstrate this conflict. A differential incidence of depression is also present in female medical students and can also be related to inherent role-strain.

Family Characteristics

a) Partners

Australian females trainees are younger, more likely have a professional partner or no partner. Within 40-50 year old specialists, 84% of women had a spouse that worked full-time compared with 31% of males. Males were also more likely to have a spouse at home compared to females (43% versus 2% respectively).

b) Childbirth, Child Care And Vocational Training

More medical women plan on providing the majority of primary child care and incorporate this plan into their plans for medical practice careers than men and it can be assumed that currently, the majority wait until training is completed to pursue this part of their life. Trends in the medical workforce indicate that many females may be forced to combine training and child birth in the future.

Because of necessary changes in the mother’s environment and the vulnerability of both mother and infant during this period, preconceived plans to combine these processes may be inaccurate and disruptions may have far reaching consequences for both mother and infant. Consequently, timely and practical flexibility and support by colleges and hospitals in relation to interrupted and part-time training is necessary for those compelled to combine these processes and is vital to their successful completion of vocational training.

Arguments Used To Maintain The Status Quo

The Pipeline Theory

The pipeline theory assumes that increasing the intake of women will lead to proportionate representation given an appropriate amount of time. Although females have comprised 25% of medical graduates and a majority in lower academia for a substantial period of time, they are still not proportionately represented in medicine. More complex issues must be at play that are not being adequately addressed.

The Element Of ‘Personal Choice’

Women are often said to ‘just choose differently from men’. The notion that deviation from traditional careers and career paths is due to true choice will continue to be a simplistic representation of the interplay of gender roles in society and professional achievement. When the differential impact of male and female lifecourses in relation to equal access and opportunity are addressed, then the argument of ‘personal choice’ may be made. Until then, the realities of the ‘personal choice’ will continue to be as a consequence of a lack of realistic alternatives.

‘Lack Of Ambition’

Another argument is that perhaps women simply have less drive for professional success than men. It is true that female doctors have different needs in medical education, in their perceptions of professional problems, professional evaluations and their value of economic and financial factors but this has not been linked to a lack of drive to professional success in medical executives or academic positions.

Women In Representative Positions

The few women in representative positions is often used as confirmation of the ease of female success in medicine despite the figures not reflecting the proportion in practice or professional training. Until there is proportionate representation, this only serves to indicate the continuing barriers for professional females. However, if we continue this line of argument then we must consider a handful of women unable to achieve their professional goals as a failure of the profession.

‘They Just Don’t Participate’

The barriers to participation of women are both cultural and structural and formally encouraging women to participate continue to be inadequate. For women to participate in executives in a meaningful way, formal systems need to be established that allow the expression, validation and incorporation of differing points of view, resources such as child care facilities to accommodate for women’s differential nonmedical commitments must be provided and they must convene at times that do not coincide with times of maximal family commitment.

Complaint As A Measure Of Good Practice

When an organisation does not receive complaints then it is often assumed that systems are effective. However, when the personal risk to an individual’s career is considered in vulnerable situations such as employment and training, it is clear to see why a lack of complaints is not a valid measure of an equitable system.

Maintenance of training standards

Current evidence indicates that part-time training is not linked to decreased quality of patient care or training despite an abundance of anecdotal evidence to suggest otherwise. Studies of part-time trainees have demonstrated greater clinical and humanistic skills than their fulltime colleagues. Poorer educational opportunities arise only when piecemeal approaches to alternative training methods are implemented without appropriate resources, staff education and high level support.

The Value Of Time Based Training And Clinical Privileging

The premise that volume is related to clinical competence continues to dictate a majority of medical training. In a very small number of highly technical procedures this has shown to be true. However, this has not extended to other areas of medical practice.

A journal often cited to confirm this relationship, stated that 70% of these studies show significant associations between volume and better outcomes. It also indicated that most of these studies were poorly designed and questioned the use of volume as a surrogate measure of outcomes and competency in health care because of the heterogeneity of the studies and models. It even alluded to an association between high-volume proceduralists and increased inappropriate procedural indications.

While further research into these areas is needed, the consideration of other forms of medical training should not be dismissed until robust and evidence based data indicates otherwise. Any reliance on rhetoric that causes considerable disadvantage to particular groups must be avoided.

Workforce Considerations

Workforce planning is a considerable obstacle in the provision of flexible work environments for trainees and practitioners. The difficulties for administrators to find job-sharers in highly specialised fields or in justifying part-time practice when under-staffed are obvious. However, if we look to the implementation of alternative methods of medical practice throughout the medical profession we may find differing trends such as the need for job sharing occurring earlier when doctors are relatively interchangeable or part-time workers working more hours in a more flexible and family friendly environment. Until we ask the complex questions and base our responses on valid and appropriate data, these questions will never be resolved and workforce concerns will continue to exist.

Displaced Responsibility

The complexities of decreasing barriers for women in medicine are further compounded by the displaced structural and fiscal responsibility currently maintained by governments, colleges and training hospitals. Doctors are continually caught in the middle and discriminated against and disadvantaged as a result. There are many forums for co-operation and communication available for the consideration of these issues and these should be utilised with urgency to address these issues in the complex manner required.

Recommendations

Valuing Gender Differences

Gender differences in medical practice must be valued by the medical culture as genuine and evidence based.

Development Of Policy Tools For Gender Mainstreaming

A policy tool for gender mainstreaming must be developed for use as an integral pillar of policy development, implementation and review in the medical profession. It must be considered in medical education, training and practice to address the differing needs of the present generation of male and female doctors from the historically male defined ‘norm’ of a different generation.

Gender Competent Research

It is necessary to develop research methodologies from a gender competent perspective and disaggregate all data initially by sex and ultimately gender, to provide the necessary platform for gender competent policy development. Currently, gender specific issues are ‘coded out’ in quantitative research and are left to present only in open-ended, qualitative research. This leads to gender specific data being considered as less valid because of our current paradigm of research evaluation and consequently not used in policy development and implementation.

Gender Competent Policy Development

Gender competent policy development is urgently needed to address the complex issues currently facing the medical workforce. Men and women are diverse in many respects and averaging data from both of these groups may represent an androgenous that is not reflective of either party. Basing policy development on this gender-neutral data cannot hope to impact on the medical workforce in the substantial way that is currently needed given geographical and specialty shortages. This process of gender-neutral workforce policy development is equally as likely to misinterpret both group’s needs and this cannot be afforded with the pressing workforce demands of the current climate.

Gender Competent Policy Implementation And Evaluation

Gender must be considered in the practical elements of policy implementation and evaluation. For this to occur, gender must be a key factor in all policy evaluation. This needs to be linked to the provision of funding and other key performance indicators for continued implementation and evaluation. Areas of policy development include but are not limited to:

  • Medical education
  • Health research
  • Health care provision
  • Vocational medical training
  • Workplace supports
  • Professional development, privileging and practice
  • Executives and academia


Future Research

Multi-disciplinary research into the impact of gender in medical practice must be urgently pursued. If this research is to have the substantial impact required on medical workforce and professional development required, it must include a cross-sectional, gender appropriate, age related review of the medical profession conducted by experts in the field. This must be overseen by organisations and working parties that have the appropriate expertise to forward the research in the gender competent manner required.

Future Coalition

A coalition must be established and funded to address the issues of gender in medicine. This coalition must be established with urgency to consider the complex interactions of gender in medical practice in areas such as the duration of specialist training, work hours and parental leave provisions and workforce distribution.

Background

In 2002, the Australian Federation of Medical Women (AFMW) held the AFMW Forum on Medical College Regulations and Workplace Issues Forum (the Forum). The Forum was initiated for a number of reasons:

1. Training registrars had approached the Office of Status of Women (OSW) and the Human Rights and Equal Opportunities Commission (HREOC) as they felt they were victims of discrimination.

2. A number of women had independently informed AFMW of ongoing harassment concerns, training issues and other workplace problems.

3. OSW was able to offer its assistance with advice and technical support around issues of sex discrimination and work and family.

4. AFMW with OSW’s general support were able to bring together a diverse range of women to discuss these matters in an informed manner.

The Forum brought together women from diverse organisations, professional status and geographical location. The group contained representatives from medical specialist colleges, hospitals, hospital administrations, trainees, the AMA and the Committee of Presidents of Medical Colleges. With this diversity of experience and opinion, the Forum was able to identify pressing issues facing women in the medical profession.

The Forum found the concepts causing greatest concerns for women doctors were the regulatory frameworks of medicine, awareness of doctors regarding the regulations and legislation that governed them and the culture of the medical profession. These areas of concern were further detailed in the Overview of the Forum on Medical College Regulations and Workforce Issues for Women Doctors in a number of areas.

It was acknowledged that many of these concerns were women specific but some could be reflected in both the male and female populations. It was continually emphasised however, that similar issues impacted on women and men in very different ways. It was also reiterated that this differential impact was not being adequately acknowledged or addressed.

Projects were then identified that related to many of the topics discussed. Initiatives and reports from organisations such as Medical Training Review Panel’s (MTRP 1998), the Australian Medical Workforce Advisory Committee (AMWAC & AIHW 1996.7, AMWAC 1998, AMWAC 2003), and more recently the Australian Medical Association’s initiatives as part of the Worklife Flexibility Project (AMA 2002, 2003) were acknowledged as steps in the right direction for addressing the concerns of women doctors.

However there were many reservations about the influence of such initiatives on policy development. The differing concerns that were continually identified were then generalised to the greater medical population and the specific differences in male and female perspectives were gender-neutralised. Therefore the real impact the research was having for the female medical workforce was being diluted when the time for policy development arose.

Australian Federation of Medical Women felt a fresh approach was needed; the ‘pipeline’ theories, the ‘women-in’ views were not adequate and women doctors were continuing to be disadvantaged. AFMW sought to review the a literature and identify new tools for policy development and implementation that would benefit the whole medical community.

The problems of generalising about a diverse female population with the view to improving the status of women in medicine is well known and is described by Carolyn Quadrio (2001) as “both necessary and problematic”. Consequently, the Australian Federation of Medical Women does not propose to define a single, ‘female model’ of medical practice. We also do not support the assumption that every female can be painted with the same brush. We are rural and urban practitioners, GPs and non-GP specialists, we are heterosexual and lesbian, some of us are even mothers and diversity is our strength. We do however, believe that we have something in common, and that is a unique female perspective of how the community and the medical society expects us to work, live and train and how these expectations may conflict with and impact on our experience of medical practice.

Although our individual experiences and opinions differ, we can start to illustrate why the female’s defined role in society, the present power relations and access to decision making and educational processes impact on a female’s experience of medicine and differs to men’s. The distinct differences between current ‘norms’ and the female experience can be used to illustrate how those in minority groups (symbolically or numerically), encounter difficulties with the current structure of medicine. It can also be used to show how systems and practices can be changed to incorporate and value differences.

This paper has been funded by the Australian Government Office of the Status of Women will outline some of the issues affecting women (and increasingly men), why these should be recognised by governments, hospitals, colleges and universities and how these should be addressed and embraced in policy development in the areas of health education, training and medical practice.

Does One Size Fit All?

Similar questions continued to be heard: why are there proportionately less women in representative and academic positions, why, despite allowing part-time training, do women still not choose various specialties, why do they experience less remuneration than men, why are they less ‘productive’ and why do they interrupt their medical practice for extended periods of time and not go to the country as often as men do? Basically, why do women not progress through medicine and practice like men?

Women In Medicine

In 1814, Dr Barry, graduated from the Edinburgh Medical School. For over 40 years, she was a leader of men in her career as a surgeon with the British Army. On her death in 1865, it was discovered that Dr James Miranda Barry had spent her life disguised as a man and was laid to rest in the manner that she had lived (Holmes, Rose).

Dr Barry knew that in order to succeed in medicine, she had to fit predefined ‘normal’ criteria of a doctor that, in the 19th century, excluded women. She had similar desires and abilities, but not the same access or opportunities as her male colleagues. She knew that to be accepted, she had to sacrifice her female characteristics for the opportunity to practice in the respected profession.

Today, society’s expectation of an intelligent, motivated, young woman is vastly different to those of our predecessors. It is expected that young women will complete secondary education and pursue the profession of medicine. Women enter medical school in the majority, are exposed to both male and female role models and often cannot name a single episode of overt discrimination. They believe that equality exists in medicine and that they will have the same opportunities as their male colleagues. Young female doctors as beneficiaries of those who have gone before, expect equal treatment and equal success.

However, young women do recognise early differences in medicine. They are assumed by patients to be nurses despite clearly identifying their professional role, and identify female patients as less accommodating to their male colleagues in performing gynaecological procedures. However, assume these examples of inequality in society as independent to their medical training and practice. They do not recognise how these ingrained societal perceptions will come to influence their professional goals and aspirations.

Soon, doctors progress towards the point of “the great gender divide” (Quadrio, 2001), the period of child bearing and rearing, and begin to realise the significant differences in the female life course are not easily accommodated into the practice or training of medicine. Women begin to realise that society (and often their partners) expects them to be the main child carer and in any case, the biologically determined responsibility of child bearing and breastfeeding cannot be handed to their partners for the sake of their career. Women begin to weigh up the personal and professional costs of combining a family and career in a culture that does not value this combination and make career decisions based on this situation.

Traditional medical stereotypes begin to act as barriers to career progression and women may even begin to experience direct and indirect discrimination. They identify that their need to incorporate their family with their professional life is frowned upon or an exception that is begrudgingly accommodated. They being to understand how mainstream society influences their perception as a practitioner and a mother and begin to feel guilty irrespective of which takes precedence.

Women begin to realise that just as in the 19th century, they still have the same desires and abilities, but not the same opportunities as their male colleagues. They are forced to make sacrifices construed as ‘choices’ even through these ‘choices’ are based on a lack of any other viable alternatives. Although medicine of today practices in an increasingly egalitarian society, we continue to ‘put on men’s clothing’ in order to conform and succeed in a male defined system, even at the expense of our family’s or our personal welfare.

“It is deemed perfectly OK for a male anaesthetist to have to go to another list and not stay for the extra cases that have popped up. If my next commitment is domestic, I dare not say it – I will make up another list (female)” (Khursandi).

The continued association of femaleness with less professional respect is perpetuated as early as medical school. Here women are faced with a multitude of high ranking academic males and subconsciously begin to assume femaleness and success are mutually exclusive and as demonstrated above, implement this in our day-to-day medical practice. This is exemplified by a rhetorical question posed by a female surgical professor to her students:

“She finished by asking the mixed sex audience how they felt about having a female professor in some of their courses...Later that day a female student came up to (op cit) and said: “Please don’t ask that question, we want to see you as the competent professor you are, not as a woman” (Wainer et al, 2002).

Covering our female traits continues to be as professionally beneficial as it has been for centuries. The professional impact of inflexible regulations and expectations are reduced when we alter our female lifecourse to fit a culture that is based on a lifecourse that is male.

Moving On From Equality To Equal Opportunity

Early ideals of equality suggested that you must treat each individual in the same manner. It was assumed that if we fulfilled this duty then individuals would have the same opportunities. As Fredman in her paper, The Future of Equality in Britain suggests, the “ideal was a colour blind and gender-neutral world, where individuals could thrive as individuals free from stereotypical assumptions”.

She went on to propose that this one-dimensional view of equality is limited in a number of respects. Firstly, it ignores that equal treatment is based on an assumption by an external assessor that two individuals have the same qualities or expertise. This can be inherently biased as the evaluator are most likely to view positively those most similar to themselves. Secondly, it assumes that group characteristics such as sex, culture and religion can be considered separately from the individual. This simplistic ideology ignores the realities of life where the diversity of culture and gender formulate how a person identifies themselves, their access to opportunities within society, and how society perceives them.

This view of equality assumes that two people who are considered the same and judged on the same criteria will proceed with the same capacity through structures. It promotes conformity to pre-defined ‘normal’ criteria which is, in medicine, traditionally male-defined. It therefore follows than in medicine, we are not all being compared to a colour blind and gender-neutral ‘norm’ but a male, heterosexual and usually Anglo-Celtic ‘norm’, where child birth is an exception and religious events are assumed to occur only on Sundays. If an individual does not identify themselves in this way then the ‘normal’ criteria proves an extremely difficult fit.

It is now acknowledged that the premise of treating individuals similarly does not facilitate equal opportunity. In order to offer people the same access and opportunities, their individual and group differences need to be embraced and incorporated into mainstream policy development and implementation. It is not enough for individuals to be judged the same at an entry point, they all must have the same capacity to proceed past this point.

Moving On From Women To Gender

Over the last decade, the United Nations has implemented the Gender and Development (GAD) approach as the framework for organisations to use to realise gender equality in society. It’s predecessor was the Women in Development (WID) approach. The two differed significantly in their underlying ideologies and implementations. The GAD moved from looking at ‘sex’ differences on to incorporate the socially constructed interactions or ‘gender’ roles of males and females within its framework, to understand its effect on both sexes within society and aimed to illustrate how these social constructs perpetuate gender inequalities.

As the terms sex and gender as used interchangeably in medicine, it is important to understand their significant differences within a sociological context. The definitions from the Medical Women’s International Association Training manual on Gender Mainstreaming in Health, highlights these differences:

“Sex is a biological description, which is determined by biology. However, even sex may not be wholly dichotomous (p.10)”. “Gender can be seen as the full range of personality traits, attitudes, feelings, values, behaviours and activities that society ascribes to the two sexes on a differential basis... which varies from society to society and over time... Gender has many components both as a social institution and as a individual perception. From a social perspective gender is seen in terms of social status, distribution of labour, kinship (family rights a responsibilities), sexual scripts, personalities (how one is supposed to feel and behave) social control, ideology and imagery. An individual’s gender is constructed by the sex category to which the infant is assigned, gender identity, marital and procreative status, sexual orientation, personality (internalised patterns of behaviour) and gender belief systems (p.10).”

Gender aims to illustrate the myriad of differences that result from different experiences such as educational or marriage status, personality traits or upbringing within same sex groups and also the different experiences of men and women who may have similar occupational or family roles.

Consider a set of fraternal twins, one male and one female, who are both doctors. When they both have children with their respective partners, both become the primary care giver of the child. Both face professional barriers associated with deviation from a male defined norm or continuous training not experienced by their full-time colleagues. However, the female twin is socially accepted in her role as primary care giver while the male experiences disadvantage. He is ridiculed by his male colleagues for interrupting his career for child care, faces day-to-day problems such as public baby change facilities in female toilets and his own family make negative comments about his commitment to his career.

His sister however, finds empathy from her friends about the hardship of combining family and career, easily accesses child care facilities that are designed for mothers and does not experience negative comments from her family. The male twin experiences more disadvantage than his sister as this role is defined by society as female.

Gender can also be applied to explain differences in health such as the changing frequency of men engaging in high risk behaviours within socio-economic groups or the increased incidence of depression in females in differing occupational groups. It can explain why suggestion from men may be met with signs of affirmation while similar suggestions from women can be received negatively (Dore) or as ‘emotional’ and why two professionals that seemingly differ only in their sex display different emotions when not able to fulfil the role of primary care giver to their children (Turner et al).

It is the concept of gender that seeks to explain why apparently gender-neutral situations impact on the sexes in very different ways and why implementing gender neutral policies will not adequately represent the varying social and professional needs of diverse populations.

Moving On From Denial To Inclusion

Amanda Sinclair in her book ‘Doing Leadership Differently’ seeks to describe the phases of executive culture when considering women.

1. The first stage is the denial of a problem. It is when the absence of women from executive levels is not regarded as a problem or a core business issue.

2. The second stage focuses the ‘problems’ on women. Women’s difference is seen as the problem and the only solution lies in women learning how to adapt to predefined norms that have usually developed from a historically male perspective.

3. The next stage is the stage of incremental adjustments. The organisation perceives that problems will be solved by adjustments to pre-existing structures to allow access to women on an individual basis.

4. The final stage is the organisation’s commitment to a new culture. The exclusion of women is recognised as a symptom of deeper problems requiring solutions focused on the existing culture. Initiatives examine the way things are currently done and the need for ‘inside-out’ change.

Medicine is generally considered to be between stages two and four. This gives weight to the assumption that women in medical practice do not feel fully included in the existing medical culture and perhaps their concerns are indicative of deeper problems within the medical culture that are still not being addressed.

Does One Size Fit All?

It is clear to see that the current model of medical practice continues to prove a difficult fit for the women of medicine today. The Australian Federation of Medical Women believes that governments, colleges and hospitals need to move quickly from earlier stages of executive culture through to the final stage, where the differential impact of the medical culture on women will be thoroughly addressed and gender will ultimately be considered as a fundamental pillar of policy development in medicine.

Perhaps when we begin to address the complexities of the deeper medical culture and its differential impact on women in medicine, the questions commonly heard will be different. Perhaps instead of continually asking why do women not progress through medicine like men, we will be asking, why don’t we value and incorporate women’s lifecourses into the training and practice of medicine to enable both sexes to pursue long and successful careers. Perhaps, when women are fully embraced into the practice of medicine, we may not have to ask these questions as the lifecourse of women will not be considered an exception or as an ‘add-on’, and the way they practice and need to pursue their careers will be considered a normal and common variant in medical practice.

National Policy Settings Requiring Equality

The following information is intended to act as a general guide to anti-discrimination and industrial relation concepts in relating to women. It does not constitute a legal opinion.

Australian medical women continue to experience harassment and discrimination because of their sex, pregnancy, family responsibilities and marital status and workplaces continue not to fulfil their obligations in relation to pregnancy and parental leave.

The British Medical Journal recently published a report on pregnant women in the NHS. Reports indicated pregnant doctors continued to be placed in unsafe conditions such as psychiatric wards despite this practice questionable. Pregnant nurses in the same departments were removed from these areas on the announcement of their pregnancy, but female doctors were not offered the same consideration (Smith). It has also been conveyed that the frequency of discrimination increases with the female doctor’s stage of medical training (Redman).

AFMW feels that, while many policies are devised and implemented with the concept of direct discrimination in mind, they may be less appropriate when considering indirect discrimination provisions. Also, colleges may be unaware of the provisions that hospitals must provide for trainees and how this may impact on the regulations set out by colleges in relation to their training in this employment setting.

So before we consider why we should accommodate women in medicine for purely altruistic reasons, perhaps we should revisit external factors such as accreditations and the law that requires the medical profession to uphold certain standards of equality and equal opportunity.

Australian Medical Council And The Medical Training Review Panel

The report from the Medical Training Review Panel reflected that women in medicine were still the victims of inappropriate questioning as well as harassment in the workplace and went onto outline the concepts of direct and indirect discrimination and described practices contravening this legislation as “not only unprofessional but illegal”. It recommended that colleges, hospital and other relevant institutions must be conscious of their responsibilities and obligations, suggested that these principles should be incorporated into best practice frameworks. The report went on to suggest that awareness of these issues may be achieved by participation in seminars regarding these topics and through specialist legal advice (MTRP 1998).

More recent attention has been given to this particular topic by the Australian Medical Council (AMC) in relation to the needs of women in training in the provision of part-time and interrupted training provided by colleges. In a recent accreditation review, the Australian Medical Council suggested a review of college training regulations to ensure they are consistent with the relevant discrimination legislation and suggested wide dissemination of guidelines relating to these issues to trainees.

Because of the recommendations above and findings from the AMWAC survey of vocational training, the Australian Federation of Medical Women undertook the project of informing trainees of their part-time and interrupted training regulations and their legislative rights when dealing with training and the workplace.

Sex Discrimination Legislation

An overview of the Commonwealth sex discrimination legislation is provided below. It does not constitute a legal opinion.

When Does Unlawful Discrimination Occur?

For an act to be considered unlawful discrimination certain criteria must be met. An act must fall within the definition of unlawful discrimination, the conduct must fall within a specified ground identified by the legislation and the conduct must come within one of the specified areas identified by the legislation. If all elements are satisfied, an individual may have an arguable case concerning discrimination.

1. Unlawful Acts

Discrimination can be both indirect and direct. Both are considered unlawful acts.

a) Indirect discrimination

Indirect discrimination examines the impact of policies and practices which, on their face, appear to operate in a neutral or non-discriminatory manner, however, the application of the policies or practices lead to a result which disadvantages one particular group or nominated persons, for example, women.

An example of indirect discrimination on the ground of sex, is when a person imposes, or proposes to impose, a condition, requirement or practise that has, or is likely to have, the effect of disadvantaging persons of the same sex.

The following may be considered examples of indirect discrimination:

  • No consideration of exemptions from full-time training for trainee doctors who require part-time training for family responsibility, pregnancy or potential pregnancy.
  • No ability to access pro-rata fee-based structures for trainees allowed to engage in part-time training.

b) Direct discrimination

Direct discrimination is well understood in the general community and occurs when someone is treated less favourably on the basis of an attribute they possess or by an act involving a distinction, exclusion or preference, such as:

  • judging someone on their religious beliefs or sex rather than their work performance;
  • using stereotypes or assumptions to guide decision-making about a person’s career;
  • undermining a person’s authority because of their race, gender or sexual preference;
  • denying promotion opportunities to staff members on the basis of age or sex;
  • making offensive jokes or comments about another worker’s racial or ethnic background, gender, sexual preference, age, disability or physical appearance;
  • denying further training to employees on the basis of impairment;
  • denying or limiting a student’s access to any benefit provided by an educational authority on the basis of sex;
  • subjecting a student to a detriment on the basis of sex in terms of access to training/education.

2. Specified Grounds

For discrimination to be unlawful it must be on the basis of a specific attribute or ground listed in the legislation. The following are attributes/ grounds found in applicable Commonwealth and most state legislation which may form the basis for unlawful discrimination:

sex

race

physical or intellectual disability

pregnancy

age

political conviction or activity

potential pregnancy

sexuality

social origin

breastfeeding

trade union activity

lawful sexual activity

family responsibilities

criminal record

gender identity

parental status

nationality

religion

relationship status

association with or relation to a person identified on the basis of an attribute

Only the grounds particularly applicable to members of the Australian Federation of Medical Women will be covered in more detail.

a) Sex

A person can be discriminated on the grounds of sex if they treat that person less favourably than a person of the opposite sex is treated. This must occur in similar circumstances that are not materially different because of:

(a) their sex;

(b) a characteristic that appertains generally to persons of that sex;

(c) a characteristic that is generally imputed to persons of that sex.

Discrimination under this section includes situations where the discriminator imposes a condition or practice that likely to have the effect of disadvantaging persons of that sex.

b) Marital status

Discrimination on the grounds of marital status includes discrimination by reason of a characteristic that appertains or is generally imputed to persons of a particular marital status. It is unlawful to discriminate against someone because of their marital status. They may be single, married, divorced or in a de facto relationship.

c) Pregnancy and potential pregnancy

Discrimination against women because they are, or are thought to be pregnant, or they look pregnant, is unlawful. As well as actual pregnancy, the legislation prohibits discrimination on the basis of “potential pregnancy”. Potential pregnancy is broadly defined and includes “the fact that the woman is or may be capable of bearing children” or has “expressed a desire to become pregnant”.

d) Family responsibilities

It is unlawful to dismiss an employee on the basis of family responsibilities. This is defined as responsibilities to care or support a dependent child or any other immediate family member.

3. Specified Areas

There are many specified areas listed by the legislation where discrimination is considered unlawful. Those areas include:

  • employment;
  • education;
  • the provision of goods, services and facilities;
  • accommodation;
  • dispossession of land;
  • membership of clubs;
  • sport;
  • administration of the Commonwealth laws and programs;
  • requests for information; and
  • superannuation.

To Whom Does The Act Apply?

The Sex Discrimination Acts apply to various bodies. These include:

  • employers
  • educational authorities
  • qualifying bodies.

1. Employers

2. Educational Authorities
An educational authority is a body administering an educational institution; an educational institution is a school, college for education or training.

3. Qualifying Bodies
Qualifying bodies are defined as an authority or body that is empowered to confer, renew, extend, revoke or withdraw an authorisation or qualification that is needed for or facilitates the practice of a profession.

When Does Harassment Occur?

Workplace harassment occurs in the workplace where offensive, threatening or abusive behaviour is directed to intimidate an individual or group of workers. Examples of this include:

  • verbal harassment such as teasing, insults or name calling;
  • physical harassment such as pushing, tripping, interfering with clothing, equipment, personal property or work space;
  • continual exclusion from work based activities;
  • interfering with another worker’s access to workplace facilities;
  • criticism or ridicule based on physical disability;
  • racial sledging.

Sexual harassment is a particular class of harassment that occurs when a person:

  • subjects another to an unsolicited act of physical intimacy (e.g. patting, pinching or touching in a sexual way or unnecessary familiarity
  • such as deliberately brushing against a person);
  • makes an unsolicited demand or request (whether directly or by implication) for sexual favours from the other person (e.g. sexual
  • propositions);
  • makes a remark with sexual connotations relating to the other person (eg unwelcome and uncalled for remarks or insinuations about a
  • person’s sex or private life or suggestive comments about a person’s appearance or body); and
  • engages in any other unwelcome conduct of a sexual nature in relation to the other person (e.g. offensive telephone calls or indecent exposure);
    and the person engaging in the conduct does so:
  • with the intention of offending, humiliating or intimidating the other person or;
  • in circumstances where a reasonable person would have anticipated the possibility that the other person would be offended, humiliated or intimidated by the conduct.

Other examples of conduct which could amount to sexual harassment include kissing, attempts at sexual intercourse or overt sexual conduct, sexually explicit conversations or references to sexual activity, sex based insults, teasing or taunting, intrusive questions of a sexual nature at a job interview, proposals of marriage or declarations of love or innuendos and crude jokes.

Case Studies

These following examples may, in circumstances where all relevant legal criteria are satisfied, amount to discrimination.

Case 1: Part-Time Training Provisions

A training program may stipulate that part-time training is not permitted in certain years of study. This means that in a situation where a trainee wishes to have or has a child, they do not have the option to continue to train because family responsibilities may prevent them from training full time. Consequently, they will be disadvantaged as they cannot continue their training until they are able to do so in a full-time capacity. This situation is unlikely to be experienced by their colleagues without family responsibilities.

Case 2: Pro-Rata Training Fees

If a student is fortunate enough to gain approval to train part-time because of family responsibilities or pregnancy, they may still be faced with the problem of no provision for pro-rata payment of their training fees. If a college charges $500 dollars a year for training, a trainee forced to undertake a five year program on a part-time basis (i.e. 10 years) will pay $5,000 while their full-time colleagues will pay $2,500 for the same full-time equivalent training. This is a clear disadvantage that is not experienced of those able to train full-time especially when the added financial burden of child care is considered (estimated for a part-time vocational trainee at around $20,000 per year).

Case 3: Accreditation And Workplace Relationship

In scenarios where a trainee is pregnant, there may come a time when her current work situation is unsafe during her pregnancy. This may necessitate an employer moving the employee to a different position or rotation for the remaining term of the pregnancy. However, if colleges require that rotations must, for example, be a full six months of continuous training in one area and the trainee has completed only five months of the six month rotation before the necessary workplace alteration, the college may make a decision that those five months of full-time training will not be accredited as it does not fulfil the requirement of six months continuous training in one area. This would be a disadvantage not posed of a trainee’s colleagues who are not pregnant.

Case 4: Recency Of Training

Some training programs stipulate that after a circumscribed period of time, training prior to this time can no longer be counted towards training. In cases where, for various reasons, a trainee may need to take time off or train part-time they may end up in a situation where they physically unable to or it is very difficult to complete their training.

If this period of time is for example eight years, a trainee has completed two years full-time, taken a year off to have child, then trained part-time for the next two years, taken the sixth year off to have another child and then trained part-time for the following two years (which is the end of their eighth year), they will have completed the equivalent of four years of training of a five year full-time course. If they then train part-time in the ninth year, they will have added another half full-time equivalent year but have lost one full year of training because of the necessity for ‘recency of training’, bringing their accredited training to a period of three and a half years or minus half a year from the end of the year before. If they continue to train in a part-time capacity in their tenth year they will have completed five years of full-time equivalent training but lost two years of accredited time bringing their accredited time to three years.

If part-time training is required because of your role as the primary care giver, illness or other family responsibilities because of the implications of the recency of training stipulation, a trainee may never be able to complete their training if they continue to train part-time. Their training will stagnate at approximately three and a half to four years of accredited training.

This scenario is illustrated in the table below.

Year from the Start of Training

1

2

3

4

5

6

7

8

9*

10*

11*

12*

13*

14*

Training Method

FT

FT

Off

PT

PT

Off

PT

PT

PT

PT

PT

PT

PT

PT

Actual Years of Training

1

2

2

2.5

3

3

3.5

4

4.5

5

5.5

6

6.5

7

Accredited Years of Training

1

2

2

2.5

3

3

3.5

4

3.5#

3##

3.5###

3.5^

3.5^

4###

FT = Full-Time
PT = Part-Time
# – loses the 1st year of full-time accredited training
## – loses the 2nd year of full-time accredited training
###– no time lost as she was on maternity leave in her 3rd year
^ – loses one year of part-time accredited training
– eight year recency of training criteria applied.

Industrial Relations Legislation

The following is the provisions stated in the Commonwealth Industrial Relations Act. State government employees with concerns relating to industrial relations should refer to the provisions of legislation in their particular state. The following does not constitute a legal opinion.

The following definitions apply to the following passages.

  • Parental Leave includes Maternity Leave, Paternity Leave or Adoption Leave.
  • Maternity Leave is a period of unbroken leave taken by female employees in connection with pregnancy or the birth of a child of the employee.
  • Paternity Leave is a period of unbroken leave taken by a male employee in connection with the birth of a child of the employee or of the employee’s spouse.
  • Adoption Leave is a period of unbroken leave taken by a female or male employee in connection with the adoption by the employee of a child under the age of 18 years (not including a child who has previously lived continuously with the employee for at least six months or a child or step-child of the employee or employee’s spouse).
  • Special Maternity Leave is a period of unpaid for a female employee that suffers illness related to her pregnancy (confirmed by a certificate from a medical practitioner) and is not on maternity leave.
  • Special Adoption Leave is leave is given to an employee to attend compulsory interviews or examinations as part of the adoption procedure.

1. Length And Entitlement To Parental Leave

Parental Leave entitles an employee to 52 weeks unpaid leave in connection with the birth or adoption of a child that cannot extend beyond a year after the birth or adoption.

Paternity Leave and Adoption Leave is further divided into Short and Extended Leave. Short Paternity Leave is an unbroken period of up to one week at the time of the birth of the child or other termination of the pregnancy and Extended Paternity Leave is a further unbroken period of leave in order to be the primary care-giver of the child. Short Adoption Leave is an unbroken period of up to three weeks at the time of the placement of the child with the employee and Extended Adoption Leave is a further period to be the primary care-giver of the child.

The period entitled for Special Maternity Leave is the period certified by a medical practitioner as necessary before returning to work. The entitlement of Special Adoption Leave is up to two days of unpaid leave.

Employees including full-time and regular casual employees who have had at least 12 months of continuous service with the employer are entitled to Parental Leave. This includes one or more unbroken contracts of employment including periods of authorised leave or absence or any period of part-time work. There are various circumstances when a casual employee may be entitled to Parental Leave.

Both parents cannot be on parental leave at the same time with the exception of Short Paternity or Short Adoption Leave. However, you may combine other leave such as Annual Leave or Long Service Leave to which you are entitled in conjunction with or instead of Parental Leave as long as the period taken does not extend beyond the maximum period of parental leave allowed. This combination excludes Sick Leave or other paid absence except if agreed by your employer.

Parental Leave does not break an employee’s continuity of service, but is not to be taken into account in calculating an employee’s period of service for any purpose. Parental Leave counts as service for any purpose authorised by law or by any industrial instrument or contract of employment.

2. Employer’s Responsibilities

An employer must inform the pregnant employee or spouse of their entitlements and obligations under the Act. If they do not inform you then they you cannot be held responsible for not complying with the necessary paperwork.

An employee’s obligations in relation to Parental Leave are as follows:

  • At least 10 weeks written notice of the intention to take Maternity leave, Extended Paternity Leave or Extended Adoption Leave before the expected birth or placement date.
  • At least four weeks written notice of the proposed start and end dates of Maternity Leave and Paternity Leave, before proceeding on this leave. (Written notice of Adoption Leave must be the proposed start and end dates for the period of leave, as soon as practicable after the employee is notified of the expected date of placement of the child but at least 14 days before proceeding on leave.)
  • A certificate must be given to the employer from the medical practitioner or a statement from an adoption agency or another appropriate body, of the expected date of birth or placement of a child for adoption purposes before the start of leave.
  • A statutory declaration must be given to the employer stating the period of Parental Leave sought or taken by a spouse period of Parental Leave. If Extended Parental Leave or Extended Adoption Leave is sought, then this must include a statement that this is for the purpose to become the child’s primary care-giver.
  • Employers must be notified of changes to the above information within two weeks of the change.

3. Alterations To Parental Leave

Alterations to Parental Leave are allowed. This may happen in a number of ways:

  • Interruptions to Parental Leave must be agreed upon by both an employer and employee an involve a return to work on a full-time, part time or casual basis.
  • An employee is entitled to one extension of leave provided this is requested in writing before the start of the extended period. This extension cannot be extended beyond the 52 week period of Parental Leave.
  • Any number of extensions can be allowed with the agreement of the employer and this may extend beyond the 52 weeks with the agreement of the employer.
  • Parental Leave may be shortened with the agreement of the employer provided notification is given in writing at least 14 days before the leave is to end.

4. Returning To Work

When an employee returns to work they are entitled:

  • To be employed in the position held immediately before proceeding on that leave.
  • The positions they held immediately before any changes to the work necessitated by pregnancy e.g. transfer to another position because of safety concerns during pregnancy or to part-time work because of pregnancy.
  • If the position held prior to leave or changes necessitated by pregnancy no longer exists, but there are other positions available for which the employee is qualified and capable then the employee is entitled to a position as nearly as possible comparable in status and pay to that of their former position.

An employer who does not comply with the above is guilty of an offence.

5. Wrongful Termination And Workplace Safety

An employer must not dismiss an employee because an employee or employee’s spouse:

  • Is pregnant or has applied to adopt a child.
  • Has given birth to or adopted a child.
  • Has applied for or is absent on parental leave.

Employers have a certain obligation to ensure the work of a female employee is, because of her pregnancy or breastfeeding, not a risk to the health or safety of the employee or of her unborn or new born child. The assessment of such a risk is to be made on the basis of a medical certificate supplied by the employee and of the obligations of the employer under the Occupational Health and Safety Act 2000. They have the following obligations if this risk occurs:

  • They must temporarily adjust the working conditions or hours of work to avoid exposure to that risk.
  • If such an adjustment is not feasible or cannot reasonably be required to be made, the employer is to transfer the employee to other appropriate work that will not expose her to that risk, and is as nearly as possible comparable in status and pay to that of her present work.
  • If a transfer is also not feasible or cannot reasonably be required to be made, the employer is to grant the maternity leave (or any available paid sick leave) for as long as is necessary to avoid exposure to that risk, as certified by a medical practitioner.

An employer who does not comply with these conditions is guilty of an offence.

Vocational training and employment

Colleges are considered for the purposes of discrimination legislation to be qualifying bodies or educational authorities and hospitals are considered to be employers. Consequently, both colleges and hospitals must comply with relevant anti-discrimination legislation and hospitals must also ensure they comply with industrial relations legislation.

It would be wise for colleges, considering their unique role in regulating the provision of vocational training that occurs in an employment situation, to ensure their training regulations do not hinder the ability of employers to provide the necessary workplace entitlements and possibly disadvantage trainees in the process. This may necessitate a review of training regulations to accommodate the workplace changes necessary during child birth or breastfeeding, to consider interruptions in training in pregnancy, child care or breastfeeding to be unrestricted and in addition to other forms of interrupted leave and to allow minimum workplace provisions for Parental Leave to be permitted during training.

The Diversity Dividend

While there are many external forces regulating equality and ensuring diversity, the organisational benefits of incorporating diversity and equality are becoming increasingly clear.

War For Talent

It is necessary for industries to attract talented people and accommodate them in the workplace for continued business success. As over 50% of medical students are now female, we must allow women to progress in all specialities and workplaces to attract the most talented people for the job.

Organisations have also identified the need to incorporate an individual’s work style into the workplace to optimise their skills. In the medical field, this may necessitate the restructuring of workplace or training environments to accommodate the individual instead of unsuccessful attempts to fit the individual to the predefined workplace or training criteria.

By identifying and addressing the specific concerns of both sexes within training and the workplace, hospitals and colleges can become an ‘Employers or Trainers of Choice’ and consequently retain a greater range of talented individuals who feel valued for their individual skills. If not, we are denying the medical community the opportunity to attract the individuals in our medical population who may not otherwise participate because of inflexible policies (Allen, 2000).

Retention Of A Skilled Workforce

The human resources and training costs associated with the loss of an employee can be expensive. These costs include advertising, interview time, training costs, termination pay, loss of organisational knowledge and subsequent low staff morale and reduced productivity.

A large American firm realised that too many talented women were walking out the door, not because of child birth, but because they had assessed the male-dominated culture and found it wanting. A program was forwarded to address this saving the company over $250 million in hiring and training costs (accessed http://www.eowa.gov.au). Similar studies have been done in Australia. The estimated cost of replacing a general staff member at NRMA was $12,000 and $40,000 at Westpac. Replacement costs for higher management at Westpac ranged between $48,000 and $60,000 (Diversity). Participants work-family programs in another United States study showed program participants with decreased resignation rates of 2% compared with 7% of non-participants (Washington Business Group on Health).

Maximising Productivity Of Doctors With Family Responsibilities

Up to 70% of working parents have at least one day a year away from work because of child-related problems (Work/Family Direction study). United States estimates the cost of lost productivity due to child care activities at $11.4 billion a year with childcare related absenteeism comprising approximately $3 billion of this figure alone. The expenditure in sick pay, cover costs, decreased motivated and decreased retention because of these family impacts are important business losses. Savings by investing in work-family programs including flexible work options and family benefits have been estimated at between $2 and $6 for every $1 spent (Washington Business Group on Health, Work/Family Direction study). To many companies, the bottom line is becoming increasingly clear.

Diversity And Productivity

It has been shown that mainstreaming diversity within an organisation has a number of benefits. An Australian study found that positively managed diversity, fuelled innovative problem solving and consequently a rise in work performance while the US Covenant Study showed poor diversity performers with an average of 8% earnings compared with 18% of excellent performers.

Litigation Risk

Cases of discrimination and industrial relations are unfortunately still quite common. Cases in these areas often places the onus on the organisation to demonstrate their consideration of all possible options taken to identify and accommodate the needs of an individual. If such a case should arise, organisations may benefit from showing that a well-informed and detailed method of addressing the implementation of policies in relation to the necessary legislation was already in practice.

Professional Responsiveness

Calman described a profession as a vocation with a unique knowledge base that determines its own standards “and implies service to others”. The study goes on to describe the medical profession as “self regulating and... accountable to patients and to the profession itself.” Calman goes onto address the impact of the increasing external scrutiny from governments and other organisations in the accountability of the medical profession.

“Under increasing scrutiny, the profession will need to look carefully at itself and ensure that from a public and professional point of view all steps are taken to assure quality and that ‘self’ regulation means just that. Unless the profession takes care of its problems, other will do it for us. Practising medicine is a privilege and we need accountability for it.”

In order to continue the medical profession’s highly regarded status, it needs to be continually accountable not only to its clients but to the entirety of its professional constituents, both male and female, in a legally sound, responsive and dynamic way.

The concerns of women’s families and partners

Women are now both the colleagues of professionals and their life partners. Men and women are moving towards equal partnerships in profession and personal circles and this is impacting on the way men choose, and require, to practice to accommodate both their partner’s and their own professional careers (Lorber).

Carolyn Quadrio reflected that  “it may seem that women are less stoic and quicker to complain, but they may also be running true to female stereotypes in being the primary presenters of distress within sick systems.” Concerns that are initially raised by women, soon start to reflect the concerns of their partners. Eisenberg states the “asymmetry of relationships... remains a major problem for women; though they may not fully appreciate the fact, it is also a problem for men”.

Trends indicate that both sexes are now making career changes for marriage and children. In a paediatric physician population, it was shown that male physicians in dual physician marriages worked less hours than their colleagues with non-physician spouses (Brotherton et al). In the United States, younger male doctors were twice as likely as their older male colleagues to make career changes for marriage and children (Warde, 1996). Although young male and female doctors still have the same core values of being “caring for patients with compassion, integrity, competence, and confidentiality,... they balance the demands of this commitment with the benefits of the autonomy that has traditionally gone with their professional training and status” (Allen, 1997).

Medical workplaces and training environments must realise that unless we keep pace and adapt ahead of this sociological change, we will be unable to provide a trained and equitably distributed workforce in the near future. To think that women’s work practices impact on others in a segmental way is naïve. The impact is global, in the present and requires urgent attention.

Women In Medicine–The Research

The majority of data below is from sex disaggregated or women specific research. It is intended to clarify much of rhetoric still present about women in medicine. We must however, remember that in any research we base our findings on ‘normal’ curves, standard deviations, confidence intervals and P-values and has inherent limitations in that features of different groups may overlap. When the intersection of gender and sex is considered, we will be better able to define the proportions of individuals differing by sex with similar social roles exhibiting similar traits.

Workforce

General Workforce

The increase of females in the medical workforce doubled the increase in males between 1998 and 2001. The increase in females under 45 was approximately one and a half times the decrease in males under 45. The entire medical population is ageing. In 1999, 52.7% of the medical student intake was female (AIHW 2000). This relatively new phenomenon ensures that the proportion of females in medicine will continue to rise. In 1996 to 2001, the proportion of females in medicine rose 3% from 27.6% to 30.7%. This represents an actual increase in the medical workforce of approximately three thousand females with a corresponding increase of only one and a half thousand male doctors from the years 1998 to 2001 (deducted from figures in AIHW 2000 & 2003). It is predicted that by 2025 females will constitute 42% of the medical population (AMWAC 1998, AIHW 2003).

There has been a decrease in the proportion of females under the age of 45 of 7% (72.8% to 66%) in five years and an increase in the proportion over 55 (9.8% to 11.5%). The male population showed similar trends with a decrease in the proportion under 45 of 4% (47.7% to 44%) and an proportional increase in the over 55 age group from 26.4% to 29.2%. Because of the continued increase of females in all age groups, the proportional decrease in the percentage of females under 45 actually represents a numerical increase of approximately 1,000 female practitioners (with a corresponding decrease of 600 male practitioners) in this age group. In the workforce over 55, there were approximately 1,400 more males than in 1996 with 550 more females (deducted from data contained in AIHW 2000 & 2003).

The average age of medical student graduation is increasing consistent with the increase in graduate medical programs as is the average age of all medical practitioners which increased from 44.9 years to 46.1 from 1998 to 2001.

Trainee Workforce

The number of females in specialty training continues to rise and continue to be skewed in multiple specialties. This sex skew may dramatically effect practitioner supply in specialties with few practitioners if workplaces do not accommodate female doctors having children after attaining fellowship. Areas with significant skew include forensic pathology (100% female trainees), paediatric surgery (92%), clinical immunology (91%), anatomical pathology (75%), gastroenterology (21%), thoracic medicine (20%), plastic surgery (17%), cardiology (13%), otolaryngology (12%), orthopaedics (8%) and urology (4%). The majority of these trainees are between 25- and 34 years of age.

The 2003 report from the Medical Training Review Panel (MTRP) showed that 46.5% of vocational trainees are female. This represented an increase of approximately 11.5% in three years (AIHW 2000). The proportion of males and females continues to be skewed with 14.4% of females in surgery to 60.5% in general practice and obstetrics and gynaecology. When the subspecialties were examined two years prior in the 2001 labour force survey, there were more significant skews (AIHW 2003).

In internal medicine, clinical immunology females represented 91.1% of trainees. The rest of the specialities ranged up to 50%, with cardiology and thoracic medicine having the least females at 12.6% and 19.4% respectively.

Surgical trainees did not all show a male bias as is often assumed: paediatric surgery had 91.5% female trainees, while vascular surgery and neurosurgery had 59% and 47.9% respectively. Surgical subspecialties with low rates of female participation were urology (4.3%), orthopaedic surgery (7.9%) and otolaryngology (12.1%).

Forensic pathology had no male trainees with clinical chemistry and anatomical pathology heading the same way (74.8% and 60.2% female trainees respectively). All pathology specialties had greater than 50% participation except immunology at 41.1%. As demonstrated below approximately 75% of trainees are under the age of 34 with the average age of trainees being 33.7 (AMWAC, 2003).

The rates differ when comparing general practice and other vocational trainees. GPs are concentrated in the 25-29 year age group while the other specialties are concentrated from 30-34. Considering that the GP program is significantly shorter than others and the length of training for the remainder is usually five years or more, the average age of attaining fellowship to the 35-39 year age bracket in the specialties and between the 25-29 and 30-34 year age brackets for general practitioners.

Specialist and general practice workforces

Between 1998 and 2001, significant changes in the numbers of female and male practitioners occurred. There was a numerical increase of 1,000 female specialists with a decrease of approximately 40 male specialists. There was an increase of 650 female general practitioners with a decrease of 200 males. The increase of 100 female surgeons offset a decrease of 130 surgical males and there was an increase in both sexes in internal medicine of 338 females and 229 males.

In 2001, 43.9% of all clinicians were in primary care, 34.7% were specialists and 11% were vocationally registered trainees. The remaining 10.5% comprised resident medical officers, interns and career and salaried medical officers.

In 2001, 18.9% of the specialist medical workforce were female, increasing from 15% in 1998. This represented a numerical increase of approximately 1,000 female specialists with a corresponding decrease of 40 males in three years.

In 1998, 33.2% of the primary care workforce was female increasing to 34.9% in 2001. This also represented an absolute numerical increase of approximately 650 females and a decrease of 200 males.

In 2001, 7.4% of surgical practitioners were female which was more than double the amount in 1996 (AIHW, 2003). Internal medicine had 19.5% female practitioners increasing from 13.1% over the same period (AIHW 2003). These figures represent an increase of 100 and 338 women in surgery and medicine respectively and a relative decrease of 130 surgical males and increase of 229 male internal medicine physicians.

The impact of the increased females in the vocationally registered trainee population is set to continue to change the composition of the entire workforce with the medical school intake of females at times above 50%.

Practice characteristics

Women are less likely to have autonomy over their work environment both locally and federally, they are considered less ‘productive’ because of an hourly rate rewarded by short consultations and procedures and are less likely to benefit from and participate in continuing medical education because of the timing and focus of these opportunities.

Women are more likely to be practice associates, salaried and part-time than full-time practice principals (Baker et al) and are less likely to be affiliated with their college (Doyle) and professional bodies. This offers them less autonomy over their work environment at a local level and less input into representative bodies that advocate for the greater medical profession. These differences may also reflect the inability of current workplace and professional structures to incorporate and address the practical needs of women doctors.

Women care for different conditions, have longer consultations and do less procedural work than men (Britt et al, Doyle, Hojat). Because of current remuneration structures that reward shorter consultations and procedural work, this affects their hourly rate. As ‘productivity’ is currently measured in terms of patients or income per hour, women are perceived to be less productive, slower and to be contributing less to practice incomes.

Women are also less able to access and participate in continuing medical education because of their role as primary care providers and the timing of such opportunities. It is known that women general practitioners also have differing education needs because of their different patient profiles and continuing medical education is not always tailored to these particular needs.

Work hours

The average lifetime contribution of women in medicine was estimated almost a decade ago. It may be inconsistent with the changes of the current work profiles of men and women given the change in men’s work hours and the greater proportions of women entering age groups with traditionally less child care responsibilities. This estimation is limited by generational effects and also gives no indication of work contributions in relation to an average Australian working week.

AMWAC estimated that women contribute approximately 68% of the average lifetime contribution of their male counterparts (AMWAC & AIHW 1996.7) because of their differing life courses. This varied from 62.8% for vocationally registered general practitioners to 74.9% for female medical specialists. While this indicates a relative comparison to male medical practitioners, it gives no indication of the capacity in which women are contributing in relation to the average Australian workforce, a contribution which in 1996 was an average working week of 40.4 hours.

While it is difficult to make assumptions about how younger female doctors will contribute to the workforce based on assumptions from a generation under different societal pressures, it can give us a guide as to what has happened in the past. However, considering the trend for males to decrease their hours at a faster rate than women, the increased proportion of working women with dependent children, the greater numbers of female entering specialties where the sex differences in work hours are less skewed and the greater numbers of women entering age groups with traditionally less child care responsibilities, these calculations estimated almost a decade ago may be out of date. The contribution of women may be proportionately greater.

Trends in work hours

The average medical working week continues to decrease with males decreasing their work hours at a faster rate than women. One of the fastest growing sectors of the workforce are women with dependent children. The provision of appropriate child care and family programs for female medical practitioners with dependent children may be one of the few ways of increasing the work hours of medical practitioners.

The average medical working week continues to decrease. The average male working week decreased by 2.7 hours from 1996 to 2001 while the corresponding decrease for females was only 1.4 hours. These changes also ensure that the gap between the male and female working week is decreasing. This was a 10.9 hour average difference in 1996 to a 9.6 hour difference in 2001.

A rapidly increasing sector of the labour force is mothers with dependent children. Between 1984 and 1994, the percentage of Australian working women with children aged between 0-4 increased by almost 13% (33.3% to 46.1%), those with children aged between 5-9 increased from 54.1% to 64.9% and those with children aged 10-14 rose from 56.5% to 70.5% (AMWAC 1996). These figures may be higher in the medical population and may indicate that more women would return to work sooner after child birth if adequate facilities that were financial viable were available.

The continued trend to decrease the average working weeks of medical practitioners will ensure that the number of full-time equivalent (FTE) medical practitioners will continue to decrease. One of the few ways to increase the overall work contribution of medical practitioners may be the provision of accessible, flexible and compensated child care and family programs for female practitioners to give them the practical opportunity to work more hours per week.

Specialist work hours

The variability between male and female doctors in the following groups is less than 4-7%: all specialists under 35 years of age and between 45-54 working 35-64 hours per week, in surgeons working 35-80+ hours per week and in internal medicine specialists working 35-64 hours per week show less than 4-7% variability. The age group of 35-44 years of age showed a 16% difference between male and female specialists working between 35-64 hours per week. Considering that up to 85% of medical females carry the main responsibility for child care of dependent children, this decrease is certainly not proportional to their non-medical commitments.

In 1998, 72% of female specialists and 79% of male specialists under the age of 35 worked 35-64 hours per week. From 45-54 years of age, 60% of females worked between 35-64 hours per week compared to 64.5% of males. The main difference in work hours is expected and occurs in the 35 - 44 age group with 53.4% of females working 35-64 hours compared with 70% of males. Considering women must take time off to child bear and up to 85% of them still carry the majority of primary child care responsibility, these differences seems proportionately small (Fett, Khursandi). Although women continue to carry the same level of family responsibility as their predecessors, they are still working in a substantial capacity.

The extremes of the working hour spectrum continue to show the most noticeable differences between the sexes. The proportion of women in the 65-79 hour per week group was half that of men at approximately 6% compared with 13%. The same pattern occurred in the 80+ hours per week group, with the proportion of women being 5% and men, 11% (AIHW 1998). Females working part-time (less than 35 hours per week) under the age of 35 was 20.8% compared with 6% of males 31.4% for women and 5.1% for males in the 35-44 year age group. The proportions of male and female surgeons in each category are fairly consistent. Eighty-two percent of female and 87% of male surgeons work between 35-80+ hours per week.

Figure 3: Hours Worked by Surgeons Disaggregated by Sex

Internal Medicine shows only a little more variation. Fifty-seven percent of females work between 35-64 hours per week compared to 61% of males. There is however, greater difference in the extremities when compared with the profile of the surgeons.

Figure 4: Hours Worked By Internal Medical Specialists Disaggregated by Sex

General practice work hours

Work hours in general practice demonstrate the greatest variance between male and female doctors with 82% of female general practitioners women working less than 49 hours per week compared to 41% of males. General Practice work hours shows the greatest variance between male and female medical practitioners. The proportions of male and female general practitioners working less than 49 hours per week was 41% and 82% respectively. Sixty-nine percent of males worked between 35-64 hours per week compared to 41% of females.

Figure 5: Hours Worked for Vocationally Registered General Practitioners Disaggregated by Sex

Intern and registered medical officer (rmo) work hours

There are no appreciable differences in work hours between male and female interns or RMOs.

There are no appreciable differences in work hours between male and female interns and RMOs.

Figure 6: Hours Worked by Interns and RMOs Disaggregated by Sex

Vocational trainee work hours

There were no appreciable differences between the sexes in vocational specialist trainees working between 35-64 hours per week. General practice trainees showed greater variability between the sexes in work hours. The following tables show the hours worked by specialists-in-training in the specialist fields and general practice training.

Figure 7: Hours Worked by Specialist Trainees Disaggregated by Sex

As you can see the proportion of male and female specialist vocational trainees working in the 35-64 hour range do not differ significantly but variation is present in the extremes.

Figure 8: Hours Worked by GP Trainees Disaggregated by Sex

The work hours of general practice trainees show a different pattern with the majority of males working between 35-64 hours and the female trainees more evenly distributed.

Part-time work

Relationship of children to part-time work

Medical women have more children under the age of five than other professional women. Dependent children continues to have a differential impact on men’s and women’s clinical hours that decreases with the increasing age of the children. The proportional of medical women with children under the age of five is 9% higher than other professional women. In 1996, 22.6% of female non-specialists and 18.6% of female specialists had children in this age group (AMWAC 1996). A survey of Australian rural general practitioners showed the differential impact of dependent children on male and female practitioners. They reduced women’s clinical hours by 20% but had no effect on men’s clinical hours (Wainer, 2004) consistent with their differential responsibility for child care.

Figure 9: Percentage of females working less than 25 hours per week by age of children, disaggregated by general practice and specialists.

It is known that the age of a female’s dependent children directly correlates to their working hours. Sixty-one percent of female general practitioners with children under the age of five worked less than 25 hours compared to 23% for those with children over 10 years of age. Fifty one percent of specialists with children under five also worked less than 25 hours per week (figures for specialists with children >5 years of age not available) (AMWAC 1996).

Trainees

The number of trainees (not disaggregated by sex) undertaking part-time training in Australia increased by 22.3% in six years. Although the provision of part-time work can be related to a woman’s choice of career, part-time trainees do not necessarily work as part-time consultants. The decision to undertake part-time training depends on various factors such as the method of part-time work provided. These factors have significant implications for future workforce planning, sex distribution among specialties and the practical implementation of any part-time training programs.

Women pursue temporary part-time work in order to combine their family and their career in medicine (Allen 1994, AMWAC 1998, Carling, Gunn, Fiander, Khursandi, Whitelaw et al) and the provision of this can be linked to a woman’s career choice (Evans et al). The ability for realistic access to part-time training is a limiting factor for women in the choice of many specialities.

In 1997, approximately 5% or 296 trainees pursued vocational training part-time. This increased to 362 trainees in 2003 representing a 22.3% increase in years (this data does not disaggregate for sex). There was also a 22.5% increase in the amount of female trainees during the same period.

If it is assumed that female practitioners represent the vast majority of part-time trainees, then the proportion of females undertaking part-time training remained constant throughout the last six years at approximately 13%. If female trainees represent 50% of the training population and the proportion requiring part-time training remained constant at 13%, then it would be expected that approximately 400-450 trainee doctors will be attempting to access part-time training every year. With the increase in dual physician marriages, the increased age of medical school graduation and the increased length of training courses, this may be an underestimation of future demand.

Women who train part-time do not necessarily work as fellows part-time. As training progresses, the majority of part-time trainees change their preference from part-time consultant work to full-time practise (Fiander, Eaton). It was noted that those who continued in their preference for part-time consultant work actually increased their sessions with time. If women are able to access part-time work during training, they may be able to and have a preference for full-time work as fellows.

Data indicates that a main consideration for women undertaking part-time training was the structure of the employment offered. It has been suggested that women with children may only participate in a split week shift system whereas week on/off programs are tailored to those studying, with illnesses or with other interests (Whitelaw). This and the professional perception of programs needs to be considered as vital for any program’s success (Arnold).

Geographical distribution

Rural practice

Men are more likely to work in RRMA 3-7 but this difference decreases with increasing remoteness. Access to female practitioners has significant implications for young rural women. Rural women have identified workforce matters, isolation, networks and child care as important in retaining and attracting rural female practitioners.

The issues facing rural female practitioners are currently being explored as part of a larger focus to attract and retain medical practitioners to rural areas (Tolhurst et al 2000, ACRRM, Tolhurst et al 2001, Wainer, White & Fergusson). Many gender difference are beginning to be identified. The policy implications of this research for workforce distribution are compelling.

Harding found that 18% of women doctors worked in RRMA1 3-7 compared to 25% of males. This difference decreases in more remote areas with 1.6% females and 1.8% of males practising in these areas. Single females were more often in RRMA 6 to 7, while RRMA 5 practitioners were more likely to be in a relationship, divorced, separated or widowed (Doyle). The decreased access to female practitioners in rural areas has implications for young rural women who only wish to see female practitioners (Bryson et al).

Rural women felt that the most important changes needed to attract and retain rural female doctors were workforce matters, isolation and lack of networks and childcare. The most important job satisfaction issues were flexible practice opportunities and transparent work arrangements.

Urban practice

Female doctors are more likely to practice urban areas. Within these areas they were more likely to practise in under-serviced sectors and treat lower income families.

In Australia, the preference of females for urban practice doctors is well documented. A similar trend is present in the USA and has necessitated further research. Hojat (1990) found that women in urban practice were more likely to practice in under-serviced areas and were more likely to treat a greater proportion of low-income families within these urban areas. These gender differences may have significant implications for the sector of the urban population that have traditionally poorer health outcomes if the same trend is identified in Australia.

1 The Rural, Remote, Metropolitan Areas (RRMA) Classification system was developed in Australia in 1994 for data analysis by zones. There are two metropolitan (RRMA 1&2), three rural (RRMA 3,4&5) and two remote (RRMA 6&7) zones based on population numbers and an index of remoteness (www.health.gov.au/ari/aria.htm)

Career choice

Women doctors are more likely to consider training requirements and domestic considerations rather than true occupational preference in their career choice and be less certain of this decision. They are more likely to make career changes because of children. Similar trends are beginning to emerge in male populations. Consideration of these factors when developing training and workforce programs will affect the distribution of male and female practitioners in the workforce of the future.

Neiman stated that occupational preference was the ‘occupation an individual would enter if there were no impediments’. It has been suggested that women doctors are more likely to enter various specialities because of domestic considerations rather than occupational preference (Goldstein, Maingay et al). Indeed, a small study has identified a change in training program because of the inflexibilities of training rather than due to true career preferences (Phillips). Certainly there is little evidence to suggest that the sex differences in the rates of specialisation are attributable to inferior skills among women graduates as often undergraduate achievement reflects a different picture (Redman).

Australian studies of vocational choice demonstrated significant sex differences (AWMAC 2003, AMA 2001). Females considered hours of work, number of years for training, appraisal of own domestic circumstances, opportunity to work flexible hours, types of patients and interest in helping people as significant in the choice of discipline. Males found financial aspects, perceived prestige, opportunity for research, opportunity for procedural work and perceived career advancement prospects as more significant in their vocational decisions.

Both sexes claimed that medical college training requirements had an influence on their vocational choice. Females were more likely to make this comment, point to the length of training as conflicting with childbearing and rearing and being required to make a trade-off “in relation to training requirements, vocational choice and timing of having children” (AMA, 2001). When the impact of training compared to consultant work practices were examined, trainees felt that a temporary (i.e. three to eight year) sacrifice was seen as compensation to work as a autonomous consultant. However, females placed significantly more emphasis on the work practices of their chosen vocation and were more likely to be deterred from vocations due to these factors.

Allen found only 60% of the male doctors and less than half of the female doctors proceeded to the same specialty they had chosen at registration (Allen 1996) and women are less certain than men about this nominated career (Lambert). This uncertainty was found as significant between multiple generations of United Kingdom doctors and in more recent Australian research in both general and hospital practice (Redman et al).

The frequency of career changes made by males (e.g. work hours, specialty change) because of marriage is increased compared to their older colleagues and approaches the frequency in the female population. However, the disproportionate frequency of career changes made by female physicians necessitated by children remains (85% versus 35%) (Warde, 1996).

All of this data highlights the need to remove the structural barriers for women to make their ‘occupational preference’ consistent with their actual career choice a provide a content and well distributed workforce of the future.

Mental health

Compared to the general population, female doctors have a three to four times increased risk of suicide compared to a one to one and a half increased risk for medical men. This has been attributed to increased role-strain experienced by women as their role as primary care giver is not considered consistent with their professional choice. Men’s roles did not demonstrate this conflict. A differential incidence of depression is also present in female medical students and can also be related to inherent role-strain.

There is considerable evidence to indicate that participation in medical education and practice increases a woman’s chance of a depressive illness and suicide (Firth-Cozens, 1990). Medical students enter as well adjusted as each other but women begin to use psychiatric services three times more during the course of their studies and hospital training (Davidson, Firth-Cozens 1986, 1987, Lloyd). The suicide rate for medical women and men is similar representing a three to four times increased risk for female doctors and a one and a half times increased risk for medical men from the general population (Carlson et al).

Davidson describes the concept of role-strain as “the built-in conflict that results from the woman’s having to choose between the demands placed on her profession as a woman/mother/wife and from her identity as a female”. It is suggested that this ‘role-strain’ may be a causative factor in the disproportionate prevalence of mental disease in women doctors as a man’s role as the breadwinner did not conflict with their occupational role of a doctor whereas the role of family carer posed considerable conflict for women.

Clark and Rieker suggested that the “emphasis on role obligations may result from the fact that professional training, like professional work, is organised to be consistent with values traditionally associated with the male role. In such a structure, work-related issues will take priority for men, and part of the stress men may derive from the demands that others make on them when they have been socialised to believe that career commitment are more important than these other demands”. They went on to delineate the role of the organisational structure of education versus interpersonal factors in the sources of stress in female students. It showed the sources of stress during medical study showed significant sex differences and could perhaps be organisationally based.

Clark and Rieker alluded to the fact that tertiary education prepared students for high stress situations such as deadlines and examinations but managing conflicting role obligations and their associated time demands was not addressed. Consequently the population with this professional need, most notably females, entered medical practice without learning these skills.

Family characteristics

Partners

Australian females trainees are younger, more likely have a professional partner or no partner. Within 40-50 year old specialists, 84% of women had a spouse that worked full-time compared with 31% of males. Males were also more likely to have a spouse at home compared to females (43% versus 2% respectively).

Australian females trainees are more likely to be younger, be unpartnered (i.e. single, divorced, separated or widowed) and to have a partner who is another professional compared to a partner with ‘home duties’ (AMWAC, 2003). In 1996, only 62% of Australian female doctors were married (AMWAC, 1996) and those who were married in dual physician marriages were more likely to have decreased levels of marital satisfaction then their male spouses (Warde, 1999).

In a study of 40-50 year old specialists, 84% of women had a spouse that worked full-time compared with 31% of males, 43% of males had a spouse with at home compared with 2% of females and the rest (36% for males and 14% of women) had spouses that were unemployed or in part-time work (Dumelow et al). Considering that between a third and a half of female medical practitioners now marry medical men (AMWAC 1998, 2003, Dennerstein, Fett, Khursandi) and the female medical school intake now approximates the male intake, the proportion of men marrying medical women would be expected to increase. This will have a significant impact on the family commitments expected of male physicians in dual physician marriages.

Childbirth, child care and vocational training

More medical women plan on providing the majority of primary child care and incorporate this plan into their plans for medical practice careers than men and it can be assumed that currently, the majority wait until training is completed to pursue this part of their life. Trends in the medical workforce indicate that many females may be forced to combine training and childbirth in the future.

Because of necessary changes in the mother’s environment and the vulnerability of both mother and infant during this period, preconceived plans to combine these processes may be inaccurate and disruptions may have far reaching consequences for both mother and infant. Consequently, timely and practical flexibility and support by colleges and hospitals in relation to interrupted and part-time training is necessary for those compelled to combine these processes and is vital to their successful completion of vocational training.

Medical women continue to plan on providing all or the majority of primary care for their children and this frequency increases as training progresses (Redman). Consequently most pre-emptively consider factors such as child birth, parental leave and part-time training and make plans to incorporate these events into their training and medical practice.

It has been shown that male trainees are more likely to have dependent children during training than women (AMWAC, 2003) and this could be safely attributed to the fact that child bearing does not necessitate the interruption of a male’s vocational training. It therefore follows that that many female trainees intend to have children after the completion of fellowship. This may not be an option for many in the future.

Currently, the average age of vocational trainees lies between 33 and 34 years of age pushing the average age of attaining fellowship to 36-37 years for an average training program of five years (varying from between three to eight years). With the trend of increasing age of medical students and the ongoing trend to increase the length of training programs, it can be safely assumed that in the future a substantial proportion of trainees will be older that is currently the case. Consequently females will have to pursue childbirth during training or sacrifice this option for their advancement of their careers. Considering the trend towards increasing prevalence of dual physician marriages, the issue of access to professionally acceptable training for female and male doctors with families is destined to increase.

While females will continue to plan for whatever path they take, women who have experienced childbirth realise their naivety in attempting to plan for a situation that in practice is very different to their expectations. This naivety can be attributed to the temporary reorganisation of a mother’s psychological environment necessary to adapt to the new role of mother and carer of an infant described by Stern.

Because of this temporary reorganisation and the vulnerability of the mother and infant during this period, it is unlikely that female trainees will be able to accurately predict for the length of time required for the adjustments necessary during this period and disruptions to this process may have far reaching consequences for both mother and child.

These factors continue to advocate for the timely and practical flexibility required by colleges and hospitals in relation to interrupted and part-time training and work necessary to support a female compelled to combine training and child birth as vital to the successful completion of vocational training.

Arguments used to maintain the status quo

Redman describes “discriminatory attitudes and practices within medicine, the limited number of specialities which offer any realistic form of part-time or interrupted training, the difficulty in balancing a career and family responsibilities, long, unpredictable and inflexible working hours, the length of postgraduate training, the lack of women role models and a lack of confidence among women medical graduates” as inherent to the inequalities faced by women in medicine. Sewell outlines the complex issues of “traditional needs of training organizations versus the personal and professional needs of trainees, the conflict between education and service in a tight fiscal environment, and the overall size, setting, distribution an safety of the junior medical workforce” as impediments to the provision of vocational training that is viable for many women.

Despite these real considerations, there are a multitude of other arguments used to perpetuate the disadvantage of women in medicine to justify the scarcity of high level action and change necessary to address these complex issues.

The pipeline theory

The pipeline theory describes the process of increased participation of minority groups and consequent change in executives by putting faith in time. This concept assumes increasing the intake of minorities into institutions will lead to proportionate representation in leadership positions with time. The main barrier is seen as the initial entry point as opposed to the existing structure.

The pipeline theory assumes that women in representative positions will represent the needs of women not in representative positions and change structures in their favour as they progress. This denies the process of their election and the way the organisation regulates the manner and means of their representation. The very election of a female to an executive, requires the doctor to represent the aims of the organisation and not the plight of women. By calling on these women to become female ‘advocates’ may be unfair as it may expect them to challenge the very pillars of administration that they are elected to represent.

Although 25% of medical graduates have been female and a females have been the majority in lower academic grades for a significant period of time, they are still not proportionately represented in representative positions or higher academic positions (Tesch). Even in numerically female dominated professions such as nursing and social work, women still displayed the characteristics of a minority and were not proportionately represented in executives (Rosenblatt). Surely these figures must indicate that the pipeline theory is not an appropriate solution.

The element of ‘personal choice’

The argument of ‘personal choice’ states that women simply ‘choose’ differently from men and so naturally fall into inherently ‘female’ professions such as general practice and paediatrics. For this to be valid, certain conditions must be in place.

Firstly, both sexes must have equal access to professional structures and must be compared to gender neutral criteria. The Trainee Selection Framework in Australian Medical Colleges (MTRP 1998) identified that this traditionally may not have been the case. It also assumes that both sexes will have the same resources to progress through training. The fact that a vast majority of females have professional husbands and also carry the primary responsibility for child care negate this second assumption. Also the practical inability for women to interrupt their training excludes certain careers for those women who ‘chose’ to have offspring during their training. It also assumes an inherent difference in the career goals irrespective of carer choice of male and female medical students. The current research has not reflected this difference.

The notion that the deviation from traditional medical paths is due to true choice will continue to be a simplistic representation of the interplay of gender roles in society and professional achievement. It is true that a parent (often two) makes the choice to have children. Once this choice is made, there is no question, however, as to who carries and breastfeeds the child as this can only be biological performed by the mother. Therefore, it is only the mother who needs alterations to workplaces and part-time and interrupted training and work to accommodate this role. Although breastfeeding and child bearing and taking on the role of primary care giver to children may be considered an individual ‘choice’, it is not yet a ‘choice’ that has equal impact. To have equal impact, women must ‘choose’ not to have children during training but faced by male trainees. Eisenberg agrees: “It would be absurd to view these alternatives as ways to resolve the professional dilemma for women by, in effect, declaring that medicine demands celibacy or childlessness of women, but not of men”.

When the premise of equal access and opportunity are in place and child birth, child rearing and breastfeeding are considered ‘normal’ and incorporated into the provision of medical training and practice, then the argument of ‘personal choice’ may be made. Until then, the realities of the current situation is ‘personal choice’ is often a consequence of a paucity of other realistic alternatives.

‘Lack of ambition’

Another argument is that perhaps women are simply ‘less driven‘ than men. This argument holds women inherently responsible for their own position and disregards the institutional barriers present to females in a male-defined structure. It is proposed that they are content with less female participation in their professional executives, are happy to work in less coveted or prestigious positions and are happy to earn less money.

It is true that female doctors have different needs in medical education, perceptions of professional problems, professional evaluations and their value of economic and financial factors (Hojat), but this has not been linked to a lack of drive to professional success in medicine. Research has indicated that this is far from the truth and has proposed that women entering medicine may even hold higher expectations in these areas than other females in other professions (Rosenblatt). Interestingly, medical students seem to show equal drive, with similar preconceptions of how their medical career will proceed and expect similar professional end points.

Women in representative positions

The importance of same-sex role models in the medical profession is well documented and the visibility of individual women in executive positions and academia is promising. However, many cite the few women in representative positions as confirmation that current structures and systems do not hinder a female doctor’s progression in medicine. If this was true, the proportion of women in these positions would surely be reflective of the proportion of medical women in practice or in professional training (Robinowitz). This is certainly not the case in the majority of Australian medical structures. However, if we continue to use this argument as a sign of success of the achievement of medical women, then we perceive the failure of a few to achieve their professional goals as a sign of failure.

This continued lack of proportional representation must only indicate there are barriers for professional females to limit their progression in medicine and that the achievement of women currently in executives is much greater than assumed.

‘They just don’t participate’

Formal encouragement in executive participation is not the only limitation to female participation in executive structures. The barriers are both cultural and structural.

Firstly, as the primary care giver in the majority of families, women have additional factors to consider before making extra commitments. They continually weigh up the advantages and disadvantages of contributing to these forums against equally important competing interests. Unless these concerns are addressed and resources such as the provision of child care facilities are provided and they convene at times that do not coincide with times of maximal family commitments, doctors with significant family responsibilities (most often women) will be unable to participate. Trends and anecdote indicate that this will also be an increasing consideration for the male doctors of the future.

A study of women’s progression in engineering found exclusion from informal male networks was a major problem for women in gaining access to critical organisational information required for their continued progression (Catalyst). This inherent patriarchal discourse of engineering and medicine is a major barrier for women in executive cultures. For women to participate in these forums in a meaningful way, a formal system needs to be established that allows the expression, validation and incorporation of differing points of view (Lewis et al).

Historically, women faced the added burden of being labelled negatively if they advocated for change. Cox reflected that women advocating for change in executive cultures are often labelled as ‘difficult’ if their views differ from the mainstream and that they were seen as transgressors and excluded and ignored until they learnt their place and remembered their manners (Cox). This representation whether historical or current of women advocating for change, needs to be addressed within the greater medical culture if women are to be truly incorporated and validated in these societal structures.

Complaint as a measure of good practice

When an organisation receives few or no complaints, it is often assumed that systems are effective and/or equitable. This perspective ignores the impact of the organisational influence and circumstance of an individual. When the personal risk of complaint to an individual’s medical career, their lack of organisational knowledge and their practical opportunities for complaint is considered, it is clear why a lack of complaints, especially in the vulnerable stage of training, would not be a valid measure of an equitable or effective system.

Even if a system is perceived as relatively good practice in a particular context, there is always room for redevelopment to ensure greater access and opportunity for all. Best practice at a given time, may in fact only represent good practice when considered retrospectively.

Organisations should see the questioning of practices as a positive experience and vital for continued development of equitable and transparent policies. This practice should be seen to represent an active and diverse constituency striving for the continual improvement of organisational processes and professional responsiveness.

Maintenance of training standards

The implementation and provision of alternative methods of training is a concern for those given the responsibility of maintaining training standards when anecdotal evidence suggests this may compromise patient care and/or training benchmarks. The reluctance of the medical profession to embrace the concept of alternatives to traditional training as a valid method, also continues to perpetuate the paucity of evidence based data on the subject. The little data available is promising.

Carling showed that the preconception of part-time trainees as less competent is not warranted. A 10 year study of part-time training, showed that part-time trainees were rate with higher standardised scores of clinical and humanistic skills and scored equally with their fulltime counterparts in the areas of leadership and teaching qualities. Part-time trainees were also noted to be highly represented in the top percentiles of vocational examination results.

It has been shown that a poorer educational experience, increased colleagues burden and miscommunications are more likely to occur when ill-informed and piecemeal part-time training policies are implemented. This is because this approach brings with it a culture of poor individual and organisational support, poor staff education and lack of clarity in relation to situations such as after hours communication, educational rosters, hand-over policies and communication processes (Allen 2000, Calman 1999, Coyle, Escott, Valentine et al). Implementing poorly constructed systems in an unprepared environment cannot hope to benefit the individual or the organisation.

The value of time based training and clinical privileging

Exploring alternative methods of training and credentialing to the current ‘master-apprentice’ and time or volume based medical education continues to be an obstacle for many medical practitioners. However, even this method can be limited in its effectiveness. It relies on the invaluable contribution of teachers, their unbiased review, a motivated trainee and the trust of time to create a skilled medical professional. Today, the argument for maintaining the current volume and time based training methods lie in the perceived association between time or volume and markers of good medical practice. Sometimes in an effort to defend our current system, we hinder our continued professional development and responsiveness by relying on data that would not be considered robust evidence in other areas of medical practice.

There is a surprising lack of evidence except in a handful of highly technical procedures to demonstrate that volume is a reliable indicator of improved health outcomes. There is even less evidence to demonstrate that volume is a reliable indicator of competency (Halm). The Halm study reports that ‘69% of studies involving medical practitioners reported statistically significant associations between higher volumes and better outcomes’. This figure is currently used to substantiate this argument for volume based measures of good practice and/or clinical competency.

These figures come from a review that stated the data on this topic was so heterogeneous that no meta-analysis was possible, that stated that less than 8% of the studies had ‘robustly discriminating and well calibrated’ risk-adjustment models and questioned the use of volume as a surrogate measure of outcomes in health care. It stated that because “reliable, valid and timely information about health outcomes is lacking, data on volume are even more attractive. The wisdom of this policy however, depends critically on the strength, magnitude and meaning of the association between volume and outcome in health care”.

The study also noted concerns in using volume as an indicator of competency. The appropriateness of patient selection was seen as a problem in higher volume practitioners as there was an association between a high-volume of procedures and the prevalence of inappropriate indications.

While further research into these areas is needed, the consideration of other forms of medical training should not be dismissed until robust and evidence based data indicates otherwise. Any reliance on rhetoric that causes considerable disadvantage to particular groups must be avoided. As medical practitioners we should continue to rely on clear and evidence based data rather than anecdotal rhetoric or poor quality studies and if these are lacking devote research to the topic.

Workforce considerations

Workforce planning is a considerable obstacle in the provision of flexible work environments. The difficulties to find job-sharers in a very specialised medical field or in justifying part-time practice when under-staffed are obvious. While considerations such as these are real and require considerable attention, what would happen if we reframed our questions?

If the opportunity to undertake flexible work was practically available earlier in trainees’ careers, perhaps they would have a more open approach to pregnancy that would allow more accurate workforce planning and the requests for job sharing would occur earlier when doctors are relatively interchangeable. Perhaps if we offered a more flexible and family centred workplace, part-time doctors would be able and want to work more hours. Until we ask the complex questions and base our responses on valid and appropriate data, these questions will never be resolved and workforce concerns will continue to exist.

Displaced responsibility

The justification the perpetuation of inequitable policies in practice is often poor communication and co-operation between various stakeholders or the displaced organisational and fiscal responsibility currently maintained by governments, colleges and training hospitals. Trainees are continually caught in the middle and discriminated against and disadvantaged as a result. These issues remain as enormous barriers to the progression of cultural change and attainment of equal opportunity in medicine. It is naïve for organisations to propose their policies are independent. It is clear the requirements of one impacts the other.

There are many forums for stakeholder co-operation and communication to consider the necessary intricacies of these situations. It is confusing why this lack of continuity between various policies still exists when it is disadvantaging people in tangible ways. Calman (1999) indicates a greater need for co-operation between various sectors in order to address these complexities.

Towards gender competence in medicine: recommendations

It is clear that one size doesn’t fit all unless the size is diverse and inclusive. Differing lifecourses and practices are clear and evidence based. In a medical culture that currently faces workforce shortages and maldistribution, increased practitioner and student age, changing practitioner preferences, new methods of medical education and a changing sex distribution, the differing needs of diverse populations cannot be ignored. The way towards the gender inclusive practices that are needed for tangible improvements in these areas requires changes in research practices, policy development, policy implementation and organisational structures.

Valuing gender differences

Gender differences in medical practice must be valued by the medical culture as genuine and evidence based.

There are many similarities in the issues currently facing medical practitioners. Indeed, the majority of medical students enter medicine with similar desires of high quality patient care and professional success. What is not widely accepted is the enormous volume of research indicating the evidence based gender differences.

The first step towards gender awareness is to appreciate that socially determined differences influence the way in which men and women conduct themselves in society. This affects their access, opportunity and control of resources. The first step to ‘gender competency’ is the acknowledgement and appreciation of these differences and the recognition that the incorporation of this diversity into policy development, implementation and assessment would be of benefit to medicine.

Development of policy tools for gender mainstreaming

A policy tool for gender mainstreaming must be developed for use as an integral pillar of policy development, implementation and review in the medical profession.

Medicine still remains a male dominated profession both symbolically and structurally. This is because professional policies, structures and work practices have evolved from a uniquely male perspective. If we accept this fact and agree that we need innovative ways of incorporating women and their methods of practice and opinion, then we have to ask, where to from here?

The United Nations as part of their Gender and Development (GAD) platform, have looked at various ways of reforming policy development to include the views of marginalised genders in baseline policy development. Gender mainstreaming has evolved as the approach advocated by the United Nations for organisations to use in order to realise gender equality and redress gender inequities. This aims to help us move from the stage of incremental adjustment to the incorporation a new medical culture.

Gender mainstreaming is the ‘process of assessing the implications for women and men of any planned action, including legislation, policies and programs, in all areas and at all levels. It is a strategy for making women’s as well as men’s concerns and experiences an integral dimension of the design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated’ (UN Economic and Social Council (ECOSOC) agreed conclusions (1997:2)).

If the medical profession develops a thorough and relevant way of incorporating gender mainstreaming into medicine, it will have the advantage of allowing organisations to consider how policies will prospectively impact on sectors of the population from a gendered perspective.

Gender competent research

It is necessary to develop research methodologies from a gender competent perspective and disaggregate all data initially by sex and ultimately gender, to provide the necessary platform for gender competent policy development.

Research methodology and policy development

Research methodologies influence research development, collation, presentation and publication. If gender is not considered in these methodologies then gender competent policies cannot be developed. McDonald et al (2002) stated that in order to address issues such as recruitment and retention, we need to “progress further and implement well-controlled quantitative research”.

Research has shown that the use of open or closed questions reveal different responses (AMA 2001, AMWAC 2002, Doyle). If gender neutral questions are asked in a closed format only gender neutral responses will be received. Consequently, the only way gender-specific responses can be obtained from gender neutral questions is in an open (or qualitative) format. While closed-format, gender-neutral questions may continue to elucidate sex differences, the reasons for these sex differences or the gender-specific concerns, continue to be ‘coded-out’.

Qualitative research will always be considered as less ‘reliable’ than quantitative research in the current paradigm of medical research evaluation. Although qualitative data can provided a more detailed overview of trends within a society, quantitative data is traditionally considered a more valid measure. If research is gender neutral, gender specific concerns will only present in an open or qualitative format as described above. Consequently, gender specific responses gained from qualitative research are automatically relegated as a less important tool for the purposes of policy development. Consequently, policy responses are gender-neutral.

Policy development in complex areas such as medical training and workforce planning will continue to be inadequate if a gender-neutral perspective is perpetuated. Gender-specific concerns in these areas are significant and a gender-specific approach is urgently required for substantial and tangible impacts in these areas.

Gender based research

When gender neutral data is disaggregated by sex, differences can be found in the frequency of response between males and females. When gender-specific motivations are explored, further differences are found.

An example a gender-neutral question could be ‘are you currently on leave from medical practice: yes or no?’. The format automatically pools maternity leave, parental leave, study leave, extended sick leave, leave to care for a elderly relative and long service leave into the ‘yes’ response. Even though the gender-based workforce implications for each of these leaves are very different (Whitelaw et al) the difference is ‘coded-out’ before workforce planning has even begun. Instead of quantifying gender-specific proportions and trends we are left to resort to assumptions.

Data collection methods must be reviewed to ensure that they are gender specific and relevant. Gender competent data collection is necessary for the development of gender inclusive policies and procedures. It would be unwise for those in policy development to implement policy initiatives based on vague estimations just as it is unwise to base these initiatives on gender-neutral data.

Gender inclusive research design

Minorities must comprise at least a third of a group for their concerns to be heard. Some suggest in relation to gender issues, the proportion needed may be higher (Rosenblatt).

As part of research into the influences of vocational training choices, the AMA (2001) enlisted a consultant to investigate these influences with a particular emphasis on gender differences.

Eleven focus groups were held during this process. To ensure gender differences could be identified, six of the focus groups comprised of a single sex, three with males and three with females, and the rest of the groups were mixed. Participants were first asked to complete a questionnaire and then answer similar questions in an open discussion format. This enabled the reasons for sex and gender differences to be identified. The design of the forums enabled the opportunity to air the views of different sexes in a supportive environment in a mixed as well as a sex-specific forum. The research enabled significant sex and gender differences to be identified despite small sample numbers.

Gender neutral versus gender inclusive questions

An example of a gender-neutral question is ‘has lifestyle influenced your choice of medical vocation’. In this situation, similar numbers of both sexes may indicate that it does. However, if a gender inclusive question is asked the differences within populations may be seen. The reasons indicated by all females and males with children are expressed in terms of family commitments whereas single males were driven by a desire to participate in sporting events, social functions and travel.

Gender competent policy development

Gender competent policy development is needed to address the complex issues currently facing the medical workforce.

Given the clear differences in practice styles, lifecourses, after hours responsibilities, patient characteristics and influences of career choice between the sexes it is necessary to quantify the impact of these factors in every area of medical practice. This includes medical education, medical training, ongoing profession development, remuneration and work and professional structures.

Gender may be considered when research is collected or data may be disaggregated by sex, but in an attempt to develop a gender-inclusive policy, demonstrated sex and gender differences may be ignored. A gender neutral policy is developed that represents an androgenous model that may not be representative of any group. With the increasing proportions of women in medicine, the differing needs of males are just as likely to be ignored in such a gender-neutral process of policy development. The aggregated data is more likely to reflect a gender varied model that will accurately not reflect the needs of either group.

To make a significant policy impact in every sector of medical practice, it is necessary to have a working gender framework that is implemented at every level of policy development. In order for this to happen, gender must be considered as an equally important pillar of policy development as other high priority policy initiatives.

Gender competent policy development

RACGP has one of the best gender responsive policies for the provision of vocational training. Minimum legislative requirements are incorporated into training regulations. This ensures that discrimination is not experienced by either men or women trainees. Part-time training is granted when full-time training is not possible due to other commitments unrelated to the practice of medicine and this is not restricted to particular years of training. There is the ability to undertake accelerated part-time training. Parental, Adoption and Legal Guardian Leave is considered equally. There are no limits to the quantity of individual periods of parental leave granted and this type of leave is considered in addition to the two year leave of absence from training.

Gender competent policy Implementation and evaluation

Gender must be considered in the practical elements of policy implementation and evaluation. For this to occur, gender must be a key factor in all policy evaluation. This needs to be linked to the provision of funding and other key performance indicators for continued implementation and evaluation.

Areas for gender policy implementation and evaluation requiring future exploration are discussed below.

Gender competent education

Gender impacts on medical education in a multitude of ways. Medical Women’s International Association has been focussing on the introduction of “gender issues in relation to medical curriculum, medical research, the medical profession and the experience of women and men as doctors” (Wainer et al).

Professor Hultcrantz described a number of questions requiring answers in order to understand the meaning of gendered medicine. These were outlined in her address to the Medical Women’s International Association Symposium on Teaching about Gendered Medicine.

1. How does the gender of patients influence the treatment of their illnesses?

2. How does the gender of medical students influences their education opportunities?

3. How is gender of the standard patient presented in textbooks?

4. What role does gender play in the relationships between female teacher/male student and vice versa and the relationship between female teacher/females student an male teacher/male students?

5. What role does gender play in the relationships between female doctor/male patient and vice versa and the relationship between females doctor/female patient and male teacher/male students?” (Wainer et al, p 12).

Gender competent education must be implemented to equip all practitioners with the skills needed to progress successfully through medicine and the skills necessary to care for our patients in a gender-competent manner.

Gender in professional education

Vast amounts of research indicates the differential experience of women and men as doctors. While medical education has moved to incorporate broad professional issues in undergraduate and postgraduate courses, the element of gender differences has not been integrated as widely.

Clark and Rieker have shown a significant predictor of stress in female medical students is the problem of conflicting role obligations. This may also be linked to the increased mental health problems in the female doctor population. As the profession role of medical practitioners has been traditionally defined from a male value base, the role stain is greater for women in medicine as their social roles are not considered consistent with their professional obligations. To equip medical practitioners adequately to deal with the professional obstacles they will experience in their careers, it is necessary to equip them in a gender competent way via continuing professional education.

Australia and gendered medical education

Monash University piloted ‘Women in Rural General Practice’, a gender based curriculum aimed to increase medical students’ understanding of the personal and professional issues of women doctors in rural areas. This was instituted as part of their compulsory rural terms. This has been reviewed to ‘Gender Issues in Rural Medical Practice’ to incorporate the learning needs of male students participating in these tutorials (Wainer, 1999).

Gender in health research

The majority of medical research used in our day-to-day practice is based on a sample group that is not representative of the diversity of the treatment population. Historically, the majority of research has been conducted on white males and generalised to a treatment population without knowledge of the effects in those who were neither white nor male. This has been linked to poorer health outcomes in women and non-caucasian populations. It may also have implications for the distribution of scarce health resources.

It has been recognised that a significant step towards improved health outcomes for diverse populations is the inclusion of a sample size representative of the treatment population. Disaggregation of the treatment data by sex and ethnicity is then needed to identify differences in outcomes. Until this is done, outcomes in women and minority groups in treatment populations may not be addressed. The importance of this requirement in health research must be explored and included in medical education and healthcare planning.

International initiatives

Canada and the United States of America have instituted legislation linking research funding to research design (Stewart et al). This ensures that designs include a sample representative of the treatment population and sex disaggregation of the data compiled. This has resulted in increased frequency of research with sex inclusive populations, sex disaggregated data and its consideration in health policy (Doyal).

Gender in health care provision

Although groups have been advocating for gender and sex as important fundamental variables in clinical research for some time, the importance of sex differences in diagnosis, investigation and treatment of various medical conditions are only beginning to be validated by the greater medical population (Institute of Medicine). Indeed, many discoveries such as the increased frequency of unrecognised myocardial infarct in women under 65, sex differences in orbital fractures and head injuries requiring differential provision of domestic violence services and sex differences in death from circulatory disease, are relatively new (Doyal, Beck et al, Hartzell et al, McKinley, Monahan et al). It has been shown that previous assumptions made about sex differences in treatment outcomes in cardiothoracic surgery have not held true when detailed sex-based research was undertaken (Mickleborough et al). These highlight that the complexities of the interaction of sex, socio-economic status, family roles and age and their effects on ill-health are not reflected in simple research designs and require more detailed research techniques.

Gender as a framework for incorporating sex and its associated societal constructs, roles, generation effects and individual perceptions offer a framework for the consideration of these complex issues. The consideration of gender in a society with limited health resources may have a significant role in a climate of decreasing health budgets and increased patient demand and expectations (Doyal). For these complex issues to be considered in future resource distribution and health care, it must be integrated into medical education and research.

International initiatives

The United Kingdom Equal Opportunities Commission a discussion paper (Doyal) to investigate the impact of gender neutral health policy development and implementation as part of the new NHS Plan (DoH, 2000). This paper indicated that the NHS may not meet key performance indicators if a gendered perspective towards health care provision is not incorporated.

Gender competent medical training

The provision of gender competent medical training requires a gendered curriculum and an training environment housed in gender appropriate regulations. The benefits of these provisions are detailed above as are examples of gender inclusive training regulations. The differing needs of males and females in the context of their social roles must be considered and regulations must be in line with legislative requirements.

International initiatives

The United Kingdom been revising its training system to incorporate alternative methods of training (Calman). There are currently quotas for accredited part-time training positions that are funded independently as an incentive for hospitals to ensure these trainees are offered positions and retained. Trainees are now able to train and work relatively easily in a part-time capacity when they may have otherwise left the workforce for a substantial period of time. An independent committee rates part-time trainees’ clinical and academic merit and places them on equal footing with their full-time counterparts. This gives independent affirmation to part-time trainees that they are as skilled, proficient and committed as their full-time colleagues. Independent infrastructure has been developed alongside these provisions to cope with the complexities of part-time training including geographical placements, filling training posts and funding.

Gender competent workplace supports

The business benefits of including workplace supports for employees has been recognised and incorporated internationally. A major workforce growth sector is currently women with dependent children under the age of five. Data has also shown that many women with children under the age of five would consider working more hours if organisational structures permitted.

Women in specialty fields do not work proportionately less hours considering the differences in roles outside of medicine as primary care providers. Therefore medical women may be more inclined to work in a full-time capacity if family friendly facilities were available. With females constituting 75% of health sector professionals, gender appropriate workplace supports must be accommodated within mainstream workplaces to provide a skilled and motivated health sector in the areas and numbers needed.

Gender inclusive workplace initiatives

Britain began to realise the role of the provision of child care in the productivity and retention of valuable employees and since then the British Medical Association campaigned for government support of such initiatives (Godlee). As part of the NHS Plan, a strategic plan was implemented to improve the working lives of employees (DoH, 2001).

The Improving Working Lives Standard identified a number of creative initiatives to address the issues of family responsibilities in a positive way in the area of roster scheduling, planning for returns to work after maternity leave, accessing training opportunities during periods away from work, availability of funded child care and new methods of working that benefit both the institution and the individual. These initiatives included annualised hours, compacted weeks, 24 hour roster adjustments and continual contact with those on maternity leave to plan for and educate their return and prevent their de-skilling.

The government also recognised that funding must be linked for the implementation of such strategies. Preliminary evidence seems to indicate improved morale, increased retention of staff, less sick days and the continuing improvement of existing structures.

Australian employers are also required to provide workplace provisions in line with Australian workplace legislation. It has been noted by the Human Rights and Equal opportunities that many employers do not rely on accurate information when considering workplace provisions required by law. This must be rectified if discrimination towards women in the workplace is to be eradicated (HREOC).

Incorporating equal opportunity into the workplace

Australia

The Australian government provides support for workplaces that are instituting equal opportunity in private sector workplaces. These resources are available at www.eowa.gov.au.

The Equal Opportunity for Women in the Workplace Agency (EOWWA) has developed a six-step program for designing and implementing a equal opportunity workplace program. This includes:

  • Preparing a workplace profile.
  • Analysing the issues for women in the workplace in each of the seven workplace matters.
  • Prioritising the issues.
  • Taking action to address the priority issues.
  • Evaluating the effectiveness of the actions.
  • Identifying future actions.
  • They also provide workshops and Employment Matter Solution Tools for employers to examine human factors and their implications
  • in a number of matters including:
  • Recruitment and selection.
  • Promotion, transfer and termination of employment.
  • Training and development.
  • Work organisation.
  • Conditions of service.
  • Sex-based harassment.
  • Pregnancy, potential pregnancy and breastfeeding.

United Kingdom

A United Kingdom Equal Opportunities Commission discussion paper has outlined good practice indicators for the implementation of equal opportunity in the public sector (Escott).

There is currently a ‘culture of silence’ surrounding medical women, child birth and professional development. It is not widely discussed as the negative career implications of chid birth are perceived to be great. Gender competent workplace supports will help to breakdown the ‘culture of silence’ and enable workforce planners to incorporate employees plans into the provision of a sustainable and motivated workforce.

Gender competent professional development and practice

The additional barriers for women in accessing relevant continuing professional development continue. Provisions must be made for women to be able to access high quality and relevant education despite their social constraints if the entirety of the medical community is to be utilised to the best of its ability. This includes physical resources such as the availability of child care to educational resources such as gender specific educational opportunities.

Innovative continuing professional development

ACRRM has implemented innovative ways of providing continuing medical education necessitated by the geographical barriers of its members. Concepts behind educational resources such as Rural and Remote Medical Education Online (RRMERO) allow us to rethink the way medical education is currently delivered. ACRRM has also used current gendered research to develop gender specific programs for continuing professional development. This is due to be implemented at their upcoming conference in mid 2004.

Gender differences in consultation style, practice involvement and patient characteristics must be incorporated into workplace structures and professional valuation systems. Women are less likely to be full-time and practice partners, they care for different conditions, have longer consultations and do less procedural work (Britt et al). With the current remuneration system that values short consultations, procedural work and less complex cases, women will continue to receive lower remuneration per hour worked. These considerations need to be addressed in the broader context of clinical privileging and government regulated finances.

Innovative practice structure

Traditional practice-partner models offer little workplace security or autonomy to those who work in less than a full-time capacity. A model that offers these professionals more autonomy is that of a full-asset partner with a pro-rata contribution for running costs based on pro-rata hours of work. This offers the security of being seen as an equal financial partner in core assets while allowing the incorporation of differing work capacities. This model has been of benefit to those with child care commitments as well as those current partners looking to retire in a step-down fashion.

Gender competent executives and academia

Significant drivers of organisational culture and practice are executive boards and educational institutions. Despite a number of women in visible positions, there is still a divide in the proportions entering professional training and those in positions of prominence and responsibility (Robinowitz, Nonnemaker). This has been attributed to the organisational discourse that incorporates a system of communication that may be foreign to those outside of the structure. This includes expected norms, skills, habits and language that provide barriers to continued progression within the structure (Sinclair).

Sinclair describes that people who are less likely to experience discrimination are less likely to appreciate the need for change. If executive boards are not representative of the population they are representing, then the organisations must have mechanisms in place to ensure minority groups’ views are incorporated in a meaningful way. For all medical practitioners to have the role models and support necessary for optimal professional education and development, then executive boards and educational leaders must ensure that organisational discourse must be more inclusive and management must be more representative.

Inclusive executive techniques

Many organisations provide skills training for those elected to executive boards. This ensures that each individual will possess the skills necessary to work within the organisational structure regardless of their skills base prior to their participation. Many organisations have the incorporation of minority views as standing business in their executive meetings. Even though a gender policy is not considered in all areas of policy development, it ensures the minority opinions are communicated with the possibility of being incorporated into broader policy development. This system has its disadvantages as it relies on the composition of the executive to forward these minority views further.

Future research

Multi-disciplinary research into the impact of gender in medical practice must be pursued urgently. If this research is to have the substantial impact on medical workforce and professional development required, it must include a cross-sectional, gender appropriate, age related review of the medical profession conducted by experts in the field. This must be overseen by organisations and working parties that have the appropriate expertise to forward the research in the manner required.

The sex-discrimination act has been legislation for approximately 20 years, research indicating gender different needs has been available for even longer and Australian government recommendations advocating the medical professional pursuit of multi-disciplinary research into gender and professional practice have been on the table for approximately eight years. Despite this, discriminatory practices continue to occur on a regular basis, the differing needs are slow to be incorporated and the professional based multi-disciplinary research has never eventuated.

Future research must be overseen by organisations and working parties that have the appropriate expertise and vision to forward the research in the manner required. It has been shown that despite government recommendations for further professional based research, this had not been given a high priority in traditional structures. The research will require the support of government and other stakeholders to give the project the consideration and co-operation required to ensure the project’s directives are not compromised. Experts in the field of gender and medical practice must be engaged in the research development from the very beginning.

Future coalition

A coalition must be established and funded to address concerns of gender in medicine comprising of all stakeholders including colleges, hospitals, governments and professional support organisations. This coalition must be established with urgency to consider the complex interactions of gender in medical practice in areas such as the duration of specialist training, work hours, parental leave provisions and workforce distribution.

A coalition must be established to forward the concerns of gender in medicine consisting of governments, professional bodies, hospitals and colleges. This is required to direct “how best to move forward, based on what is educationally desirable, economically affordable and practically achievable in ways that are consistent with the needs of the services” (Calman). It must consider the complex interactions of issues such as the duration of specialist training, working hours, maternity provisions and workforce distribution (Maingay et al).

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