This study at a Swedish university showed that physician teachers assessed gender less important in contact with students, colleagues, and staff than in contact with patients. The study also demonstrated differences in gender awareness between specialty groups. Family physicians were most likely to score the importance of gender high and surgical doctors to score low. The differences between specialty groups were mainly due to disparities among male physicians. Male surgical doctors assessed the role of gender in professional relations significantly less important than male family physicians and male non-surgical doctors. Women were more likely than men to assess the importance of gender high and among women there were no significant differences between specialty groups.
On method
Of the sample 35 % did not answer the questionnaire. Did only persons interested in gender answer? It does not seem so. There were many low ratings and some open-ended remarks display very questioning attitudes and opinions. For instance, one low-scoring physician wrote: "I hope health care professionals stop thinking about gender and start dedicating themselves to helping poor women as well as poor men who suffer in the health care system and in society!"
Male surgical doctors scored lowest. They also had a low response rate. Had more of them answered the differences between specialty groups and between men and women that we found might have been more pronounced.
Our study took place at Umeå University in northern Sweden, one of six universities with medical schools in Sweden. The education and curricula do not differ in any particular way from other medical universities in Sweden. The specialization pattern is the same as in the rest of the country and in the western world. We have no grounds to believe that the medical faculty in our study differs from those of other western universities. Still one must be cautious when trying to generalize our results, as the sample referred to only one medical school.
When we categorized specialties into groups we classified all operating specialties and also anesthetists as part of the surgical doctor group. Consequently, and in contrast to many reports about surgical specialties, our surgical doctor group included gynecologists, obstetricians, ENT-doctors, ophthalmologists, and anesthetists. This difference must be taken into account when comparing our results with other research. Gynecology and obstetrics are specialties that have many women doctors, in our sample eight out of seventeen. This made the proportion of woman in our surgical group as high as 19 %, almost twice the figure if only general surgery and subspecialties had been considered. Since women assessed gender important to a higher degree than men, the differences we demonstrated between specialty groups might have been larger if we had omitted gynecologists and obstetricians from the surgical specialty group.
Using a continuous VAS might imply problems, since one cannot assume that the distance between points in the middle of the scale line has the same significance as the same distance between points at the ends of the scale. However we did not use continuous values. In our regression analyses and for most chi-2 tests we dichotomized the scales in the middle.
We wanted to assess gender attitudes of physicians engaged in education. We found no gender-attitude questionnaire used before so we created one. We used statements about the importance of gender in professional relationships since we consider finding gender important in relations as one significant indicator of gender awareness and as a prerequisite for introducing and discussing gender issues and applying a gender perspective in medicine. However, it might be argued that doctors' own assessments on the scales do not disclose attitudes and behavior and that our statements and "the importance-of-gender"-scale do not reveal or characterize gender awareness. Other methods, such as open-ended interviews or observations might have been more valid. Still, we argue that the marks on the scales could well be considered to represent gender awareness. We consider it less likely that a person who is interested in and aware of gender issues and the role of gender should find gender of low importance in professional relations. In our open-ended answers there were no reflections about psychosocial conditions or power from low-scoring doctors but quite a few from those with high scores. For example one high-scoring doctor wrote: "Do I take more seriously demands about investigations and treatment from male patients? Do I understand women's symptoms as less important, easier to underestimate? If you score gender of low importance you are most likely not aware of the gender order that influences all human interactions. Several comments on the open-ended answers support this presumption. For instance one low-scoring man wrote: "I like to think that we are all human beings and can understand each other." On the other hand, a person less aware or a person who did not understand the questions might be provoked by the statements and in a few cases handle this by marking high on the scales, trying to be politically correct. However, there were few open-ended remarks about not understanding the questions.
When research focuses differences between women and men there is always the risk of strengthening existing gender-related dichotomies. We do not think of "femininity" and "masculinity" as opposites but rather highly overlapping categories also interacting with other contextual hierarchical categories such as class, ethnicity and age. In our study, for instance, there is an interaction between gender and the medical specialty hierarchy. Still there are unmotivated gender differences on the group level and their consequences have to be addressed and challenged. It is a delicate matter, in research as in everyday life, to find a way to do so, which does not reinforce sociocultural norms of gender.
On findings
Two out of three physician teachers found gender important in doctor – patient encounters. This is promising for the future since it increases the likelihood that gender is recognized as an important factor for health problems and that physicians will reflect upon gendered expectations and preconceptions. It might be due to the last decade's emphasis on women's health issues, to awakening reports on gender-biased treatment of women and men, and to an ongoing discussion about power and gender in consultation research [20, 21].
However, relatively few physician teachers, especially men, and certainly in surgical specialties, assessed gender important in clinical tutoring and in relationships with colleagues and staff. This unawareness is unquestionably worth addressing. Numerous studies illustrate how gender reflects in hierarchies and division of labor in medical schools [8, 11, 22], wards [6, 23], and health care centers [24]. Research also confirm the importance of role models and gender climate for the students' career choice [12, 25] and that both female and male students prefer same-gender role-models [26]. One woman in our study commented like this about importance of gender in clinical tutoring: "When I was a student my role models were almost all men. I had a hard time finding a way to behave as a doctor. There was no one to 'imitate'."
In the following we will discuss how our findings might be related to the distribution of men and women and to the working climate in different specialties.
The proportion of women and men
The variation in gender awareness between different specialty groups partly mirrors the skewed representation of women and men. Women were more likely than men to assess gender important. As a consequence, a higher proportion of women in a specialty group increased the probability of high gender awareness. Still, varying proportions of women were not the sole explanation for differences in specialty groups, as these remained significant also when respondent gender was taken into account.
Gender climate
Apart from the number of women, what might there be in the working conditions of the specialty itself that can explain the different gender attitudes? Family doctors, more than hospital specialists, explore health and illness in a wider psychosocial context, including gender-specific circumstances. There are studies that show that medical students who wish to become family physicians have higher patient-centeredness than those who wish to become surgeons [27]. This might be part of the explanation why family physicians assess gender more important than other specialties.
The surgical specialties assessed the importance of gender low in our study. In what context can this be understood? One well-known opinion is that surgeons operate on sedated bodies, and therefore gender is not on the agenda – under the skin organs are mainly the same! If you think of surgical operations only, these arguments are reasonable, gender is of little importance. However there are more tasks than operations for a surgical doctor.
Another conception is that surgery is not suitable for women. This specialty demands, it is said, action, decisiveness, long working hours and leadership abilities [4, 6]. A common stereotype in society and even among doctors is that "surgeons are kings, they're the real men" [19]. These arguments are extreme and part of a chauvinistic jargon, but never the less they help promote the perception of surgery as a "boys' club" [28] and may cause closure mechanisms for women [14, 18, 29]. A Norwegian study showed that female medical graduates were as likely as male ones to start a working career in surgery but they completed surgical training to a much lesser degree [29]. An analysis of attrition in a general surgery training program in Texas revealed that women were more than twice as likely as men to withdraw [30].
What can be done?
There are ways described to heighten awareness of gender and promote integration in segregated specialties; for example more women teachers [31], courses on gender issues among teaching physicians [32], and development of gender in the curricula of medical schools [33].
Women role models
As role models physician teachers considerably influence the career choice of medical students [19]. Absence or low representation of female role models in surgical specialties has been reported as an important reason why women reject or hesitate to enter these specialties [13, 34, 35]. Seven medical schools in USA, with varying proportions of women surgeons on the faculty, were compared. It was shown that female graduates chose surgery in relation to the proportion of women in the surgical faculty [31]. Considering this, more attention has to be given to the importance of equal representation of women and men as teachers and role models in medical education.
Implementation of gender among teachers and into curricula
Teachers' attitudes, interest and knowledge are crucial factors for implementing gender issues into medical curricula. Gender programs for teaching physicians is a way to encourage them to continuously reflect on their attitudes to gender and how gender affects their professional work and duties [32]. Such programs also help to make gender a question of competence and knowledge. Looking for and trying to eliminate gender-based stereotypes and androcentricity in medical curricula has been described as an accessible way to implement a gender perspective [33]. Experiences show that a strong, clear commitment from the faculty leadership is required to prevent backlash [32].
