Gender awareness among physicians – the effect of specialty and gender. A study of teachers at a Swedish medical school

Study design

Sample

Procedure

Questionnaires, covering letters ensuring confidentiality, and numbered and pre-stamped envelopes for the answers were distributed by post. When response had been registered in the original name list the envelope was destroyed and the questionnaire was given a new number. Thus no response can be identified with a person. The non-respondents received one follow-up letter.

The Umeå Clinical Research Ethics Committee approved the study.

Analysis

The marks on the VAS were translated into scores between 0 and 100, the higher the figure, the more the respondent agreed. A summary variable was created by adding the figures from each of the five statements, getting a scale ranging from 0 to 500. This summary variable was labeled "importance-of-gender "-scale, and the score was assigned to characterize the degree of gender awareness in professional relations.

For the statistical analyses the scales of the outcome variables were dichotomized in the middle, as agreeing/disagreeing (>50/≤ 50) for the five gender attitude statements, and as high/low (>250/≤250) for the "importance-of-gender "-scale

Bivariate associations between outcome variables (including the " importance-of-gender "-scale) and respondent specialty and respondent gender respectively, were assessed by chi-2 tests. P-values <0.05 were considered statistically significant. Multivariate logistic regression analyses were used to adjust for respondent sex, age, academic degree and years in the profession. A 95% confidence interval (CI) was used. The analyses regarding specialty were performed also for men and women separately. SPSS 8,0 was used.

Demographics and dropouts

Low gender awareness in the teaching/tutoring situation

Table 3 shows how physician teachers agree to the five statements. They agreed least with the importance of gender in relationships with students and most with the importance of gender in consultation. This pattern was consistent in all three specialty groups and among male as well as female physicians. The male physician group, in contrast to the female one, also assessed gender of relatively low importance in contact with colleagues and staff.

Low gender awareness among surgical doctors

Figure 1a shows the dispersion of ratings on "importance-of-gender"-scale as divided into quintiles. There were no family physicians scoring in the lowest quintile. The distribution was similar for each statement. Table 3 (column "all respondents") illustrates that significantly higher proportions of family physicians and non-surgical doctors, compared to surgical doctors, agreed to the importance of gender in their professional relationships. For example, on "importance-of-gender "-scale 76 % of family physicians and 67 % of non-surgical doctors scored high (>250) compared to 51 % of surgical doctors. When adjusting for respondent gender, age, academic degree, and years in the profession the difference between specialty groups remained statistically significant for all outcome variables except for statement 4. The results for the "importance-of-gender"-scale are seen in table 4. The odds for a family physician to score high on "importance-of-gender"-scale were almost three times higher, and for a non-surgical doctor almost two times higher when compared to a surgical doctor.

Differences between specialty groups only among men – lowest gender awareness among male surgical doctors

Figure 1b and 1c shows the dispersion of ratings on the "importance-of-gender"-scale as divided into quintiles for men and women separately. There were almost no women scoring in the lowest quintile. The distribution was similar for each statement. Table 3 (columns "total") demonstrates that women physicians assessed gender important to a higher degree than men did on all variables. The adjusted OR for a woman compared to a man to score high on " importance-of-gender "-scale was 2.4 (table 4).

Analyzing each outcome variable, men and women separately, demonstrated that differences between specialty groups reached significance among male physicians only (table 3). In the multivariate regression analyses these differences among men remained statistically significant (exemplified in table 4, columns "men" and "women"). The odds for a male family physician to assess gender important were three times higher, and for a male non-surgical doctor two times higher when compared to a male surgical doctor. Age, academic degree, and years in profession were not related to the outcome variables in the multivariate logistic regression analyses (table 4).

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].