Paper Plus: Do male medical students get a raw deal in obstetrics and gynaecology training?

This month, Trish Groves takes you through a retrospective study of the clinical log books that students completed during their two or three months' obstetrics and gynaecology training

Why do the study?

The study was done at one London medical school between 1998 and 2002, but it's likely that it represents what was going on in other medical schools at that time, at least in the UK.

The paper was published as a Short Report, a format the BMJ uses to get a straightforward research message across in a short and sweet way. Short reports don't have abstracts, so the box shows an abridged version of the paper.

We are in danger of running out of obstetricians and gynaecologists in the United Kingdom. Fewer and fewer men join these specialties, and, as in most areas of medicine, women doctors in this field tend not to be full timers. At first sight, seeing why a career in obstetrics and gynaecology might appeal to women more than men is not hard. But, if men's reluctance to work in these specialties is all down to lack of general interest and empathy, why is it getting worse? And, anyway, where does that lack of interest come from?

SAMUEL ASHFIELD/SPL

Some women feel uncomfortable with men examining "down there"

The authors of this study had a feeling that men were being put off by their early experiences of the field when still medical students. As they say in the paper, previous research has shown that "students of both sexes have voiced discomfort about what has been perceived as an anti-male environment in obstetrics and gynaecology."

How would you show that men were getting a worse deal than women? Ideally, you would ask the students directly about their experiences through a questionnaire study or some kind of interviews; I will come back to this later.

As the authors had all the clinical logs to hand, they decided to go through them and look for signs that male students were doing less and learning less than women during the few weeks they spent on the obstetrics and gynaecology unit.

Was the study scientifically strong?

Retrospective studies, looking back at information collected for another reason, are not as reliable as prospective studies in which the right information is collected specifically from a set point for an agreed length of time. If you are collecting information for research, you are likely to do it more carefully and completely and to record exactly what you have been asked to. Records kept routinely for other reasons may not be so complete and accurate. The clinical logs used in this study were an important part of the medical students' assessments and were checked and signed by the teachers, so they were probably pretty complete. We do not know, however, how accurate they were.

Something else we do not know is how these men did in other clinical subjects over the same four years. Maybe they were not, on average, as keen or as clever as the women. This lack of context does limit the usefulness and importance of this study.

A strength of this study is the complete sampling: the authors analysed all the students' logs during the four years of the study. If they had missed, for instance, even 10% or 20% of the students' logs, and the missing ones were mostly for women who had underachieved, the poor results for men might be exaggerated.

Another strength is the clear and relevant outcome measures. The term "outcome measure" is more or less self explanatory: it is what researchers reckon (usually in advance) will be the most important type of result. Here the main outcome measures were participation in the core clinical activities of the training and exam results. The authors could have looked at other outcomes, like whether students turned up for teaching, but this probably would not have been so useful or meaningful.

Why does the study matter?

An important thing to understand about this study is that, like all studies that observe something happening, it cannot prove cause and effect. All it can show is what happened. The authors have discussed their findings cautiously, and have not said that clinical performance as a medical student is definitely linked to career choice as a doctor.

This research is a small brick in an important wall. It shows that, in this medical school at least, involvement of male students in obstetrics and gynaecology training was worryingly lacking. Saying at the end of a paper, "More research is needed," is too vague and unhelpful, but this research needs following up with further studies.

What kind of studies would help? Qualitative studies could be particularly useful. Qualitative methods involve collecting, analysing, and interpreting freely expressed views. It would have been good to know what the men and women in this study actually felt and thought while they were delivering the babies and examining the women.

Several readers sent rapid responses to bmj.com about this paper. Looking at these is always worthwhile, if you have time, because they usually contain a great mixture of expert and practical comment. One doctor argued that a qualitative study would have been better than this retrospective survey of clinical logs and wondered whether the apparently small differences between the performance of the men and women really meant anything (the paper was looked at carefully by a statistical reviewer before publication, and actually the numbers do stand up). This doctor also wrote that the reasons behind a falling number of men considering a career in obstetrics and gynaecology could have many causes, including the effect of the Calman reforms (changes in higher specialist training in the UK introduced in 1996), the increasing fear of litigation within the specialty, the normal pendular swings in fashionable specialties, the increasing prominence of women within medicine, and the potential disturbing problem of sex discrimination against men within their department. All of these interesting points could also lead to further research.

BSIP, LECA/SPL

Students have described an anti-male environment in obstetrics

Another rapid response said, "As a female patient, I have often wondered how men can successfully become gynaecologists when they have absolutely no physical or emotional concept of the pain involved in conditions such as dysmenorrhoea or endometriosis. Many women find it difficult enough explaining problems ‘down there' to another woman, but many would find it impossible to discuss gynaecological problems with a man. I think that if male obstetric and gynaecology students were given the opportunity to learn from women who have suffered in the past from gynaecological disorders, they might learn and understand ways in which they could improve their communication with women." But this prompted a rather sarcastic response: "[This patient] makes a strong case for a man gynaecologist being less able to understand women's problems than a woman gynaecologist. This is self evident and by the same token I suggest that recruitment to geriatrics is restricted to elderly doctors and enrolment into the speciality of psychiatry confined to those who are frequent contributors to BMJ rapid responses."

Also, a group of doctors from Hong Kong responded with some data from their own medical school showing that female students scored significantly better than male students in surgery. But this weaker academic performance by male students in surgery has not resulted in a reluctance of male students to choose a career in surgery. Career choice, they say, is probably influenced by multiple factors like lifestyle of the specialty, duration of training, and perceived career prospects. Which are again good points.

Why did I choose to tell you about this study?

Mainly because it asked a useful research question, used an adequate method, and got interesting answers. But also because we all love reading about ourselves. And because I thought this might get you writing to the studentBMJ.

Trish Groves, senior assistant editor, BMJ
Email: tgroves@bmj.com


studentBMJ 2004;12:89-132 March ISSN 0966-6494