Gender and choosing a specialty

Lifestyle, role models, and expectations associated with gender shape our career plans. Alan Salter discusses the implications

Throughout training, medical students encounter a variety of experiences in many specialties. These experiences are crucial because they form the basis for the student's ultimate career choice. This is a decision of great importance, not just for the individual, but for healthcare provision as a whole. But what is it about these experiences that motivates medical students to pursue certain careers within medicine? This article will explore three of the most influential factors, using general surgery and obstetrics and gynaecology to illustrate the broad themes.

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Only one in 500 new male doctors choose to specialise in obstetrics and gynaecology.^w1 One of the main reasons is the perception that this discipline is dominated by women, with male medical students having negative experiences during training. A recent study showed that 42% of all reported incidents of discrimination towards medical students were during obstetrics and gynaecology placements, and the vast majority of these reports came from men.^w2 Many of the complainants cited insufficient contact with patients because patients withheld consent. This refusal to give consent was detrimental to the students' education and also led to them feeling "disappointed and unwanted,"^w1 reducing their motivation to pursue the specialty.

More than three quarters of male respondents felt that their sex was a hindrance in a further study carried out on 250 third year medical students during their obstetrics and gynaecology rotation. This was in stark contrast to female students, of which 67% perceived their sex to have a positive effect.^w3 They also felt that they received more training in speculum examinations, labour management, and independent deliveries, again suggesting that gender and amount of clinical experience are closely linked.

Can you assume that these patients are also uncomfortable about qualified male doctors carrying out intimate procedures, given the extensive research concluding that in general male medical students are made to feel unwelcome by female patients in obstetrics and gynaecology wards? This would strengthen the argument why more women enter the specialty. However, the sex of the doctor is usually not important, despite some studies showing that for psychological or cultural reasons a minority of women do prefer their doctor to be a woman for obstetrical and gynaecological procedures. The main consideration for female patients is to receive a competent and professional service.^{w4 w5} Furthermore, male gynaecologists and obstetricians have an important role as medical advisers, with regard to fathers and male partners being encouraged to become more involved in child care and contraception.

Surgery, on the other hand, is commonly perceived as a male dominated discipline and is often accused of discriminating against women. One study concluded that general surgery has the highest incidence of reported discrimination against women, followed only by emergency medicine and paediatrics.^w2 Female students may feel unwelcome, with the culture and ethos of the specialty being inherently male, perceiving it as an "old boys' club" made up of "surgical personalities."^w6

Few factors involved in driving medical students towards a particular discipline of medicine are more crucial than having a positive role model.^w7 Conversely, a lack of role models can leave medical students without the drive to pursue a career that they might otherwise have been interested in.^w8 To give an indication of their importance, research findings published in BMJ Careers showed that of all the sources of information available to medical students, role models were the most important. Their advice was valued above the views of the students' friends and family and even senior doctors.^w7

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Gender is an important factor when selecting a role model, but more particularly it is a lack of role models of the same sex that may be detrimental.^w11 One problem is the current deficit of female surgeons; female medical students become acutely aware of this during training and this may take away their drive and belief that they can succeed in an area of medicine so dominated by men.^w12 A recent study at Newcastle Medical School showed that fewer than 11% of the female students had a surgical role model. They felt the specialty favoured their male colleagues, a reason for turning their back on a surgical career.^w12 This study also questioned established female surgeons about their career choice and concluded that they were "far more positive" about the profession and not overly concerned about possible bias towards their male colleagues.^w11 This shows that sex discrimination is commonly not a problem for qualified surgeons, but instead there may be real and perceived barriers that female medical students face when considering a career in surgery.

Conversely, fewer men than women are currently entering obstetrics and gynaecology. Although more consultants are men, it is the reduced intake of male junior doctors into the specialty that causes a shortage of male role models for male medical students.^w13 Adverse media attention towards men may also contribute to discourage male students. In the film The Hand That Rocks the Cradle a male gynaecologist sexually assaults a patient, and in the recent television series Bodies male gynaecologists are depicted discussing "freaky fannies."^w1 This negative publicity might leave male medical students with little inclination to enter the field.

Being able to identify with role models is vital to allow students to see themselves in that position. Students may, therefore, be naturally drawn towards a mentor who comes from a similar cultural and religious background. A study carried out in 2004 at a culturally diverse medical school found that more than a third of students believed that cultural similarities were an "important consideration" when trying to find an individual to motivate and inspire them.^w9 A further study carried out at King's College School of Medicine even concluded that students felt that some medical practices were "incompatible" with some religious beliefs.^w10 This indicates that the differences between different cultures and their values may ultimately affect students' choice of role model.

Several studies have recently been carried out to understand what polarises opinions about surgery. What makes some students become so motivated by surgery and what deters others?

In one study, fourth year medical students were asked to rank a series of reasons that could affect their decision to pursue surgery as a career. Of the 18 factors investigated, "prestige" and "career opportunities" were found to be highly positive aspects.^w14 However, "lifestyle, working hours, and doctor-patient relationships" all proved to be negative, indicating that surgery is perceived as a career that is not as attractive, at least in this respect, as other specialties.^w14

Further research concluded that although medical students generally consider a surgeon's salary good, many think that it is not adequate compensation for the high workload. Many students are not willing to work what they expect to be far longer hours to earn slightly more.^w15 Even the introduction of the European Working Time Directive, which will limit the number of doctors' working hours to 48 a week, is commonly not seen as the solution with regard to surgery. One study argued that the measures are "unworkable," with clinical and operating experience reduced by 30-35%, and another study of 284 surgical specialists concluded that 82% felt that surgical training should be exempt because of the "detrimental effect" that they perceive it would have on training future surgeons.^w16

With regard to obstetrics and gynaecology, a total of 1128 graduates were asked over a 10 year period what factors made the specialty appealing or unappealing.^w17 Continuity of patient care scored highly, with the perception that doctors were able to get to know their patients on an individual level and therefore allow empathy to develop.^w17 Although the associated high workload was acknowledged, it was perceived less negatively than surgery.^{w17 w18} This suggests that other factors, such as the professional relationships built between the doctor and patient, are highly influential, and their importance as a motivational factor should never be underestimated.^w17

The ability to control lifestyle is becoming increasingly important in the decision making process of medical students. Three medical schools were involved in a study that analysed the selection of graduates' specialties in the past 10 years. The choices of specialty were divided into those providing "controllable lifestyles," including psychiatry and radiology, or "non-controllable lifestyles," such as surgery, obstetrics and gynaecology, and paediatrics.

The results showed that at all three medical schools the number of students selecting a specialty with a controllable lifestyle significantly increased in the period investigated while intake to the specialties with non-controllable lifestyles significantly dropped.^w19 This evidence is supported by research that investigated whether lifestyle increasingly influences career decisions. Indeed lifestyle and income were shown to have risen in relative importance for medical students, indicating that today's students generally take a broader view and look at their future life as a whole when considering career options.^w18

Many factors at medical school influence students' possible career choices after graduating. So what can be done to correct misconceptions and to motivate?

Part of the solution is to show that it is possible to succeed regardless of gender. To do this, sex discrimination within medical training needs to be tackled. To tackle the inadequate practical training in obstetrics and gynaecology that many male medical students receive because of refused consent from patients and relatives requires that patients and relatives understand the importance of education to all medical students, male and female, if they are to become effective health professionals. Students should never be forced on patients; therefore, a sustained effort is required from students and qualified staff to build good relationships with patients. Indeed, many of the concerns with regard to students witnessing procedures will be eased through effective communication. And this will also help to develop students' interpersonal skills.

For surgery, research indicates that the shortage of female surgeons is at least in part because of outdated myths and stereotypes surrounding the specialty. Dispelling them will help female students to gain the confidence and motivation to pursue a career in this specialty.

The enthusiasm and encouragement from a role model has the ability to give students the necessary conviction that they can succeed in any discipline. Barriers caused by a lack of same sex role models in certain specialties must be recognised and removed. A healthy balance of male and female entrants into all specialties will ensure role models are there for all medical students.

Today's students are increasingly unwilling to pursue a career in a specialty that they consider will result in a poor work-life balance.^{w15 w19} To address this, the positive aspects of these specialties need to be promoted, such as the highly valued working relationships with patients in obstetrics and gynaecology. Although surgery commands good pay and prestige, the long working hours and a lack of contact with patients make it unappealing to some. There is currently no shortage of applicants for surgical posts, but a long term review of working conditions, including effective implementation of measures, such as the European Working Time Directive, is needed.^w16

Despite all of the reasons that motivate students towards different specialties, career choice is exactly that—a choice. Every student will react differently to the influences and experiences that he or she encounters in training, and the factors discussed here will only go part of the way to help make what will ultimately be one of the most important decisions of their life.

Competing interests: None declared.

References w1-w19 are on studentbmj.com.

1. w1. Hamilton A. “GAMMS”: - Go away, male medical student. sBMJ March 2006;14:89 – 132
2. w2. Haivas I. Sexual discrimination and harassment affects career choices. sBMJ June 2005;13:221-264
3. w3. Emmons SL, Adams KE, Nichols M, Cain J. The impact of perceived gender bias on obstetrics and gynaecology skills acquisition by third-year medical students. Acad Med April 2004;79(4):326-332
4. w4. Johnson AM, Schnatz PF, Kelsey AM, Ohannessian CM. Do women prefer care from female or male obstetrician-gynecologists? A study of patient gender preference. J Am Osteopath Assoc August 2005;105(8): 369-379
5. w5. Lund JD, Rohrer JE, Goldfarb S. Patient gender preferences in a large military teaching hospital. Obstet Gynecol April 2005;105(4):747-750
6. w6. Gargiulo DA, Hyman NH, Hebert JC. Women in surgery: do we really understand the deterrents? Arch Surg April 2006;141(4):405-407
7. w7. MacDonald R, Easton G. Impartial careers advice for doctors and medical students. sBMJ July 2003;11:219-262
8. w8. Wright S, Wong A, Newill C. The impact of role models on medical students. J Gen Intern Med January 1997;12(1):53-56
9. w9. McLean M. Is culture important in the choice of role models? Experiences from a culturally diverse Medical School. Med Teach March 2004;26(2):142-149
10. w10. Lempp H, Seale C. Medical students’ perceptions in relation to ethnicity and gender: a qualitative study. BMC Med Educ March 2006;8:6:17
11. w11. Park J, Minor S, Taylor RA, Vikis E, Poenaru D. Why are women deterred from general surgery training? Am J Surg July 2005;190(1):141-146
12. w12. Richardson HC, Redfern N. Why do women reject surgical careers? Ann R Coll Surg Engl. October 2000;82(9):290-293
13. w13. Schnuth L, Vasilenko P, Mavis B, Marshall J. What influences medical students to pursue careers in obstetrics & gynaecology. Am J Obstet Gynecol 2003;189: 639-643
14. w14. Azizzadeh A, McCollum CH, Miller CC 3rd, Holliday KM, Shilstone HC, Lucci A Jr. Factors influencing career choice among medical students interested in surgery. Curr Surg March-April 2003;60(2):210-213
15. w15. Gelfand DV, Podnos YD, Wilson SE, Cooke J, Williams RA. Choosing general surgery: insights into career choice of current medical students. Arch Surg August 2002;137(8):941-945
16. w16. Morris-Stiff GJ, Sarasin S, Edwards P, Lewis WG, Lewis MH. The European Working Time Directive: One for all and all for one? Surgery March 2005;137(3): 293-297
17. w17. Fogarty CA, Bonebrake RG, Fleming AD, Haynatzki G. Obstetrics and gynaecology- to be or not to be? Factors influencing one’s decision. Am J Obstetrics Gynaecol September 2003;189(3):652-654
18. w18. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two U.S. medical schools, 1998-2004. Acad Med September 2005;80(9):809-814
19. w19. Schwartz RW, Jarecky RK, Strodel WE, Haley JV, Young B, Griffen WO Jr. Controllable lifestyle: a new factor in career choice by medical students. Acad Med October 1999;64(10):606-609.

   

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