Key words
feminisation - gynaecology - obstetrics - career planning - motivation
Schlüsselwörter
Feminisierung - Frauenheilkunde - Geburtshilfe - Karriereplanung - Motivation
Introduction
Even when in antique times and the early middle ages is was possible but not usual
for women to study and to teach in academies, in the following centuries women only
gained access to education when they entered a nunnery or convent [1]. In a few cases they became famous, like Trotula di
Ruggiero, who worked in the 11th century as a practicing physician in the medical
school of Salerno and also contributed to the medical encyclopaedia Practica brevis.
In some cases women even received a doctoral degree, like Marianne Theodore
Charlotte v. Siebold Heidenreich, née Heiland (1788–1859), who in March 1817 in
Gießen/Germany defended a doctoral thesis on “pregnancy outside the uterus and in
particular about abdominal pregnancy” (http://de.wikipedia.org/wiki/Frauenstudium).
In 1898 Ms. Hermine Heusler-Edenhuizen began to study medicine in Germany. In 1903
at the university gynaecological clinic she became the first woman in Germany to
obtain a paid position as assistant physician. In 1909 she completed her specialist
training and became the first consultant for gynaecology and obstetrics in Germany
[2]. However, in general, it only became possible from
1900 onwards for women in Germany to read human medicine at universities [3].
Although men dominated in medicine in the following decades, the situation has
markedly changed in the meantime. In 2006 the proportion of females among the newly
enrolled medical students was 63 % whereas the proportion of female professional
physicians amounted to 40 % [4]. This change has led to
changes in the medical services as it is expected today the women carry their weight
both professionally and at the same time manage their families in private life,
although they most probably receive less social support and relief from their
partners than their male colleagues [2]. Women also appear
to have another motivation for entering the medical profession. They are less
interested in money and power when they strive for a leading position, instead they
rather want to create, to give themselves a reason for being and to increase their
knowledge [4]. Because of these differences the careers of
female physicians follow a different course. They more often take on a part-time
occupation, strive less often for a doctoral degree and markedly less frequently aim
to qualify as university lecturer [4].
An analysis of the German Medical Association dated 2009 revealed clear differences
between the proportions of female physicians in the various specialist fields [5]. In the field of gynaecology and obstetrics the
proportion of females was then 55 %. But, as [Fig. 1]
shows, the developments towards feminisation/feminization, as this process is called
in the current literature, had started already much earlier [6].
Fig. 1 Total number of completed consultant training examinations in the
field of gynaecology and obstetrics subdivided according to gender (source:
German Medical Association).
Already in 2008 a questionnaire was sent to departments of gynaecology and obstetrics
in Germany asking about gender distribution, opinions on this topic and estimations
of its consequences. This revealed that even then more that 80 % of the consultants
and assistant physicians were female and that the proportion of women in job
applications was on average about 90 % [7]. The details of
this questionnaire, however, were never published as an original paper. Because of
the possible importance of gender changes for the field of gynaecology and
obstetrics, the questionnaire survey with additional questions was repeated at the
end of 2011/beginning of 2012.
Material and Methods
Questionnaire
Based on the questionnaire of the earlier survey and the above-mentioned
literature, the original questionnaire with 10 questions was expanded in order
to record aspects of the impact of gender changes, for example, in research
work. For interested persons an example of the questionnaire is available on
request to the author.
The questionnaire was sent by post at the end of 2011/beginning of 2012 to the
senior physicians, head surgeons and medical directors of all 470 hospital
departments of gynaecology and obstetrics in Germany [13]. The completed questionnaires could be returned by post, fax or
e-mail. In March 2012 those departments that had not yet replied were reminded
about the questionnaire. The study was initiated after a positive decision had
been received from the Gießen Ethics Committee (application number 83/2011).
Registering of the data and statistical analyses were performed with the help of
SPSS.
Results
In all, 203 questionnaires were returned and the response rate thus amounted to
43.2 % (203/470). Data from 106 general hospitals, 50 specialist clinics, 31 medical
centres and 13 university hospitals were evaluated. The average numbers of medical
staff members in the individual hospitals were 8.8 for general hospitals, 12.5 for
specialist clinics, 15.1 for medical centres and 27.6 for university hospitals.
Current gender and age distributions
[Fig. 2] shows the proportion of female and male
personnel among the assistant physicians, consultants, senior and head
physicians differentiated according to full-time or part-time positions. Female
staff members dominated in the assistant physician, consultant and senior
physician groups and especially in the part-time group. Female staff members are
only under-represented in the groups of senior physicians and medical directors.
Here their proportions were only 33.5 %, and, respectively 16.5 %. Further
analysis revealed that male physicians in part-time positions were markedly more
frequently found in the departments of medical centres or university hospitals
(32 and 23 % vs. 15 and 8 % in general or regional hospitals;
χ2 = 8.8; df = 3; p = 0.032). The results were independent of the
gender of the medical director of the department or the type of hospital
(ONE-WAY ANOVA). However, there is a trend that the proportion of female medical
directors was higher in the general and regional hospitals in comparison to
medical centres and university hospitals (pχ² = 0.069).
Fig. 2 Proportion of female and male staff members in part-time
positions as assistant physicians, consultants and senior physicians.
[Fig. 3] shows the proportion of female staff members
in the various age groups and illustrates that female staff members dominate in
the younger age groups.
Fig. 3 Proportion of female staff members of various age groups in
various hospitals.
Application situation and subjectively perceived reasons for the
changes
As far as the job application situation is concerned the proportion of
applications by female physicians is estimated to amount to 84.2 %. The type of
the hospital or the question as to whether the medical director is male or
female did not play any role here (ONE-WAY ANOVA). The impression that in the
past years a change in the application situation had occurred in favour of
female physicians was shared by 96.5 % (193/200) of the replies. [Fig. 4] shows the answers to the question: “What
factors do you considered to be responsible for the fact that mostly female
colleagues apply?” From the list of possible answers – that was based on the
results of reports in the literature – low income, loss of face for the medical
profession, and poor career changes were chosen most frequently. Since the
responders also had the chance to present spontaneous answers, the spontaneous
answers are distinguished by the use of colour. Here the responders mentioned
the increasingly female-oriented image of gynaecologists and the working
conditions in hospitals as the main reasons.
Fig. 4 Reasons perceived by the responders for the changes in gender
ratio in the field of gynaecology and obstetrics. Blue – predefined answers.
Green – spontaneous answers under miscellaneous.
The question if the increasing proportion of female staff members has an impact
on the organisation of the clinical routine was answered with yes by 75.5 %
(151/200). According to the estimations markedly less female staff members
strive for a long-term career in the hospital or are interested in taking on a
leading position in a hospital. On the other hand, female staff members are
markedly more often interested in general practice work ([Fig. 5]). 80.4 % of the responders (160/199) found that it was, on
the whole, more difficult to motivate young colleagues of both sexes to take up
a long-term hospital career and/or a surgical career. The majority (63,9 %;
127/194), however, found male and female colleagues to be equally motivated to
take on tasks outside of working hours and this also applied to motivation to do
research (71.4 %; 125/175). The analysis of those who held the opinion that
there were differences between the genders revealed that female staff members
were considered to be only marginally more willing to take on tasks outside of
working hours (52.6 %) whereas male staff members were considered to be more
willing to participate in research (58,9 %). These estimations were also
independent of the gender of the medical director of the department
(χ2 test).
Fig. 5 Estimated proportion of female and male staff members with
various professional targets (mean value and standard deviation).
Organisation of hospital services with full- and part-time staff members and
freelance physicians
The question if the hospital services can be better organised with full-time or
part-time staff members or with a balanced ratio of both was answered by the
majority (64.8 %; 129/199) in favour of full-time staff members. Only 5.0 %
(10/199) preferred part-time staff and 30.2 % (60/1999) answered in favour of a
balanced ratio of full- and part-time staff members. The χ2 test
revealed that this estimation was independent of the type of hospital in which
the medical director was employed, however, there is a trend (p = 0.060) that
female medical directors rather preferred a balanced ratio of full- and
part-time staff members. On average, a ratio of 1 part-time to 2 full-time
positions was considered to be reasonable.
30.3 % (60/198) of all hospitals worked together with freelance physicians. This
proportion was about equal in the various types of hospital, however, only one
of the university hospitals worked together with freelance physicians. Freelance
physicians are significantly more often called in for duty when the proportion
of female consultants in the department is higher (ONE-WAY ANOVA; F = 3.95;
df = 2; p = 0.029). Freelance physicians are predominantly male. On average 0.4
positions (SD = 0.8) in the hospitals were occupied by female freelance
physicians, 1,2 positions with male freelance physicians (SD = 0.9). Freelance
physicians are mostly employed for the night shift (45.6 %; 26/57), but also
often in day and night shifts (38.6 %; 22/57) and only rarely exclusively in day
shifts (15.8 %; 9/57). In this point there were gender-specific differences.
Male freelance physicians are mainly employed for night shift or, respectively
day and night shift work ([Table 1]).
Table 1 Gender-specific differences in the employment of
male and female freelance physicians (χ2 = 11.2; df = 4;
p = 0.025).
|
|
Day-time duty
|
Night-time duty
|
Day- and night-time duty
|
Total
|
|
Female
|
4 (50.0 %)
|
3 (37.5 %)
|
1 (12.5 %)
|
8 (100.0 %)
|
|
Male
|
4 (11.4 %)
|
14 (40.0)
|
17 (48.6 %)
|
35 (100.0 %)
|
|
Both
|
0 (0.0 %)
|
6 (60.0 %)
|
4 (40.0 %)
|
10 (100.0 %)
|
Discussion
The present analysis of the employment situation for female and male physicians in
gynaecology confirms the progression of feminisation in the field of gynaecology and
obstetrics as mentioned in the introduction and that it is more pronounced here in
comparison to other specialties. The decision in favour of the specialty is already
made at the end of the studentship or even earlier and gynaecology and obstetrics as
well as paediatrics are the fields for which women show the highest preference [8]. The present study confirmed the earlier analysis of
2008 [7] and revealed that this process is not only
positively evaluated, since these changes and the increases in the proportion of
part-time staff members have made changes in general hospital organisation
necessary. The majority of responders consider it to be easiest to fill the duty
plans with full-time staff members. It is possible that the potential utility of
part-time positions has not yet been recognised since, according to a study prepared
for the Federal German Ministry for families, seniors, women and youth, the
provision of part-time positions makes it easier for qualified mothers to rejoin the
working population and thus counteract the general lack of qualified workers, the
state also profits from this situation by way of increased income tax and
contributions to social insurance services
(http://www.iza.org/en/webcontent/publications/reports/report_pdfs/iza_report_33.pdf).
Furthermore, it is interesting to note that the viewpoints of male and female medical
directors in the specialty do not differ and also that the type of hospital has
hardly any impact on the answers. The finding that male and female freelance
physicians are assigned different duty periods poses the question if participation
in night shifts or emergency service at weekends is in principle less attractive for
female personnel than for male personnel. This question has not yet been addressed
in research studies. Also with regard to duty times, there are different ideals
between men and women. Only 40 % of the female medical students after completion of
their consultant training strive for a full-time position [8]. The differing professional targets of male and female assistant
physicians after completion of consultant training accordingly make it difficult to
attract the next generation of physicians to enter the surgical fields and thus
undergo training to become highly qualified surgeons and future medical directors.
According to a study by Gedrose et al. [8] the proportion
of men who want to become consultants is 1.5 times higher than that of women and
with regard to positions of medical director even 5.4 times higher. In contrast the
proportion of women who “only” want to work as a consultant in a hospital is 3.7
times higher than that of men and, altogether, 1.3 times more women than men strive
for their own practice as family doctor. In addition, women often do not seek after
further qualifications for various reasons [4].
Since the coming generation of gynaecologists is almost exclusively female and the
male staff members in the consultant stage are generally older, it seems highly
probable that the lack of consultants in hospitals will become more critical. This
holds above all for the employment of full-time staff members. As can be seen from
[Fig. 1] the absolute number of physicians who
complete consultant training has continuously decreased since the end of the 1990s,
which even further intensifies the problem.
A possible scenario for the future is that during the day time patients in office
surgeries and outpatient departments will be managed almost exclusively by female
physicians, whereas in cases of necessary inpatient operations and in the duty times
of the emergency services they will rather encounter a predominantly male team [7]. Whether or not this becomes reality depends on the
extent to which more female physicians can be motivated in future to take up their
careers in hospitals. Since the comparatively lower income and unfavourable working
times in hospitals (night duty) represent reasons to decide against a hospital
career, attempts should be made to effect changes in these areas, in order to
guarantee an adequate personnel situation in hospitals in the future.
One advantage of the developments leading to more female gynaecologists is that
Islam-oriented population groups prefer female gynaecologists whereas most other
women are more concerned about the professional competence of their physician [9], [10], [11]. Another positive aspect is that female gynaecologists are less often
involved in legal conflicts than their male colleagues because they tend to achieve
a better level of communication with their patients [12].
Since female physicians are considered to be equally willing to participate in
research, the gender changes in this particular field should not have any negative
impact.
In summary, the feminisation represents a major structural challenge since women are
markedly less willing to take up a surgical career or to strive for higher positions
than their male counterparts. This study was not designed to examine all background
aspects of this complex topic. Even so, these as well as research on the motivation
of staff members with regard to their professional desires in working life appear to
be very important in order to be able to implement the findings of studies like this
in the creation of an appropriately improved working environment with more
attractive working conditions. This will surely be a most constructive means to cope
with the deficit of qualified personnel.
