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|A Life, not a Wife|
Ms Jo Wainer, Dr Lexia Bryant, Professor Roger Strasser, Mr Dean Carson, Ms Kelly Stringer
Monash University Centre for Rural Health
Box 424 Traralgon, Victoria 3844
There is a seachange happening in medicine. For the first time in medical history in Australia the 1999 national student intake into medicine has a majority (50.8%) of women.
Medicine, and rural medicine in particular, used to be an almost exclusively male occupation. Now forty percent of young doctors taking up rural general practice are female. This change has profound implications for rural medicine.
This paper explores some of the dynamics and possible consequences of this change. It will outline some of the differences in the way women and men practice, assess this against the available data on rural practice, and consider the impact on the younger generation of male doctors of the presence of women in equal numbers in the student and graduating cohorts.
Several previous papers (Wainer 1998, Carson 1998, Thompson 1997) have analysed the evidence for an emerging cultural change within the rural medical workforce. Studies published by the Australian Medical Workforce Advisory Committee 1998, Australian Institute of Health and Welfare 1996, and the Department of Human Services and Health 1995, have documented the increasing participation by women in the medical workforce, and Tolhurst (1997) has drawn out some of the tensions experienced by female rural doctors. The Australian College of Rural and Remote Medicine (1997) has included issues for female practitioners in its foundation documents, and authors such as Pringle (1998), Bryant (1997), Wear (1997) and Quadrio (1991) have addressed the general question of women in medicine. This paper will not retrace this ground, but rather consider how things got to be the way they are, and draw out the implications for rural practice.
How things got to be the way they are
It has been well-established that in order for the minority culture to be heard, members need to form at least one third of the group to avoid being silenced or subverted. It seems to have taken more than one third in medicine, which may reflect its conservative, hierarchical nature and the high regard with which the profession is held in the community.
There is a flood of change sweeping through the world. In Australia this is reflected in the changing roles of women (but not yet men) and in substantial and continuing change in health service provision. Both of these changes impact on medicine and the medical workforce. Individuals, medical schools and medical colleges can resist these changes, attempt to influence the changes, or lead the change, but they ignore it at their peril.
Medicine is well-placed to resist change because of its role in saving lives, and in intervening at critical moments of need and vulnerability for its patients. Medicine rests on the solid foundation of positivist epistemology which has held the status of assumed truth in the Western world for several centuries (Sinclair 1997. Wertheim 1997, Kuhn 1970). Medicine is based on science, and science has claimed to hold the truth. Sinclair (1997) describes how the precision of the language of medical science, and the use of the question and answer pedagogy serves to overcome linguistic and cultural barriers, which is a testimony to the efficacy of medical training and the power of its culture.
Control of truth is established and maintained by a self-referencing and reinforcing system of selection, rewards and punishments which values only that which supports orthodoxy, and silences or punishes or excludes all else. Medical orthodoxy and command of agreed truths has been possible because of the socialisation of relatively homogenous populations in a relatively stable society, where education and the accompanying authority belonged to the few, who defined reality for the many. Doctors could define health and illness because they were educated and their patients were not.
Today scientific truths are being questioned, as is the very existence of the notion of a single truth (Lindenbaum & Lock 1993, van Manen 1990, Irigaray 1985, Daly 1978).
International organisations are now recognising that twenty-first century science will demand a twenty-first century work place where women and men from diverse regions of the world are fully and equally empowered to do their best for the world's future (Consultative Group on International Agricultural Research 1999).
The biggest challenge to the prevailing social order is the release of the productive and creative energy of women from the tyranny of reproduction. For the first time in three thousand years women are beginning to take their place in the public arena and to contribute to the public discourse about truth and the proper order of the cosmos. The truth which women experience is different from the truth which has dominated the public domain up until now (Belenky et al 1997, Gilligan 1982). The challenge facing all of us is to incorporate the knowledge and culture and experience of women into thought systems and knowledge structures, such as medicine, which have been developed without their input.
Medicine and the feminine
In the past the requirement for women who wanted to become doctors was to give up their identity as female. Women's health theorists have pointed out that excluding women from medicine has had profound consequences. One of these consequences is the assumption that the male body and experience is the norm, and the female is aberrant. Within medicine there is a secret understanding that the normal body, in fact the normal person, is male. This is not articulated but is a hidden assumption behind the construction of the medical curriculum, the definition of illness, the setting of research priorities, and behind therapy.
Dorothy Broom ( 1991) points out that many attributes of illness are the same as those socially attributed to women, and contends that while medicine is male, illness is female. She has suggested that the very concept of a 'healthy woman' is.. a contradiction in terms'
Bryant (1997) has noted that “For women’s voice to be heard there needs to be an atmosphere of safety and respect and an absence of the traditional methods of silencing”. She lists four ways in which the voice of women has been silenced in medicine. These are medicalisation of women’s health issues, ignoring what women say, labelling what women say as ‘emotional’, and oppression by the power of the stronger voice.
But women, after all, are not a minority, and ultimately cannot be silenced.
Rural medicine is the boundary for change
Rural medicine is the point in the profession where the changes stemming from the presence of women will be felt first and most fully. Rural medicine is almost the only branch of the profession with a shortage of applicants. The specialist medical colleges have no need to adapt their rules and training procedures to ensure that they reflect and draw on the best that the whole of the young doctor cohort can offer because of a shortage of positions.
Rural medicine is different. It needs more recruits than apply for positions. As a consequence it has to appeal to as wide a range of young doctors as possible. Half of the graduating doctors are women, and this makes it imperative that rural medicine structures itself to incorporate the world view and experience of this half of the graduating cohort.
The Australian College of Rural and Remote Medicine (ACRRM) has already recognised this. Its Prospectus (ACRRM 1997) includes explicit discussion of women’s different ways of knowing, and its Fellowship criteria include contributions to the profession and community which reflect the way women work.
There is a parallel between the dialogue within rural medicine and between women and medicine. Both groups (rural and women) are saying they do medicine their own way. Their way converges with the prevailing medical culture in core skills and knowledge, and differs in context and priorities. Both are struggling to be heard by the urban malestream. Of the two dialogues, there is more certainty that the women will prevail in changing medicine to include them, than that rural will. Rural, after all, does not have the required one third which would protect it from being silenced.
It is ironic that we should be witnessing a serious discussion about incorporating the culture of women into medicine within the rural context. The Australian rural culture is manifestly masculine (Dempsey 1992) and in many ways antithetical to professional women (Wainer 1998). Rural communities can be dangerous places for young women in particular (Somerville 1996) and some of the young women recruited into medicine from rural communities have been so angered by their experience of rural culture that a lot of trust-building will have to occur before they will go back (personal communication, 6th year medical students at Monash University). Discussion with female medical students from Melbourne and Monash Universities documented instances of hostility toward them as females during their rural terms which will make it hard for them to consider rural practice.
These medical students suggested there was a need to have a part of the course which shows young women how to cope with comments such as the ones they received and said they do not know whether this happens in the country in a worse form than in the city, but if it does they do not want to expose themselves to it.
Women and men practice medicine differently
There is now good evidence from Australia and other Western countries that while all doctors have a shared body of knowledge, core competencies and professional ethos, there are different preferred working styles which can be identified as favoured by women and men. Because the current system of Western medicine has always been practiced by men, there has been an unacknowledged convergence between “medicine” and “male-practiced medicine”. It has taken the presence of women in sufficient numbers to begin to assert their own style to raise the possibility that there is a way to practice medicine which reflects their different priorities and values.
Research has demonstrated that in general, men value psychosocial aspects of health less than women do, and tend to operate more strongly from a biomedical rather than biopsychosocial paradigm. They place less emphasise on wholistic care, practice less preventive medicine, deal with one problem at a time rather than the many which patients present with, do less counselling, and prefer to carry out procedures rather than deal with mental health issues. Patients are much less likely to present to male doctors with issues of interpersonal violence or sexual assault. (Wainer 1998). These different priorities are reflected in different styles of practice (AMWAC 1998.4) and combine with different expectations from patients (Brown et al 1997, Bundrock 1996, Rogers 1996).
Canadian work with women doctors quoted by Rourke, Rourke & Brown (1996) suggested that women and men might practice medicine differently because women are more involved with the ‘art’ of medicine, and men more captured by the politics, economics and technology.
Most doctors attending workshops conducted in Sydney and Dublin in 1998 (Bryant & Wainer 1998, Wainer, Bryant & Strasser 1998) agreed that women and men practice medicine differently. The women know this and the men tend to contest it.
Do women and men practice medicine differently ?
The doctors concluded that men need to be more flexible and women need to set limits, and that medical students and young doctors should be taught about this.
In addition, women and men have different patterns of relationships with their careers and family life, and this will influence the way they practice medicine. Women have cyclical and interrupted careers which reflect their other productive roles as members of the community and their families, and particularly as parents. Women and men in medicine have parallel work experiences until the women have babies, at which point the women have to find other ways to work (Carr et al, 1998)
The new generation in rural medical practice
Strasser (1992) found there are significantly fewer female general practitioners in small town rural practice (19%) as compared with suburban general practice (32% female) in Victoria and this still applies today. Twenty percent of general practitioners practice in rural areas and only one quarter are women.
The comparatively small proportion of rural doctors who are female is changing. Among the younger doctors in rural and remote practice (age less than 35), forty percent are women.
Table 1: Percentage of female practitioners in metropolitan, provincial and rural areas by age group (Australian Institute of Health & Welfare, 1994)
The National Rural General Practice Study (Strasser, Kamien, Hays and Carson 1997) identified that young women are an increasing component of the rural medical workforce, although they are not going into rural practice in the same proportion as they are going into urban practice. It also found that male and female rural doctors agreed on the importance of some aspects of rural practice, and disagreed on others.
The Study was able to compare the importance attributed to various aspects of rural practice on the basis of sex and age cohorts. It identified that some of the difference between the sexes was also reflected in a difference between younger and older doctors. So that it seems that issues and values identified by the women (who are predominantly in the younger age cohort) are to some extent being taken up by their young male colleagues.
The Study found that young doctors and female doctors agreed that hours worked each week, an ability to practice public health, the availability of continuing medical education in a rural setting, the ability to use a wide range of skills, and the availability of leave and professional support were more important to them than they were to the survey respondents as a whole.
The women ( but not younger doctors in general ) also highlighted the importance of the availability of non-medical education, other health and human services, an environment which supported the practice of preventative medicine, access to health care for their own needs and the availability of specialists.. These may be the issues which the younger generation take up next.
Female rural doctors in the Study rated the ability to carry out in-patient care and access to hospital facilities, as well as an opportunity to use a wide range of skills, as less important than their male colleagues did. This does not imply that these issues do not matter for female rural doctors, rather that they do not assume the same importance as they do for male doctors. This finding is consistent with the findings of Campbell’s study (Campbell & Strasser 1997) that thirty three percent of doctors in Victorian rural towns without hospitals were women, compared with only seven percent of doctors in rural towns with hospitals.
While the differences noted here are differences of relative rather than absolute importance, they may still offer important explanations for the difficulties in attracting female doctors to the country. The areas where there are differences in magnitude appear to be those areas which have been identified as distinguishing rural practice from urban practice. For example –
Details of the emerging rural medical workforce culture have been documented by Carson (1998). He concluded that there is evidence beginning to emerge that young male practitioners, who have learnt their medicine alongside an equal number of female students, are adopting many characteristics traditionally associated with the female practitioner.
It seems that what comes naturally to the young women (good communication skills, wholistic approach, balanced life-style, rejection of the ethos of overwork, and co-operation) is now becoming available to the young men, and the male students are beginning to pick up some of the women’s language.
Thomspon (1997) suggests that younger general practitioners have identified overwork as a problem of rural medicine. His survey of RACGP Rural Training Stream Registrars in South Australia found that few of the Registrars saw burnout as an issue which might lead them to leave rural practice because, as they put it “we are acutely aware that burnout is a major issue for rural GPs and we will not let it happen to us – we ourselves will determine our workload.”. Like Carson, he found that Registrars have different values from existing rural doctors, and that they place a higher value on family and lifestyle.
The young women and some of their male colleagues are out there, doing the work and quietly reprioritising rural medical practice to include the things they value.
Existing rural practice models do not encourage or even permit some of these different practice characteristics. The effect may be that female practitioners and young doctors will continue to challenge the traditional structures of rural practice. Communities, medical colleges in addition to ACRRM, training programs, and individual practices need to make the decision to permit and encourage a range of ways of practicing rural medicine, and to promote this decision to the next generation of young doctors.
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