Saturday, March 12, 2011

A Subject That Takes Up a Lot of Room in My Brain

The Changing Face of Medical Care
March 7, 2011

The plastic surgery unit at Chelsea and Westminster Hospital welcomes patients in a spare waiting room with padded blue chairs and a bright yellow lane of stripes running along the floor like a street intersection.

It is the crossroads for Dr. Shweta Aggarwal, a plastic surgeon in training, who summons her patients for consultations ranging from burns and breast reconstruction to tummy tucks and implants.

Across the Western world, it is her generation of young women that is transforming the once-male bastion of medicine, swelling medical schools and flocking to the front lines of primary care.

They wear the stethoscopes and wield the scalpels in increasing numbers: women make up 54 percent of physicians below the age of 35 in Britain, 58 percent in France and almost 64 percent in Spain, according to the latest figures from the Organization for Economic Cooperation and Development, which tracks the trend in more than 30 countries.

“It’s like social work — to be able to do something with meaning, to be able to help someone while you are doing a job,” said Dr. Aggarwal, 36, the mother of a year-old child and a holder of dual Indian and British citizenship. She graduated from an Indian medical school but said she chose to study plastic surgery in London because of better training opportunities and the flexible scheduling that it offered.

As the world marks a century of International Women’s Day on Tuesday, women in the medical field can pride themselves in having made huge strides.

Over the past three decades, the proportion of women in medical schools has risen in Europe, the United States, Canada, Australia and South Africa. Most medical schools in England have more female students than male, with almost 56 percent, or 5,170, in the entering classes last year. At the current rate, the Royal College of Physicians expects women to make up the majority of all doctors in Britain by 2017.

But the steady advance of women, generally lauded in the West and increasingly seen everywhere, has also left the medical establishment in Britain and other countries fretting about the future, provoking studies and sharp debates about the trend.

Will the feminization of medicine lead to losses in income and status? Will countries need to train and pay for more doctors to make up for maternity leaves, part-time schedules and job sharing, which are often sought by female doctors trying to balance work with their personal lives?

Some experts are intrigued by another question: Are female doctors offering lessons in more effective care-giving?

The National Clinical Assessment Service, which tracks and evaluates patient complaints in the United Kingdom, is urging further study of the differences. It issued a report last month that reviewed suspensions over the past nine years of general practitioners, a field that women will dominate by 2013. The figures, adjusted to reflect the composition of the total work force, showed that men were five times more likely to be suspended than women for patient complaints. They were also more likely to be the subject of complaints by patients.

“The $64,000 question is, Why?” said Dr. Alastair Scotland, the medical director of the assessment service. “We have some untested theories that women consult in different ways. They are less likely to take risks than men. Someone who is cautious and risk-averse is more likely to seek help and to talk through issues with their colleagues, interacting as a team.”

Some German researchers also detected signs of a female factor in treatment. A 2008 study in the Journal of Internal Medicine found that patients with Type 2 diabetes responded better under the care of women, showing more improvement in blood pressure and cholesterol counts and taking their medicine doses. The researchers said that female doctors were more likely to communicate well and involve patients in their own care.

The Medical Women’s Federation, the largest organization of female doctors in Britain, is reluctant to draw differences between the care-giving techniques of female and male physicians and resisted proposals at its own conferences to declare there are too many women in the field. In the view of the leadership, women are not taking over, but catching up.

“All doctors have changed the old patriarchal style of ‘I am the all knowledgeable doctor, and I tell you what to do,”’ said Dr. Fiona Cornish, a general practitioner who worked part-time while raising four children and is the president-elect of the M.W.F. “If one had to make a generalization, women are more cautious. Women spend longer talking to the patient and listening. If you listen well, you’ll get the right story.”

Some patients still have qualms despite the good bedside manners. “Men find many G.P. practices very female environments, for example, a waiting room full of women’s magazines and posters about women’s health issues,” said Colin Penning, a spokesman for Men’s Health Forum, a charity based in London that raises awareness about male health issues. He added that female doctors often practice fewer hours, making it difficult for men to break away from work to see them.

The first surge of female medical students in Britain started in the 1980s, and by 2007 young women accounted for 57 percent of entering medical students. By 2010, the numbers started leveling at about 56 percent. More men were pursuing careers in information technology, engineering and mathematics — fields where the ratio of women has barely changed, hovering at less than 20 percent, a Royal College of Physicians report about women and medicine says.

Experts suspect that men are drawn to higher-paying fields, like computer engineering, which requires less training.

Money and the gender shift trouble Dr. Bernard Ribeiro, the former president of the Royal College of Surgeons of England and a new British lord. At a conference of the Medical Women’s Federation in 2009, he raised the issue of whether there were too many female doctors.

Dr. Ribeiro said in an interview that he still believed that work needed to be done to save “the lost tribe of medicine,” which he described as men who are attracted to more lucrative ventures like the financial services industry.

“Medicine has moved from being a vocation, which is sad,” Dr. Ribeiro said. “Smart kids coming out of school are looking at medicine as any other job — what are the prospects and the terms of remuneration.” Dr. Ribeiro said research was needed to explore why boys are outpaced by girls at earlier levels of school.

Among female doctors who have finished their training in Britain, 44 percent are pediatricians, 49 percent are in public health and only 8 percent are surgeons, according to the Royal College of Physicians report. Within surgical specialties, women are drawn to delicate work such as plastic surgery as opposed to orthopedic surgery, which requires heavy lifting.

“Women choose specialties that deal more with outpatients and less emergencies because the jobs are more plannable, while men choose specialties that are techie and exciting,” said Dr. Jane Dacre, a physician and vice dean of University College Hospital Medical School, who also notes that young male and female doctors share the same desire to reduce hours.

Typically, female doctors find it harder to rise to leadership positions in hospitals and medical schools. They are also more likely to make less than their male colleagues. The British Medical Association detected a salary gap of £15,000, or $24,000, in 2009 between male and female doctors in the National Health Service.

With many women seeking part-time work, new organizational challenges are emerging, including the possibility that some countries will need more doctors. France and Germany, for instance, have warned about future shortages, as older male doctors retire and are replaced by women working part-time. The German Medical Association has called it an urgent threat, particularly in rural areas. In France, some doctors are trying to set up a pilot project for a “maison médicale,” or House of Medicine, where part-time doctors can parachute in to offer different disciplines.

“It’s difficult to get the work-life balance completely right. It’s part of the challenge,” said Dr. Beryl De Souza, a plastic surgeon at Chelsea and Westminster Hospital and a mother of three who works with Dr. Aggarwal and two other female surgeons, Dr. Effie Katsarma and Dr. Sherine Ravendran.

Dr. Aggarwal, the plastic surgeon, relied on her parents who came from India to help care for her baby. Dr. De Souza, whose husband is also a surgeon, also turned to her parents. Other women patch together strategies, sharing jobs and working less than three days a week. Some hospitals offer child care centers — not a solution for doctors on call late at night.

Late last year, the junior doctors conference of the British Medical Association called on the national Department of Health to start preparing for a demographic transformation by creating a regional system of job pooling.

Dr. Eleanor Draeger, deputy chair of the conference, who is training in genitourinary medicine in London and a mother of two, recalls that when she had her first child in 2007, four of the 11 trainees in her rotation left on maternity leave. In a rotation of doctors in a pediatric unit she knows, nine of the 10 women working there became pregnant last year and announced plans to go part-time after giving birth.

Most studies issued in England show that women ultimately return to work, increasing hours as their children grow up. As her four grew older, Dr. Cornish, the president-elect of the Medical Women’s Federation, did just that.

“I think most places are more family friendly now. When I started, I would be terribly nervous to say that I need to leave to go to a Nativity play. Now what really amuses me is that the men are announcing with great pride that they are going to a Nativity play,” she said.

But as female doctors pursue careers — and care for children and parents — some researchers in Spain and in France have found that female physicians are more vulnerable to the combined pressures of career and home life.

Last year, a study by the European Union of more than 3,000 French doctors found that women in particular had a higher burnout rate than men in emergency care. A lack of teamwork among medical staff members contributed to the meltdowns, according to the report.

“When you rush from one patient to another, you feel guilty for your family life. When you don’t feel that work is properly done, you feel guilty,” said Dr. Madeleine Estryn-Béhar, one author of the report and a physician with the Hôpital Hôtel-Dieu in Paris. “Social support protects from burnout. People who work well together have less problems.”

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