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Gender inequalities in the medical profession: are there still barriers to women physicians in the 21st century? ^夽

Pilar Arrizabalaga

, Rosa Abellana

, Odette Vi ˜nas

, Anna Merino

, Carlos Ascaso

aNephrologyandRenalTransplantService,InstitutClínicd’UrologiaiNefrologia,HospitalClínic,Barcelona,Spain

bBiomedicalInvestigationInstituteAugustPiiSunyer(IDIBAPS)

cDepartmentofPublicHealth,UniversityofBarcelona,Barcelona,Spain

dImmunologia,CentredeDiagnòsticBiomèdic,HospitalClínic,Barcelona,Spain

eHemotherapyandhemostasis,CentredeDiagnòsticBiomèdic,HospitalClínic,Barcelona,Spain

a r t i c l e i n f o

Articlehistory:

Received4November2013 Accepted6March2014 Availableonline2June2014

Keywords:

Medicalstaff Hospital Genderidentity

a b s t r a c t

Aim:Toanalyzewomen’sadvancementcomparedwiththatofmenandtodeterminewhetheradvance- mentinhierarchicalstatusdiffersfromadvancementintheprofessionalrecognitionachievedbywomen from1996to2008.

Methods:AretrospectivestudywascarriedinHospitalClínicinBarcelona.Weanalyzeddataontempo- raryandpermanentpositions,hierarchy,promotions,specialty,age,andsexamongtheparticipants.

Results:Thefemale-tomaleratioamongtraineemedicalspecialistswashigherthan1throughoutthe studyperiod.Aftercompletionofspecialisttraining,theproportionofwomenwithtemporarycontracts morethandoubledthatofmen.Lessthan50%ofwomenachievedpermanentpositionscomparedwith 70%ofmen.Forpermanentnon-hierarchicalandhierarchicalpositions,thefemale-to-maleratiograd- uallydecreasedfrom0.5tobelow0.2.Althoughmorethan50%oftraineespecialistswerewomen,the numberoffemaleconsultantsremained25%lowerthanthatofmen.In2008,thefinalyearofthestudy, thepercentageofwomenwhohadachievedthegradeofseniorconsultantwasone-thirdthatofmen (29.5%ofmenvs10.9%ofwomen;p<0.0001).

Conclusions:Thesignificantdifferencesinmedicalpositionsheldbymenandwomenillustratethe‘leaky pipelinephenomenon’,consistingofadisproportionatelylownumberofwomenachievingleadingmedi- calpositions.Thefullpotentialoftheincreasingnumberofwomenphysicianswillnotbereachedwithout continuingeffortstoimprovethehospitalmedicineenvironment.

©2013SESPAS.PublishedbyElsevierEspaña,S.L.U.Allrightsreserved.

Desigualdadesdegéneroenlacarreraprofesional:¿aúnexistenbarrerasalos médicosmujeresenelsigloXXI?

Palabrasclave:

Médicos Hospital Género

re s um e n

Objetivo:Analizarelavancedelasmujeresencomparaciónconloshombresenlamedicinayanalizarsi elavancejerárquicodifieredelavanceensureconocimientoprofesionalenelperiodo1996-2008.

Métodos:EstudioretrospectivoenelHospitalClínicdeBarcelonamedianteelanálisisdedatosrelativosa posicióntemporalypermanente,jerarquía,carreraprofesional,especialidad,edadysexodelosmédicos.

Resultados:Laproporcióndemujeresyhombresentreresidentesfuesuperiora1duranteelperíodode estudio.Finalizadalaresidencia,laproporcióndemujeresdoblalaproporcióndehombresentreposi- cionesmédicastemporales.Menosdel50%delasmujeresencomparaciónconel70%deloshombreslogra posicionesmédicaspermanentes.Laproporcióndemujeresyhombresentreposicionespermanentesno jerarquizadasyjerarquizadasdesciendegradualmentedesde0.5hastallegaramenosde0.2.Apesar dequemásdel50%deresidentessonmujeres,ellasalcanzanelgradodeconsultor25%menosquesus colegasmasculinos.En2008,elúltimoa ˜nodelestudio,unterciodelasmujeres(10,9%)encomparación conloshombres(29,5%)alcanzóelgradodeconsultorsenior(p<0.0001).

Conclusiones: Diferenciassignificativasenposicionesmédicasentrehombresymujeresconfiguranel fenómenoconocidocomo“tuberíasconfugas”’,queconsisteenunnúmerodesproporcionadodemujeres quelleganaposicionesmédicasprincipales.Elpotencialdelafeminizaciónmédicanosealcanzarásin esfuerzosdemejoraambientalcontinuaenlamedicinahospitalaria.

©2013SESPAS.PublicadoporElsevierEspaña,S.L.U.Todoslosderechosreservados.

夽 Subsequentlytothedevelopmentofthestudyin2013,and,afterincludingonegradeofprofessionalcareerpromotion,60%ofthe2-consultantsandmorethan82%of theSeniorconsultants,thetwohighestgrades,arestillmen.Oralcommunicationin“LasituacióprofessionaldeladonametgeaCatalunya”.June14,2014.ColegioOficialde MédicosdeBarcelona(bookinpreparation).

∗ Correspondingauthor.

E-mailaddress:parriza@clinic.ub.es(P.Arrizabalaga).

http://dx.doi.org/10.1016/j.gaceta.2014.03.014

0213-9111/©2013SESPAS.PublishedbyElsevierEspaña,S.L.U.Allrightsreserved.

Introduction

Thepresenceofwomeninthepracticeofmedicinegoesback totheancienttimes.Somewomenwerecanonizedinthe10thand 11thcenturiesfortheircareduringtheEuropeanplagues.From the13thcenturytothe18thcentury,healingwomenwerecon- sideredaswitchesandforbiddenaccesstothemedicaleducation ofthetime.Thisbanlasted untilthefirsthalfofthe19thcen- tury,therebyjustifyingtheinferiorityofwomen.Itwasnotuntil theendofthe19thcenturythatwomenwereabletohaveaccess totraining inmedicine.InSpainwomen didnothaveaccessto highereducationuntilthe20thcentury,andfullincorporationinto themedicinebeganinthe1970swiththeirincorporationintothe worldofwork.

Overthepastfourdecades,thenumberofwomenphysicians hasincreasedfromlessthan10%ofthemedicalstudentsandless than15%ofpracticingphysicianstobeingthemajorityofnewgra- duatesinmedicineand morethan 40%ofpracticing physicians inWestern countries¹.The proportionof women among Span- ishcollegiatephysiciansasawholehasrisento93.4%incontrast withmenwhohavebarelyincreased12.6%from1994to2011². Womenphysiciansrepresentmorethan70%ofthepractitioners inprimaryhealthcareandmorethan40%intheCatalanhospital setting³.

Althoughthefeminizationofmedicineinthedevelopedworld has risen dramatically, women are under-represented in the advancedechelons,witharemarkablelackoffemaleleadersreach- ingtherankoffullprofessor^4,5.Studiesontherepresentationof womenamonghighermedicalstaffpositionsundertakeninthe UnitedStatesemphasizethepotentialconflictthatmayensuefrom beingbothaphysicianandamotherwhichappearstobelessa causeofdissatisfactionthantheopportunityforadvancementand practicecontrolintheircareers^6,7.IntheUnitedKingdom,since theearly1990s,theprobabilitythatfewerwomenthanmendoc- torsreachedthecategoryofconsultantappearstobeassociated withapreviouspart-timecontractwiththeBritishNationalHealth Service⁸.InSpain,theadvanceofwomenphysiciansintheircareers isunknownduetoreluctancetoprovidesuchdata.

WeobtaineddatafromtheHospitalClínicofBarcelona(HCB)and analyzedtheproportionofwomenandmenholdingtemporary, permanentandmanagerialmedicalpositions,aswellasthegender ratiosforeachofthepromotiongradesoverthepasttenyears.The structureandmedicalorganizationoftheHCBhasbeenreported previously⁹.

Thisarticleevaluatestheadvanceofwomenincomparisonwith meninmedicineanddetermineswhethertheadvancebetween thehierarchicalstatusandtheprofessionalrecognitionachieved bywomendiffers.Weanalyzedthedisparitybetweenwomenand menphysiciansalongtheformalhierarchalpromotionprocessand therecognitionofprofessionalcareerpromotioninthe21^stcen- tury.

Methods

Aretrospective longitudinaldescriptive studywas designed.

Data related tothemedical workforcewere obtainedfromthe HumanResourcesDepartmentoftheHCB.Allphysiciansworking atthehospitalinOctober1996wereincluded,usinginformation basedongender,age,medicalspecialtyandprofessionalstatus.

Calculationofthesamplesizewasnotdonesincethesamplesize wasthetotalnumberofphysicians.

Variables

Thetwo mainvariables studiedwerethe hierarchicalstatus andthegradeofprofessionalcareer.Thefollowingvariableswere

studied:permanent,temporaryandtrainingmedicalpositionsand datarelatedtomedicalexecutivemanagementhierarchyandpro- fessionalcareer(PC)promotionwithinthepermanentpositions.

Regardingthe category of executivemanagement hierarchy, dataonthesectionorunitchief,departmentandinstitutechairs;

grade attained on PC promotion: specialist, senior specialist, consultantandseniorconsultant;specialty,sexandagefrom1996 to2008werecollected.

Feminizationwasevaluatedasfemininityindex.Thisisamea- sure of frequent use and simple interpretation and defined as thepercentagerepresentingwomenwithrespecttothetotalof thevariable.Theratiobetweenthenumberofwomenandmen inpermanentmedicalpositions,andinhierarchalpositionsand PC promotion within the permanent positions was calculated.

Accordingthefemininityindexineachspecialty,weclassifiedthe specialtiesintothreegroups:i)feminisedspecialties,iftherela- tionshipwasmorethan1;ii)parityspecialties,iftherelationship was1;iii)andmasculinisedspecialties,iftherelationshipwasless than1.

Statisticalanalysis

Thedemographic characteristicsofthemedicalworkforceby yearofstudywereexpressedasabsolutefrequencies.Thefem- ininityindexrelatedtopositionsofhierarchywasplottedusing a bar graph. The Chi-square and the Fisher exact tests were used to compare differences in the proportion of the type of employment status–permanentand temporary-and hierarchal positions held by men and women. The association between age,hierarchalpositionand sex wasanalysedwiththeANOVA test.

Theratioofthenumberoffemaleversusmalephysicians,fem- ininityindex, and relationto thegrade of PC wasrepresented byabargraph.AChi-squaretestwasusedtodeterminetrends related to hierarchal positions and grade of PCover thestudy period.Atimeseriesanalysiswasnotusedbecausethenumber ofyearsstudied-orperiods-wassmall.AChi-squarewasused forlineartrendinordertostudytheincreaseinthenumberof womenphysiciansforeachdegreeofpromotionduringthestudy period.

Results

Thestudy wasmadeup of695physicians, 216women and 479men.Professionalsbeginningworkfrom1996and2008were alsoincluded,raisingthenumberofphysiciansstudiedto1135, 492 women and 643 men at the end of the study period in 2008.

Thenumberofwomenphysiciansholdingatrainingmedical specialistpositionattheHCBhasbeengreaterthan50%since2000.

Thus,theratioofthefemininityindexamongthetraineeswasfrom 1.05in2000to1.14in2008.Aftercompletionoftheirspecialist trainingwomenheldsignificantlymorethandoublethetempo- rarymedical positionsthanmen,withlessthan50% ofwomen comparedto70%ofmenphysiciansachievingpermanentpositions (p<0.001)(Table1).

Childpsychiatry and anaesthesiawerefeminisedspecialties.

Dermatology and laboratory (clinical chemistry, microbiology, pathological anatomy, genetics and immunology) specialties appearedtoshowgenderparity.Inninespecialties,themeanratio ofthefemininityindexwaslessthan0.59to0.34,andfinally,7 specialtieswerestronglymasculinised,with24%(neurology)to3%

(traumaandorthopaedicsurgery)ofthesespecialtiesbeingcom- prisedofwomen(Table2).

Table1

DemographiccharacteristicsofthemedicalworkforceattheHospitalClínicfrom1996to2008.

Year Totalnumber doctors

Permanent

Numberandpercentage betweenbrackets

Temporary

Numberandpercentage betweenbrackets

Chi-square^a p Trainee

Numberandpercentage betweenbrackets

Men Women Men Women Men Women

1996 695 348(72.7) 120(55.6) 25(5.2) 16(7.4) 3.449 0.063 106(22) 80(37)

2000 808 367(71.5) 136(46.1) 16(3.1) 22(7.5) 16.270 0.000 130(25.3) 137(46.4)

2002 928 400(70.8) 178(49) 39(6.9) 45(12.4) 17.031 0.000 126(22.3) 140(38.6)

2004 949 401(69.9) 177(47.2) 39(6.8) 39(10.4) 11.684 0.001 134(23.3) 159(42.4)

2006 995 401(68.5) 185(45.1) 45(7.7) 68(16.6) 33.569 0.000 139(23.8) 157(38.3)

2008 1135 451(70.1) 229(46.5) 45(7) 96(19.5) 57.815 0.000 147(22.9) 167(33.9)

aPermanentversustemporarypositions.

Hierarchalpromotion

The ratios between the numbers of women versus men among permanent medical positions were around 0.5 (0.45- 0.60)fornon-hierarchalpositionsandmarkedlydecreasedbelow 0.2 for hierarchal positions throughout the study. According to data from 2006, this ratio slightly rose to 0.3 for section or unit heads, the lowest hierarchal position, but no trend to an increase was observed in any hierarchal position (p>0.05) (Fig.1).

Amongthedoctorswithhierarchalpositions(sectionorunit chief,departmentandinstitutechairs),theproportionofwomen was8.1%,5.8%,7.3%,9%,10.2%and8.3%versustheproportionof menwhich was24.4%,20.5%,21.4%,22.5%,23.3%and 20.08%in 1998,2000,2002,2004,2006and2008,respectively(p<0.001).

Thedifferenceinageofinstituteand departmentchairswas 13.13±0.82years(mean±standarddeviation)whilethatforsec- tionorunitheads was8.33±0.66years, beinggreaterthanthe remainingnonhierarchalpermanentmedicalpositions(F=266.53, p<0.001)withnosignificantdifferencesrelatedtohierarchalpos- itionsbetweenthetwogenders.

Table2

Femininityindex-ratiobetweenthenumberofwomenandmen-inpermanent medicalpositionsinthespecialtiesthroughoutthestudyperiod.

Femininityindexmean FeminisedSpecialties

ChildPsychiatry 2.077

Anaesthesia,painandtransplantcoordination 1.984

Pharmacy 1.840

Specialtieswithgenderparity

Dermatology 1.112

ClinicalLaboratory/Biochemistry 0.814 MasculinisedSpecialties

Paediatrics 0.595

MedicalImaging 0.565

Emergencymedicine 0.523

ObstetricsandGynaecology 0.461

RheumatologyandRehabilitation 0.438 PsychiatryandClinicalpsychology 0.417

HaematologyandOncology 0.391

OphthalmologyandOtolaryngology 0.386 EvaluationsupportandpreventionUnit^a 0.340

Neurology 0.239

Nephrology,RenaltransplantandUrology 0.214

CardiologyandRespiratory 0.188

GastroenterologyandHepatology 0.082

InternalMedicine^b 0.080

GeneralSurgeryandsubspecialties^c 0.065 TraumaandOrthopaedicSurgery 0.039

aIncludingpharmacologyandinternationalhealthresearch.

bIncludinginfectiousdiseases,autoimmunediseasesandcriticalcaremedicine.

c IncludingCardio-vascular,oral,andplasticsurgery.

Professionalcareerpromotion

Promotion for women in comparison with men physicians under the PCsystem followed a differentpathway throughout thestudy.Malephysiciansdevelopedhomogeneousprogression throughthe4successivegradesofPCwithalmosthalfofthose applyingforanygradeofpromotionachievingsuccess,whilesig- nificantlyfewerwomendoctorsattainedthegradeofconsultant:

49.5% versus 37.4% (p=0.01), respectively. The ratios between womenversusmenamongpermanentmedicalpositionsdidnot showequityforalmostanyofthegradesofPCpromotion.There wasnosignificantchangeinthenumberofwomenspecialists(Chi- square=0.64,p=0.423).Ontheotherhand,thenumberofwomen inseniorspecialist(Chi-square=34.19,p<0.001),consultant(Chi- square=52.29,p<0.001)andseniorconsultant(Chi-square=12.79, p<0.001) positionsincreasedsignificantlythroughoutthestudy period (Fig. 2). However, in 2008, the last year of the study, one-third of women (10.9%) compared to men (29.5%) (Chi- square=32.68,p<0.0001)reachedthegradeofseniorconsultant.

1997 0,0

0,1 0,2 0,3 0,4 0,5 0,6

2000 2002

Year of study

Feminity index

2004 2006 2008

Hierarchal position

Non-hierarchal position Section or unit chief Department chair Institute chair

Figure1.Femininityindexaccordingtothehierarchalpositionthroughoutthe yearsofthestudy.

1997 1998 1999 1996

0,0 0,2 0,4 0,6 0,8 1,0

2000 2001 2002 2003 Year of study

Feminity index

2004 2005 2006 2007 2008

Grade of professional carrer Specialist Senior specialist

Senior Consultant Consultant

Figure2.Femininityindexaccordingtothegradeofprofessionalcareerpromotionthroughouttheyearsofthestudy.

Otherwise,morethan65%oftheconsultants(p<0.0001)andmore than85%ofseniorconsultants(p<0.0001)continuedtobemen.

Discussion

Thisstudyshowssignificantdifferencesbetweenwomenand men holding permanent medical positions. These differences progressivelyincrease in relation tothe grade of advancement overhierarchalpromotionaswellasoverPCpromotion.Therefore, when male physicians apply for promotion, female physicians havenotyetobtainedapermanentposition,delayingthetimefor promotioncomparedtothatofmalephysicianswithsimilaryears ofprofessionalexperience.Thesedifferencesinpermanentmed- icalpositionsheldbymenandwomenarethebasisofthe‘leaky pipelinephenomenon’,indicatingadisproportionatelownumber ofwomenachievingleadingmedicalpositionsandadvancement inPCpromotion.AlthoughthegradeofPCpromotionforwomen physicians slightly increased throughout the study, the results showthatprofessionalpromotionisharderforwomenthanfor meninmedicine,andaddweighttoearliersuggestionsderived inapreviousone-yearstudyperformedintwoCatalanhospitals⁹.

Thedifferencebetweenwomen andmenphysicians inrelation to PC promotion agrees with the growing gender gap in the startingsalariesofphysiciansafteradjustmentsforhoursworked ininternalmedicine,paediatrics,familypracticeandemergency medicine^10,11.

Someauthorshavepointedoutthatagenderrolecontributes tothetrendsinthepopularityofspecialtiesforwomen.Academic achievementandthedurationofmedicalstudiescouldinfluence specialtypreference¹².Beingfemaleandhavingaparentingeneral practicewasfoundtobepositivelyassociatedwithapreferencefor acareeringeneralpracticeandpaediatrics.Amongfirst-yearstu- dentsandinthosewithnoclerkshipexperience,femalegenderwas positivelyassociatedwithapreferenceforpsychiatry.Infact,the threespecialties-primarycareinfamilymedicine,paediatrics,and psychiatry–areallrelatedtohigherimportanceontheperspective- takingscaleoftheempathymeasurethatisafemalebeliefwithin theculture.Amongstudentswithclerkshipexperienceandfinal- yearstudentsthedurationofstudywaspositivelyassociatedwith apreferenceforacareerininternalmedicine.Surgicalspecialties continuetobechosenthreetimesmorefrequentlybymenthanby womendoctors.

Personality factors had many indirect influences upon sex.

A questionnaire conducted among 2867 British medical stu- dents was assessed by path analysis factors which could be groupedasfourtypes ofmotivations- helping people,respect, science and indispensability- indicated the attraction of differ- entaspectsofmedicalpractice¹³.Helpingpeoplewasparticularly related to agreeableness and interest in general practice, pae- diatrics, geriatric medicine, and with none of the specialities.

Respect wasrelatedtoa surface approachto learning,and sci- encebeing more opentoexperience and related to pathology.

Indispensability wasrelated tohigher strategic learning scores, lower fantasy and stress scores and interest in surgery and acute medical specialties. Therefore, feminization of the medi- cal professionsuggeststhe needfor measuresto stimulatethe interestoffemalemedicalstudentsinthesurgicalfieldinorder to optimize human resources in the current health care sys- tems.

Therapidincreaseofthenumberoffemalemedicalstudents in Spainoverthepast three decadesis nowbeingreflected by thegrowingproportionsof women in allmedical specialties¹⁴. Nonetheless,accordingtodatafromourhospital,mostmedical specialtiesstillshowapredominantnumberofmenincompari- sonwithwomenamongthepermanentspecialistpositions,with thedifferenceinfavourofmenbeingevengreateramonghigher hierarchalpositions.

It hasbeen suggested that theslowercareer progression of womencompared withtheirmalecolleaguesisa cohorteffect;

thereforewomenwillincreasinglyassumeleadershiprolesasthey maturein themedical establishment.In fact,theproportion of womenamongconsultantphysicians,thetoplevelintheBritish NationalHealthServicehospitals,rosefrom19%in1995to25%in 2004¹⁵andreached28%in2007,withover40%ofallwomencon- sultantsconcentratedinfourspecialties:anaesthetics,paediatrics, pathology,andpsychiatry¹⁶.Theanalysisofourdatain2008,the lastyearofthisstudy,showedthatone-thirdofwomencompared tomenphysiciansreachedthegradeofseniorconsultant,thetop levelofthePC.

The reason for the continuation of the“leaky pipeline phe- nomenon”inthe21^stcenturyremainsunclear.Onemayarguethat thesignificantlackofequityshownbyourdataimplythatwomen havealowerleveloftraining thanmeninhospitalmedicine.A lackofhighprofileacademicduetolesserscientificoutput^17–19 couldbethe reason whyfewer women reachthehighest pos- itionsofleadership.Womenphysicianstendtobemorecareful thanmeninaddressingemotionalissuesandassessingthesocio- culturalaspectsthatgobeyondobjectivepathology;theyspend moretimeoncareandthepromotionofagoodrelationshipwith theirpatients²⁰.Therefore,womenmayspendlesstimeonresearch thanmenduetotheconflictinthepriorityoftheirdedicationto thepatientfortheirprofessionalsatisfaction.Thus,gendercould playaroleincurricularevaluationbecausetherulesandmerits helpingmenprogressmaynotbeasappealingorevenfeasiblefor women.

In the recent survey among 800 Catalangeneral practition- ersaformalhierarchalpositionwasheldby18.7%ofthewomen compared with33.8% ofmenstudied.It isofnotethat women accountedfor8pointsmorethanmen,28.8%versus21.3%,while theproportionofmenwithahierarchalpositionwashigherthan thatofwomen,withnorelationshipwithage,seniorityortypeof institution²¹.

Differencesin gender values and ambitions have been sug- gestedasreasonswhyfewerwomenthanmenreachthehighest levels of medical positions. The predominant responsibility for child care is still borne by women and the issue of balanc- ing career and family seems to be of paramount importance for women physicians in Europe^22,23. The reason why fewer

womenreachtheechelonsof formalmedicalhierarchymaybe due to their resignation because theydo not want to assume such roles, but hardly explains the weak progress of recogni- tion under the PC system shown by ourresults. Gender roles contribute to unconscious assumptions that have little to do with the actual knowledge and abilities of an individual and negatively influencedecision-making when itcomestopromo- tion.

Undoubtedlywomeninmedicinehaveforgednewpathways toallowphysicianstobalancecareerandfamilyresponsibilities.

Medicalcentreshaveaccommodatedtheneedsoftheirworkforce andadjustedpoliciestoallowwomentoworkparttime.Buttime- to-tenurerulesandfamilyindicatethatabalancebetweenwork andlifemustbeappliedtobothsexesinordertopromoteequal- ityofopportunitybetweenmenandwomenandthatnotpenalise womeninthiscareer.

Our studyhad some limitations.This wasconductedin one workplaceandthus generalizabilityoftheresultsmust becau- tious.Wecannotexcludethepossibilitythataproportionofwomen haveleftthecompetition.Furtherdeterminationoftheunderlying factorsforthedifferencesobservedbetweenwomenandmenin advancedmedicalpositionsarerequired.Nonetheless,ourstudy hasthestrengthofbeingthefirsttoobtainandanalysedataabout theadvancesachievedinthecareersoffemalephysiciansovera periodof13years.

In ameta-analysisEagly²⁴ emphasizedtheability ofwomen encouragingleadership.Womentendtodemonstratemoreinter- estthanmeninthepersonaldifficultiesofteammembersbeyond thestrictlyoccupational,whichisusefultoavoidinterferenceinthe workplace.Womenfocustheirworkmoretowardstheresultsof theteamthanontheirownprestigewhichmaystillbeperceivedas

“risks”associatedwithanychangeinservicedeliverywhichcould endangerthepredominantmedicalpowerwithintheinstitutional model²⁵.

Differencesinworkandopportunities,hierarchicalandinsti- tutionalsupport,lackoffemalementormodelsandinstitutional genderbias maycontributetotheslowcareerprogression and limitedvisibilityofmedicalwomenwithrespecttotheirmalecol- leagues.Despitethefeminizationofmedicine,womenconstitute theworkforce,whereasthetasksofmanagementanddirectionof the“productionprocess”continuetobeinthehandsofmenas occursintheclassicalgeneralsocialscheme.

Scarcity ofwomen insenior positions inevitablymeansthat theirindividualandcollectiveopinionsarelesslikelytobevoiced indecision-makingprocesses.Ifwomeninmedicinearenotseen tobesucceedingintheircareers,youngwomenwillnotbemoti- vatedtoachievetopcareers.Ithasbeendemonstratedthatpolitical andgovernmentinitiativesalonearenotsufficienttoadvancethe positionofwomeninmedicine^26–28.Strategiestoaddressgender inequalitymustarisefromtheinstitution:attitudesoftheman- agers, visible commitment,provision of supportduring and on returnfrommaternityleave,and,finally,encouragingwomento applyforappointmentsandpromotions.

Genderequalityhasanimpactonthewayhospitalmedicine followsthefeminizationofmedicinebecausegenderbarriersare nolongeracceptedbywomenaseasilyaspriortothe21stcentury.

Thefullpotentialoftheincreasingnumberofwomenphysicians willnotbeachievedwithoutcontinuingeffortstoimprovetheways inwhichtheyareeducatedandtrainedinbecomingspecialistsand thementoringwomenreceive.Thefeminizationofmedicinewill involveacontinuousrenewalofthehealthsystemthatshouldbe foreseeninhumanresourcespolicies.

Editorofthearticle CarmenVives-Cases.

Whatisknownaboutthetopic?

Thenumberofwomenhasincreasedfromlessthan10%

ofthemedicalstudentsand lessthan15%ofphysiciansto beingmajorityamongnewgraduatesinmedicineandmore than40%ofphysiciansinWesterncountriesoverthepastfour decades.

Thereislittleknowledgeontheadvancement ofwomen physiciansintheircareersduetoreluctancetoprovidesuch data.

Whatdoesthisstudyaddtotheliterature?

Whereaswomenamongtrainingphysiciansholdupto50%

permanentpositions,hierarchalandinternprofessionalpro- motionissignificantlylowerthanthatofmen.Strategiesto addressgenderinequalitymustarisefromtheinstitution.

Contributionsofauthorship

P.Arrizabalagaconceivedanddesignedthestudy,acquiredthe datafromtheHumanResourcesDepartmentsinHospitalClínicand didthedataanalysisandthedraftingofthemanuscript.R.Abellana designedthestatisticalanalysis,collaboratedintheinterpretation ofdatawithrevisionofthetextthroughoutitspreparation.O.Vi ˜nas andA.Merinoworkedontheselectionoftheresultsforpublication withintellectualcontributions.C.Ascasoprovidedthedefinition andusageofthefemininityindex,collaboratedasstatisticalcon- sultantandin thediscussionof theresults,and didthecritical revisionofthemanuscript.Alltheauthorshaveapprovedthefinal versionofthemanuscript.

Funding

ThisarticlewasmadethankstofundingfromtheAgènciade Gestiód’AjutsUniversitarisideRecerca(AGAUR)delaGeneralitat deCatalunya,(N2007RDG00008).

Conflictofinterest

Nonedeclared.

Acknowledgements

TheauthorsacknowledgetheassistanceofLauraCorredoirafor thestatisticalanalysisandsupportinthevisualrepresentationof thedata,andtheassistanceofMercéVigerforthePubMedsearch strategy.

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