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Gender Roles, Medical Practice Roles, and Ob-Gyn Career Choice a
Nancy G. Kutner PhD & Donna Brogan PhD a
b
Department of Rehabilitation, Emory University
b
Rollins School of Public Health, Emory University Published online: 26 Oct 2008.
To cite this article: Nancy G. Kutner PhD & Donna Brogan PhD (1990) Gender Roles, Medical Practice Roles, and Ob-Gyn Career Choice, Women & Health, 16:3-4, 99-117, DOI: 10.1300/ J013v16n03_06 To link to this article: http://dx.doi.org/10.1300/J013v16n03_06
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Gender Roles, Medical Practice Roles, and Ob-Gyn Career Choice: A Longitudinal Study
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Nancy G. Kutner, PhD Donna Brogan, PhD
ABSTRACT. This paper discusses follow-up data from physicians who were studied ten years earlier when they were medical students. Seventeen physicians were practicing ob-gyn, and 57 of the physicians studied had been interested in an ob-gyn career when they were medical students. At Time 1, women were more likely than men to be strongly interested in ob-gyn, but they were no more likely than men to be ob-gyn physicians at Time 2. The desire to have a surgical specialty was much more important to men than to. women practitioners. Men ob-gyn practitioners were significantly more traditional in their sex-role outlook as medical students than were either women practitioners or women who had been stron ly interested in the field but did not enter it. The data suggest t at women ob-gyn physicians are more likely than their male peers to be egalitarian in their relationships with female patients.
t
Increasing the number of women physicians practicing gynecol-
ogy and obstetrics has been viewed a s an important goal in efforts to Nancy G . Kutner is affiliated with the Emory University Department of Rehabilitation Medicine, 1441 Clifton Road N.E., Atlanta, GA 30322. Donna Brogan is affiliated with the Emory University Department of Epidemiology & Biostatistics, 1599 Clifton Road N.E., Atlanta, GA 30329. This research was supported by a grant from the National Center for Health Services Research, HS01924, and by a 1985-86 grant from the Emory University Research Committee. This article is a revised version of a paper presented at the Society for the Study of Social Problems Annual Meeting, Atlanta, GA 1988. We would like to thank Brooke Fielding and Betty Roberson for assistance in data analysis. Q
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increase the responsiveness of the medical care system to women's health needs (Edwards, 1974; Jensen & Miklovic, 1986; Zambrana et al., 1987). Often, the only primary care contact for women is their contact with their gynecologist/obstetrician.' The percentage of physicians in this specialty who are women is relatively small, 18.5% (American College of Obstetricians and Gynecologists, 1989). A marked increase occurred in the number of women receiving graduate training in ob-gyn between the mid-1970s and the mid1980s, but the number of women medical students selecting this field peaked in 1975-79 (Weisman & Teitelbaum, 1987). This paper discusses longitudinal data obtained from physicians during their medical school training and ten years later when they were practicing physicians that (1) highlight continuing concerns for women interested in working in this specialty of medicine and (2) identify differences in women and men practitioners' early sex-role attitudes that have potentially significant implications for health care delivery to female patients. More generally, these data address issues in the relationship between gender roles and doctor-patient roles that deserve continued research attention (Zambrana et al., 1987; Martin et al., 1988).
OBSTETRICS/GYNECOLOGYAS A CAREER CHOICE Specialties of medicine can be grouped into three broad categories: (1) specialties entered disproportionately by women, such as pediatrics and public health; (2) specialties entered disproportionately by men, such as general surgery; and (3) specialties entered at approximately equal rates by women and men (Kutner & Brogan, 1981a). Ob-gyn until recently illustrated the latter category. Among active physicians as of December, 1976, for whom information was available to the American Medical Association, 6.5% of women and 6.4% of men were practicing this specialty (Goodman, 1977). Reasons that have been emphasized for the historically lower representation of women in ob-gyn as coinpared to pediatrics, both of which might be considered "natural" areas of interest for women, include male dominance in fields that involve technology (Epstein, 1971; Lorber, 1984) and surgery (Weisman et al., 1980; Ramos & Feiner, 1989) and the disconcerting sexist biases that women may
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encounter in ob-gyn training (Campbell, 1973; Scully & Bart, 1973; Weiss, 1978; Leserman, 1981). The women's movement stressed the importance of women taking control of women's bodies (Ruzek, 1978), and women medical students in the 1970's began to include ob-gyn in their career plans more often than had their predecessors (Weisman & Teitelbaum, 1987). The result was a marked increase in the number of women electing to receive graduate medical training in this field. Women were 23% of ob-gyn residents in 1978 (Braslow & Heins, 1981), but were 45% of ob-gyn residents in 1986 (Klass, 1988). As of 1983, over half of the obstetricians in the U.S. under the age of 30 were women (Zambrana et al., 1987). However, it will be important to monitor future trends in medical students' choice of this field. Concerns about malpractice suits and the typically demanding work schedule associated with an ob-gyn practice may deter young physicians, both men and women, from pursuing this specialty. A committee appointed by the Institute of Medicine recently concluded that medical professional liability adversely affects the delivery of obstetrical services, limiting the provision of care to highrisk women (Rostow & Osterweis, 1989). The attraction of a career in ob-gyn may be further diminished by the prospect of "physician overload." A 1987 AMA survey found that ob-gyn physicians worked more hours than the "average physician" and that the average work week for ob-gyn residents approached 90 hours (Page, 1989). The changing demography of the medical profession, with growing percentages. of women and minorities, is increasingly evident, and Relman (1989) believes that women's greater representation in medicine has profound implications for our health care system. Women continue to choose primary care specialties more often than do men, and greater emphasis on primary care is anticipated as government and private insurers seek to control costs while ensuring general access to good-quality care. Obstetricslgynecology, a primary care specialty, has been a popular career choice for women in recent years. Whether this will necessarily mean a qualitative difference in the delivery of care in this field is a separate question, however. Women physicians may be better able than men to empathize with the reported experiences of their female patients, but
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their communication style and treatment recommendations, like those of their male colleagues, may be shaped primarily by training received in a traditional medical education system. In the view of one woman physician, "given the fine mesh of the admissions sieve and the rigorous training to which medical students are exposed, female and male physicians are more likely to resemble each other on a number of important dimensions than they are other members of their own sexes" (Eisenberg, 1989:1544). More research on the interaction of gender role influences and outlooks among studentphysicians, and acquired views of appropriate norms governing medical practice, is clearly needed. GENDER AND THE PRACTICE OF MEDICINE
In the early 1970s, observers began to speculate that the increased entry of women into medicine had significance that extended beyond a change in the demographic composition of the profession. They postulated that influences stemming from the women's movement would affect the attitudes and values demonstrated by new female entrants into medical school. For example, Knight (1973:189) speculated that " . . the changes in society involving women will surely influence their life and work in medical school and in the practice of medicine," and Levine et al., (1974) suggested that recent societal changes would bring a "new kind" of female medical student into the profession. Our own research (Kutner & Brogan, 1980a), investigating reasons for the choice of a medical career among students who entered medical school during the academic years beginning 1972-1975, found that women and men students were equally attracted by positive characteristics they attributed to medicine (e.g., interesting, fulfilling work), by a perceived congruence between medicine and their own self-image, and by the job flexibility and job security they felt to be associated with a career in medicine. Moreover, all of these reasons for becoming a physician seemed more important to women than a wish to correct'a sex imbalance among physicians or a wish to "prove they could do it." Women more often than men, however, emphasized their desire to undertake the challenge posed
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by a career in medicine, possibly reflecting the positive sanctioning of women's achievement in professional fields that emanated from the feminist movement of the early 1970s. Earning a high income was not as often a top priority to the women as compared to the men whom we studied, and women were more likely than men to express a preference for salaried positions as opposed to traditional fee-for-service orivate oractice-two characteristics which are viewed as useful in physicians' successful adaptation to the structural changes occurring in American medicine (Relman, 1989). We found that women medical students viewed their career choice very seriously. Many had turned to medicine because they considered it a field in which they could obtain a higher sense of achievement and satisfaction than they had formerly experienced in traditional female activities, e.g., nursing, social work, raising a family. Some of these women were significantly older than their peers, and their new career choice appeared to represent a deepseated commitment. It has been suggested that women possess greater sensitivity to social issues than do men, which will, over time, affect the medical profession's position on matters such as national health insurance (Heins et al., 1979; Relman, 1980), or at least its willingness to experiment with different economic arrangements for medical practice (Relman, 1989). The most widely shared prediction about the effects of increased numbers of women in medicine has been that women physicians will give the profession an increased capacity for demonstrating caring attitudes toward patients (e.g., Elliott, 1981; Zeno, 1982), which may be "more valuable in healing than all the medicine in the textbooks" (Keeler, 1980:8). It is unfair to attribute the qualities of warmth, nurturance, compassion, and empathy exclusively to women, but these qualities are usually more emphasized during females' than males' socialization experiences. Women have more cultural freedom to be expressive. Women may possess more effective interpersonal skills and may pay more attention than do men to relationships with their patients, which is regarded as a necessary requirement for "humanizingM health care. Leserman (1981) found that more women than men valued being
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open and honest with patients and communicating health information to them. The potential contributions that women can make to the practice of medicine are especially important in the practice of gynecology and obstetrics. Women may be more motivated to develop a practice that reduces the traditional fragmentation of women's health care into separate obstetric care, family planning, abortion services, and gynecological care (Wallace, 1980). If women physicians are less fee-oriented than men, Ceasarean sections and hysterectomies may be less often recommended for patients. Women physicians may communicate more fully with their patients, and it would be desirable if women patients were encouraged to participate more actively in decision-making about their treatment and care; feminist health education has as its goal a true consumer-informed base of information from which preferences and choices can emerge that fit the needs of individual women (Whatley, 1988). As Zambrana et al., (1987) point out, the traditional medical care model is far from a collaborative relationship between doctor and patient; the patient is usually expected to accept the doctor's recommendations. This expectation is further reinforced if the patient is a woman, because traditional sex-role stereotypes emphasize passivity and acceptance as appropriate feminine characteristics. In general, however, women's sex-role attitudes are more liberal than are men's (Brogan & Kutner, 1976). We decided, therefore, to examine the sex-role orientation of women and men students interested in pursuing ob-gyn as a career, and the relation of sex-role orientation to the actual career choice characterizing these same individuals ten years later. In a longitudinal study design, we collected followup data in 1985-86 from women and men physicians whom we had interviewed when they were medical students in 1975-76, in order to identify their actual career patterns. In this paper, we discuss the "fit" between women and men medical students' expressed career interests in ob-gyn and these same individuals' decision to practice ob-gyn. The first wave of data: obtained in 1975-76, coincided with a time period in which the enrollment of women in U.S. medical schools had dramatically increased2and there was heightened sensi-
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tivity to women's special health needs. Support groups for women medical students helped to,reinforce this sensitivity and to encourage women to consider entering ob-gyn (Kutner & Brogan, 1981b).
METHODS
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Sample In academic year 1975-76 (Time I), 169 women and 169 men who were enrolled in the two medical schools in Georgia (one private, one public) were interviewed for a study comparing motivations for entering medicine, specialty and practice plans, and differential medical school experiences of women and men (see Kutner & Brogan, 1980a, 1980b, 1980c, 1981a, 1981b). The investigators contacted all women who were currently enrolled at the two schools; 97% of the women at the private school (n = 71), and 90% of the women at the public school (n=98) were actually interviewed. For purposes of comparison, an approximately equal number of men students were also interviewed from each institution, using stratified random sampling of men enrolled in the first-, second-, third-, and fourth-year classes. Response rates for the men were similar to those for women. During academic year 1985-86 (Time 2), followup information was requested by mail from the 298 women and men we had previously interviewed who were alive and for whom current addresses were available. Most of these individuals had graduated from rnedical school during 1976-79, and by the fall of 1985 they had been in practice for two to five years. Completed questionnaires were returned by 126 women physicians and 132 men physicians (86% of the women and 87% of the men from whom information was requested). Respondents who are the focus of this paper are 37 women and 28 men physicians for whom both Time 'I and Time 2 data were obtained and who at Time 1 expressed interest in an ob-gyn career and/or at Time 2 were practicing ob-gyn.
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Instrumentation
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The data collection instrument was a structured interview schedule when respondents were medical students, and interviews averaged one hour in length. The questionnaire mailed to physicians ten years later was short (2 pages), and a stamped, addressed return envelope was included to further encourage respondents' cooperation in the followup study. Variables and Measures
Specialty Interests and Specialty Choices. Interviewers asked respondents when they were medical students to name four specialties that interested them in terms of a career in medicine, specifying the one specialty in which they were most interested. Ten years later, respondents to the mailed questionnaire were asked to name the specialty (or specialties) in which they were currently working. Then two open-end items asked respondents to indicate why they did notpursue specialties they had named as interests when they were medical students, if this applied to them, and to indicate why they had chosen a specialty that was not one of their earlier interests, if in fact they had made such a choice. The specialties that students had identified during their 1975-76 interview were printed in advance on the followup questionnaire so that respondents would provide answers pertaining to those specific specialties. Specialty Prestige. Respondents were asked as medical students (Time 1) and again as practicing physicians (Time 2) to assign a prestige rating (1 =low standing to 5 =high standing) to seven specialties: general surgery, internal medicine, pediatrics, ob-gyn, family medicine, psychiatry, and public health. A similar item was used in studies conducted by Merton et al., (1956) and by Zimet and Held (1975). Work Productivity. Physician respondents were asked to report the approximate number of 'hours per week that they typically worked. Demographic Characteristics. Information about current marital
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status and number of children was requested from medical students and again from physician respondents. Sex-role orientation. Medical student respondents completed a sex-role orientation (SRO) scale developed by the authors (Brogan & Kutner, 1976). The scale consists of'36 Likert-type statements; respondents are asked to answer each item on a 6-point scale ranging from strongly agree to strongly disagree. Total scores can range from 36 (traditional) to 216 (nontraditional). Scale reliability and validity are discussed in Brogan and Kutner, 1976. Data Analysis
Specialty prestige ratings obtained at Time I and Time 2 were compared by a repeated measures (time at 2 levels) ANOVA with two crossed factors (gender at 2 levels and current practice at 2 levels). Mean SRO scores were compared by t-tests.
FINDINGS
Gender Differencesin Choice of an Ob-Gyn Career
In our followup study of 258 physicians whom we had interviewed when they were medical students ten years earlier, women (6.3%) and men (6.8%) physicians were equally likely to be practicing ob-gyn. However, when we interviewed these 258 respondents as medical students in 1975-76, more women (27%) than men (17%) named ob-gyn as a possible career interest, and among those who expressed interest in this specialty as medical students, women were twice as likely as men to say that ob-gyn was the specialty that interested them most. Thus, opposite patterns of career choice oc-
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curred for the women and men physicians in our study. More women were strongly interested in ob-gyn as medical students, but most of these women did not pursue this interest. As medical students, men rarely started out with a strong interest in ob-gyn, but men physicians were just as likely as the women in our study to end up practicing in this specialty. What factors tended to deter women from pursuing a career in ob-gyn, and what factors attracted men to the field despite their relative lack of initial interest in it? We relied on two sources of information to address these questions. One source was the prestige rating assigned to ob-gyn by respondents at Time 1 (as medical students) and at Time 2 (as practicing physicians). We hypothesized that women would tend to assign less prestige to the specialty at Time 2 than they had at Time 1, indicating that their opinion about the field had become less favorable over time. We hypothesized that men would assign higher prestige to the specialty at Time 2 than they had at Time 1, suggesting that over time their feelings about the specialty had become more favorable. Only the latter hypothesis was supported by the data. Two effects in the ANOVA were significant: the main effect of time [F(1,53) = 19.62, p = .0001] and the interaction of time with current practice [F(1,53) = 8.70, p = .0047]. Both men and women who chose to practice ob-gyn assigned significantly higher prestige to the field than they had assigned to it as medical students (p < .005). Prestige ratings by women and men who were interested in ob-gyn as medical students but who did not enter the field did not change significantly from Time 1 to Time 2 (Table 1). Thus, both women and men who entered ob-gyn tended to legitimize their choice by assigning higher status to the field than they had done as medical students, which is a common social-psychological phenomenon. Neither womcn nor men who did not enter ob-gyn changed their view of the field's general status as a specialty, suggesting that failure to select this field of practice was a function of factors other than the individuals' assessment of the intrinsic nature and worth of the specialty. The second source of information about physicians' career decisions was their response to the open-end questions requesting explanations for not pursuing specialty interests that they had named as
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TABLE 1 Average P r e s t i g e R a t i n g s A s s i g n e d t o OB/GYN, by G e n d e r , Time a n d C u r r e n t P r a c t i c e
MEN
WOMEN Current P r a c t i c e
Time 1
Time 1 -
Time 2
Time 2 -
P h y s i c i a n s who c h o s e t o p r a c t i c e ob-gyn Physicians interested i n ob-gyn a s m e d i c a l s t u d e n t s b u t who made a n o t h e r c a r e e r choice
3.28
3.60
(25)'
3.33
a . 1 r e s p o n d e n t d i d n o t p r o v i d e r a t i n g s a t b o t h T i m e 1 and Time 2 . b. 2 r e s p o n d e n t s d i d n o t p r o v i d e r a t i n g s a t b o t h Time 1 and Time 2. c. 4 r e s p o n d e n t s d i d n o t p r o v i d e r a t i n g s a t b o t h Time 1 and Time 2 . d . 1 r e s p o n d e n t d i d n o t p r o v i d e r a t i n g s a t b o t h Time 1 and Time 2 .
3.50
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medical students, or for choosing to work in a specialty that was not among the interests they had named when they were medical students. Three factors seemed primarily responsible for women's attrition from their original interest in ob-gyn. In order of the frequency with which these were mentioned, these factors were: Long hours, "horrendous call schedule"; difficult to have a "manageable life" as a physician in this field Difficulty of completing training in a system characterized by derogatory attitudes toward women Too much surgery involved Consistent with the prestige rating data discussed above, none of these factors suggest a negative evaluation of ob-gyn as a specialty. Rather, these factors indicated women's dislike of specific working conditions or medical training experiences related to ob-gyn. The men who chose ob-gyn as a career even though they had not listed it as an interest when they were medical students cited their desire to be in a surgical specialty as one of the main reasons for their choice. Similarly, Zambrana et al., (1987) reported that the most common reason given by male residents for their choice of obgyn was that this specialty combines medicine and surgery. However, only one of the men in our sample who entered ob-gyn had named surgery as his strongest interest at Time 1; most had named family medicine. The factor on which there was the most'agreement between women and men who ended up in an ob-gyn practice was the opportunity they found in this field for combining multiple interests and practicing "all phases of medical care." Sex-Role Orientation Scores in Relation to Gender and Ob-Gyn Career Choice
Table 2 indicates the average sex-role orientation (SRO)scores of women and men physicians who were practicing ob-gyn, and of women and men physicians who were most interested in an ob-gyn career as medical students but who did not go on to practice in this specialty. All of these scores, as explained above, were obtained when the respondents were medical students. Statistical comparison
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SRO S c o r e s , by Gender and C a r e e r C h o i c e Range
--
SRO Score Minimum
S RO Score Maximum
Respondent Group
n
Mean SRO Score
Women ob-gyn p r a c t i t i o n e r s
8
203.5
10.9
187
215
Women s t r o n g l y i n t e r e s t e d i n ob-gyn b u t made a n o t h e r c a r e e r choice
10
194.9
15.4
168
215
s.d.
Men ob-gyn p r a c t i t i o n e r s
aa
162.1
23.3
131
201
Men s t r o n g l y i n t e r e s t e d i n ob-gyn b u t made another c a r e e r choice
2
181.0
1 5 .O
166
196
a. One r e s p o n d e n t r e f u s e d t o c o m p l e t e t h e SRO s c a l e .
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via t-tests indicated that, as medical students, women physicians practicing ob-gyn were significantly more nontraditional than were the men physicians who chose to practice ob-gyn (t = 4.54; p < .001). Women physicians who were strongly interested in ob-gyn as medical students but did not enter the specialty were also significantly more nontraditional in their sex-role attitudes than were the men who chose to practice ob-gyn (t = 3.58; p < ,002). The average SRO score of women initially interested in ob-gyn but who did not enter the field was less nontraditional than the average SRO score of women who did enter ob-gyn, but this difference was not statistically significant (t = .333; p = .37). The data suggest that the nontraditional SRO outlook characterizing women obgyn practitioners as medical students may have contributed to their choice of this career, while women who were strongly interested in the field as medical students but whose average SRO was less nontraditional were deterred from following their initial career interest. Our SRO data were obtained at only one point in time, when respondents were enrolled in medical school. It is possible that individuals' sex-role attitudes changed over the following ten years, and that no significant gender difference would be found if women and men physicians were remeasured on SRO. Another possibility, however, is that an even stronger SRO difference would be evident between women and men ob-gyn practitioners. Martin et al., (1988) point to a growing body of data that characterize women physicians as more accepting than men physicians of their patients, willing to communicate with them rather than to them. Women who were strongly interested in ob-gyn as medical students but did not enter the specialty were significantly more nontraditional in their sex-role attitudes as medical students than were the men physicians who ended up in an ob-gyn practice. This can be viewed as an unfortunate outcome, if it is agreed that more egalitarian relationships between physicians and patients is a desired goal (Zambrana et al., 1987). DISCUSSION
It is recognized that initial interest in a particular area of medicine, or even completion of a residency in a particular specialty, does not necessarily mean that an individual physician will go on to
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practice, or remain in practice, in that specialty (Holden & Levit, 1978; Jacobs & Messikomer, 1988). According to Ernst and Yett (1985), 50% of medical students change their specialty plans during medical school. However, differential patterns of specialty change for women and men suggest that they are influenced in significantly different ways during their medical school and graduate training. Our data indicated that women medical students were more likely to be strongly interested in having an ob-gyn career but often abandoned these career plans and entered another specialty, whereas men entered ob-gyn without having been strongly interested in the field as medical students. The women in our sample who did not go on to practice ob-gyn even though they had an early interest in the field most often attributed their change in career plans to a concern about the difficulty of having a "manageable life" as an ob-gyn physician. The prospect of "physician overload" was not appealing. Weisman and Teitelbaum (1987) recently investigated the practice characteristics of a national sample of young, married ob-gyn physicians. Their subjects graduated from medical school between 1974-79, just as did the physicians in our sample. Married women physicians in the national sample worked on the average 7.5 fewer hours per week than did married men physicians (61.8 hourslweek vs. 69.3 hours/ week). The investigators concluded that the professional work time of women physicians, but not of men physicians, is "affected negatively" by home responsibilities, and that "gender-role expectations still play a part in determining the professional productivity of young physicians who are likely to have been influenced by the women's movement . . . " (Weisman & Teitelbaum, 1987:256). All of the women in our sample who were practicing ob-gyn were married; all but one of the men in our sample who were practicing ob-gyn were married. Family characteristics of the two groups were also similar; all but one of the women physicians, and all but one of the married men physicians had one or more children. The average number of hours worked per week by married ob-gyn practitioners in our sample was similar to the averages reported by the national sample surveyed by Weisman and Teitelbaum. Women reported working an average of 63.5 hourslweek, and men reported working an average of 68.5 hourslweek. Although womcn's average work week was less than that of their male peers, working over 60 hours
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per week does indicate that these women are "highly productive members of the profession," as Weisman and Teitelbaum note. However, if a 5-7 hour per week gender difference in "productivity," as measured by hours worked, suggests that women have less cumulative career achievement relative to their male peers and that it is therefore wasteful to train women to enter ob-gyn, women may receive limited encouragement to practice in this field. Concerns about professional liability were mentioned by only three of our respondents and did not seem to have significantly affected ob-gyn career decision-making. The malpractice threat crisis was less evident when respondents entered graduate training in the late 1970s than it is at the present time. There has been little investigation of possible qualitative differences in the care delivered by women and men physicians. We have noted that men in our sample who selected ob-gyn as their field of medical practice stressed the appeal of the surgical dimension of the field. This emphasis, along with the more traditional sex-role outlook of the men in our sample, suggests that these physicians might be more likely than their female peers to recommend procedures such as Ceasarcan sections and hysterectomies without discussing alternatives with their patients. It is true that the effect of an increased number of women physicians on the actual practice of medicine remains "an open question" (Eisenberg, 1989:1544). Our data suggest that women who enter ob-gyn may be characterized by a more egalitarian sex-role outlook than are their male peers, but Zambrana et al., (1987), focusing on obstetricians' attitudes towards women in childbirth, concluded that women entering the field face many barriers to the maintenance of a woman-centered perspective. The "ideal" ob-gyn practitioner, regardless of gender, is a physician who views gynecology and obstetrics as a rewarding primary care field that provides an opportunity to take a holistic view of patient needs. Open communication between physician and patient is necessary in order to accurately define those needs. Goals for women's health care in gynecology and obstetrics must include fostering this patient-oriented perspective as well as the goal of support for the inclusion of more women physicians in this specialty of medicine.
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NOTES I. Some female respondents in our study intentionally referred separately to gynecology and obstetrics, or purposely referred to gynecology/obstetrics, rather than obstctrics/gynecology, to indicate their interest in a medical practice emphasizing women's special health needs rather than delivering babies. In this paper we follow the conventional terminology, i.e., obstetrics/gynecology, or ob-gyn. 2. At both medical schools, the percentage of women in the entering freshman class in Fall, 1975, represented a marked increase over the percentage of women in preceding classes. At the private school, 28% of the 1975 entering class were women as compared to 11% of the 1974 enteringclass; at the state school, 23% of the entering class in 1975 were women, as compared to 14% of the class that had entered the previous year.
REFERENCES American College of Obstetricians and Gynecologists. (1989). Unpublished data. Braslow, J. B., & Heins, M. (1981). "Women in Medical Education: A Decade of Change." New England Journal of Medicine 304,1129-1 135. Brogan, D., & Kutner, N.G. (1976). "Measuring Sex-Role Orientation: A Normative Approach." Journal of Mam'age and the Family 38,31-40. Campbell, M. (1 973). Why Would a Girlgo into Medicine? Medical Education in dre United States: A Guide for Women. Old Westbury, NY: The Feminist Press. Edwards, C. (1974). "A Candid Look at Health Manpower Problems." Journal of Medical Education 49(1),19-26. Eisenbcrg, C. (1989). "Medicine is No Longer a Man's Profession: Or, When the Men's Club Goes Coed It's Time to Change the Regs." New England Journal of Medicine 321 ?1542-1544. Elliott, C.M. (1981). "Women Physicians as Workers." JournaloftheAmerican Medical Women S Associafion 36,105-108. Epstein, C.F. (1971). Woman's Place: Options and Limifs in Professional Careers. Berkeley: University of California. Ernsl, R.L., &Yell, D.E. (1985). Physician Location and Specialty Choice. Ann Arbor: Health Administration Press. Goodman, L.J. (1977). Physician Distribution and Medical Licensure in the U.S.,1976. Chicago: American Medical Association. Heins, M., Hendricks, J., Martindale, L., Smock, S., Stein, M., & Jacobs, J . (1979). "Attitudes of Women and Men Physicians." American Journal of Public Healfh 69,1131-1 139. Holden, W. D., & Levit, E.J. ( 1978). "Migration of Physicians From One Specialty to Another: A Longitudinal Study of U.S. Medical School Graduates." Journal of the American Medical Association 239,205-209. Jacobs, J.A., & Messikomer, C. (1988). "The Interspecialty Mobility of Physi-
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cians." Paper presented at the Annual Meeting of the American Sociological Association, Atlanta, GA, August. Jensen, J., & Miklovic, N. (1986). "Consumers Cite Physicians' Interest as Most Important Factor in Selection." Modem Healthcare January 17, 48-49. Keeler, M.L. (1980). "What to Expect in Medical School." American Medical News January 25, 8,12. Klass, P. (1988). "Are Women Better Doctors?" The New York Times Magazine April 10,32-35, 46, 48, 96-97. Knight, J.A. (1973). Medical Student: Doctor in the Making. New York: Appleton. Kutner, N.G., & Brogan, D.R. (1980a). "The Decision to Enter Medicine: Motivations, Social Support, and Discouragements for Women." Psychology of Women Qua~erly5,341-357. . (1980b). "Persistent Sources of Sex-Role-Related Stress Among Women Medical Students." International Journal of Women's Studies 3,19-
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27.
(1980~). "A Comparison of the Practice Orientations of Women and Men Students at Two Medical Schools." Journal of the American Medical Women's Association 35,8046. . (1981a). "Occupational Role Innovation and Secondaty Career Choice Among Women Medical Students." International Journal of Women f Studies 4,157-167. (1981b). "Problems of Colleagueship for women Entering the Medical Profession." Sex Roles 7,739-746. Leserman, J. (1981). Men and Women in Medical School. New York: Praeger. Levine, D.M., Barsky, A.J., Fox, R.C., Freidin, R.B., Williams, S.R., & Wysong, J.A. (1974). "Trends in Medical Education Research: Past, Present, and Future." Journal of Medical Education 49(2),129-136. Lorber, J. (1984). Women Physicians: Careers, Status, and Power. New York:
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Tavistock. Martin, S.C., Arnold, R.M., & Parker, R.M. (1988). "Gender and Medical Socialization." Journal of Health and Social Behavior 29,333-343. Merton, R. K., Bloom, S., & Rogoff, N. (1956). "Studies in the Sociology of Medical Education." Journal of Medical Education 31,552-565. Page, L. (1989). "Physician Overload." American Medical News January 20.78.
Ramos, S.M., & Feiner, C.J. (1989). "Women Surgeons: A National Survey." Journal of the American Medical Women's Association 44.21-25. Relman, A.S. (1980). "Here Come the Women." New England Journalof Medicine 302,1252-1253. -(1989). "The Changing Demography of the Medical Profession." New England Journal of Medicine 321,1540-1542. Rostow, V.P., & Osterweis, M. (1989). "Medical Professional Liability and the Delivery of Obstetrical Care." New England Journal of Medicine 321,10571060.
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Ruzek, S. B. (1978). The Women's Health Movement. New York: Praeger. Scully, D., & Bart, P. (1973). "A Funny Thing Happened on the Way to the Orifice: Women in Gynecology Textbooks." American Journal of Sociology 78,1045-1050.
Wallace, H.M. (1980). "Women in Medicine." Journal of the American Medical Women's Association 35,201-21 1. Weisman, C. S., Levine, D.M., Steinwachs, D.M., & Chase, G.A. (1980); "Male and Female Physician Career Patterns: Specialty Choices and Graduate Training." Journal of Medical Education 55,813-825. Weisman, C.S., & Teitelbaum, M.A. (1987). "The Work-Family Role System and Physician Productivity." Journal of Health and Social Behavior 28,247Downloaded by [Purdue University] at 01:43 13 April 2015
257.
Weiss, K. (1978). "What Medical Students Learn About Women." In C. Dreifus (Ed.), Seizing Our Bodies. New York: Random House. Whatley, M.H. (1988). "Beyond Compliance: Towards A Feminist Health Education," in S.V. Rosser (Ed.), Feminism Within the Science & Health Care Professions: Overcoming Resistance. New York: Pergamon. Zambrana, R.E., Mogel, W., & Scrimshaw, S.C.M. (1987). "Gender and Level of Training Differences in Obstetricians' Attitudes Towards Patients in Childbirth." Women & Health 12, 5-24. Zeno, K. (1982). "Caring and Curing: Women in Medicine." Whole Life Times April/May, 21-24,59. Zimet, C.N., & Held, M.L. (1975). "The Development of Views of Specialties During Four Years of Medical School." Journal of Medical Education 50,157-166.
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
Gender Roles, Medical Practice Roles, and Ob-Gyn Career Choice a
Nancy G. Kutner PhD & Donna Brogan PhD a
b
Department of Rehabilitation, Emory University
b
Rollins School of Public Health, Emory University Published online: 26 Oct 2008.
To cite this article: Nancy G. Kutner PhD & Donna Brogan PhD (1990) Gender Roles, Medical Practice Roles, and Ob-Gyn Career Choice, Women & Health, 16:3-4, 99-117, DOI: 10.1300/ J013v16n03_06 To link to this article: http://dx.doi.org/10.1300/J013v16n03_06
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Gender Roles, Medical Practice Roles, and Ob-Gyn Career Choice: A Longitudinal Study
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Nancy G. Kutner, PhD Donna Brogan, PhD
ABSTRACT. This paper discusses follow-up data from physicians who were studied ten years earlier when they were medical students. Seventeen physicians were practicing ob-gyn, and 57 of the physicians studied had been interested in an ob-gyn career when they were medical students. At Time 1, women were more likely than men to be strongly interested in ob-gyn, but they were no more likely than men to be ob-gyn physicians at Time 2. The desire to have a surgical specialty was much more important to men than to. women practitioners. Men ob-gyn practitioners were significantly more traditional in their sex-role outlook as medical students than were either women practitioners or women who had been stron ly interested in the field but did not enter it. The data suggest t at women ob-gyn physicians are more likely than their male peers to be egalitarian in their relationships with female patients.
t
Increasing the number of women physicians practicing gynecol-
ogy and obstetrics has been viewed a s an important goal in efforts to Nancy G . Kutner is affiliated with the Emory University Department of Rehabilitation Medicine, 1441 Clifton Road N.E., Atlanta, GA 30322. Donna Brogan is affiliated with the Emory University Department of Epidemiology & Biostatistics, 1599 Clifton Road N.E., Atlanta, GA 30329. This research was supported by a grant from the National Center for Health Services Research, HS01924, and by a 1985-86 grant from the Emory University Research Committee. This article is a revised version of a paper presented at the Society for the Study of Social Problems Annual Meeting, Atlanta, GA 1988. We would like to thank Brooke Fielding and Betty Roberson for assistance in data analysis. Q
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increase the responsiveness of the medical care system to women's health needs (Edwards, 1974; Jensen & Miklovic, 1986; Zambrana et al., 1987). Often, the only primary care contact for women is their contact with their gynecologist/obstetrician.' The percentage of physicians in this specialty who are women is relatively small, 18.5% (American College of Obstetricians and Gynecologists, 1989). A marked increase occurred in the number of women receiving graduate training in ob-gyn between the mid-1970s and the mid1980s, but the number of women medical students selecting this field peaked in 1975-79 (Weisman & Teitelbaum, 1987). This paper discusses longitudinal data obtained from physicians during their medical school training and ten years later when they were practicing physicians that (1) highlight continuing concerns for women interested in working in this specialty of medicine and (2) identify differences in women and men practitioners' early sex-role attitudes that have potentially significant implications for health care delivery to female patients. More generally, these data address issues in the relationship between gender roles and doctor-patient roles that deserve continued research attention (Zambrana et al., 1987; Martin et al., 1988).
OBSTETRICS/GYNECOLOGYAS A CAREER CHOICE Specialties of medicine can be grouped into three broad categories: (1) specialties entered disproportionately by women, such as pediatrics and public health; (2) specialties entered disproportionately by men, such as general surgery; and (3) specialties entered at approximately equal rates by women and men (Kutner & Brogan, 1981a). Ob-gyn until recently illustrated the latter category. Among active physicians as of December, 1976, for whom information was available to the American Medical Association, 6.5% of women and 6.4% of men were practicing this specialty (Goodman, 1977). Reasons that have been emphasized for the historically lower representation of women in ob-gyn as coinpared to pediatrics, both of which might be considered "natural" areas of interest for women, include male dominance in fields that involve technology (Epstein, 1971; Lorber, 1984) and surgery (Weisman et al., 1980; Ramos & Feiner, 1989) and the disconcerting sexist biases that women may
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encounter in ob-gyn training (Campbell, 1973; Scully & Bart, 1973; Weiss, 1978; Leserman, 1981). The women's movement stressed the importance of women taking control of women's bodies (Ruzek, 1978), and women medical students in the 1970's began to include ob-gyn in their career plans more often than had their predecessors (Weisman & Teitelbaum, 1987). The result was a marked increase in the number of women electing to receive graduate medical training in this field. Women were 23% of ob-gyn residents in 1978 (Braslow & Heins, 1981), but were 45% of ob-gyn residents in 1986 (Klass, 1988). As of 1983, over half of the obstetricians in the U.S. under the age of 30 were women (Zambrana et al., 1987). However, it will be important to monitor future trends in medical students' choice of this field. Concerns about malpractice suits and the typically demanding work schedule associated with an ob-gyn practice may deter young physicians, both men and women, from pursuing this specialty. A committee appointed by the Institute of Medicine recently concluded that medical professional liability adversely affects the delivery of obstetrical services, limiting the provision of care to highrisk women (Rostow & Osterweis, 1989). The attraction of a career in ob-gyn may be further diminished by the prospect of "physician overload." A 1987 AMA survey found that ob-gyn physicians worked more hours than the "average physician" and that the average work week for ob-gyn residents approached 90 hours (Page, 1989). The changing demography of the medical profession, with growing percentages. of women and minorities, is increasingly evident, and Relman (1989) believes that women's greater representation in medicine has profound implications for our health care system. Women continue to choose primary care specialties more often than do men, and greater emphasis on primary care is anticipated as government and private insurers seek to control costs while ensuring general access to good-quality care. Obstetricslgynecology, a primary care specialty, has been a popular career choice for women in recent years. Whether this will necessarily mean a qualitative difference in the delivery of care in this field is a separate question, however. Women physicians may be better able than men to empathize with the reported experiences of their female patients, but
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their communication style and treatment recommendations, like those of their male colleagues, may be shaped primarily by training received in a traditional medical education system. In the view of one woman physician, "given the fine mesh of the admissions sieve and the rigorous training to which medical students are exposed, female and male physicians are more likely to resemble each other on a number of important dimensions than they are other members of their own sexes" (Eisenberg, 1989:1544). More research on the interaction of gender role influences and outlooks among studentphysicians, and acquired views of appropriate norms governing medical practice, is clearly needed. GENDER AND THE PRACTICE OF MEDICINE
In the early 1970s, observers began to speculate that the increased entry of women into medicine had significance that extended beyond a change in the demographic composition of the profession. They postulated that influences stemming from the women's movement would affect the attitudes and values demonstrated by new female entrants into medical school. For example, Knight (1973:189) speculated that " . . the changes in society involving women will surely influence their life and work in medical school and in the practice of medicine," and Levine et al., (1974) suggested that recent societal changes would bring a "new kind" of female medical student into the profession. Our own research (Kutner & Brogan, 1980a), investigating reasons for the choice of a medical career among students who entered medical school during the academic years beginning 1972-1975, found that women and men students were equally attracted by positive characteristics they attributed to medicine (e.g., interesting, fulfilling work), by a perceived congruence between medicine and their own self-image, and by the job flexibility and job security they felt to be associated with a career in medicine. Moreover, all of these reasons for becoming a physician seemed more important to women than a wish to correct'a sex imbalance among physicians or a wish to "prove they could do it." Women more often than men, however, emphasized their desire to undertake the challenge posed
.
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by a career in medicine, possibly reflecting the positive sanctioning of women's achievement in professional fields that emanated from the feminist movement of the early 1970s. Earning a high income was not as often a top priority to the women as compared to the men whom we studied, and women were more likely than men to express a preference for salaried positions as opposed to traditional fee-for-service orivate oractice-two characteristics which are viewed as useful in physicians' successful adaptation to the structural changes occurring in American medicine (Relman, 1989). We found that women medical students viewed their career choice very seriously. Many had turned to medicine because they considered it a field in which they could obtain a higher sense of achievement and satisfaction than they had formerly experienced in traditional female activities, e.g., nursing, social work, raising a family. Some of these women were significantly older than their peers, and their new career choice appeared to represent a deepseated commitment. It has been suggested that women possess greater sensitivity to social issues than do men, which will, over time, affect the medical profession's position on matters such as national health insurance (Heins et al., 1979; Relman, 1980), or at least its willingness to experiment with different economic arrangements for medical practice (Relman, 1989). The most widely shared prediction about the effects of increased numbers of women in medicine has been that women physicians will give the profession an increased capacity for demonstrating caring attitudes toward patients (e.g., Elliott, 1981; Zeno, 1982), which may be "more valuable in healing than all the medicine in the textbooks" (Keeler, 1980:8). It is unfair to attribute the qualities of warmth, nurturance, compassion, and empathy exclusively to women, but these qualities are usually more emphasized during females' than males' socialization experiences. Women have more cultural freedom to be expressive. Women may possess more effective interpersonal skills and may pay more attention than do men to relationships with their patients, which is regarded as a necessary requirement for "humanizingM health care. Leserman (1981) found that more women than men valued being
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open and honest with patients and communicating health information to them. The potential contributions that women can make to the practice of medicine are especially important in the practice of gynecology and obstetrics. Women may be more motivated to develop a practice that reduces the traditional fragmentation of women's health care into separate obstetric care, family planning, abortion services, and gynecological care (Wallace, 1980). If women physicians are less fee-oriented than men, Ceasarean sections and hysterectomies may be less often recommended for patients. Women physicians may communicate more fully with their patients, and it would be desirable if women patients were encouraged to participate more actively in decision-making about their treatment and care; feminist health education has as its goal a true consumer-informed base of information from which preferences and choices can emerge that fit the needs of individual women (Whatley, 1988). As Zambrana et al., (1987) point out, the traditional medical care model is far from a collaborative relationship between doctor and patient; the patient is usually expected to accept the doctor's recommendations. This expectation is further reinforced if the patient is a woman, because traditional sex-role stereotypes emphasize passivity and acceptance as appropriate feminine characteristics. In general, however, women's sex-role attitudes are more liberal than are men's (Brogan & Kutner, 1976). We decided, therefore, to examine the sex-role orientation of women and men students interested in pursuing ob-gyn as a career, and the relation of sex-role orientation to the actual career choice characterizing these same individuals ten years later. In a longitudinal study design, we collected followup data in 1985-86 from women and men physicians whom we had interviewed when they were medical students in 1975-76, in order to identify their actual career patterns. In this paper, we discuss the "fit" between women and men medical students' expressed career interests in ob-gyn and these same individuals' decision to practice ob-gyn. The first wave of data: obtained in 1975-76, coincided with a time period in which the enrollment of women in U.S. medical schools had dramatically increased2and there was heightened sensi-
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tivity to women's special health needs. Support groups for women medical students helped to,reinforce this sensitivity and to encourage women to consider entering ob-gyn (Kutner & Brogan, 1981b).
METHODS
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Sample In academic year 1975-76 (Time I), 169 women and 169 men who were enrolled in the two medical schools in Georgia (one private, one public) were interviewed for a study comparing motivations for entering medicine, specialty and practice plans, and differential medical school experiences of women and men (see Kutner & Brogan, 1980a, 1980b, 1980c, 1981a, 1981b). The investigators contacted all women who were currently enrolled at the two schools; 97% of the women at the private school (n = 71), and 90% of the women at the public school (n=98) were actually interviewed. For purposes of comparison, an approximately equal number of men students were also interviewed from each institution, using stratified random sampling of men enrolled in the first-, second-, third-, and fourth-year classes. Response rates for the men were similar to those for women. During academic year 1985-86 (Time 2), followup information was requested by mail from the 298 women and men we had previously interviewed who were alive and for whom current addresses were available. Most of these individuals had graduated from rnedical school during 1976-79, and by the fall of 1985 they had been in practice for two to five years. Completed questionnaires were returned by 126 women physicians and 132 men physicians (86% of the women and 87% of the men from whom information was requested). Respondents who are the focus of this paper are 37 women and 28 men physicians for whom both Time 'I and Time 2 data were obtained and who at Time 1 expressed interest in an ob-gyn career and/or at Time 2 were practicing ob-gyn.
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Instrumentation
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The data collection instrument was a structured interview schedule when respondents were medical students, and interviews averaged one hour in length. The questionnaire mailed to physicians ten years later was short (2 pages), and a stamped, addressed return envelope was included to further encourage respondents' cooperation in the followup study. Variables and Measures
Specialty Interests and Specialty Choices. Interviewers asked respondents when they were medical students to name four specialties that interested them in terms of a career in medicine, specifying the one specialty in which they were most interested. Ten years later, respondents to the mailed questionnaire were asked to name the specialty (or specialties) in which they were currently working. Then two open-end items asked respondents to indicate why they did notpursue specialties they had named as interests when they were medical students, if this applied to them, and to indicate why they had chosen a specialty that was not one of their earlier interests, if in fact they had made such a choice. The specialties that students had identified during their 1975-76 interview were printed in advance on the followup questionnaire so that respondents would provide answers pertaining to those specific specialties. Specialty Prestige. Respondents were asked as medical students (Time 1) and again as practicing physicians (Time 2) to assign a prestige rating (1 =low standing to 5 =high standing) to seven specialties: general surgery, internal medicine, pediatrics, ob-gyn, family medicine, psychiatry, and public health. A similar item was used in studies conducted by Merton et al., (1956) and by Zimet and Held (1975). Work Productivity. Physician respondents were asked to report the approximate number of 'hours per week that they typically worked. Demographic Characteristics. Information about current marital
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status and number of children was requested from medical students and again from physician respondents. Sex-role orientation. Medical student respondents completed a sex-role orientation (SRO) scale developed by the authors (Brogan & Kutner, 1976). The scale consists of'36 Likert-type statements; respondents are asked to answer each item on a 6-point scale ranging from strongly agree to strongly disagree. Total scores can range from 36 (traditional) to 216 (nontraditional). Scale reliability and validity are discussed in Brogan and Kutner, 1976. Data Analysis
Specialty prestige ratings obtained at Time I and Time 2 were compared by a repeated measures (time at 2 levels) ANOVA with two crossed factors (gender at 2 levels and current practice at 2 levels). Mean SRO scores were compared by t-tests.
FINDINGS
Gender Differencesin Choice of an Ob-Gyn Career
In our followup study of 258 physicians whom we had interviewed when they were medical students ten years earlier, women (6.3%) and men (6.8%) physicians were equally likely to be practicing ob-gyn. However, when we interviewed these 258 respondents as medical students in 1975-76, more women (27%) than men (17%) named ob-gyn as a possible career interest, and among those who expressed interest in this specialty as medical students, women were twice as likely as men to say that ob-gyn was the specialty that interested them most. Thus, opposite patterns of career choice oc-
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curred for the women and men physicians in our study. More women were strongly interested in ob-gyn as medical students, but most of these women did not pursue this interest. As medical students, men rarely started out with a strong interest in ob-gyn, but men physicians were just as likely as the women in our study to end up practicing in this specialty. What factors tended to deter women from pursuing a career in ob-gyn, and what factors attracted men to the field despite their relative lack of initial interest in it? We relied on two sources of information to address these questions. One source was the prestige rating assigned to ob-gyn by respondents at Time 1 (as medical students) and at Time 2 (as practicing physicians). We hypothesized that women would tend to assign less prestige to the specialty at Time 2 than they had at Time 1, indicating that their opinion about the field had become less favorable over time. We hypothesized that men would assign higher prestige to the specialty at Time 2 than they had at Time 1, suggesting that over time their feelings about the specialty had become more favorable. Only the latter hypothesis was supported by the data. Two effects in the ANOVA were significant: the main effect of time [F(1,53) = 19.62, p = .0001] and the interaction of time with current practice [F(1,53) = 8.70, p = .0047]. Both men and women who chose to practice ob-gyn assigned significantly higher prestige to the field than they had assigned to it as medical students (p < .005). Prestige ratings by women and men who were interested in ob-gyn as medical students but who did not enter the field did not change significantly from Time 1 to Time 2 (Table 1). Thus, both women and men who entered ob-gyn tended to legitimize their choice by assigning higher status to the field than they had done as medical students, which is a common social-psychological phenomenon. Neither womcn nor men who did not enter ob-gyn changed their view of the field's general status as a specialty, suggesting that failure to select this field of practice was a function of factors other than the individuals' assessment of the intrinsic nature and worth of the specialty. The second source of information about physicians' career decisions was their response to the open-end questions requesting explanations for not pursuing specialty interests that they had named as
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TABLE 1 Average P r e s t i g e R a t i n g s A s s i g n e d t o OB/GYN, by G e n d e r , Time a n d C u r r e n t P r a c t i c e
MEN
WOMEN Current P r a c t i c e
Time 1
Time 1 -
Time 2
Time 2 -
P h y s i c i a n s who c h o s e t o p r a c t i c e ob-gyn Physicians interested i n ob-gyn a s m e d i c a l s t u d e n t s b u t who made a n o t h e r c a r e e r choice
3.28
3.60
(25)'
3.33
a . 1 r e s p o n d e n t d i d n o t p r o v i d e r a t i n g s a t b o t h T i m e 1 and Time 2 . b. 2 r e s p o n d e n t s d i d n o t p r o v i d e r a t i n g s a t b o t h Time 1 and Time 2. c. 4 r e s p o n d e n t s d i d n o t p r o v i d e r a t i n g s a t b o t h Time 1 and Time 2 . d . 1 r e s p o n d e n t d i d n o t p r o v i d e r a t i n g s a t b o t h Time 1 and Time 2 .
3.50
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medical students, or for choosing to work in a specialty that was not among the interests they had named when they were medical students. Three factors seemed primarily responsible for women's attrition from their original interest in ob-gyn. In order of the frequency with which these were mentioned, these factors were: Long hours, "horrendous call schedule"; difficult to have a "manageable life" as a physician in this field Difficulty of completing training in a system characterized by derogatory attitudes toward women Too much surgery involved Consistent with the prestige rating data discussed above, none of these factors suggest a negative evaluation of ob-gyn as a specialty. Rather, these factors indicated women's dislike of specific working conditions or medical training experiences related to ob-gyn. The men who chose ob-gyn as a career even though they had not listed it as an interest when they were medical students cited their desire to be in a surgical specialty as one of the main reasons for their choice. Similarly, Zambrana et al., (1987) reported that the most common reason given by male residents for their choice of obgyn was that this specialty combines medicine and surgery. However, only one of the men in our sample who entered ob-gyn had named surgery as his strongest interest at Time 1; most had named family medicine. The factor on which there was the most'agreement between women and men who ended up in an ob-gyn practice was the opportunity they found in this field for combining multiple interests and practicing "all phases of medical care." Sex-Role Orientation Scores in Relation to Gender and Ob-Gyn Career Choice
Table 2 indicates the average sex-role orientation (SRO)scores of women and men physicians who were practicing ob-gyn, and of women and men physicians who were most interested in an ob-gyn career as medical students but who did not go on to practice in this specialty. All of these scores, as explained above, were obtained when the respondents were medical students. Statistical comparison
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SRO S c o r e s , by Gender and C a r e e r C h o i c e Range
--
SRO Score Minimum
S RO Score Maximum
Respondent Group
n
Mean SRO Score
Women ob-gyn p r a c t i t i o n e r s
8
203.5
10.9
187
215
Women s t r o n g l y i n t e r e s t e d i n ob-gyn b u t made a n o t h e r c a r e e r choice
10
194.9
15.4
168
215
s.d.
Men ob-gyn p r a c t i t i o n e r s
aa
162.1
23.3
131
201
Men s t r o n g l y i n t e r e s t e d i n ob-gyn b u t made another c a r e e r choice
2
181.0
1 5 .O
166
196
a. One r e s p o n d e n t r e f u s e d t o c o m p l e t e t h e SRO s c a l e .
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via t-tests indicated that, as medical students, women physicians practicing ob-gyn were significantly more nontraditional than were the men physicians who chose to practice ob-gyn (t = 4.54; p < .001). Women physicians who were strongly interested in ob-gyn as medical students but did not enter the specialty were also significantly more nontraditional in their sex-role attitudes than were the men who chose to practice ob-gyn (t = 3.58; p < ,002). The average SRO score of women initially interested in ob-gyn but who did not enter the field was less nontraditional than the average SRO score of women who did enter ob-gyn, but this difference was not statistically significant (t = .333; p = .37). The data suggest that the nontraditional SRO outlook characterizing women obgyn practitioners as medical students may have contributed to their choice of this career, while women who were strongly interested in the field as medical students but whose average SRO was less nontraditional were deterred from following their initial career interest. Our SRO data were obtained at only one point in time, when respondents were enrolled in medical school. It is possible that individuals' sex-role attitudes changed over the following ten years, and that no significant gender difference would be found if women and men physicians were remeasured on SRO. Another possibility, however, is that an even stronger SRO difference would be evident between women and men ob-gyn practitioners. Martin et al., (1988) point to a growing body of data that characterize women physicians as more accepting than men physicians of their patients, willing to communicate with them rather than to them. Women who were strongly interested in ob-gyn as medical students but did not enter the specialty were significantly more nontraditional in their sex-role attitudes as medical students than were the men physicians who ended up in an ob-gyn practice. This can be viewed as an unfortunate outcome, if it is agreed that more egalitarian relationships between physicians and patients is a desired goal (Zambrana et al., 1987). DISCUSSION
It is recognized that initial interest in a particular area of medicine, or even completion of a residency in a particular specialty, does not necessarily mean that an individual physician will go on to
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practice, or remain in practice, in that specialty (Holden & Levit, 1978; Jacobs & Messikomer, 1988). According to Ernst and Yett (1985), 50% of medical students change their specialty plans during medical school. However, differential patterns of specialty change for women and men suggest that they are influenced in significantly different ways during their medical school and graduate training. Our data indicated that women medical students were more likely to be strongly interested in having an ob-gyn career but often abandoned these career plans and entered another specialty, whereas men entered ob-gyn without having been strongly interested in the field as medical students. The women in our sample who did not go on to practice ob-gyn even though they had an early interest in the field most often attributed their change in career plans to a concern about the difficulty of having a "manageable life" as an ob-gyn physician. The prospect of "physician overload" was not appealing. Weisman and Teitelbaum (1987) recently investigated the practice characteristics of a national sample of young, married ob-gyn physicians. Their subjects graduated from medical school between 1974-79, just as did the physicians in our sample. Married women physicians in the national sample worked on the average 7.5 fewer hours per week than did married men physicians (61.8 hourslweek vs. 69.3 hours/ week). The investigators concluded that the professional work time of women physicians, but not of men physicians, is "affected negatively" by home responsibilities, and that "gender-role expectations still play a part in determining the professional productivity of young physicians who are likely to have been influenced by the women's movement . . . " (Weisman & Teitelbaum, 1987:256). All of the women in our sample who were practicing ob-gyn were married; all but one of the men in our sample who were practicing ob-gyn were married. Family characteristics of the two groups were also similar; all but one of the women physicians, and all but one of the married men physicians had one or more children. The average number of hours worked per week by married ob-gyn practitioners in our sample was similar to the averages reported by the national sample surveyed by Weisman and Teitelbaum. Women reported working an average of 63.5 hourslweek, and men reported working an average of 68.5 hourslweek. Although womcn's average work week was less than that of their male peers, working over 60 hours
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per week does indicate that these women are "highly productive members of the profession," as Weisman and Teitelbaum note. However, if a 5-7 hour per week gender difference in "productivity," as measured by hours worked, suggests that women have less cumulative career achievement relative to their male peers and that it is therefore wasteful to train women to enter ob-gyn, women may receive limited encouragement to practice in this field. Concerns about professional liability were mentioned by only three of our respondents and did not seem to have significantly affected ob-gyn career decision-making. The malpractice threat crisis was less evident when respondents entered graduate training in the late 1970s than it is at the present time. There has been little investigation of possible qualitative differences in the care delivered by women and men physicians. We have noted that men in our sample who selected ob-gyn as their field of medical practice stressed the appeal of the surgical dimension of the field. This emphasis, along with the more traditional sex-role outlook of the men in our sample, suggests that these physicians might be more likely than their female peers to recommend procedures such as Ceasarcan sections and hysterectomies without discussing alternatives with their patients. It is true that the effect of an increased number of women physicians on the actual practice of medicine remains "an open question" (Eisenberg, 1989:1544). Our data suggest that women who enter ob-gyn may be characterized by a more egalitarian sex-role outlook than are their male peers, but Zambrana et al., (1987), focusing on obstetricians' attitudes towards women in childbirth, concluded that women entering the field face many barriers to the maintenance of a woman-centered perspective. The "ideal" ob-gyn practitioner, regardless of gender, is a physician who views gynecology and obstetrics as a rewarding primary care field that provides an opportunity to take a holistic view of patient needs. Open communication between physician and patient is necessary in order to accurately define those needs. Goals for women's health care in gynecology and obstetrics must include fostering this patient-oriented perspective as well as the goal of support for the inclusion of more women physicians in this specialty of medicine.
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NOTES I. Some female respondents in our study intentionally referred separately to gynecology and obstetrics, or purposely referred to gynecology/obstetrics, rather than obstctrics/gynecology, to indicate their interest in a medical practice emphasizing women's special health needs rather than delivering babies. In this paper we follow the conventional terminology, i.e., obstetrics/gynecology, or ob-gyn. 2. At both medical schools, the percentage of women in the entering freshman class in Fall, 1975, represented a marked increase over the percentage of women in preceding classes. At the private school, 28% of the 1975 entering class were women as compared to 11% of the 1974 enteringclass; at the state school, 23% of the entering class in 1975 were women, as compared to 14% of the class that had entered the previous year.
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