Leo van der Reis, M.D.

It is no secret that the number of women in medicine has steadily increased during the past two to three decades. But it seems to be a secret, at least in the halls of Congress and the offices of all to many university administrators. Such a negligent attitude might be of no major significance, were it not that the increase in the number of women has important implications and consequences that have a major impact on the practice of medicine, whether general medicine or dentistry, veterinary medicine or pharmacy. Obviously what is happening in human medicine is of paramount interest to us as physicians.

But even for those who have horses, cattle or other animals, the change in the gender ratio also has an impact. Today's veterinarian is no longer a man dressed in blue jeans and a plaid shirt who is stepping around in muddy gum boots. The vet is more than likely a woman who is in practice with another vet, also likely to be a woman. Data from the veterinary school at the University of California at Davis show that some 85 percent of its students are women. 1

The figure on page S6, based on data supplied by the American Association of American Medical Colleges, shows absolute numbers revealing the trend that has taken place over the years. The percentage of female students has increased significantly. The five schools, picked at random, represent different areas of the country as well as private and state-run schools. In many medical schools this trend has resulted if not in a preponderance of female medical students then certainly in parity of the sexes. It is noteworthy that the class size has not changed very much over the period depicted.

Impact
The impact of the changes in gender ratio can be measured by 1) the decrease in the total number of medical school applicants and graduates and 2) the variation in personal and professional styles of men and women.

As to the first factor, while there was an 8 percent decrease in the number of male medical student applicants from 26,810 in 1995 to 18,142 in 2001, the number of female applicants for the same period dropped only 3 percent, from 19,776 to 16,717.2 This disparity accentuates the current trend and the gradual but definite progression that, if it continues, in due course will lead to the majority of physicians being women. In 2002, Barzanski reported that 46 percent of U.S. medical students were women, a major shift from 20 years ago.3

The second factor takes into consideration the differences in personal and professional style, behavior and attitudes. A number of issues contribute to this variance. They include different approaches toward professional activities, the need or wish to devote time and effort to family affairs, as well as a lessened need to make money, especially in two-earner households.

Gender Differences
There is evidence that women are apt to more collegial toward each other and have a tendency to protect each other more than their male counterparts. Even though there are female physicians who wish to break through the glass ceiling and attain high positions, generally this seems to be more a male characteristic. In part this explains why women are poorly represented in administrative and top positions in medical schools. Most certainly their lack of representation does not reflect the percentage of female physicians overall. Only 28 percent of medical school faculty members are women, many in the lower ranks.4

In the health care professions, gender is the most powerful indicator of income. In 1983 when comparing male with female physicians, the women earned 81.6 percent of men's pay, while in 1999 this percentage dropped to 62.5 percent.5 In a 2002 survey the median salary of male assistant professors was $75,000 and that of female assistant professors was $71,000. Male associate professors' median income was $97,000, that of their female counterparts $94,000, while male full professors earned $131,000 versus $114,000 for women.6

Consequences
The consensus is that there still exists a negative, discriminatory gender perception on the part of many men, a phenomenon that will take a long time to overcome.7 As noted above, there are other gender-related issues and factors that contribute to the differences between male and female physicians. They all impact on the disparities in gender representation within medicine (for instance, the so-called medical specialties - internal medicine, general practice, pediatrics and obstetrics - show higher female representation than the surgical specialties), as well as the increasing shortage of physicians, in both urban and rural settings.

To top matters off, today it is well nigh impossible for a young physician to start a practice on her or his own, due to the worsening financial aspects of medicine and managed-care related discrimination. Men in particular are more apt to seek other professional careers that, at least on the surface, bring greater financial benefits and fewer professional threats and problems.

The accumulated net results of the changes in gender ratio are clear. The net effect of a high percentage of part-time practice and, frequently, a different, less intensive approach to practice on the part of female physicians leads to a situation that requires more than one female physician to fill the place of a male physician. This phenomenon gradually but steadily accentuates the overall shortage of physicians to a significant degree, secondarily resulting in decreased access to health care services.

Recommendation
Medical school deans, chancellors, university administrators and politicians need to pay more attention to the fact that women have become numerous in medicine and take into consideration the important social changes that already have occurred and those that are still awaiting acceptance and implementation, such as mutual gender support, maternity leave and, last but not least, equality in compensation. Even though an increase in the number of students may be costly, without such an increase, the American health care delivery system will continue to deteriorate.

Dr. van der Reis is an adjunct professor in health care management and clinical professor of community and rural medicine at the University of Alabama. He is a long-time member of the San Francisco Medical Society and serves on the editorial board of San Francisco Medicine.

References
1. UC Davis, Registrar. 202.
2. AAMC, Women Applicants US Medical Schools 1992-2001. 2003, Association of American Medical Colleges.
3. Barzansky, B, Etzel, SI. Educational programs in US medical schools, 2001-2002. JAMA 2002. 288(9): p. 1067-72.
4. Chin EL. This side of doctoring. Reflections from women in medicine. 2002, London: Sage Publications.
5. USDL 2000, united States Dept of Labor.
6. Academy Health, Median Academic Salary by Gender. 2002, Academy Health.
7. Padavic I, Reskin B. Women and Men at Work. Second ed. 2002, Thousand Oaks, Calif.: Pine Forge Press.