Women in hospital medicine in the United Kingdom: glass ceiling, preference, prejudice or cohort eVect?

Objective—To assess from oYcial statistics whether there is evidence that the careers of women doctors in hospitals do not progress in the same way as those of men. Design—The proportions of female hospital doctors overall (1963–96), and in the specialties of medicine, surgery, obstetrics and gynaecology, pathology, radiology/ radiotherapy, anaesthetics and psychiatry (1974–1996) were examined. Additionally data were examined on career preferences and intentions from pre-registration house oYcers, final year medical students, and medical school applicants (1966–1991). Analysis—Data were analysed according to cohort of entry to medical school to assess the extent of disproportionate promotion. Results—The proportion of women in hospital career posts was largely explained by the rapidly increasing proportion of women entering medical school during the past three decades. In general there was little evidence for disproportionate promotion of women in hospital careers, although in surgery, hospital medicine and obstetrics and gynaecology, fewer women seemed to progress beyond the SHO grade, and in anaesthetics there were deficits of women at each career stage. Analyses of career preferences and intentions suggest that disproportionate promotion cannot readily be explained as diVerential choice by women. Conclusions—Although there is no evidence as such of a “glass ceiling” for women doctors in hospital careers, and the current paucity of women consultants primarily reflects historical trends in the numbers of women entering medical school, there is evidence in some cases of disproportionate promotion that is best interpreted as direct or indirect discrimination. (J Epidemiol Community Health 2000;54:10–16) In 1987 Frances LeVord, in an influential paper examining the proportions of women in hospital careers in England and Wales, concluded that “the number of women consultants remains disproportionately low ... even allowing for the inevitable time lag [of women medical students progressing to consultant posts]”, and she contrasted specialties such as psychiatry, pathology and radiotherapy/radiology (“Cinderella specialties”), where women consultants had increased in number, with “the three most popular and competitive disciplines—surgery, medicine and obstetrics and gynaecology (O and G)—(where) the proportion (had) not changed substantially”. She concluded, “The record suggests that being female is a handicap to achieving consultant status, particularly in the popular specialities”. LeVord’s view is echoed in other UK and US studies, including Isobel Allen’s influential Doctors and their careers, 8 which stimulated the Department of Health’s Women in Surgery Training (WIST) scheme. Interpreting data on the proportions of women in hospital careers is not straightforward as groups such as consultants, senior registrars, etc, are a mixture of medical school entry cohorts. A typical consultant might enter medical school at 18, qualify at 23, become a senior house oYcer (SHO) at 25, a registrar at 28, a senior registrar (SR) at 31 and a consultant at 36, retiring at about age 62. An average SHO, registrar, senior registrar or consultant is therefore about 26, 29, 33 or 49; and hence a typical SHO, registrar, SR or consultant in 1993 entered medical school in 1985, 1982, 1978 or 1962, with the consultants aged between 36 and 62 entering medical school from 1949 to 1975. The proportion of women medical students remained between 20 and 25% until 1968, since when it increased steadily, exceeding 50% in 1991. Most consultants in 1993 had therefore entered medical school before the recent rise in female entrants, and hence cohort eVects may explain LeVord’s apparent shortfall of women consultants relative to women medical students (see fig 1). The apparent shortfall of women consultants may also result from what we will call here discrimination, women being promoted less than men, the so called “glass ceiling” beyond which women do not rise. Discrimination may be direct discrimination, as with promotion committees not appointing women, or outright disparagement of their abilities and a refusal to promote, or indirect discrimination resulting from women being “persuaded” not to apply for promotion, by inappropriate working conditions, by less access to informal patronage networks, 14 by the “Salieri eVect” of faint praise and subtle denigration, or by mistreatment and harassment. DiVerential choice may also occur if women choose not to enter some specialties, although the distinction from J Epidemiol Community Health 2000;54:10–16 10 Centre for Health Informatics and Multiprofessional Education (CHIME), Royal Free and University College London Medical School, Archway Campus, Highgate Hill, London N19 3UA