Medical Careers and Feminist Agendas

American, Scandinavian and Russian Women Physicians

Elianne Riska

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9780202306681
• eBook ISBN: 9781351506311
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The increasing proportion of women in the medical profession has been followed keenly both by conservative and feminist observers during the past three decades. Statistics both in Europe and in the United States tend to confirm that women work mainly in niches of the health care system or medical specialties characterized by relatively low earnings or prestige. The segregation of medical work has become increasingly recognized as a sign of inequality between female and male members of the medical profession.Medicine as a social organization is not a universal structure: Health care systems vary in the extent to which physicians work in the private or public sector and in the extent to which they have as a corporate body been able to influence their numbers and the character of their work. The aim of this book is not only to review and to provide an account of women's position in medicine but also to provide an analytical framework. The text revolves around three key issues that illuminate this argument: numbers, medical practice, and feminist agendas of women physicians. The issues are addressed in all the chapters but highlighted as central analytical themes in a cross-cultural context.Challenging previous studies of the medical profession, which have assumed for the most part a gender-neutral stance, Riska's text provides a unique focus. Medical Careers and Feminist Agendas presents a comprehensive, cross-national analysis of the current status of women in three societies where the economics of medical practice vary considerably: a market society, a welfare state, and a formerly communist society in transition. Aimed at a wide audience, this book will be useful for years to come in medical sociology, the sociology of professions, and women's studies. Its historical breadth, current data, and trenchant probing will furnish practitioners and policy-makers alike with a needed analytical tool.

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Introduction

Doctor Discontent

Many American doctors are unhappy with the quality of their professional lives. Abundant anecdotal evidence and several surveys identify some of the factors that underlie their discontent. The actions doctors are taking confirm that there is substantial dismay. What are they complaining about, and what are they doing about it? Can a health care system function effectively if a sizeable fraction of its physicians are disgruntled? Are patients well served by unhappy physicians?

Kassirer, “Editorial” New England Journal of Medicine

Recent changes in the character of medical work have made the medical profession in many societies concerned about the lack of control over its work. Some of the reactions have been collective and have resulted in strikes or threats of such measures (Burke 1996). Other reactions have taken more individualized expression and are appearing as a growing prevalence of health problems, stress, alcoholism, and suicides among physicians (Stimson 1985; Lindeman, Läärä, Hakko, and Lonnqvist 1996; Arnetz 2001; Firth-Cozens 2001). During the same period that the profession is experiencing a loss of control over the conditions of its work, women have entered the profession in increasing numbers. As new members and with new capacities, will women physicians be able to “humanize” the profession?

The increasing proportion of women in the medical profession has been followed keenly both by conservative and feminist observers during the past three decades. The conservative observers have been mollified by the statistics that show that women physicians remain active members of the profession even after forming a family. But the feminist voices continue to be heard, and for various reasons. One of the early arguments for an increase of women in the medical profession was the quest for equality between the sexes. Liberal feminists demanded that women should have the same educational opportunities as men. Many formal barriers to women’s entry into medical schools have been eliminated over recent decades. For example, U.S. medical schools followed affirmative-action policies in the 1970s and 1980s in order to increase the educational opportunities for women.

Subsequently, the focus of criticism has shifted to the skewed career advancement of women within the profession. Statistics both in Europe and in the United States tend to confirm that women work mainly in niches of the health care system or medical specialties characterized by relatively low earnings or prestige. Since the mid-1980s, gender segregation of medical work has become increasingly recognized as a sign of inequality between female and male members of the profession. Furthermore, that women in the profession advance more slowly than men has been alleged to equate with the continuation of discriminatory practices within the profession. Certain structural barriers—such as lack of mentors, collegial support, information, and professional networks that aid career opportunities—have been identified as the mechanisms that hamper women’s careers in the profession (Epstein 1970; Lorber 1984,1993).

In addition to the above structural interpretation of women physicians’ position in the medical profession, there is another explanation of the gendered structure of medicine—an essentialist and voluntaristic explanation. According to this view, women harbor essentially different qualities than men (James 1997). This view results in a valorization of women’s gender-specific tasks in medicine (e.g., Altekruse and McDermott 1987:85; Ulstad 1993:75). The argument is that the gender division of labor in medical work reflects women’s unique female qualities and their own preferences and choices in career decisions rather than discriminatory structures that cluster them in certain niches of medicine. Accordingly, the assumption is that an increase—both numerically and proportionally—of women in the medical profession will in the future radically alter the content of care and the direction of medicine because women can make a special contribution, because of their special gender skills and values. In a health care system with a sizeable proportion of women physicians, patients would encounter more empathic and care-giving physicians. Furthermore, some feminist scholars argue that the sexism inherent in medicine and in the diagnosis and treatment of women patients would disappear as the profession changes from a male-dominated to a more female-dominated one (e.g., Fisher 1995).

These two perspectives address the potential of women physicians in medicine, an issue raised by Lorber (1984, 1985) in her work on women physicians. She predicted that women physicians were likely to be split into two groups: “those who align with other physicians in the fight to maintain professional dominance, and those who align with other female health care workers and consumers in the fight for a health care system with a flatter hierarchy and a holistic and self-care perspective” (Lorber 1985:53). Almost two decades later, there are no major indications of a substantial change in the professional collaboration between women physicians and the nursing profession (e.g., Porter 1992; Gjerberg and Kjolsrod 2001). In fact, the nurses have been actively involved in a professional project of their own, and in a collective mobility project.

As women now constitute almost half and in some countries even the majority of the first-year medical students, the potential of women physicians in the future is an issue that has gained a new prevalence and raised a set of inquiries: Do women physicians represent a potential humanistic and holistic approach to medicine that will head the rest of the profession toward a substantial change in the way medicine is practiced? Or has such a potential been co-opted by a still predominantly male profession that has integrated women as members of the profession but delegated women physicians to marginal and “feminized” niches of medical work where they are ghettoized and mainly pursue traditional female tasks? And to what extent have women physicians at all been able to advance to such positions where they would be able to implement substantial changes in medical practice and medical knowledge?

These questions have to be analyzed from a comparative perspective. Medicine as a social organization is not a universal structure: Health care systems vary in the extent to which physicians work in the private or public sector and in the extent to which they have as a corporate body been able to influence their numbers and the character of their work (e.g., Wilsford 1991; Jones 1991; Moran and Wood 1993; Hafferty and McKinlay 1993; Johnson, Larkin, and Saks 1995). Nor is the gender system a universal one, although some feminist theorists portray it in terms of an all-encompassing patriarchal system (e.g., Walby 1990). Women’s social position varies among countries and is related to the country’s prevailing gender system. Likewise, the feminist strategies and debates also tend to differ among countries.

This book takes a look at the history and current position of women physicians in three different political and cultural contexts—the United States, the Scandinavian countries—Denmark, Finland, Norway, and Sweden, and Russia/Soviet Union—to illuminate how women’s status as professionals has been formed in different settings. In 1950, the proportion of women in the medical profession differed markedly from country to country: In the United States 6 percent of physicians were women, in the Soviet Union 77 percent, in Finland 21 percent, and in the other Scandinavian countries around 10 percent. Today, fifty years later, the Russian figures are almost unchanged, the Scandinavian countries have an almost genderbalanced medical profession, and about one-fourth of U.S. physicians are women.

What are the reasons for these persistent differences, and how far back do they go in the history of medicine in these countries? Have women physicians substantially changed medicine in those countries where they constitute half or a majority of the physicians? Is medicine turning into women’s work? These inquiries posed in current literature and public debate have guided the analysis of women physicians’ careers and agendas presented in this volume. Broadly characterized, three contexts will serve as analytical tools for understanding the conditions of women physicians and the influence of women physicians: market societies, welfare-state societies, and communist/postcommunist societies.

The title of this book—Medical Careers and Feminist Agendas: American, Scandinavian, and Russian Women Physicians—encompasses issues that have been addressed in the research of different disciplines: for example, women’s history, sociology of professions, organizational theory, health care policy, social policy, and research on the women’s movement. So far, the accumulated knowledge has been descriptive and fragmented. The central argument advanced in this book is that the history of women in medicine provides a lens for the examination of the vast changes that have taken place in medicine. Ever since the entry of women into the medical profession, their presence and agendas have epitomized the major scientific, professional, and organizational transformations of medicine.

In the sociology of professions, major concepts and theories have chiefly been based on a notion of a society as market-oriented, a notion that is not immediately applicable to communist or welfare-state societies, and that does not consider the built-in gender contract in the latter kind of societies. In the Soviet Union, and also in the Scandinavian countries, changes in and the developments of the health care system and health policies have been state endeavors. A majority of the physicians work now, as they have worked in the past, in the public sector.

Much of the research on women physicians has been of a narrow factfinding nature and consequently detached from the ongoing theoretical discussion within the mainstream of the sociology of professions. Chapter 2 presents an overview of the major theories about professions: the functionalist, the interactionist, the neo-Marxist, the neo-Weberian, and the social-constructionist perspectives. Chapter 2 shows that most of the major sociological theories about professions harbor underlying gendered assumptions. The chapter also looks at theories about work and organizations that have addressed the segregation and hierarchization of work by gender.

The aim of this book is not only to review and to provide an account of women’s position in medicine but also to provide an analytical framework that privileges some key sociological issues. The text revolves around three key sociological issues that illuminate this argument: the numbers, medical practice, and feminist agendas of women physicians. The three issues are addressed in all the chapters but highlighted as central analytical themes in some chapters.

The first key sociological issue—the number of women practitioners—relates to women’s entry into and later collective mobility in medicine. This issue will be addressed in Chapters 3,4, and 5.

The pioneering women physicians were a product of and served as catalysts in the fundamental process of social change that signaled the rise of modern society and medicine as an integral part of the modern project. While there were many converging trends in the development in most societies, there were also profound differences. To illustrate these different patterns, Chapters 3,4, and 5 describe the inroads made by the pioneering women in medicine in the United States, the Scandinavian countries, and Russia in the nineteenth century. The data presented in Chapters 3,4, and 5 draw on the extensive research done by medical historians. While their approach has focused on individual heroines, my presentation treats these women as a social group and cohort who became part of a collective mobility endeavor of women. In this process, women encountered common barriers but also shared the challenge to move into new activities where women had never worked before.

Chapter 3 looks back at the first entry of women into medicine in the United States and the later practice in medicine in the twentieth century. The chapter provides a summary of the history of the character of medical education available to women during the era of pluralistic medicine (1850-1910) in the United States. In the early 1850s, women began in increasing numbers to enter medical practice in the United States. This early entry was enabled through a separatist strategy—by the establishment of special medical schools for women. Chapter 4 presents an overview of the entry of women into medicine in the Scandinavian countries. Women in the Scandinavian countries entered the profession only in the late 1880s and 1890s, but then immediately through coeducational programs and by earning medical degrees equivalent to those of men. Although the programs were all coeducational from the beginning, the Finnish path was influenced by Finland’s ties to Russia, while the other Scandinavian countries followed a somewhat different path. Chapter 5 provides a review of the four phases of medical education—domestic and foreign—available to Russian women before 1917.

While the development in the nineteenth century gives a profile of women physicians as a group, later developments in the proportion and representation of women in the ranks of medicine cannot merely be explained by different early educational policies. In fact, the profile of women’s later representation in medicine in the United States and Russia negates such an explanation. For example, in both the United States and Russia women constituted around 6 percent of the medical profession at the turn of the century. While women still constituted 6 percent of the physicians in the United States in 1950, in the Soviet Union as many as 77 percent of the physicians were women. At that time, women constituted 21 percent of the physicians in Finland, a rate equivalent to women’s representation in the medical profession in U.S. medicine in the year 2000.

So what has happened in Russian and Finnish medicine during the past fifty years? Can we discern the kind of genuine integration and progressive career advancements that optimistic voices in U.S. medicine are expressing about the future position of women? Is the issue of women’s representation in, for example, U.S. medicine today a mere issue of a representational lag? That is, as women enter medicine at the bottom—as students, residents, practicing physicians, and juniors in academic medicine—will their representation gradually level off throughout the system? Or do we find a consistent and permanent pattern of ghettoization of women in medicine, or alternatively a pattern of resegregation in Russian and Scandinavian medicine? Both latter trends confirm a gendering of medical work: Ghettoization suggests that, while men and women have the same job title, they do different jobs—and “gendered niches” of medical practice emerge. Resegregation suggests that an entire occupation or a major occupational specialty is switching from a predominantly male to a predominantly female labor force (Reskin and Roos 1990). In health care, resegregation means that medicine is turning into women’s work, and the term “feminization” has been used to illustrate the change from a previously male-dominated occupation to a female-dominated one (Britton 2000). Furthermore, can the past fifty years of history of the careers of women physicians in the Russian and the Finnish health care systems provide some clues about equity between the genders in medicine and about the crumbling of the alleged glass ceiling of medicine? Or does the current high-technology health care industry generate a need at all levels for the kind of holistic and caring skills that women physicians have represented in the past?

Chapters 3,4, and 5 certainly document that women have advanced in many areas of medicine in all the countries examined here, especially those areas that relate to women’s traditional female skills of caring and taking care of children and the elderly. Yet regardless of the proportion of women in medicine—be it in Russia, Scandinavia, or the United States—we find a common pattern of gender segregation. For example, women constitute about 10 percent of the surgeons in U.S. and Scandinavian medicine, while pediatrics seems to be a gender-balanced specialty. But we also find a regressive trend in the hierarchy of medicine: The higher up the echelons of academic and administrative structure of medicine, the lower the representation of women in all the countries examined in this volume.

The representation of women in medicine and career advancement in medicine is a question of gender equality. Chapter 6 looks at the second key sociological issue raised in this book: whether gender really does matter in the practice of medicine. As practitioners, are men and women physicians similar or different? In other words, do gender or professional attributes and affiliations matter in the practice of medicine? The chapter presents an overview of two research approaches: the nominal and the embedded. The nominal approach looks at the sex composition of specialties and draws conclusions about the different practice styles of men and women physicians as related to gender. In this approach, gender is treated as a static and individual attribute acquired through sex-role socialization. The embedded approach, on the other hand, does not focus on the individual traits of the physician but rather on gender as a structure and institution. This approach privileges the gendered medical practices and the gendered medical discourses of medicine. This theoretical framework is able to address the divergent practice style of women physicians and to illuminate both their conformity and resistance. The chapter concludes by presenting the typologies suggested by current research on the professional identities and strategies adopted by women physicians. These strategies and identities both confirm and resist the stereotypical gender portrayals of women physicians. The different gendered professional identities indicate that we cannot homogenize women in medicine and that we need to recognize different voices and strategies.

While most of the chapters in this volume address the macrolevel issues of power and professional work in medicine, Chapter 7 analyzes the same issues at the micro level. In focus is women physicians’ work in the traditionally male-dominated specialty of pathology. This specialty is, as is surgery, imbued with values and expected capacities of the practitioner that rest on the assumption that the practitioner is a man. This master status of the pathologist is gradually crumbling as pathology increasingly becomes part of the forefront of biomedicine, i.e., medicine done through microscopy, exemplified by cancer research, medical genetics, and molecular biology. Women physicia...

Table of contents

• Cover Page
• Title Page
• Copyright
• Preface
• 1 Introduction
• 2 Sociological Theories about Medical Work and Gender
• 3 Women’s Entry into Medicine and Medical Practice in the United States
• 4 Conditions Influencing Women Physicians’ Careers in Scandinavia
• 5 Women Physicians in Russia and the Soviet Union
• 6 Does Gender Matter?
• 7 New Pioneers: Women in Pathology
• 8 Women’s Challenge of Medicine
• 9 Conclusions
• References
• Index