HELENA TEEDE: When our children were at kinder equivalent, we used to both drop off and pick up and one of the mothers came up to me and said, “You are so lucky, you know, your husband comes to pick-up—obviously he’s got a really easy job he can do that?” And I said, “No, he’s an intensive care specialist. What does your husband do?” And she said, “He’s an intensive care specialist.”
And the next week he was at pick-up.
I suppose the moral of the story is my husband had gone and said, “My wife and myself are both in the profession, we both have to be able to juggle this.”
MIC CAVAZZINI: Welcome to Pomegranate, podcast of the Royal Australasian College of Physicians. I’m Mic Cavazzini, and today we talk about gender equity in medicine. While more than half of all medical students and trainees are women, they make up only about 30 per cent of registered physicians. When it comes to clinical leadership positions, it’s down to single digits, and the gender pay gap in medicine is also worse than what it is across all professions.
While there are many reasons for this, a significant factor affecting career progression is child-rearing, both in terms of the time conflicts and the structural biases associated with it. To understand these in more detail, I spoke to Stefanie Schurer.
STEFANIE SCHURER: I’m a senior lecturer in applied health economics at the University of Sydney.
MIC CAVAZZINI: We met with Catherine Yelland, Director of Medicine and Older Persons Service at Redcliffe Hospital, Brisbane. Although most listeners will know her as the current President of the RACP.
CATHERINE YELLAND: For many years when I had young children, the working hours were all the working hours—and so that trying to work a normal working day, look after children and then study on the top of it, is really a superhuman effort. Now you can say, “Well, don’t men have that too?” Yes, but we know that there is a gap in participation in household chores which roughly divides at two thirds women, one third men.
But if you wait to complete your training, you may be compromising your ability to have a family. And so there is this dilemma. The men do not have the same time pressure and many of us are pretty keen that our daughters complete their education and their training as early as they can so that they have the maximum choices.
Now, who is responsible for this drop-off in women’s participation in higher-level training? I think it is complicated. And yes, we have provision for family leave or other leave, and we have made that as flexible as we possibly can, but there’s only so far you can go. And in the end, you do have to produce a competent specialist.
MIC CAVAZZINI: Now, some figures of a different sort. Stefanie, your studies have found that Australian female GPs earn 24 per cent less than men and for specialists the earnings disadvantage was around 17 per cent. Can you tell us what the main explanation for this gap is?
STEFANIE SCHURER: So in this particular study we have conducted recently we wanted to identify labour force attachment factors. And it is true differences in work hours between men and women explain a large proportion of this gender earnings gap. But it doesn’t explain everything—usually it explains up to 60 per cent of the differences.
So we try to dig a little bit deeper, and what we find that by age 40 plus women were up to 50 per cent more likely to have interrupted their career at least for one year independent of whether they had children or not. Whereas for men, this figure was only 15 per cent.
So we realise that women, even if they don’t have children, they may have other reasons why they interrupt their careers. So what is very common in the medical discipline is to have partners from the same area or from the occupation, so what we think may be going on is that some women don’t have to work necessarily. They may opt out and say, “For 2 years I interrupt the career”—but this is just pure speculation.
There’s many other factors we looked at—how long the consultations are: we find that women practitioners spend a little bit longer per patient, so we think maybe women don’t churn through patients that much. But taken together, it’s only 65 per cent of the gender earnings gap or pay gap that we can explain.
MIC CAVAZZINI: Another explanation for the pay gap is the fraction of women in different specialties. The more lucrative surgical specialties have proportions as low as 10 to 15 per cent, and ophthalmology and intensive care are also particularly low. Conversely, paediatrics, obstetrics and gynaecology, reproductive health and public health medicine all have a majority of women.
Research shows that women and men chose specialities for the same reasons, whether it’s an interest in specific types of patients, procedural skills, or work hours. Here’s ENT surgeon Elizabeth Sigston.
ELIZABETH SIGSTON: Well, I chose surgery because I love the surgery. I love the fact that I can assess a situation quickly, be able to help people. You need a certain level of decisiveness and I enjoy variety, so I get that from my surgical specialty that I've chosen.
MIC CAVAZZINI: Liz is a leader in Monash Health’s program to support career development of women in medicine. Along with endocrinologist Helena Teede, who runs the Diabetes Unit.
HELENA TEEDE: I also lead a research group as a professor of women’s health and I’m the executive director for Monash Partners Academic Health Science Centres. And I have too many hats.
MIC CAVAZZINI: I asked them whether the time demands of certain specialties in particular made them less compatible with family life.
HELENA TEEDE: There are many strategies, I think, within that. For example, people who go into cardiology, they don’t necessarily have to be interventional cardiologists, and if they do they now tend to have really good roster systems so they’re on one night a week which is much more manageable. The reality is some specialties will always be more on-call, more after-hours, more hands-on. But you know you can still be flexible around that.
I remember I was in one of those scenarios where there was me and all the heads of units of endocrine in Melbourne, and I was the only woman there. And they started having a conversation where they were complaining about the fact that they couldn’t get young women to step up into senior roles. But I said, “Well, what jobs are you offering?” Every single job was full-time and full-time only, immediately after they qualified. There was no mentoring or role models or any other women in senior positions in those units.
ELIZABETH SIGSTON: Yeah, and I think the other thing is that when we’re talking about flexibility is it’s not just for women. You can’t have a good career as a female doctor if your partner doesn’t have some of that flexibility as well. So it shouldn’t be that this is a special thing for women so that they can still go and do all the things for their children. It should be something across the board, so everyone has a better input into their family life.
MIC CAVAZZINI: It’s sometimes argued that the poor rate of progression of women to senior positions is a reflection of experience. New Zealand data show that women doctors between the ages of 35 and 55 work on average 10 hours less per week than their male colleagues. And in the US, female lawyers and MBA graduates will have lost a total of eight months in the workplace in the 15 years after having had a child. Helena, would it be fair to say that a doctor of age 50 with eight months less in the hospital somehow lacked expertise?
HELENA TEEDE: You can’t get away from the fact that you have to have a reasonably intense period of training and you have to have a minimum number of hours of technical skill. But I also think that the concept of working 60 hours a week versus 30 hours a week is arguably probably not much different.
ELIZABETH SIGSTON: And you know when you come into the senior positions, again: does the job really need to be full-time, rather than on what your outcome is? And when you look at experience, you know, there’s advantages in having life experience that becomes important in making you a better doctor, and I don’t think we should minimise that.
MIC CAVAZZINI: Catherine Yelland, once more.
CATHERINE YELLAND: You’re talking about a whole range of issues here. But career progression on the whole isn't about how good a doctor you are—career progression for women is much more about all the added extras, not just seeing the patients. It’s about participating in committees, about perhaps conducting research, about having all those added extras and—this may be one of the critical issues—is those added extras are often done at the end of the day or after work.
MIC CAVAZZINI: It’s all the little extra things—it’s not that you’re any worse at your job because you’ve taken time, it’s the volunteering for committees and—
CATHERINE YELLAND: —do we choose the College committee or the Parents’ and Citizens’ Association Committee—
STEFANIE SCHURER: —getting these publications out. And that brings me to a point that what could solve some of these problems, you may need to be willing to outsource some of these responsibilities. So you may have to hire someone who helps you to pick up the kids at five o'clock from childcare and then have this extra one and a half hours in the workplace. Or you may purchase support in the house to help your cleaning and purchasing the food.
So one policy measure, how the government can support the career progressions of women, is that you make these expenditures tax deductible. So Sweden is a pioneer in this: since 2007, you can tax deduct 50 per cent of your expenditures on activities in the household.
HELENA TEEDE: And increasingly, I mean if you’re a physician and you’re going for a senior position or a head of unit, you need to have an academic track record. However, these days it’s become so incredibly competitive and the reality is it is very difficult to just disappear and go to an international conference and leave your family at home for a week. So the research sector is challenged by this at the moment and, you know, if you look at the gender success rate in a lot of the recent fellowships and grant rounds it continues to be inequitable.
But there are ways around it. So in mentoring a large team of mainly women—because I work in women’s health—we have very deliberate planning around those career stages. In my team when they come near the end of their physician training to their PhD, we plan their PhD around their planned interruptions. If they wish to have a family we very proactively talk about that and the type of research they do, and the way they keep up their output while they’re on maternity leave. All of that is structured and planned.
And I think in a way, being an academic gives you more flexibility. So when my children were young I could work from home, I could work after-hours. So actually it allowed me to progress my career in a way that I didn't have to necessarily be hands-on in clinics all the time.
MIC CAVAZZINI: Some conservative voices in the U.K. have argued that a tendency for female doctors to work part-time and retire earlier means that it’s not an effective way to spend the public’s half a million pounds to train each of them. Catherine, is there a more generous way to frame this economic rationalist argument?
CATHERINE YELLAND: I think we have to look at this in a slightly different way. Women have longer working lives now. The carer responsibilities don’t go on at the same intensity and they don’t go on forever. When that changes, then, why aren't women saying, “OK, I'm ready now?” There is not enough encouragement of middle-aged women back into those positions. They have dropped off the radar and they don’t put themselves forward and say, “Look, I’d like to do this. It would be enjoyable and fulfilling and I've got a lot to offer in the professional sphere—I know how to chair a meeting, I know how to work with other people, I know how to get things done.”
STEFANIE SCHURER: I can’t really comment on that exact question but I can comment on something else that goes in this direction, and Catherine has alluded to this. I've seen many women who used to work in academia but interrupted their career and then five or six years down the track they felt they’re no longer competent enough to push their careers again—well-trained women then saying, “I can’t really demand anything from a workplace.” So this is not a loss in actual human capital, but a loss in self-confidence. And I think this is some of the troubles that women have in the workplace.
There can be tools that, for instance, the College can provide or that universities can provide to start mentoring programs that women in middle-age are assigned a mentor who helps them come back. So in some countries retirement age has been set at the age of 67, so that the work life is anyhow longer and could be more flexible, and therefore this also has an impact on what is the net effect of training someone. Because people may cost that amount, but they may work much longer.
MIC CAVAZZINI: Liz, is it more difficult to run a surgical ward or any hospital department with more flexible roles or part-time positions in the mix?
ELIZABETH SIGSTON: I think it’s about developing really clear strategy around building the team—sort of planning a few years out, rather than sort of, “It’s happening and oh, let’s find who we can.” I believe moving forward the only way that we’re going to have a strong sustainable public health system is to have properly co-located public and private practice. Because otherwise the temptation is for people just to do private practice. But it needs to be on a different model to what exists at the moment, because the model we have isn't financially viable.
HELENA TEEDE: The other thing is even on logistics. So I have quite a few young women in the unit now and a lot of them are almost rotating on maternity leave. So the more women you get in, there the more logistics you can shuffle to actually maintain positions of people when they come back in.
But there are also inherent barriers. So, for example, if you’re a registrar and you finish your full-time work I then employ you as a part-time consultant, if you go on maternity leave any time in the next nine months I have to pay you as almost a full-time consultant out of our unit budget—even though you’re only working two days a week. And I get absolutely no support from the organisation for maternity leave. Two years ago, I had seven of my staff on maternity leave—we were for the first time in ten years in the red, substantially. And you know we went to the organisation and they said, “Well yes, all the nursing budgets have maternity leave but no, none of the medical budgets have maternity leave and you can’t have it.”
So there are inherent problems. They’re structural and those things can be fixed by organisations. That’s part of our culture.
STEFANIE SCHURER: So this is a very difficult question to answer because first of all, 14 weeks at minimum pay are being paid by the government. But of course high-skilled women want to have not only a minimum pay, but they want to have at least, I don’t know, 80 per cent of their full pay because they’re so high-skilled. And some organisations do pay this in the private sector. So in order to compete for the best people you need to offer that in a research or in a hospital environment as well.
There is a very famous study that looked at the “glass ceiling” in Sweden and parental leave schemes—that they’re perceived as being very costly to the employers. And so there may be indeed negative discrimination against women because they need to be paid for at least one year at full pay scale. And I think the only way out there is that men have to take parental leave as well, and that you have to schedule in paid parental leave into the budget. Sweden is doing this on a national level. Men have to take, for two months, paid parental leave—otherwise the woman will not get the paid parental leave. And once you force men and women alike to take it, you take out the whole discrimination aspect.
More mandating in terms of avoiding discrimination by force, so to speak, I think will not work out because employers will be always smarter in finding out who should not be hired.
CATHERINE YELLAND: We should acknowledge that the career penalty for men who take substantial time out is actually greater than it is for women, because it is not so socially acceptable. And until we also look at that one—
MIC CAVAZZINI: —as a social problem, as a cultural problem—
CATHERINE YELLAND: —as a cultural issue. That’s a problem that they have as well.
MIC CAVAZZINI: In the public system, there is a transparent pay scale. So there really shouldn’t be room for such discrimination. But is it possible that women are started on a lower step so they’ve got a longer way to go?
STEFANIE SCHURER: So data in the U.S. doesn't find this, the Alicia Sasser article doesn’t find that. She doesn't find any differences in entry-level pay—it comes up later. And it may not be discrimination, it may be just that women don’t negotiate in the same way, that they’re saying “I accept any offer.” Whereas a man may say, “You have to give me two scales up the scale. I'm not taking the job at this scale.”
I think for women, the solution will not be to be framed in this victim position saying, you know, “We earn less money and we are discriminated against.” I think women who do want to have certain careers need to send signals and that cannot only be legislated.
CATHERINE YELLAND: And remember also it’s not an ongoing trajectory upwards from, you know, admin officer to CEO. It may be, “I want to be this kind of doctor, looking after these patients. I get there after I do my training and other experience, and then I actually just want to work in that area as a clinician for the rest of my life.” That’s a very acceptable career.
MIC CAVAZZINI: Although it’s illegal in Australia and New Zealand for an employer to discriminate against a woman on the basis that she might become pregnant, value judgements about having children pervade the medical culture. Over a quarter of members surveyed by the RANZ College of Obstetricians and Gynaecologists said that they’d been asked about future pregnancies by a prospective employer. Helena Teede, once again.
HELENA TEEDE: A good colleague of mine was told at her interview, “If you give me your uterus in a jar, you can have the job.” Now, you know, that was a while ago, and was completely unacceptable. And there are also institutions—there is a very well-known hospital in Melbourne, and the entire environment in that organisation is really adversarial. No one works part-time, there’s no flexibility—if you have a child, you’re pretty much out. And it’s not malicious or vindictive, it’s just a very bloke-y culture and it can make women quite uncomfortable. And it may not just be…there are some fantastic empathetic males out there, but they also may not have been able to survive the hierarchical, self-promotion-type of arrangement which got people to those senior positions in the past.
ELIZABETH SIGSTON: I think there’s a difference between being assertive and being aggressive, and I think they often get confused and often what you see is aggression. And I've been very fortunate to be able to step outside medicine—I run a couple of businesses—and when you step out of the hierarchical system, leadership becomes about action, creativity, inspiration and purpose, rather than about power. And that’s why, you know, the nursing staff and the registrars love being in my theatre.
HELENA TEEDE: Because you don't throw knives at them and yell at them.
ELIZABETH SIGSTON: No.
HELENA TEEDE: I've been in some of those, and that was quite daunting.
And I think, as Liz said, a lot of this is about the changing of the guard in leadership style. The only reason, to be honest, I went on to any of my leadership roles is because early in my career I was nominated for a leadership training program. And the facilitator said at the end of 18 months, “Do you aspire to have power?” To which I quite emphatically stated, “Definitely no. Under no circumstances is that what I want to go to work for.”
And he said, “What you’re doing is conceptualising power as a top-down control concept of power, which is not something that would appeal to most women. But if you think about leadership as the ability to influence and impact, then it’s beholden on you, if you have the opportunity, to take the sorts of positions that will strategically put you in a position to do that.” And that one conversation changed my entire career. And it just made me brave, basically.
ELIZABETH SIGSTON: I absolutely agree. I think I’ve had the same experience. It’s about having a relatable role model, and being a woman doing that position—not a women being like a man doing that position. And I think certainly the Women in Medicine program has really opened up that conversation across campus, across specialties. Because it’s not something that you’re ever taught or have the opportunity to be exposed to in medicine. It just kind of gets skipped.
Because women tend to sit back and wait to be asked. We wait to be invited in general, whereas the guys tend to put themselves forward and, you know, if there’s a job application that has ten factors, you know, women will need to tick off all ten before they apply. Whereas men will tick off five and go, “Yeah, I can do it.” And that’s certainly a difference that may have an impact on what we see in leadership roles.
HELENA TEEDE: I agree, I think the main thing about it is it’s changed the focus in the organisation to be about empowerment and enabling and training and building capacity. It’s been linked to really tangible things—opportunities for, you know, more junior stepwise roles in leadership. A unit isn't really run by one person: we have an executive, and that executive has younger people with smaller, valued, funded roles. For example one’s the education lead, one’s a quality and safety lead, one’s the professional development lead, and they can rotate those portfolios and get experience.
And I've found that over the years young women have gravitated to me for mentorship, I think partly because they can now say, “Well, that’s what I’d like my career to look like: a well-balanced life with children, having a career clinically and academically. Or I might choose to be very part-time for a while, or I might choose not to have children.” All of those decisions are fine, but it looks like you've got a choice.
MIC CAVAZZINI: Thanks for listening to this episode of Pomegranate. Of course, we haven’t been able to cover every issue faced by women in medicine, so email us with your experiences and feedback, or tweet us @TheRACP. To read more about the Monash Health Women in Medicine program and other resources related to the story, visit the Pomegranate website at racp.edu.au/pomcast.
Many thanks to our guests Helena Teede, Elizabeth Sigston, Stefanie Schurer and Catherine Yelland. The views expressed are their own, and may not represent those of the Royal Australasian College of Physicians. Also thanks to Beverly Bucalon and Marion Leighton for their help in researching the story.
I’m Mic Cavazzini, and I hope you’ve enjoyed the program.