Gender Inequalities in Medical Education: Accessibility of Orthopedic Training for Female Interns in Egypt

Research Project (to be discussed at the Winter Academy) by Marwa Schumann.

Marwa Schumann works as an instructor at the medical education department, faculty of medicine of the Alexandria University. She is currently researching gender inequalities in medical education.

Feminizations of medicine and gender inequality are paradoxical factors with an increasing influence on the field of surgery in general and orthopedic surgery in particular. The increased number of female medical students and graduates has led to a paradoxical shortage of orthopedic surgery residents; only a very small proportion of female graduates choose to become orthopedic surgeons. Reasons included female disinterest in orthopedics, the long working hours, increased physical demands, male domination and male nature of the field causing biases and stereotypes about and against women. Female exposure to negative attitudes discouraging them from choosing a specific “male-dominated” career show how education can function as means of reinforcing social and gender inequalities rather than correcting them.

Main objectives of the research are to determine the gender influences on access to education and training of interns, to explore the motivations and expectations of a female intern training in the orthopedic surgery department and to explore the challenges facing the first female intern choosing orthopedic surgery training.

This is a qualitative study carried out within the framework of a narrative inquiry methodology where data is generated in the form of stories. It is situated in constructivist epistemology where knowledge is “socially constructed”. Purposeful sampling was carried out to conduct semi- structured interviews with the first female intern training in the orthopedic surgery department to explore her motivation, expectations, preparation and challenges she faced to get the approval for orthopedic training. A focus group discussion is chosen to elicit the attitudes of peers. Interviews and focus group discussions will be audio-recorded, transcribed, translated and analyzed.

Gender issues seem to affect the training and learning experience of house officers in general and those training in the surgery departments in particular. Sexism and negative attitudes towards women working as physicians in general and as surgeons in specific, act as barriers against achieving expected skills and competences. The hidden curriculum plays an important role in gender discrimination. Negative effects of gender discrimination among house officers extend beyond de-motivation of trainees and limiting the career choices to affect the quality and safety of healthcare provided. Equal training opportunities should be provided to medical interns regardless their gender.

The problem of gender inequality in the field of surgery in general and orthopedic surgery in particular has been documented in the medical education literature by a number of researchers across the globe, for example in the United States (Biermann, 1998), the UK (Bucknall & Pynsent, 2009), Canada (Baerlocher, 2007), Malawi (Kollias et al, 2010) and Israel (Schroeder et al, 2014). “Women continue to be underrepresented among surgery residents and surgeons in practice” (Baerlocher, 2007, p.434).

The increased number of female medical students and graduates has led to a paradoxical shortage of orthopedic surgery residents; only a very small proportion of female graduates choose to become orthopedic surgeons (Biermann, 1998; Baldwin et al, 2011; Schroeder et al 2014). Reasons included female disinterest in orthopedics, the long working hours, increased physical demands, male domination and male nature of the field causing biases and stereotypes about and against women (Biermann, 1998; Bucknall &Pynsent, 2009; Baldwin et al, 2011).

However, when comparing the attitudes of patients, orthopedic surgeons and female medical students Bucknall and Pynsent ( 2009) discovered a contradiction between the patients’ and surgeons’ perceptions on the one hand and those of the female medical students on the other hand: no sex-preference for orthopedic surgeons was identified among patients; “seventy-five percent believed women are surgically as skilled as men and 4% of the patients stated they had more confidence in female orthopedic surgeons compared to males” (Bucknall and Pynsent,2009,p.89). The majority of orthopedic surgeons welcomed females in the career as a source of diversity. Therefore the authors attributed the female negative attitudes to rumors during their learning experience.

Female exposure to negative attitudes discouraging them from choosing a specific “male-dominated” career show how education can function as means of reinforcing social and gender inequalities rather than correcting them. Female students did perceive orthopedic surgery as an instant gratification providing profession with high income and good private practice opportunities, research has shown equal surgical and mechanical skills competency of both male and female residents , however only 2% of female medical students and interns were interested in it due the male- dominance of that field (Schroeder et al, 2014).

The problem of the “man’s world” profession goes beyond being a social one preventing female medical students from choosing a career they might be interested in, into a problem affecting the quality of health care provided in some countries: With a growing and aging population the demand for orthopedic services rises (Schroeder et al, 2014). However, there is no parallel increase in the number of orthopedic surgeons let alone the increased feminization of medicine and increased number of female medical students.

Research done so far used quantitative methods to estimate figures and numbers, focused more on the female medical students and residents with less emphasis on interns who are actually making the career choice. There is also a gap in the medical education literature about female orthopedic surgeons in the Middle East, a region where cultural aspects would add a more interesting dimension to the research done so far.

This research therefore aims at bridging these gaps: It is a qualitative research to understand the meaning of the experience of females in orthopedic surgery and to gain more depth of their fears and challenges. Interns are the focus of this study; they are the ones experiencing the so called ‘metamorphosis of medical students into junior doctors’ (Tavabie and Baker 2012) requiring a smooth transition from the university to clinical life, to be able to join the new community of practice and health care team and become an effective team member and leader.

Being carried out in a medical school in Egypt throws more light on the Middle East with some of its taboos and cultural challenges. Female medical students in Egypt so far prefer what they call the more “feminine” medical specialties such as dermatology, clinical pathology and radiology (personal communication). In the last decade some female residents started entering the surgical “men’s club” and specialized as general surgeons but certain specialties remained taboo such as neurosurgery, urology and orthopedic surgery.

This case study is interested in documenting the experience of a female house officer (intern) gender inequalities and the experience of the first female intern choosing to train in the orthopedic surgery department, her expectations, fears and challenges and the attitudes of her peers and colleagues.

This study is not only concerned with “what” are the gender influences and barriers towards equal education and training experiences but also “how” it feels to be the first female training at the orthopedic surgery department.

That’s why qualitative methodology is used which is based on the assumption that there is no single but rather multiple different realities experienced by different people based on individual and social contexts (Lingard and Kennedy, 2014). It allows in- depth exploration of the individual experience and perspectives of interns who construct a diverse and rich reflection of their perceived realities to produce rich data exploring real- life behaviors (Kuper et al, 2008).

This study is carried out within the framework of a narrative inquiry methodology where data is generated in the form of stories that are interpreted and represented in a narrative or storied form to reflect the gender factors influencing the training experience (Schwandt, 1997).

 

References

Baldwin, K, Namdari, S, Bowers, A, Keenan, M, Levin, L, & Ahn, J 2011, ‘Factors affecting interest in orthopedics among female medical students: a prospective analysis’, Orthopedics, 34, 12, pp. e919-e932

Biermann, J 1998, ‘Women in orthopedic surgery residencies in the United States’, Academic Medicine: Journal Of The Association Of American Medical Colleges, 73, 6, pp. 708-709

Bucknall, V. & Pynsent, P.B. 2009, “Sex and the orthopaedic surgeon: A survey of patient, medical student and male orthopaedic surgeon attitudes towards female orthopaedic surgeons”, The Surgeon, vol. 7, no. 2, pp. 89-95.

Illing, J. 2014 Thinking about research: theoretical perspectives, ethics and scholarship in Swanwick, T. & Association for the Study of Medical Education 2014, Understanding Medical Education: Evidence, Theory, and Practice / edited by Professor Tim Swanwick, Wiley-Blackwell, Chichester.

Kuper, A., Reeves, S. & Levinson, W. 2008, “Qualitative research: An introduction to reading and appraising qualitative research”, BMJ, vol. 337, no. 7666, pp. 404-407.

Lingard, L. and Kennedy, T.J. 2014 Qualitative Research Methods in Medical Education in Swanwick, T. & Association for the Study of Medical Education 2014, Understanding Medical Education: Evidence, Theory, and Practice / edited by Professor Tim Swanwick, Wiley-Blackwell, Chichester.

Riessman, C.K. 2008, Narrative methods for the human sciences: Catherine Kohler Riessman, Sage Publications, Los Angeles, Calif.

Schroeder, J.E., Zisk-Rony, R.Y., Liebergall, M., Tandeter, H., Kaplan, L., Weiss, Y.G. & Weissman, C. 2014, “Medical students’ and interns’ interest in orthopedic surgery: the gender factor”, Journal of surgical education, vol. 71, no. 2, pp. 198-204.

Schwandt, T.A. 1997, Qualitative inquiry: a dictionary of terms / Thomas A. Schwandt, Sage, Thousand Oaks.

Tavabie, O. and Baker, P. 2012 Preparing final-year students for medical emergencies. Medical Education, 46: 1110–1111


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