Women in general practice: Responding to the sexual division of labour?
Introduction
Women currently represent just over one third of all general practitioners in the U.K. (Department of Health Joint Working Party on Women Doctors and their Careers, 1991), a position which is set to alter radically over the next decade with twice as many women as men wishing to enter general practice (Allen, 1996). The numbers of women as a proportion of all new recruits have been increasing and women now account for approximately 60% of recruits into general practice. This change has occurred despite an overall picture of low recruitment, retention and morale within general practice (Handysides, 1994; Allen, 1996).
At the same time, a popular view appears to have emerged which suggests that improvements in the delivery of women's health care could be achieved by women workers. Riska and Wegar (1993), p. 77) indicate that this perspective is grounded in two assumptions. Firstly, that increases in the numbers of female physicians will result in an increased prioritisation and promotion of women's health issues (Ehrenreich and English, 1979; Relman, 1980, Relman, 1989). Secondly, the potential to alter the character of doctor–patient interaction positively has been a key feature of women workers' perceived contribution to women's health care. During the 1980's a substantial body of critical literature emerged which focused on the negative impact of the behaviour and functioning of male medical practitioners in relation to female service users (Oakley, 1980; Macintyre, 1981; Roberts, 1985). Women workers, it has been suggested, are more likely to provide an equal and empathic dialogue with women service users (Leeson and Gray, 1978; Altekruse and McDermott, 1987; Foster, 1989; Kutner and Brogan, 1990). However, as some commentators have pointed out (Lorber, 1985; Weisman and Teitelbaum, 1985), such assumptions beg further evaluation.
This paper offers a critical exploration of women GPs' approach to the provision of health care for women. The discussion seeks to present an exploratory analysis of the working experience of women in general practice and to examine critically the notion that women GPs will offer a `woman-centred' approach to the delivery of health care for women.
The paper will firstly identify the body of literature concerned with the character of the sexual division of labour within medicine, and specifically general practice. The concept that women GPs are both marginalised and ghettoised within general practice will be explored (Lawrence, 1987). Then secondly, through consideration of existing literature and analysis of women GPs' own accounts, an examination will be provided of the influence of the sexual division of labour on role definition, apportionment of responsibilities within general practice and on the character of women GPs' relationships with both colleagues and patients. Consideration will also be given to how the sexual division of labour may be ultimately influential in determining the status of women's health care as a speciality within general practice. This is not to suggest a prior assumption concerning the existence of a sexual division of labour but to highlight the need to explore its potential existence and level of impact.
The final aim of this paper is to build on these analyses further by presenting a model of the way women GPs may be attempting to manage their role, through an exploration of the different strategies adopted by a sample of women GPs. This will attempt to provide a framework to interpret any diversity of approaches among women GPs. In particular women GPs' reactions to the marginalised position of women's health work is investigated.
Section snippets
Method
Findings are reported from a three year project which aimed to develop an understanding of the role women health workers play in the construction and provision of primary health care services and to explore women users' priorities and preferences in terms of primary health care (Brooks and Phillips, 1996; Phillips and Brooks, 1997). One of the main objectives of the project was to identify the nature of the relationship between women workers and women service users.
The project employed a
The position of women in medicine
The sociological field of “women and work” has provided important theoretical insights into the nature of women's position within male dominated professions. Specifically, it can be largely characterised as “continuity in change” (Hakim, 1979); i.e. despite an increase in the numbers of women in these professions, women's position has remained one of relative disadvantage.
Studies undertaken in the U.K., by McPherson and Small (1980), Lawrence (1987)and Elston (1993)and also in Europe (Riska and
Women's work in general practice
Lawrence (1987)noted that the perception of general practice as offering an opportunity to undertake a generalist role constituted a major motivational factor for women wanting to enter general practice. General practice in the U.K. is currently characterised by a climate of rapid change and as a result the “traditional generalist” role of a GP may be disappearing, a factor which could in part account for the reported low morale among general practitioners (Handysides, 1994). However, the
Orientations to practice and the doctor patient relationship
Women physicians have generally been perceived as being inclined to possess a social as opposed to a medical orientation to their work (Calnan, 1988, p. 582). A number of studies have identified differences between male and female physicians in their approach to clinical practice and patterns of interacting with patients. These studies suggested that women physicians were more likely to provide user-centred health care, such as: negotiating with patients, responding to them as equals, spending
The potential for resistance?
The literature concerned with the position of women in the health professions has given relatively less attention to exploring the range of women's responses and strategies for managing their working roles in the light of their disadvantaged position. Although it is important to recognise that, as Lorber (1993), p. 81) indicates, occupational choices of women doctors are likely to be reactive responses to restricted options generated by institutional barriers, Walby (1986)has argued that women
Discussion and findings
From the women GPs' accounts of their motivation in entering general practice, three features emerged which were seen as the most attractive aspects. The first was the desire to combine a family with a career, also found by Parkhouse (1986). Secondly, many felt that general practice offered opportunities to employ caring skills and develop a degree of personal involvement with patients which was absent from a hospital based medical career.
General practice just covers all sorts of areas of life
Responses to the sexual division of labour: a typology
In terms of the findings presented so far, an attempt has been made to clarify the nature of the sexual division of labour within general practice and to demonstrate the main implications such a sexual division of labour has for women GPs. Section 7identified the manner in which the majority of female GPs interviewed overtly acknowledged pressure to focus their clinical time within the area of women's health care and to accept responsibility for the emotional work of the practice. However,
The women's GP
The first main narrative apparent in the GPs' accounts was that of a GP who actively welcomed her role being primarily concerned with the provision of women's health care (19 GPs). Those working in exclusively female practices were more likely to conform to the portrait of a “woman's GP” as were those working in practices with a higher ratio of males to females.
The “women's GP” group accepted or frequently sought to direct their role towards seeing proportionately more women patients and
“A generalist GP”: a GP who happens to be a woman
The GP's allocated to the “generalist group” (25 GPs) conformed to Lawrence's (Lawrence, 1987) assessment, that many women GPs feel they are prevented from being “true” GPs in the sense of being a well rounded family doctor by the pressures they encounter to specialise in women's health work. These pressures were seen to limit their opportunities to practice general medicine, as their surgery time would be fully booked up by women presenting with “women's health issues” and as a result they
Conclusions
Previous research concerned with the nature of the relationship between women users and women providers has tended to focus on the identification of any improved quality of communication between female physicians and female users in medical encounters; while critical accounts of this relationship are rare (Brozovic, 1989). The findings discussed here suggest that an explanatory model incorporating an understanding of the functioning of the sexual division of labour within medicine can enable a
Acknowledgements
I owe many thanks to John Paley, Penny Curtis, David Clark, David Phillips and Peter Scott for their very helpful advice on drafts of this paper and general encouragement. Thanks also go to Sue Thompson and Karen Ricci who were researchers on the project and who were involved in the GP interviews. I am very grateful to the anonymous reviewers for Social Science and Medicine, for their constructive advice and encouraging response to the paper. The greatest debt is to the women, both members of
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