A century of ‘feminization’ has made medicine better for all Canadians, but it could be better still

When Dr. Shelley Ross graduated from medical school at the University of Alberta in 1974, there were only 20 women in the class of 120.

Back then, there was still a quota. Not affirmative action, but the opposite – a cap meant to limit the number of women entering the profession. The assumption was that training women would largely be a waste of time and money because they would soon get pregnant and quit, whereas men would have a long career.

Fifty years later, Dr. Ross is still a practising family physician in Burnaby, B.C. “Guess they got their money’s worth out of me,” she says with a laugh. And, yes, she had children – two.

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The way women have been treated in medicine, however, is no laughing matter. For centuries, they have been shut out and marginalized: paid less than their male counterparts, passed over for leadership roles, steered toward less prestigious specialties, treated as nurses, denied maternity leave and more.

As one male medical professor said in 1873: The end result of medical education for women was “monstrous brains and puny bodies.”

Systems of education, training, clinical practice, academia and research were all designed by men, for men.

Those systems are evolving. The macho 100-hour work weeks, the teaching-by-bullying, the paternalistic approach to patient care, the old boys’ networks and more, are disappearing. The culture of medicine is changing. Slowly.

This shift is often referred to as the “feminization” of medicine. It’s a loaded term, one with often negative connotations and stereotypical beliefs, such as female doctors work slower and work less. In particular, the influx of women into medicine is often blamed the decline in access to care – everything from the inability to find a family doctor to longer waits for surgery.

But the data don’t really bear that out. According to a study published earlier this year in the Canadian Medical Association Journal, the median average weekly hours worked by physicians in this country has steadily declined for decades; the average physician works about seven fewer hours weekly today as in 1987. That decline is most pronounced for men, whose weekly hours have dropped to 47.7 hours from 55.2 hours. In the same period, the average workweek of female physicians has declined only slightly, to 43.7 hours from 44.7 hours.

What doctors do during their working hours has also changed markedly over the years, and so too have the needs of patients and priorities of health systems. Patients are sicker and more complex, and waiting lists ever-growing so the work is more intense. The amount of paperwork has become stifling, even in the digital age. Those are much larger factors in determining access than the gender of practitioners.

There are those who find the term “feminization” distasteful, saying it implies that a “masculine” system is the norm, and that women taking their rightful place in the hallways of medicine is an anomaly.

Male domination is cemented into medicine’s very foundations. What female physicians have long been seeking is gender equity.

In this country, the fight for equity started in earnest a century ago, in 1924, with the founding of the Federation of Medical Women of Canada. (That was five years before women were recognized as persons under Canadian law.)

When Dr. Maude Abbott, the FMWC’s founding president, rallied her colleagues, medical schools were reluctant to accept women. There were about 8,000 doctors in Canada, and only 187 were women (2 per cent), and many of them had been trained in the U.S. or Europe.

By 1954, that number had crept up to 4 per cent.

Half a century after the founding of the FMWC, when Dr. Ross graduated, only 12 per cent of physicians in Canada were women.

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Today, 43,209 of Canada’s 96,020 licensed medical doctors are women – 45 per cent of the total. And gender parity is near because between 50 and 60 per cent of students in Canada’s 17 (and soon to be 20) medical schools are women.

But overall numbers don’t tell the whole story.

“Is medicine equitable now? Absolutely not,” says Dr. Ivy Bourgeault, a professor of sociological and anthropological studies at the University of Ottawa, where she serves as the University Research Chair in Gender, Diversity and the Professions. “Gender still permeates all experiences in medicine: applying for med school, studying, residency, practice and promotion.”

Dr. Bourgeault says the biggest problem is the still a paucity of women in leadership positions in health care institutions, academia, research enterprises and physician associations. The glass ceiling may be starting to show cracks, but it hasn’t yet been shattered.

Male to female ratios vary a lot by specialty: It’s 50-50 in family medicine, 58-42 in medical specialties, and 66-34 in surgical specialties, according to data from the Canadian Institute for Health Information. Female physicians gravitate – or are pushed – toward family medicine, pediatrics and public health, not more prestigious and higher paid specialties.

“The reality is that women get the most complex patients, those that require a lot of time, and those cases are remunerated the least,” says Dr. Shirley Schipper, a family physician who is the vice-dean of education in the faculty of medicine at the University of Alberta.

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Physicians are well-paid generally. But equal pay for work of equal value is far from the norm in medicine.

What is clear is that female physicians make practical choices. They are drawn to jobs with more flexibility, because they are torn between personal and professional responsibilities, particularly in their child-bearing years. Research also shows that female doctors tend to be more empathetic. They take more time with patients, do more follow-up and prefer working in teams, which is more time-consuming.

“Women strive to practice in ways that make sense,” Dr. Schipper says. “They work in a collaborative fashion and try to balance work with their lives.”

But that’s not how doctors are trained and it’s not how the health system is designed to function. It rewards individualism and volume. Not results.

But there is a growing body of evidence that female physicians must be doing something right because they get better results.

A large study that examined data from 770,000 records of U.S. Medicare patients who were hospitalized, published recently in the Annals of Internal Medicine, found that patients (both male and female) whose care was led by a female doctor were less likely to die and had lower readmission rates 30 days after leaving hospital. Female patients benefited significantly more from being seen by a female doctor than male patients did, as well. A 2018 study examining the records of 580,000 cardiac patients admitted to Florida ERs also found death rates for men and women were lower when they were seen by a female doctor; women who were treated by male doctors fared the worst. Another research paper, published last year in JAMA Surgery, analyzed the outcomes of more than one million surgical patients, and found that patients treated by female surgeons were less likely to suffer adverse outcomes at 90 days and one year after surgery. A 2021 Canadian study found that women operated on by a female surgeon were 25 per cent less likely to die, and the same was true for 13 per cent of men.

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The differences in outcomes are certainly not due exclusively the presence or absence of a Y chromosome in the treating physicians. Rather, researchers believe that better results are explained principally by differences in communication styles seen between male and female doctors. In short, female physicians spend more time with patients, and they spend that time in conversation – on average two minutes more in each encounter – than male doctors. While two minutes of conversation doesn’t seem like something that would lower death rates, consider that, on average, a physician listens to a patient for 11 seconds before interrupting. Again, female doctors listen a lot longer than men before interjecting.

Are women better doctors than men? That question, which has found its way into many a provocative headline, is difficult to answer because “better” depends on the patient being treated and the outcome being measured.

What is clear though is that many patients prefer to be treated by a female physician. That is especially true for women, particularly for gynecological and sexual-health issues.

Throughout history, female physicians have been at the forefront of advocating for better women’s health, especially reproductive rights, notably access to contraception and abortion. One of the founders of the FMWC, Dr. Elizabeth Bagshaw, established Canada’s first birth control clinic in 1932 in Hamilton. That was decades before birth control was legalized in 1969. Dr. Bagshaw also continued to work as a physician until her retirement at the age of 95.

In recent years, that advocacy has extended to areas such as cardiovascular health and chronic pain. Heart disease and stroke are the No. 1 killer of women, but they are still viewed largely a men’s issues.

Child care and caring for aging family members remain largely the burden of women, even those with well-paying and powerful positions. That sexist societal reality has clearly affected female physicians and how they practice.

A study conducted in the U.S. during the height of the COVID-19 pandemic – when many daycares and schools were closed, and remote learning was the norm – drove this point home. It found that female physicians were 30 times more likely to be solely responsible for child care and schooling of children compared with their male counterparts – 24.6 per cent of women versus 0.8 per cent men. Another study found that female clinicians spend, on average, 100.2 minutes a day more on household activities and child care than their male counterparts.

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In medicine, time is money. In Canada, most physician income (72 per cent) is paid on a fee-for-service basis. Doctors are essentially small businesses doing piece work. Very few are salaried. That can make taking time off for child-rearing costly. For a long time, it was near-impossible.

Dr. Noni MacDonald, a professor emeritus of pediatrics at Dalhousie University, recalls that, when she had her first child in 1976, while working as a medical resident at the Children’s Hospital of Eastern Ontario, she could only take four weeks off – her entire allotment of holidays.

“If I had taken one more day, I would have lost my whole year. It was brutal,” Dr. MacDonald said. Her first day back at work, she had a 48-hour shift.

To add insult to injury, when Dr. MacDonald got her first clinical job, she was paid half as much as a man in a similar position – because he had four children and a wife, while she had a husband and two kids.

Parental leave programs are relatively new in medicine, but now commonplace. But taking time off to have a baby can still be an impediment to career advancement.

In the early years of a career, physicians have a lot of time and energy and can do demanding work such as surgery, overnight shifts, obstetrics and palliative care. When children come along, they should be able to step back a bit, work part-time, or predictable hours, then, as their children grow up, return to more demanding leadership roles. In short, says Dr. Schipper, medicine needs to do a better job of adapting to the realities of modern family life.

“I graduated 25 years ago, and the system is exactly the same today as it was then. It hasn’t adapted,” she says.

The result is that physicians (mostly women) leave the profession, or never work to their full potential. The combination of a rigid system and a “leaky pipeline” is one reason there are so few women in positions of power.

But there is a distinct lack of research and interest in how women’s careers progress and why they struggle to get into positions of power in medicine, says Dr. Bourgeault of the University of Ottawa. “If we’re going to fix problems, first we have to recognize there are problems,” she says.

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There are some data on equity (or lack thereof) in academic medicine, but virtually none in clinical medicine.

The data we do have are telling.

The Canadian Medical Association, founded in 1867, has had 152 presidents in its history. Only 12 have been women, and nine of those in the past 20 years.

The Canadian Medical Hall of Fame has 161 laureates, only 25 of them women.

There have only been 11 female deans of faculties of medicine in the 200 years since Canada’s first medical school opened in 1824.

Dr. MacDonald was the first female dean of medicine, appointed to the position at Dalhousie University in 1999. But, after one term, she returned to clinical practice.

“People don’t understand that women don’t always want to be king of the castle,” she says. It can be exhausting to be a trailblazer. (She was also inducted in the Hall of Fame.)

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The most positive impact of “feminization,” Dr. MacDonald says, is that there is a lot less bullying and abusive behaviour. The military boot camp approach to teaching, rife with humiliation, is no longer tolerated.

Women in medicine, however, still experience a lot of sexual harassment and violence, from both staff and patients. The profession is ripe for its #MeToo moment.

“There’s a new world coming,” says Dr. Ramneek Dosanjh, a family physician in Surrey, B.C. and president-elect of the Federation of Medical Women of Canada, which will mark its 100th anniversary at a conference in Ottawa on Sept. 27 to 28. The progress women have made in medicine in the past century is inspiring, she says, but a lot remains to be done. “Nearly half of physicians are women. Now we need to look beyond the numbers and embolden the push for equity.”

Dr. Dosanjh says medicine needs to look like society, and that means promoting racial equity in addition to gender equity. The solution is largely about fixing archaic systems, and the starting point has be making them more equitable.

“When I see the young women coming into medicine today, I want to give them hope and optimism that the future is theirs.”

Women in medicine through the ages

Women have practised healing since antiquity, but often on the margins, limited to treating the “diseases of women,” namely pregnancy and childbirth. Here are some milestones.

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• Circa 2700 BCE: Merit-Ptah is often described as the first female physician; she served the pharaoh in dynastic Egypt;
• 4th century BCE: Agnodice, the first female physician in ancient Greece, disguised herself as a man;
• 11th century: Trota of Salerno wrote an influential medical text, “On The Treatments of Women”;
• 12th century: Hilgard of Bingen, a nun and healer became a legendary figure in Germany;
• 1754: Dorothea Erxleben was the first female doctor in Germany and the first woman worldwide to be granted an MD by a university;
• 1850s: Dr. James Miranda Barry was the first female to practise Western medicine in Canada, but the British surgeon’s gender was only revealed after death;
• 1867: Dr. Emily Stowe was the first openly female physician in Canada. Trained in the U.S., she practised in Toronto;
• 1883: Augusta Stowe-Gullen, Dr. Stowe’s daughter, graduated from the University of Toronto in 1883, the first woman to obtain a medical degree in Canada. (U of T would not admit another woman for 25 years.)
• 1883: Dr. Emily Stowe founded Women’s College Hospital in Toronto because no other hospital would take women as medical residents;
• 1885: Dr. Helen Elizabeth Reynolds Ryan was the first woman granted membership in the Canadian Medical Association, which was founded in 1867;
• 1911: Dr. Jennie Smillie Robertson was the first woman to perform major surgery in Canada; however, she was not allowed to register as a surgeon because of her gender;
• 1924: The Federation of Medical Women of Canada was founded to fight for the rights of women physicians;
• 1929: The Supreme Court of Canada ruled that women were persons under the law;
• 1932: Dr. Elizabeth Bagshaw founded the first birth control clinic in Canada, in Hamilton; she also started Planned Parenthood;
• 1939: Dr. Jessie Gray became the first registered female surgeon in Canada;
• 1941: Dr. Jean Flatt Davey became the first woman to serve in the medical corps of the Canadian armed forces; prior to that, women could only serve as nurses;
• 1952: Dr. Jessie Boyd Scriver became the first female president of the Canadian Paediatric Society, founded in 1922;
• 1974: Dr. Bette Stephenson was elected the first female president of the Canadian Medical Association, 107 years after it was founded;
• 1987: Dr. Joan Bain became the first female president of the College of Family Physicians of Canada. It was established in 1954;
• 1999: Dr. Noni MacDonald (Dalhousie) and Dr. Carol Herbert (Western) became the first female deans of medicine in Canada. Canada’s first medical school opened in 1824;
• 2003: Dr. Louise Samson became the first female president of the Royal College of Physicians and Surgeons of Canada. It was founded in 1929;
• 2015: Dr. Jane Philpott becomes the first physician (male or female) to serve as federal Minister of Health.

Source: Federation of Medical Women of Canada