Introducing gender perspectives into medical curricula



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INTRODUCING GENDER PERSPECTIVES INTO MEDICAL CURRICULA

Jo Wainer, Lexia Bryant & Ann Maree Nobelius

October 2002

Authors: Wainer J., Bryant L. and Nobelius AM., 2002
Project Manager: Ms Jo Wainer
Project Management Team: Professor Roger Strasser, Dr Sarah Strasser, Dr Lexia Bryant & Ms Jo Wainer
Monash University Gippsland Teaching Team: Ms Jo Wainer, Dr Gillian Murray, Dr Sue Deed, Dr Sue Clarke, Dr Kaye Birks, Dr Anne Miller, Dr Jo McCubbin, Dr Janet Watterson, Dr Heather Hunter, Dr James Brown, Dr Liz Fitzgerald, Dr Sudesh Arora, Dr Tim McArdle
Citation: Wainer, J., Bryant, L. and Nobelius, AM. (2002). Introducing Gender Perspectives into Medical Curricula. Monash University School of Rural Health, Traralgon, Victoria, Australia, 2002.

Website: www.med.monash.edu.au/mrh/gendermed

Acknowledgements: The authors would like to thank Dr Sarah Strasser and Professor Roger Strasser for their contribution to the success of the curriculum development project. Particular note must be made of the importance of the contribution of Professor Strasser. As Professor of Rural Health at Monash University, Professor Strasser was responsible for the Rural Health Curriculum. Without his foresight, authorisation and support this project would not have been possible.
Funding for this RUSC Project of National Significance was made available by the Commonwealth Department of Health and Ageing, through the Rural Undergraduate Support and Coordination Program.
EXECUTIVE SUMMARY

Women are less likely to practice in rural areas and when they do, they are less likely to work the extended hours that have traditionally been the lot of the country doctor. From 1996 until 2001 the Commonwealth Government of Australia funded the development of a curriculum unit at Monash University, teaching about issues for female rural doctors to encourage female students to consider rural medical practice. This was extended to include teaching about gender issues for doctors, and is now part of the core curriculum for medical students at Monash.


Five additional universities have introduced teaching about gender issues into their rural curriculum and it is anticipated that other medical schools will do so now that this curriculum has been named as a National Priority for rural medical education funding by the Commonwealth Government. Introducing teaching about gender issues has required the demonstration of the validity of the subject to funding bodies, faculty and students, the training of tutors, and meeting of the needs of students for an intellectual framework within which to think about gender and medicine.

Outcomes of the Curriculum Development Project

  • Gender awareness training made a new core RUSC target in 2002

  • Take up of opportunities to mainstream gender sensitivity into the new general curriculum as well as the rural curriculum, as Monash University moves from six year undergraduate entry course to a five year undergraduate entry course in 2002.

  • Monash University has established a Gender Working Party of the Five Year Curriculum Committee to implement mainstreaming of a gender perspective into the medical curriculum.

  • Gender competency accepted as one of the core clinical skills that students must acquire

  • Monash University has trained six female and one male rural doctor to teach about gender issues to medical undergraduates

  • Female and male rural doctors part of the teaching team for the Transition Residential for First year students

  • Gender perspective in the case teaching about stress for 1st year students

  • Half day seminar for 6th year students on Sex and Medicine, with input from a rural male doctor

  • 6th year tutorials on Gender Issues as part of the rural hospital ‘selectives’

  • Whole day Seminar on Sex, Gender and Medicine for 2nd year students, including a rural gender case about a female rural doctor

  • A Faculty Symposium on Sex and Medicine, 2002

  • The universities of Newcastle, Melbourne, Flinders, Adelaide and Western Australia have trained female rural medical staff to introduce new curriculum

  • The University of Adelaide has introduced gender competence into its 3rd year clinical skills curriculum

  • Workshop on gender issues for rural doctors conducted at the invitation of the rural club students at Flinders University, 2002

  • Case presentation based on a rural female doctor at NRHN conference, Shepparton 2002



National and International Theory Building Outcomes
Policy:
ACRRM Policy on Women in Rural Practice, published in their Prospectus, 1997

Project Manager and management team members were co-authors


Wonca Policy on Rural Practice and Rural Health, 1999

Project Manager was co-author and member of editorial board


Wonca Calgary Commitment to Women in Rural Family Medical Practice, 2000

Project Manager, Management team members and members of the teaching team were co-authors


Wonca Discussion Paper on Female Rural Family Physicians, 2002

Project Manager was primary author



Publications:
Book Chapter (in press) in the book ‘Teaching Gender, Teaching Women’s Health: Case Studies in Medical and Health Sciences Education’ edited by Lenore Manderson. Chapter entitled

‘Gender and the Medical Curriculum: A Rural Case Study’


Report on 10 day residential course held in Sweden by Uppsala University,

‘The Experience of an International Programme in a Gender Perspective in Medicine’, 2002.


Report on the one day International Symposium on Teaching About Gender in Medicine

‘Increasing Rigour in Medical Education’, 2002


Australian Journal of Rural Health, 2001: 9(Suppl.),S43-48

‘Sustainable Rural Practice for Female General Practitioners’


Report on the Victorian Female Rural Practitioner Survey, Rural Workforce Agency Victoria (RWAV)

‘Female Rural Doctors in Victoria: It’s Where We Live’, April 2001


South African Family Practice, Journal of the South African Academy of Family Practice, 22:6 Aug/Sept 2000

‘Women and Rural Medical Practice’


Australian College of Rural and Remote Medicine (ACRRM) Primary Curriculum, containing core curriculum unit, Strategic Skills for Rural Doctors, May 2000
RUSC Project of National Significance - Gender Issues in Rural Medical Practice: Teaching Gender Seminar, 22 February 1999
Women in Rural Practice Policy published as part of the Prospectus for the Australian College of Rural and Remote Medicine (ACRRM), February 1997
Association of Monash Medical Graduates Newsletter, Spring 1997

‘Teaching About Women in Rural General Practice’



Presentations:
Paper presentation: ‘Gender Perspectives in Medicine’

5th Wonca World Rural Health Conference, Melbourne, May 2002


Paper Presentation: ‘Gender Issues in Rural General Practice Settings’

By Dr Ursula Russell, R McNair, K Hegarty & M Evans

5th Wonca World Rural Health Conference, Melbourne, May 2002
Case presentation: ‘Women in Rural Practice’

Panel discussion: ‘Gender Issues for Rural Health Professionals’

National Rural Health Network National (NRHN) pre-Wonca Symposium, Shepparton April 2002
Presentation: ‘The Silencing of Women’

Presentation: ‘International Women’s and Men’s Health and Human Rights’

International Programme in a Gender Perspective in Medicine, Fejan Island. Residential Training workshop run by Uppsala University, Sweden August 2001
Convenor of the Organising Committee

Symposium Co-ordinator

Presentation: ‘Women in Medicine’

MWIA Satellite Symposium, ‘International Symposium on Teaching about Gender in Medicine’, Sydney, April 2001
Convenor of Session “Women in Medicine

MWIA International Congress, Sydney April 2001
Keynote Presentation: ‘Women as Rural Doctors’

Drafting of the ‘Calgary Commitment to Women’ Policy on Rural Practice and Health

Formation of the ‘Women in Rural Practice Working Group’ as part of the Wonca Working Party in Rural Practice

4th Wonca World Rural Health Conference, Calgary, August 2000


Presentation: ‘Teaching Gender Issues in Rural Medicine’

4th National Undergraduate Rural Health Conference, Joint RUSC Rural Health Academic/Student Meeting, Wagga Wagga, September 1999


Plenary Presentation: ‘Global Issues in Rural Women’s Health’

3rd Wonca World Rural Health Conference, Kuching, Malaysia, July 1999


Paper: ‘A Life, not a Wife’

5th National Rural Health Alliance: National Rural Health Conference ‘Leaping the Boundary Fence’, Adelaide, March 1999


Paper: ‘Teaching about Gender in Medicine’

Paper: ‘Female Doctors and the Culture of Medicine’



Wonca Conference, ‘People and their Family Doctors: Partners in Care’, Dublin, June 1998
Paper: ‘Generation and Gender: the emerging culture within the rural and remote medical workforce.’

41st Scientific Convention, Royal Australian College of General Practitioners (RACGP), Melbourne, October 1998


Chair and member of Conference Organising Committee

Presentation: Gender Issues in Rural Practice

3rd National Undergraduate Rural Health Conference (NRHN), First Joint RUSC Academic Rural Health Conference/Student Meeting, Philip Island, July 1998
Paper: Women in Rural General Practice

Paper: Curriculum Development Project

Third Biennial Australian Rural and Remote Health Scientific Conference, Toowoomba, 1996

Workshops:
Workshop: ‘Teaching Women- paving the way for the next generation: (1) Process’

Workshop: ‘Teaching Women- paving the way for the next generation: (2) Content’

Australian College of Rural and Remote Medicine(ACRRM) Teacher Training Workshops, Traralgon, 2002
Workshop: ‘Supporting Female Rural Doctors Through Flexible Practice Management’

Workshop: ‘Flexible Delivery of Professional Development and Training’

Australian College of Rural and Remote Medicine (ACRRM) & Rural Workforce Agency of Victoria Scientific Forum, Melbourne April 2002
Residential Workshop: Developing a gender mainstreaming manual for doctors to teach other doctors about gender

MWIA Gender Mainstreaming Workshop, Bellagio, December 2001
Workshop: ‘Gender Impact on Sustainable General Practice’

Workshop: ‘Profitable, Female-Friendly General Practice

Rural Workforce Agency of Victoria (RWAV), Victorian Rural General Practice Conference, Lorne, May 2001
Panel Member: ‘Women in Leadership’ Workshop

Wonca Conference Durban, May 2001
Workshop: ‘Women in Medicine’

XXV International Congress of the Medical Women’s International Association (MWIA), Sydney, April 2001


Workshop: ‘Leading Academic Women’

Professional Development Training for Key Female Rural Academic Doctors, Bondi, December 2000


Workshop: ‘Leading Medical Women’

Professional Development Training for Key Female Doctors in Medical Faculties and Learned Colleges, Howquadale, Victoria, February 2000


Workshops: Gender Issues for Rural Health Professionals

4th National Undergraduate Rural Health Conference, Joint RUSC Rural Health Academic/Student Meeting, Wagga Wagga, September 1999


Workshop: ‘Women’s Health in Practice’

Workshop: ‘Women in Rural Practice’

3rd Wonca World Rural Health Conference, Kuching, Malaysia, July 1999
Organiser and Convenor: ‘Teaching Gender Seminar’

Project of National Significance - Gender Issues in Rural Medical Practice, Medical Education Meeting, Monash University, Melbourne, February 1999


Workshop: ‘Women in General Practice’

Wonca Conference, ‘People and their Family Doctors: Partners in Care’, Dublin, June 1998
Workshop: ‘Putting Gender on the Agenda’

Royal Australian College of General Practitioners’ (RACGP) Training Programme National Medical Education Conference, Sydney 1998


Workshop: ‘Communicating about Gender Issues in Medical Education’

Australian and New Zealand Association of Medical Educators (ANZAME), Melbourne, December 1997


Workshop: ‘Women in Rural Practice’

Recommendations on Women in Rural Practice accepted by Conference and subsequently 1998 embedded in the Wonca Policy on Rural Practice and Rural Health adopted by Wonca in 1999. 2nd Wonca World Conference on Rural Health, Durban, September 1997


Workshop: ‘Family and Professional Issues in Rural Medical Practice’

Pre-Conference Workshop organised by The World Organisation of Family Doctors (Wonca), ‘Preparation, Practice & Politics’, Perth 1997


Workshop: ‘Teaching about Gender in Rural Medical Practice’

Rural Undergraduate Steering Committee(RUSC) Meeting, Townsville 1996


The success of the rural curriculum unit has demonstrated the need to address issues of gender throughout all aspects of medical education, resulting in the establishment of a Faculty Working Party on Gender to mainstream teaching a gender perspective in medicine throughout the entire new five year curriculum at Monash University. This report provides a description of the social, political and professional impetus that facilitated the evolution of this timely curriculum unit and ultimately contributed to the development of an international debate on medical education.
1. INTRODUCTION

Between 1997 and 2001 Monash University, in Australia, taught a curriculum unit on gender issues for rural doctors to undergraduate medical students. The unit focused on gender issues within medicine, including the construction of medical knowledge, professional structures and reward systems, as well as sustainable ways women and men have found to work in rural medicine. Development of the unit was funded by the Commonwealth Government as part of a long-term, vertically integrated strategy to attract and retain doctors, particularly female doctors, in rural medical practice.


Three major issues prompted the government to identify community needs and take action to fund change within the medical curriculum: the long-standing shortage of doctors, particularly female doctors, working in rural and remote Australia (a world-wide phenomenon); the political imperative to improve health services to rural and remote Australians and finally the changing sex ratio of the medical student body.
Why the Need for a New Curriculum?

The under-servicing of rural and remote Australia by medical practitioners is a long-standing problem that has been well documented (Strasser, Karmien et al. 1997; AMWAC 1998; Makan 1998). According to RUSC, (the then Rural Undergraduate Steering Committee, now Rural Undergraduate Support and Coordination Program) attracting and retaining health practitioners to rural communities is an Australia wide problem (RUSC 1994). Women now make up a quarter of the medical workforce, but they are not evenly spread through the different types of practice. According to Medicare data women make up 29% of the general practitioner workforce (DHSH 1995), 14% of the specialist workforce and 33% of the hospital workforce.


Maldistribution of Doctors

The maldistribution of doctors has been identified as an important equity and workforce issue in many countries (Makan 1998). In Australia, the Australian Medical Workforce Advisory Committee (AMWAC) reported that the problem is confounded by the changing sex ratio of doctors, and the different way female and male doctors contribute to medicine (AMWAC 1998). Doctors are underrepresented in rural and impoverished areas and female doctors are currently even less likely to go into rural practice than their male colleagues (Strasser, Karmien et al. 1997). The maldistribution of women doctors (over-represented in general practice, under-represented in rural practice and hospital salaried positions) reflects the general maldistribution of the medical workforce. Strasser found there are significantly fewer female general practitioners in small town rural practice (19%) as compared with suburban general practice (32% female) in Victoria (Strasser 1992). Twenty percent of general practitioners practice in rural areas and only one quarter are women (Wainer, Bryant et al. 1999; Wainer, Carson et al. 2000). It was argued that resolving some of the difficulties faced by women doctors may assist in resolution of broader issues of maldistribution (DHSH 1995).


Changing Sex Ratio of Medical Students

In the developed world there has been a radical change in the sex ratio of the students studying medicine. Until recently women were a small and largely silent minority of students. In the year 2000 fifty six percent of first year medical students and forty five percent of the whole student body in South Africa were women (MWIA 2001). The proportion of women among medical students in the United States has increased steadily, especially over the past decade; in 1999, 44% of first-year medical students were women (de Angelis 2000). The increased numbers of women in the medical workforce is also apparent in Canada (Birenbaum 1995) and the United Kingdom (AMWAC 1996). In Australia there were equal numbers of female and male students enrolled in first year medical courses Australia-wide for the first time in 1999.


Increasing Female Participation in Medical Workforce

Levitt has pointed out that increasing female participation in the medical workforce, combined with the different work characteristics of male and female practitioners, is likely to have a substantial impact on the future supply and distribution of medical practitioners in Australia (McEwin 2001). Female medical practitioners tend to choose general practice, to work part-time and to practice in capital cities or major urban areas. Women also tend to leave medicine or practice at quite low activity levels for a period of time during their careers (AMWAC 1998). On average they work fewer hours over a lifetime than males. The Australian Medical Workforce Advisory Committee has calculated that over a lifetime, a female GP is estimated to work 62.8% of the total hours worked by a male GP. For specialist practice, the proportion is around 75%, although this varies among specialties (AMWAC 1996).


Difference in Male and Female Practice Styles

In addition, there is now good evidence from Australia and other Western countries that while all doctors have a shared body of knowledge, core competencies and professional ethos, there are different preferred working styles that can be identified as favoured by women and men (Hojat, Gonnella et al. 1995) (Turner, Tippett et al. 1994). Australian researchers have found that women doctors are more influenced than men in their choice of speciality by the need for “the opportunity for holistic care” (86% of women compared with 58% of men) (Redman, Saltman et al. 1994).


Recent research conducted in South Africa highlighted the scarcity of women in practice partnerships and the lack of provision of maternity leave for female family physicians (Moodley, Barnes et al. 1999). Another study conducted in Australia indicated that female medical practitioners have distinct work characteristics. These researchers found that by comparison with males, female general practitioners tend to have longer consultations; manage significantly higher numbers of problems per encounter; see a higher percentage of younger patients and new patients; and manage depression more often (Britt, Sayer et al. 1999).
It has been reported that men value psychosocial aspects of health less than women do, and tend to operate more strongly from a biomedical rather than biopsychosocial paradigm (Redman, Saltman et al. 1994). Men place less emphasise on holistic care, practice less preventive medicine, deal with one problem at a time rather than the many which patients may present with, do less counselling, and prefer to carry out procedures rather than deal with mental health issues (Britt, Sayer et al. 1999). Patients are much less likely to present to male doctors with issues of interpersonal violence or sexual assault (Wainer 1998). These different priorities are reflected in different styles of practice (AMWAC 1998) and combine with different expectations from patients (Brown, Young et al. 1997), (Bundrock and Harvey 1996), (Rogers 1995).
Because the current system of Western medicine has always been practised by men, there has been an unacknowledged convergence of ‘medicine’ and ‘male-practised medicine’. Yet the broad general nature of rural medical practice should provide the holistic component to medical practice that women doctors seem to value. It has taken a recognised shortage of rural doctor, particularly female rural doctors coupled with the presence of women in sufficient numbers, asserting their own style of medical practice, to raise the possibility that there are alternative ways to practice medicine, especially rural medicine, that reflect the priorities and values of women.
Research commissioned by AMWAC demonstrates that the estimated shortage of rural doctors (1000 doctors) contains an even greater shortage of female rural doctors (AMWAC and AIHW 1996). Women comprise less than a quarter of the rural medical workforce. Now that half the graduating doctors are women, it is imperative that rural medicine restructures itself to incorporate the world-view and experience of this half of the graduating cohort. There is a parallel between the dialogue within rural medicine and between women and medicine. Both groups (rural and women) are saying they do medicine their own way. Their way converges with the prevailing medical culture in core skills and knowledge, and differs in context and priorities.
Rural medicine is the point in the profession where the changes stemming from the presence of women will be felt first and most fully. Other specialist medical colleges have no need to adapt their rules and training procedures to ensure that they reflect and draw on the best that the whole of the young doctor cohort can offer, because of strong competition for training positions. In that sense rural medicine is different. It needs more recruits than apply for positions.
Rural Medical Practice

Several papers (Wainer 1998), (Wainer 2000),(Strasser, Karmien et al. 1997), (Thompson 1997) have analysed the evidence for an emerging cultural change within the rural medical workforce. Tolhurst has drawn out some of the tensions experienced by female rural doctors, including additional ‘on-call’ time and pressure to work more hours than they want to. There is even pressure from colleagues who reportedly consider them ‘not real doctors’ if they choose to work part time (Tolhurst, Bell et al. 1997). In 1997 the Australian College of Rural and Remote Medicine (ACRRM) included issues for female practitioners in its foundation documents (ACRRM 1997).


In as much as medicine has been developed from masculine experience the structure and values of the profession often do not work well for women. This is highlighted in rural areas where the definitions of appropriate male and female behaviour is narrower in range than in metropolitan cultures. An example of the discontinuity of the medical culture and women’s experience is the expectation that rural doctors will be available on call at all hours (Strasser 1992). According to Strasser rural general practitioners experience substantially more hours on call, and call outs while on call, than metropolitan based general practitioners, and this expectation conflicts with the equally strong expectation that women must put first priority on the care of their families. At first glance, being on call for your community and for your family seem incompatible.
Medicine has been a predominantly male domain for so long, and access to the study of medicine so competitive that, up until now, it has not been possible for women to question whether this is as it ought to be. The result has been that female students and doctors have had to adapt to a male culture that, for some, has been an awkward fit. In addition rural culture can heighten the unquestioned masculinity of medicine. At the very least it seems that women in rural medicine do not often experience a valuing of their femaleness.
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