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THE FATE OF OXFORD MEDICAL WOMEN
1158
Medical Education THE FATE OF OXFORD MEDICAL WOMEN A. H. T. ROBB-SMITH M.D. Lond., F.R.C.P. NUFFIELD READER IN
PATHOLOGY,
UNIVERSITY OF OXFORD
time when a shortage of doctors is said to be impending, and when there is some doubt about the contribution which women make to medicine, it seemed appropriate to review the progress of a group of Oxford graduates. In 1922 the B.M. degree was conferred on the first four Oxford women graduates and by the end of 1960, the number of women who had received the degree was 227. This inquiry was limited to the 139 who qualified before 1951, as the aim was to ascertain their subsequent career, which needed an interval of at least ten years. Unhappily, less than half were in the Medical Directory, but the colleges helped with current addresses and a questionnaire was sent to each graduate inquiring as to civil state, number of children, husband’s occupation, whether they were, or had been, practising medicine, and if so in what branch of the profession. If they had given up practice they were asked why and whether they would like to resume. The response was excellent, though persistence was " necessary (one graduate addressed me as Importunate Sir "), but 138 of the 139 finally replied. (The solitary failure left the country in 1924 without registering her degree so cannot have practised here.) Though this analysis is based on small numbers, the good response enhances its value, for in wastage-assessment lack of information may be as significant as the silent watchdog of King’s Pyland. The graduates were divided into those who qualified in AT
a
1922-30, 1931-40, and 1941-50. The
amount
no
clinical work for five years, and worked half-time for years, clinical activity would be shown as 50%.
next ten
HUSBANDS
AND
MEDICAL
WORK
Single Women It seemed reasonable
to treat the careers of single untrammelled by husbands and separately: for, achievements their should children, depend on their own their to capabilities and ability compete, albeit on unequal terms, with their male colleagues. women
single graduates (table II) nearly half were cona marked preponderance in pathology. (" Medicine " includes 2 pxdiatricians, 1 psychiatrist, 1 neurologist, 1 dermatologist, and 1 radiologist, and surgery 2 general Of the 40
sultants, with
"
"
surgeons, 2 ear, nose, and throat surgeons, and 1 obstetrician
and gynaecologist. Nearly practising abroad.)
a
third of the consultants
were
None of the consultants indicated that they had found any difficulties in their careers, though several mentioned that in the 30’s, women had difficulty in obtaining house-officer
special
TABLE II-CAREERS OF SINGLE GRADUATES
of work since
qualification was expressed as a percentage of clinical activity, 100% being full-time from qualification to 1960. Thus for a woman who qualified in 1940, worked full-time for five years, did the
78% were married. By 1960 the 75 married graduates in this group had borne 190 children in 184 pregnancies. The mean family size was higher than the national figures for occupied married women. Thus, as far as vital statistics go, the Oxford medical women compared favourably with their non-professional sisters. It remains to consider their clinical activities.
FAMILIES
Table I gives the basic information about the three groups. While 60% of the 1922-30 group remained single, only 27% of the 1931-40 group and 19% of the 1941-50 group did so. Of the married women in the two younger groups just over half have medical husbands. The proportion of married women in the 1941-50 group was high, but their age at marriage was later than the national average, though the ultimate difference in the
proportion remaining single was small; 16% married before graduation, and within four years of graduation TABLE I-CIVIL STATE AND CLINICAL ACTIVITY OF THE THREE GROUPS
posts and the surgeons observed that the F.R.c.s. hurdle; but this is not peculiar to the female sex.
was a
real
quarter were in general practice, and all were in partnership or singlehanded, though some mentioned the difficulty of finding domestic help. Only 2 were in public health. 3 had given up medicine because of ill health and 4 had died.
Just
over a
enjoying it, whether
Widowed and Divorced The average number of children of the 11 who were widowed or divorced was only a little below that of the women with husbands, but their " clinical activity " approached that of the was provided by one of the single women. The explanation " know how I should have who work. I don’t graduates managed to educate my three sons when my marriage broke up if I had not had the advantage of a profession like medicine." 4 were consultants (general physician, neurologist, psychiatrist, and pathologist), 5 in general practice, 1 in public health, and 1 an assistant professor of anatomy. 2 of the general practitioners commented on the difficulties of returning to active practice and 2 others on its interference with family life. Married Women The 71 married
graduates was the largest group, and also the group in which a professional career was most likely to be modified by environment. Their careers are shown in table in. Of the 1922-40 married graduates 5 (and probably the 1 graduate who was not traced) had never practised, 5 others (apart from 2 who had retired on grounds of age) did not wish to resume medical work. Of the 1941-50 married graduates,
1159 TABLE III—CAREERS OF MARRIED GRADUATES
husband-and-wife relationships are as important as the nature of the work. Of 27 married women in general practice, two-thirds with medical husbands had continued in practice and on an average they had larger families than those who had to give it up. 60% of those married to non-medical husbands had to abandon it with regret and one of those who had continued in general practice, felt that her family had suffered as a result of it.
Difficulty of specialising after early marriage would seem, with the possible exception of psychology, to be Most of the married consultants did not marry until had established themselves, so it was easier to obtain they maternity leave and they were earning enough to have trained staff to look after the children. The average age at marriage of all graduates was 28, of the practising consultants 33, and of those graduates who were training for a specialty but gave it up on marriage, 30. On the other hand the average marriage-age of graduates specialising in psychology was 29, and most of these had trained after true.
practised and 4 others did not wish to resume practice; accordingly only 14% of the married Oxford medical 2 had
never
women
did
not
wish
to
continue in their
career.
About half the graduates who were not practising would have liked to do so and of those who were, many were anxious for more work. Among the 1941-50 graduates a higher proportion of those with medical husbands were in practice, either as consultants or general practitioners, while most of those with non-medical husbands were in the public-health service. Over a third of the reasons proffered for failure to obtain enough work related to marriage and families, and this was rather higher in those with medical husbands. As 40% of the medical husbands were general practitioners this may partly be due to the problems of this branch of medicine.
Many in active practice emphasised the importance of retiring for only a reasonable perinatal period, and not resigning their work, with the consequent difficulty of finding a new post, at a time when natural maternal feelings were strong. Lack of domestic help was a more with the wives of medical men; in some it lack of accommodation for resident domestic help, but for most it was lack of help, and those who were in practice usually added that " they had been blessed with an adequate supply of nannies and domestic staff ". The wages of resident domestic and nursery staff have increased more than any other workers, and a young married woman can rarely afford adequate help. Many of these difficulties would be overcome if the Ministry of Health altered its policy on day-nurseries and allowed them to be built to meet the needs of working mothers. common reason
was
Difficulties connected with the husband’s occupation arose in graduates with non-medical husbands, and it was surprising how many of the professional men moved their place of work after their training. This had an adverse effect on the wife’s career as she had to start looking for work in a new area.
marriage. 18 of the married graduates were living abroad and their difficulties were similar to those at home, except in underdeveloped countries, where there was no difficulty in obtaining medical work and ample domestic staff.
Of the 1941-50 married graduates, those who. were working between half and two-thirds full-time were content and had on an average 3 children. Those who were not working and had three or more children were also content. On the other hand those who were not working or were working quarter time or less, wanted to work half time and had on an average two children. Two-thirds of graduates with medical husbands were working, but only half of them were content, whereas just over half of those with non-medical husbands were working and only a third of them were content. Most of the married women practising a specialty were content, about a third of those in general practice wanted more work, and of those in public health a third wanted more work, and a third wanted to change to something ’ more interesting or worth-while ’. Of the 34 not working, 23 wished to engage in a specialty, which may either be due to the considerable number (17%) who were training for a specialty and abandoned it on marriage, or to the Walter Mitty syndrome.
only
YEARS OF WORK
The clinical activity of the graduates during their professional life, which was assumed to be about 35 years, was
estimated
as
follows:
Incompatibility of general practice with family life chiefly affected the wives of doctors. Temperament and TABLE IV-REASONS FOR
GIVING UP
OR REDUCING MEDICAL WORK
The single women of the three age-groups can be expected to work full time, and the widows and divorced about three-quarter time. The married women of the 1922-40 age-groups will work about half-time, but on the present opportunities, the married women of the 1941-50 group can only expect to work a quarter of their professional life though they would like to work half-time; this wastage of a professional career is the more serious as 80% of this age-group are married. DISCUSSION
If the lack of clinical opportunities of the Oxford medical women graduating between 1941 to 1950 applies
1160
all medical women, it deserves the serious attention of the Ministry of Health, the University Grants Committee, and the medical schools; it would seem a waste to give a large number of women a lengthy and expensive training, and then ensure that their professional activities were restricted to 40% especially at a time when there is believed to be a shortage of doctors. to
Statistics about women doctors are murky and we do not know how many there are, how many are working, and how many who are not working, want to. There is no doubt that the spectrum of medical women is different from that of men, and this must influence all assumptions and calculations with regard to the effective number of doctors. It is established, however, that the number of women in medicine is increasing disproportionately to the number of men. If we take the Census figures for England and Wales between 1931 and 1951, there had been a 237 % increase of women doctors but only a 36% increase of male doctors. The Medical Register shows the same trend: the number of women on the register, from licensing bodies in the British Isles, increased just over threefold between 1935 and 1960, whereas the men only increased by 37%, or, putting it another way, in 1935 there were 10% of women on the British Isles register, in 1960 it was 19-5%. The University Grants Committee’s annual returns confirm that these trends are firmly established and, if anything, becoming more pronounced. At first sight it might seem that the sex of registered practitioners is immaterial. The standards for acceptance in both sexes should be the same; but in point of fact the quality of some of the women rejected may be higher than that of some of the men accepted. Their method of training is identical and though a slightly higher proportion of women than men fail to qualify, this is not usually due to intellectual shortcomings, and there is no evidence that their examination results are less good. Nevertheless for a variety of reasons the clinical effectiveness of women doctors is less than that of men.
According to the figures from the Central Medical RecruitRegister prepared by the British Medical Association in 1955 for the Willink Committee, there were 11,492 medical women in Great Britain in 1955, of whom 7421 were thought to be practising medicine. But owing to replicate counting of house-appointments this was an over-estimate and adjusting the figures according to the Platt Committee’s census the proportion of women known to be practising medicine in 1955 was probably 50% rather than 64%. By 1960 the 11,500 women doctors of 1955, not unnaturally, had become five years older, and 1439 of them (12-50/’0) were over the age of sixty-five, ment
and 388 had died, while a further 2406 women from Great Britain had been added to the Medical Register. A current estimate, in which some of the figures are presumptive rather than factual, reveals no real change since 1955, as just over half the women appeared to be practising medicine.
Even if this assessment were unduly gloomy, and in fact of medical women were not in practice, this would still mean that, in Great Britain, there were over 5000 unemployed women doctors mostly between the ages of thirty and forty-five. Each year nearly 400 women are added to the Medical Register and so each year, unless there is a major change, there will be a further 200 doctors who are not working in medicine, which at first sight would provide a larger replacement than the 10% increase in student-intake recommended by the Government. However as many of the 200 unemployed practitioners will be married, probably a quarter would not wish to resume practice and most of them would only wish to hold a part-
only 40%
time post. Accordingly there are likely to be available now the equivalent of 2600 whole-time doctors, and a further 120 each year, if the employing authorities would offer part-time appointments in all grades of the health services, except resident posts, and not, as at present, only in the consultant grade.
Industry has increased the size of its labour forces by adjusting working conditions so that married women can be employed, and between 1950 and 1960, the number of women in the working population rose by 12-7%, while the increase among men was only 3-6%. The medical profession is faced with an analogous situation. During the past ten years, despite an increasing demand for medical care, there has been a 12-5% decrease in the number of male medical students, while the number of female students has remained constant. But the profession has yet to accept the consequences of these
facts.
At present a single woman has no difficulty in securing a post as house-officer, though it will be harder in some branches than others; in the registrar grade she will have to be significantly better than her three male competitors to be appointed, and this negative sex prejudice becomes more extreme as appointments increase in seniority, but these are all whole-time appointments until consultant status is achieved. It is not regarded as unusual or undesirable that a consultant should spend part of his time in hospital work and part of his time elsewhere-in private
pursuit unrelated to medicine. Before 1948 it was common for the junior hospital staff above the rank of housemen to be appointed part-time, and their salary was such that they had to
practice, research,
or
occasionally
some
increase their income in various ways, but the service
to
patients did not suffer. Yet since 1948, boards of governors and regional boards have shown little enthusiasm for part-time junior appointments, particularly if the applicants were women. Half-time or three-quarter-time appointments, analogous to the medical-assistant grade suggested by the Platt Committee, would be eminently suitable for married women. The professional day of a woman with children must end in the early afternoon. If this restriction is accepted, the woman doctor with a family contribute much to medicine and the amount of work might increase when the younger children reach adolescence. If the scheme of possible evolution to a consultant post were adopted, it would not be a dead-end can
job. In some specialties-such as anaesthesia—in which part-time appointments would be perfectly effective there is an undue degree of sex prejudice, and the hospitals staffed exclusively by women, which tend to be frowned on from an administrative point of view, can play an important part in enabling women to reveal their skill in specialties, such as surgery, where this prejudice is even more
obvious. Medical officers of health seem to prefer to have their responsible medical officers whole-time, and there is an impression, among medical women, that it is becoming harder to get worthwhile part-time public-health posts. Sometimes a woman is offered whole-time appointments with the bait that they might become part-time later, and if she is married with a family, either she finds the strain too great, or an addition to her family brings the post to an end. Clearly there is scope for useful and interesting part-time work in public health, and the heads of regional more
1161
services, such as
mass
radiography and blood-transfusion,
should realise that an intelligent medically qualified woman needs something more than routine clinics and bleeding sessions. General practice is more complex. From the Oxford
study, where husbands and wives
are in general practice to work this would appear admirably, though together, some women admitted that they were working as assistants rather than full partners. Alternatively in a large practice, a married woman can work as a part-time assistant, taking morning surgeries and visits, but no evening surgeries or night work, and this has proved a useful and satisfying arrangement. On the other hand, locum and temporary assistantships are usually unsuitable, as these are commonly most needed at times and seasons when a mother is herself most heavily committed. Industrial medicine has some part-time appointments, and other possibilities are follow-up surveys for clinical research teams, teaching appointments, and medical ’
journalism. Maternity leave is equally important, and the conditions of service of the Whitley Council for the health services allow 11 weeks off-duty before the confinement, and 18 weeks after. Myrdal and Kleinhave suggested that it would not be unreasonable to introduce an extended maternity leave of 1-2 years, on an analogy with release for National Service, with the corollary that it would be a temporary release and that the woman would be reappointed when she returned to her professional work. If the Ministry of Health decided to make an attempt to bring married women back into medicine, it would clearly have to change its attitude to the provision of local-
authority day nurseries, for at the moment the three categories of mothers to whom day nurseries may be available do not include the ordinary working mother. Or these could be provided at hospitals and used by all married staff and perhaps day patients with small children. Economic incentives and income-tax concessions seem less important. The Oxford survey does not suggest that the prime reason for remaining in professional work was to increase the joint income, but rather to satisfy a natural urge to use one’s talents. On the other hand the cost of domestic help and the other necessities of a professional life, should not reduce the family income, but if the surtax changes come into effect in January, 1963, this should no longer occur. The real problem is to find the domestic help and accommodate her, and this is not easily resolved by employing authorities or tax concessions. Another real find the
difficulty mentioned in the Oxford survey right work in the right place. If there are some 5000 unemployed medical women anxious to return to medicine, might not one of the medical foundations was to
resettlement bureau ? On the other hand the Medical Women’s Federation only received about forty replies to the letter, published in the medical journals in December, 1961, inviting medical women who were unsuccessfully seeking employment, to write to the association. establish
This paper is an epitome of a lengthy essay, which could not find a in which the evidence was presented for the statements contained in this précis. It could not have been written without the collaboration of the Oxford women medical graduates. I have also had a great deal of help from the Oxford women’s colleges, the General Medical Council, the British Medical Association, the Medical Women’s Federation, the General Register Office, and the Ministry of Health.
publisher,
a
Training for re-employment is another need, and many of the Oxford women emphasised their anxiety at returning to a profession, of which they had probably had little experience before they abandoned it. This would have to be met by trainee appointments analogous to those 1.
instituted for ex-Servicemen after the war, but with an important difference. Candidates must be carefully selected and the trainee appointment must be the initial stage of a definite established post; it would be not only useless, but grossly wasteful and frustrating to provide women with trainee posts of limited tenure and then leave them to find a permanent post. Such a scheme would require full Ministry of Health support and control. It would be pointless, if a hospital applying for a trainee post leading to a medical assistantship, were informed that woman-power approval was granted, but the cost would have to be found out of ordinary revenue. The University Grants Committee and the medical schools may also have to modify their attitude. The recommendation of the Goodenough Committee on ’the proportion of women medical students has not only been implemented but exceeded, so that the overall ratio is 3:1 rather than 4:11 suggested, and it is steadily rising. This increased proportion of women is due in the past ten years more to a decrease in the number of men medical students, than an increase in the number of women. Selection of women medical students is more rigorous than of men, and in an attempt to prevent the ratio rising still further,women applicants are rejected who are said to be more suitable than some of the men who are accepted. How this is assessed is one of the many educational enigmas. It costs the nation about S5000 to train a doctor and if half the women trained are unable to practise their profession, is this expenditure justified ? Unless some of the suggestions put forward here are brought into effect, the work of the married medical woman will continue to be restricted in scope and time. However, it is essential, unless she is confident that she has made a mistake in taking up medicine, that she should never, as far as is humanly possible, abandon medical work, but obtain maternity leave and resume practice as soon as it is physiologically desirable. Apart from the physical and financial difficulties of combining professional work with bringing up a family, there is its impact on the husband, the home, the children, and the wife. Many of the Oxford medical women wrote that they were much more pleasant people to live with when they were working, and that this view was endorsed by husband and children. It was equally clear that there was a great sense of frustration and unhappiness in the minds of those who wished to work, and were unable to do so.
Myrdal, A., Klein, V. Women’s Two Roles. London, 1956.
"... All the children’s diseases have been reduced to almost nothing in their incidence. The Chief Medical Officer of the Ministry of Education reported the other day that rheumatic fever used to kill 1700 children a year, and it now kills 31. Tuberculosis is down from thousands to 9; and similarly with diphtheria, polio and other children’s diseases. But children’s deaths on the road number 767. Why, if 70 children were killed in accidents by fire or flood or a catastrophe of nature, all the flags would be half-masted; there would be a Lord Mayor’s Fund and all the rest of it! But when it happens on the road we try to pretend it is not and look the other way." -Bishop of SOUTHWELL, Hansard, House of Lords, Nov. 21, 1962, col. 918.
Medical Education THE FATE OF OXFORD MEDICAL WOMEN A. H. T. ROBB-SMITH M.D. Lond., F.R.C.P. NUFFIELD READER IN
PATHOLOGY,
UNIVERSITY OF OXFORD
time when a shortage of doctors is said to be impending, and when there is some doubt about the contribution which women make to medicine, it seemed appropriate to review the progress of a group of Oxford graduates. In 1922 the B.M. degree was conferred on the first four Oxford women graduates and by the end of 1960, the number of women who had received the degree was 227. This inquiry was limited to the 139 who qualified before 1951, as the aim was to ascertain their subsequent career, which needed an interval of at least ten years. Unhappily, less than half were in the Medical Directory, but the colleges helped with current addresses and a questionnaire was sent to each graduate inquiring as to civil state, number of children, husband’s occupation, whether they were, or had been, practising medicine, and if so in what branch of the profession. If they had given up practice they were asked why and whether they would like to resume. The response was excellent, though persistence was " necessary (one graduate addressed me as Importunate Sir "), but 138 of the 139 finally replied. (The solitary failure left the country in 1924 without registering her degree so cannot have practised here.) Though this analysis is based on small numbers, the good response enhances its value, for in wastage-assessment lack of information may be as significant as the silent watchdog of King’s Pyland. The graduates were divided into those who qualified in AT
a
1922-30, 1931-40, and 1941-50. The
amount
no
clinical work for five years, and worked half-time for years, clinical activity would be shown as 50%.
next ten
HUSBANDS
AND
MEDICAL
WORK
Single Women It seemed reasonable
to treat the careers of single untrammelled by husbands and separately: for, achievements their should children, depend on their own their to capabilities and ability compete, albeit on unequal terms, with their male colleagues. women
single graduates (table II) nearly half were cona marked preponderance in pathology. (" Medicine " includes 2 pxdiatricians, 1 psychiatrist, 1 neurologist, 1 dermatologist, and 1 radiologist, and surgery 2 general Of the 40
sultants, with
"
"
surgeons, 2 ear, nose, and throat surgeons, and 1 obstetrician
and gynaecologist. Nearly practising abroad.)
a
third of the consultants
were
None of the consultants indicated that they had found any difficulties in their careers, though several mentioned that in the 30’s, women had difficulty in obtaining house-officer
special
TABLE II-CAREERS OF SINGLE GRADUATES
of work since
qualification was expressed as a percentage of clinical activity, 100% being full-time from qualification to 1960. Thus for a woman who qualified in 1940, worked full-time for five years, did the
78% were married. By 1960 the 75 married graduates in this group had borne 190 children in 184 pregnancies. The mean family size was higher than the national figures for occupied married women. Thus, as far as vital statistics go, the Oxford medical women compared favourably with their non-professional sisters. It remains to consider their clinical activities.
FAMILIES
Table I gives the basic information about the three groups. While 60% of the 1922-30 group remained single, only 27% of the 1931-40 group and 19% of the 1941-50 group did so. Of the married women in the two younger groups just over half have medical husbands. The proportion of married women in the 1941-50 group was high, but their age at marriage was later than the national average, though the ultimate difference in the
proportion remaining single was small; 16% married before graduation, and within four years of graduation TABLE I-CIVIL STATE AND CLINICAL ACTIVITY OF THE THREE GROUPS
posts and the surgeons observed that the F.R.c.s. hurdle; but this is not peculiar to the female sex.
was a
real
quarter were in general practice, and all were in partnership or singlehanded, though some mentioned the difficulty of finding domestic help. Only 2 were in public health. 3 had given up medicine because of ill health and 4 had died.
Just
over a
enjoying it, whether
Widowed and Divorced The average number of children of the 11 who were widowed or divorced was only a little below that of the women with husbands, but their " clinical activity " approached that of the was provided by one of the single women. The explanation " know how I should have who work. I don’t graduates managed to educate my three sons when my marriage broke up if I had not had the advantage of a profession like medicine." 4 were consultants (general physician, neurologist, psychiatrist, and pathologist), 5 in general practice, 1 in public health, and 1 an assistant professor of anatomy. 2 of the general practitioners commented on the difficulties of returning to active practice and 2 others on its interference with family life. Married Women The 71 married
graduates was the largest group, and also the group in which a professional career was most likely to be modified by environment. Their careers are shown in table in. Of the 1922-40 married graduates 5 (and probably the 1 graduate who was not traced) had never practised, 5 others (apart from 2 who had retired on grounds of age) did not wish to resume medical work. Of the 1941-50 married graduates,
1159 TABLE III—CAREERS OF MARRIED GRADUATES
husband-and-wife relationships are as important as the nature of the work. Of 27 married women in general practice, two-thirds with medical husbands had continued in practice and on an average they had larger families than those who had to give it up. 60% of those married to non-medical husbands had to abandon it with regret and one of those who had continued in general practice, felt that her family had suffered as a result of it.
Difficulty of specialising after early marriage would seem, with the possible exception of psychology, to be Most of the married consultants did not marry until had established themselves, so it was easier to obtain they maternity leave and they were earning enough to have trained staff to look after the children. The average age at marriage of all graduates was 28, of the practising consultants 33, and of those graduates who were training for a specialty but gave it up on marriage, 30. On the other hand the average marriage-age of graduates specialising in psychology was 29, and most of these had trained after true.
practised and 4 others did not wish to resume practice; accordingly only 14% of the married Oxford medical 2 had
never
women
did
not
wish
to
continue in their
career.
About half the graduates who were not practising would have liked to do so and of those who were, many were anxious for more work. Among the 1941-50 graduates a higher proportion of those with medical husbands were in practice, either as consultants or general practitioners, while most of those with non-medical husbands were in the public-health service. Over a third of the reasons proffered for failure to obtain enough work related to marriage and families, and this was rather higher in those with medical husbands. As 40% of the medical husbands were general practitioners this may partly be due to the problems of this branch of medicine.
Many in active practice emphasised the importance of retiring for only a reasonable perinatal period, and not resigning their work, with the consequent difficulty of finding a new post, at a time when natural maternal feelings were strong. Lack of domestic help was a more with the wives of medical men; in some it lack of accommodation for resident domestic help, but for most it was lack of help, and those who were in practice usually added that " they had been blessed with an adequate supply of nannies and domestic staff ". The wages of resident domestic and nursery staff have increased more than any other workers, and a young married woman can rarely afford adequate help. Many of these difficulties would be overcome if the Ministry of Health altered its policy on day-nurseries and allowed them to be built to meet the needs of working mothers. common reason
was
Difficulties connected with the husband’s occupation arose in graduates with non-medical husbands, and it was surprising how many of the professional men moved their place of work after their training. This had an adverse effect on the wife’s career as she had to start looking for work in a new area.
marriage. 18 of the married graduates were living abroad and their difficulties were similar to those at home, except in underdeveloped countries, where there was no difficulty in obtaining medical work and ample domestic staff.
Of the 1941-50 married graduates, those who. were working between half and two-thirds full-time were content and had on an average 3 children. Those who were not working and had three or more children were also content. On the other hand those who were not working or were working quarter time or less, wanted to work half time and had on an average two children. Two-thirds of graduates with medical husbands were working, but only half of them were content, whereas just over half of those with non-medical husbands were working and only a third of them were content. Most of the married women practising a specialty were content, about a third of those in general practice wanted more work, and of those in public health a third wanted more work, and a third wanted to change to something ’ more interesting or worth-while ’. Of the 34 not working, 23 wished to engage in a specialty, which may either be due to the considerable number (17%) who were training for a specialty and abandoned it on marriage, or to the Walter Mitty syndrome.
only
YEARS OF WORK
The clinical activity of the graduates during their professional life, which was assumed to be about 35 years, was
estimated
as
follows:
Incompatibility of general practice with family life chiefly affected the wives of doctors. Temperament and TABLE IV-REASONS FOR
GIVING UP
OR REDUCING MEDICAL WORK
The single women of the three age-groups can be expected to work full time, and the widows and divorced about three-quarter time. The married women of the 1922-40 age-groups will work about half-time, but on the present opportunities, the married women of the 1941-50 group can only expect to work a quarter of their professional life though they would like to work half-time; this wastage of a professional career is the more serious as 80% of this age-group are married. DISCUSSION
If the lack of clinical opportunities of the Oxford medical women graduating between 1941 to 1950 applies
1160
all medical women, it deserves the serious attention of the Ministry of Health, the University Grants Committee, and the medical schools; it would seem a waste to give a large number of women a lengthy and expensive training, and then ensure that their professional activities were restricted to 40% especially at a time when there is believed to be a shortage of doctors. to
Statistics about women doctors are murky and we do not know how many there are, how many are working, and how many who are not working, want to. There is no doubt that the spectrum of medical women is different from that of men, and this must influence all assumptions and calculations with regard to the effective number of doctors. It is established, however, that the number of women in medicine is increasing disproportionately to the number of men. If we take the Census figures for England and Wales between 1931 and 1951, there had been a 237 % increase of women doctors but only a 36% increase of male doctors. The Medical Register shows the same trend: the number of women on the register, from licensing bodies in the British Isles, increased just over threefold between 1935 and 1960, whereas the men only increased by 37%, or, putting it another way, in 1935 there were 10% of women on the British Isles register, in 1960 it was 19-5%. The University Grants Committee’s annual returns confirm that these trends are firmly established and, if anything, becoming more pronounced. At first sight it might seem that the sex of registered practitioners is immaterial. The standards for acceptance in both sexes should be the same; but in point of fact the quality of some of the women rejected may be higher than that of some of the men accepted. Their method of training is identical and though a slightly higher proportion of women than men fail to qualify, this is not usually due to intellectual shortcomings, and there is no evidence that their examination results are less good. Nevertheless for a variety of reasons the clinical effectiveness of women doctors is less than that of men.
According to the figures from the Central Medical RecruitRegister prepared by the British Medical Association in 1955 for the Willink Committee, there were 11,492 medical women in Great Britain in 1955, of whom 7421 were thought to be practising medicine. But owing to replicate counting of house-appointments this was an over-estimate and adjusting the figures according to the Platt Committee’s census the proportion of women known to be practising medicine in 1955 was probably 50% rather than 64%. By 1960 the 11,500 women doctors of 1955, not unnaturally, had become five years older, and 1439 of them (12-50/’0) were over the age of sixty-five, ment
and 388 had died, while a further 2406 women from Great Britain had been added to the Medical Register. A current estimate, in which some of the figures are presumptive rather than factual, reveals no real change since 1955, as just over half the women appeared to be practising medicine.
Even if this assessment were unduly gloomy, and in fact of medical women were not in practice, this would still mean that, in Great Britain, there were over 5000 unemployed women doctors mostly between the ages of thirty and forty-five. Each year nearly 400 women are added to the Medical Register and so each year, unless there is a major change, there will be a further 200 doctors who are not working in medicine, which at first sight would provide a larger replacement than the 10% increase in student-intake recommended by the Government. However as many of the 200 unemployed practitioners will be married, probably a quarter would not wish to resume practice and most of them would only wish to hold a part-
only 40%
time post. Accordingly there are likely to be available now the equivalent of 2600 whole-time doctors, and a further 120 each year, if the employing authorities would offer part-time appointments in all grades of the health services, except resident posts, and not, as at present, only in the consultant grade.
Industry has increased the size of its labour forces by adjusting working conditions so that married women can be employed, and between 1950 and 1960, the number of women in the working population rose by 12-7%, while the increase among men was only 3-6%. The medical profession is faced with an analogous situation. During the past ten years, despite an increasing demand for medical care, there has been a 12-5% decrease in the number of male medical students, while the number of female students has remained constant. But the profession has yet to accept the consequences of these
facts.
At present a single woman has no difficulty in securing a post as house-officer, though it will be harder in some branches than others; in the registrar grade she will have to be significantly better than her three male competitors to be appointed, and this negative sex prejudice becomes more extreme as appointments increase in seniority, but these are all whole-time appointments until consultant status is achieved. It is not regarded as unusual or undesirable that a consultant should spend part of his time in hospital work and part of his time elsewhere-in private
pursuit unrelated to medicine. Before 1948 it was common for the junior hospital staff above the rank of housemen to be appointed part-time, and their salary was such that they had to
practice, research,
or
occasionally
some
increase their income in various ways, but the service
to
patients did not suffer. Yet since 1948, boards of governors and regional boards have shown little enthusiasm for part-time junior appointments, particularly if the applicants were women. Half-time or three-quarter-time appointments, analogous to the medical-assistant grade suggested by the Platt Committee, would be eminently suitable for married women. The professional day of a woman with children must end in the early afternoon. If this restriction is accepted, the woman doctor with a family contribute much to medicine and the amount of work might increase when the younger children reach adolescence. If the scheme of possible evolution to a consultant post were adopted, it would not be a dead-end can
job. In some specialties-such as anaesthesia—in which part-time appointments would be perfectly effective there is an undue degree of sex prejudice, and the hospitals staffed exclusively by women, which tend to be frowned on from an administrative point of view, can play an important part in enabling women to reveal their skill in specialties, such as surgery, where this prejudice is even more
obvious. Medical officers of health seem to prefer to have their responsible medical officers whole-time, and there is an impression, among medical women, that it is becoming harder to get worthwhile part-time public-health posts. Sometimes a woman is offered whole-time appointments with the bait that they might become part-time later, and if she is married with a family, either she finds the strain too great, or an addition to her family brings the post to an end. Clearly there is scope for useful and interesting part-time work in public health, and the heads of regional more
1161
services, such as
mass
radiography and blood-transfusion,
should realise that an intelligent medically qualified woman needs something more than routine clinics and bleeding sessions. General practice is more complex. From the Oxford
study, where husbands and wives
are in general practice to work this would appear admirably, though together, some women admitted that they were working as assistants rather than full partners. Alternatively in a large practice, a married woman can work as a part-time assistant, taking morning surgeries and visits, but no evening surgeries or night work, and this has proved a useful and satisfying arrangement. On the other hand, locum and temporary assistantships are usually unsuitable, as these are commonly most needed at times and seasons when a mother is herself most heavily committed. Industrial medicine has some part-time appointments, and other possibilities are follow-up surveys for clinical research teams, teaching appointments, and medical ’
journalism. Maternity leave is equally important, and the conditions of service of the Whitley Council for the health services allow 11 weeks off-duty before the confinement, and 18 weeks after. Myrdal and Kleinhave suggested that it would not be unreasonable to introduce an extended maternity leave of 1-2 years, on an analogy with release for National Service, with the corollary that it would be a temporary release and that the woman would be reappointed when she returned to her professional work. If the Ministry of Health decided to make an attempt to bring married women back into medicine, it would clearly have to change its attitude to the provision of local-
authority day nurseries, for at the moment the three categories of mothers to whom day nurseries may be available do not include the ordinary working mother. Or these could be provided at hospitals and used by all married staff and perhaps day patients with small children. Economic incentives and income-tax concessions seem less important. The Oxford survey does not suggest that the prime reason for remaining in professional work was to increase the joint income, but rather to satisfy a natural urge to use one’s talents. On the other hand the cost of domestic help and the other necessities of a professional life, should not reduce the family income, but if the surtax changes come into effect in January, 1963, this should no longer occur. The real problem is to find the domestic help and accommodate her, and this is not easily resolved by employing authorities or tax concessions. Another real find the
difficulty mentioned in the Oxford survey right work in the right place. If there are some 5000 unemployed medical women anxious to return to medicine, might not one of the medical foundations was to
resettlement bureau ? On the other hand the Medical Women’s Federation only received about forty replies to the letter, published in the medical journals in December, 1961, inviting medical women who were unsuccessfully seeking employment, to write to the association. establish
This paper is an epitome of a lengthy essay, which could not find a in which the evidence was presented for the statements contained in this précis. It could not have been written without the collaboration of the Oxford women medical graduates. I have also had a great deal of help from the Oxford women’s colleges, the General Medical Council, the British Medical Association, the Medical Women’s Federation, the General Register Office, and the Ministry of Health.
publisher,
a
Training for re-employment is another need, and many of the Oxford women emphasised their anxiety at returning to a profession, of which they had probably had little experience before they abandoned it. This would have to be met by trainee appointments analogous to those 1.
instituted for ex-Servicemen after the war, but with an important difference. Candidates must be carefully selected and the trainee appointment must be the initial stage of a definite established post; it would be not only useless, but grossly wasteful and frustrating to provide women with trainee posts of limited tenure and then leave them to find a permanent post. Such a scheme would require full Ministry of Health support and control. It would be pointless, if a hospital applying for a trainee post leading to a medical assistantship, were informed that woman-power approval was granted, but the cost would have to be found out of ordinary revenue. The University Grants Committee and the medical schools may also have to modify their attitude. The recommendation of the Goodenough Committee on ’the proportion of women medical students has not only been implemented but exceeded, so that the overall ratio is 3:1 rather than 4:11 suggested, and it is steadily rising. This increased proportion of women is due in the past ten years more to a decrease in the number of men medical students, than an increase in the number of women. Selection of women medical students is more rigorous than of men, and in an attempt to prevent the ratio rising still further,women applicants are rejected who are said to be more suitable than some of the men who are accepted. How this is assessed is one of the many educational enigmas. It costs the nation about S5000 to train a doctor and if half the women trained are unable to practise their profession, is this expenditure justified ? Unless some of the suggestions put forward here are brought into effect, the work of the married medical woman will continue to be restricted in scope and time. However, it is essential, unless she is confident that she has made a mistake in taking up medicine, that she should never, as far as is humanly possible, abandon medical work, but obtain maternity leave and resume practice as soon as it is physiologically desirable. Apart from the physical and financial difficulties of combining professional work with bringing up a family, there is its impact on the husband, the home, the children, and the wife. Many of the Oxford medical women wrote that they were much more pleasant people to live with when they were working, and that this view was endorsed by husband and children. It was equally clear that there was a great sense of frustration and unhappiness in the minds of those who wished to work, and were unable to do so.
Myrdal, A., Klein, V. Women’s Two Roles. London, 1956.
"... All the children’s diseases have been reduced to almost nothing in their incidence. The Chief Medical Officer of the Ministry of Education reported the other day that rheumatic fever used to kill 1700 children a year, and it now kills 31. Tuberculosis is down from thousands to 9; and similarly with diphtheria, polio and other children’s diseases. But children’s deaths on the road number 767. Why, if 70 children were killed in accidents by fire or flood or a catastrophe of nature, all the flags would be half-masted; there would be a Lord Mayor’s Fund and all the rest of it! But when it happens on the road we try to pretend it is not and look the other way." -Bishop of SOUTHWELL, Hansard, House of Lords, Nov. 21, 1962, col. 918.