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Women physicians in Quebec
Pergamon
Soc. Sci. Med. Vol. 44, No. 12, pp. 1825 1832, 1997
PII:
S0277-9536(96)00292-4
~i 1997 Elsevier Science Ltd All rights reserved. Printed in Great Britain 0277-9536/97 $17.00 + 0.00
WOMEN PHYSICIANS IN QUEBEC M A R I A DE K O N I N C K , ' * P I E R R E BERGERON'- and RENI~E B O U R B O N N A I S ~ 'D6partement de m+decine sociale et preventive, Universit6 Laval, Qu6bec, Canada, -'Centre de sant6 publique de Quebec, D+partement de m+decine sociale et preventive et D+partement de management, Universit+ Laval, Qu6bec, Canada and ~D6partement d'ergoth6rapie, Universit+ Laval, Qu+bec, Canada Abstract--This article presents the results of a qualitative study on women physicians in Quebec which aimed to go beyond a mere statistical description of the tendencies observed in their practices. It proposes an interpretation of their discourses on their practice and its context bringing to light the interdependence of individual strategies and structural constraints. We met 30 women physicians and eight men physicians asking them to talk freely about their personal and professional experience. The data reveal how the individual characteristics and interests of women physicians prevail in their decisions at key moments in their lives which have repercussions on the shaping of their practice. These moments include admission into the faculty of medicine, training, professional orientation and the choice of a specialized field, organization of professional practice and personal life. The medical practice of women is constructed through these choices and the gender variable plays a more or less significant role at each stage of this construction. Their distinctive choices reflect how gender relations are reproduced in the private sphere and the interactions between their private and professional lives. According to our participants, a difference lies in the place occupied by their profession in women and men physicians' lives. The private life of women physicians appears to be closely linked to their decisons regarding the organization of their professional life and as a result to the health services they provide, suggesting they have their own way of "being a physician". The individual nature of the strategies they adopt can have, at a collective level, consequences on the planning and the distribution of medical resources in the publicly managed health care system in Quebec while raising the global issue of gendered division of labor. (~: 1997 Elsevier Science Ltd Key words--women physicians, medical practice, medical manpower, health care system
INTRODUCTION
A strong increase in the number of women physicians has been observed in all Western industrialized societies (OCDE, 1993) and the nature and volume of health services they provide tend to differ from those of their male colleagues. This entry of women in medicine is of great interest since, while being meaningful for gender relations in our societies, it may also have important repercussions on health services systems. Indeed, studies of women physicians fall into two major research areas. The first focuses on the evolution of the medical profession and the potential impact of the growing presence of women. The picture painted by these studies reveals similar tendencies in a variety of countries (Riska and Wegar, 1993) and is consistent with the overall observations made in other professions that women have more recently joined, in terms of career progression, distribution within the professions and incomes (Collin, 1992; Daune-Richard and Devreux, 1992; Dufort, 1992). In medicine, as a whole, women tend to prefer general practice and to be unevenly represented in specialized fields (Riska and Wegar, 1993) as in 1o*Author for correspondence.
cations and settings of medical practice, with a higher proportion of women physicians in salaried positions (Cohen et al., 1991; Pineault et al., 1991; Williams et al., 1990). The average number of work hours among women (Contandriopoulos et al., 1992; Dedobbeleer et al., 1995; Gross, 1992; Williams et al., 1990) and the incomes they receive are also lower than men's (Williams et al., 1990). Some studies focus on gender differences in physician practice style (Bertakis et al., 1995; Kutner and Brogan, 1990; Maheux et al., 1989; West, 1993), or in their quality of life (Ferris et al., 1995; Richardsen and Burke, 1991). Others discuss the potential of change for patterns of health services delivery, particularly humanistic orientation (Williams et al., 1993). The second major research trend focuses on the feminization of the medical profession as an illustration of changes in women's status. The medical profession is of particular interest because it requires a high educational level, enjoys high prestige in most societies, and guarantees a good income. The concept of gender relations is usually central to the analytical framework of these studies and different theoretical approaches lead to a range of interpretations (Armstrong and Armstrong, 1992; Lorber, 1984). Among them, recent feminist writings emphasize the ways women deal with gen-
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dered organizations and discrimination and how they either try to change the rules or manage to get through in spite of them (L6pine and Simard, 1991). Both major research trends, that is, the impact of the growing number of women physicians on medical practices and the evolution of women's status, particularly regarding their access to education and professions, refer to social change. Studies of both trends put a focus on aggregated medical and social practices. Few studies aim at obtaining knowledge on women physicians" individual actions and on the relation of these actions with patterns of medical practices and larger social practices. Still, a better knowledge of women's actions, whatever their nature or scope, is crucial to the analysis of social change (Diamond and Quinby, 1988; Smith, 1991) Our research is aimed at increasing this knowledge through a methodological approach centered on women physicians as individual actresses with concrete social practices, and through an analysis taking into account both the production or reproduction of social practices by women physicians and the rationale behind their individual actions (Giddens, 1986). Using data collected from physicians working in the province of Quebec, we show how the practice of women physicians is constructed through their personal itineraries and how these individual paths participate in the production or reproduction of the health care delivery system and of gender relations. METHODOLOGICAL APPROACH
Our research strategy is based on interviews during which physicians were asked to talk freely about their personal and professional experiences. Such a methodological choice provides insight on the rationale behind the actions of individuals, who have both professional and private lives, and on the meaning they give to their reality (Denzin and Lincoln, 1994; Levy, 1994; Reinharz, 1992). It allows for an interpretation which integrates many elements of the practice of women physicians while facilitating an understanding of the interactions between these elements. It also makes room for distinctions between a range of issues (choice of profession, of specialization, of work environment) in the variety of specific contexts structuring their individual practice. Physicians invited to be interviewed were selected from the list of practicing doctors in which available data were exclusively on their professional characteristics; the criteria used for selecting women aimed not to ensure statistical representation but to cover a wide diversity of experiences in terms of number of years in practice, specialization, practice setting (private office, local community services center, hospital) and region. During the interview, standard sociodemographic data were collected.
Since the design of our sample aimed to ensure the heterogeneity of our population but not its demographic reflection of the general population (Denzin and Lincoln, 1994), this information was not used for statistical interpretation of the data collected. A few male physicians, paired with the women interviewed on the basis of specialty and work setting, were included in the study to intersect information gathered from women with information obtained from men and to identify the elements which appear more distinctive of women. A total of 38 interviews were carried out between December 1992 and October 1993; 30 with women and eight with men. Women had been in practice for 1 17 years and men for 4-12 years. Among the women, 21 were general practitioners (GPs) and nine were specialists (anesthesia, thoracic surgery, internal medicine, obstetrics-gynecology, orthopedics, neurology, pediatrics, psychiatry) while the men were equally distributed between general practitioners and specialists (anesthesia, thoracic surgery, internal medicine). Finally, the women interviewed were distributed geographically over most regions of Quebec. This heterogeneity among the subjects gave us access to diverse personal itineraries revealing different forms of interaction between personal choices and motivations and structural constraints. It must be pointed out that most of our informants have been in practice for some years and that the rules governing the distribution of medical manpower were, until recently, globally less strict than they now are. For this reason, the freedom recent graduates and future physicians in Quebec can expect to have as regards the location and context of their practice is without a doubt more limited than it was for the people who participated in this study. The interviews took place in the physician's office, or, in some cases, at their home, and lasted from one and a half to three hours. The number of interviews is relatively small, but during the last few, the data gathered did not add any significant elements to the questions central to the study, indicating we had reached saturation (Denzin and Lincoln, 1994; Ghiglione and Matalon, 1978). Moreover, the information on marginal cases (such as a woman surgeon with a very heavy workload) did not counter the patterns drawn in our interpretation and the content of the interviews with the male physicians also supported our findings. This latter content did not contradict the information provided by the women interviewed and in fact supports, from a different perspective, the material gathered from their female colleagues. Interviews were recorded and transcribed verbatim for content analysis carried out with the computer program Ethnographer (Seidel et al., 1988) that allowed for coding by themes. The themes selected for coding were articulated around broad
Women physiciansin Quebec categories: the choice of profession and specialty; training; the choice of location and work setting; the type of practice including relations with colleagues and clients; and private life. Our analysis of these qualitative data is consistent with the results of a previous study drawing a profile of women physicians in Quebec: their training, practice and health status (De Koninck et al., 1993). This study, carried out through a vast postal survey of 3000 physicians equally distributed by gender, confirmed that tendencies observed elsewhere also apply to Quebec (professional hours, income, work context); it also demonstrated that in spite of the disparities with the situation of their male colleagues, and even though they declare more physical and mental health problems than them, women physicians generally seem to function without major repercussions on their general health status (De Koninck et al., 1995). The results of this study also emphasized the relevance of issues such as the burden of double work, professional and domestic, to understand the personal biographies of women physicians as well as the nature and volume of health services they dispense. THE QUEBEC HEALTH CARE SETTINGS
The Canadian health care system provides universal and comprehensive coverage for hospital and medical services (OCDE, 1995). It is highly decentralized to the provinces for its administration and financing. The Quebec health care system is one component of this system. In general, care is provided by physicians in private practice or in nonprofit hospitals which are managed by a board of directors representing both the population and the establishment. The main distinctive feature of the Quebec system is its administrative decentralization with regional organizations and local community health centers (Centre local de services communautaires, CLSC) that cover both health and social services. These public establishments are spread over the province and, along with physicians" private practices, constitute the main entry point for primary services. They employ salaried physicians under conditions governed by collective work agreements. Women physicians are over-represented in CLSCs (Pineault et al., 1991). Women's admission into medicine in Quebec is relatively recent and their number has grown extremely rapidly. This evolution reflects the democratization of education initiated in the early 1960s, and women's massive integration into high education and the job market. In fact, Quebec women's participation in the job market went from 28.3% in 1961 to 53.6% in 1994 (CSF, 1993; Statistiques Canada, 1995). Whereas they were barely represented at all in medicine in the 1950s and 1960s, by 1992 they constituted 24% of the medical body
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and have composed the majority of the student population since the mid-1980s. Such an increase in the number of women physicians in Quebec constitutes an interesting case of the feminization of the medical profession.
ENTERING MEDICINE: H O W TO REMAIN ONESELF
While the women's motivations to enter medicine, a variety of personal and educational paths, fit in with those of the men interviewed, the majority of our female respondents maintain that they did not take only professional factors into consideration when making career choices. Several stated that when they chose medicine, they promised themselves they would '~remain women". Their accounts reveal that medicine can be perceived as a threat to the possibility of having a "private" life, a spouse or children, and a well-balanced family life, a threat to which women said they are particularly sensitive. This assertion concerning a greater sensitivity of women to events in their private live is confirmed by the data obtained in the survey previously realized. These results indicated that women reacted with greater stress to events such as a divorce or having illness in the family, than did their male counterparts (De Koninck et al., 1993). Preoccupied by aspects other than professional, several of the female participants said they became critical of the training they received, particularly what they qualified as dehumanization and rigidity, as well as what they consider to be a denial of the individual being trained: The system is created by specialists, for specialists, especially in the first few years. It is based mostly on knowledge and on performance, and very little on savoir-~tre (attitudes) (GP 9). Some of the participants draw a parallel between rigidity in their training and the rigidity they sometimes experience in practice. They accuse the profession of placing too much importance on competition and performance: I don't consider it a pleasure to stay awake for 36 hours straight, 1 believe it's completely ridiculous and that that's how mistakes are made and it's very dangerous when dealing with people's health (GP 7). Moreover, some women respondents reject the controlling, disciplinary and even coercive aspect of their training. While they did not openly show their opposition, they claim that they did not want to renounce a part of themselves to take on a purely professional identity: "'What I found difficult, is the negation of one's personality, we did not exist by what we were, our personality traits, we were relatively standardized" (GP 33). Furthermore, the women interviewed point out the lack of role models and mentors, a problem which is shared by other women who enter traditionally male professions (Osborn et al., 1992;
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Weilepp, 1992). They say they could find no model for balancing professional and private lives once they would be in practice. Men we interviewed also recognize the importance of role models during their professional training and stress the role played by those who inspired them, thus confirming their female colleagues sayings. Finally, some women respondents emphasized the sexism in their training. Contrary to what might be expected, the worst cases were presented by women who were trained most recently such as this woman who had been in practice for just three years. If you want to be accepted by tlae boss or by the specialist, I think that as a woman, you have to be genderless. You have to act like they do. They can have a sex, but not us (GP 3). This statement was confirmed by a specialist in anesthesia who said: "I felt as if I were asexual because being a woman made no difference as long as I did not get pregnant" ($6). Sexist practices during the years of training were also pointed out to us by the participants to our initial survey where 23% of our women respondents indicated they had experienced some form of gender discrimination (based on stereotyped professional roles, sexism or harassment) (De Koninck et al., 1993).
PROFESSIONAL ORIENTATION AND THE CHOICE OF A SPECIALIZED FIELD: PROTECTING A PERSONAL FUTURE
Once medical school is over, women and men begin specialty training and the direction taken reflects how they view medicine and how practicing this medicine fits into their plans for a personal life. The notion of a therapeutic relation most often comes up as a characteristic of medical practice, that is, helping or relieving others. It is noteworthy that the verb "to help" was used by 16 physicians in their definition of medicine. Moreover, the limits of medicine in helping and saving others are acknowledged, and both women and men respondents maintain that the recognition of such limits constitutes one of the observable differences between women and men physicians. Thus, we were told that women are more at ease with those limits and feel less challenged as individual by them. One has to learn to have no answers (GP9). I am a doctor in order to "repair" but one cannot always "repair", neither "repair everything" although we can relieve a lot (GPI0). Interesting is the way in which the physicians we interviewed spontaneously refer to what they call "real medicine", used as a standard to evaluate medical practice. However, the definition of "real medicine" does not always involve the same criteria. For some, "real" medicine includes emergency, technical and curative practices; it is highly pro-
ductive, based on intervention aiming at quantifiable performance and requires the physician's complete availability. On the basis of this definition, some of our respondents feel that their practice is not "real medicine", especially if they do not do emergency work or if they work part time. However, some physicians give "real medicine" a different meaning. They believe it is a comprehensive, humanistic approach based on a therapeutic relation and on receptivity which is coherent with the insistence on the need to protect the human dimension while in training. Women participants recognize that there is a continuum between these two poles, nevertheless they are more attracted to humanistic medicine, while we were told that men are closer to a form of medicine based on productivity. What is important for women is not the size of their practice, the income, or publications, but the type of practice, personal satisfaction, fulfilling needs,..women talk about other things than medicine and performance (GP19). A particular aspect of "talk" was often mentioned by our women informants. They insisted on this activity, "to talk about something else than work" when among colleagues, as significant for them and as an evidence they were able to do something else than practice medicine. Personal plans are also at the heart of professional orientation, the decision to specialize, and if so, in what discipline. General (or family) practice was chosen by a certain number of female respondents because it corresponded to what they wanted to do: "Specialized medicine takes care of disease, family medicine takes care of people" (GP9). However, in other cases, the choice was made not only based on interest but on the possibilities this type of practice presented for reconciling personal and family life with professional life. Women respondents explicitly mentioned that when making their decision, they took into consideration the fact that it would allow them to work part time. For the same reasons, some started a specialty but abandoned. One quit an obstetric-gynecology specialty because she found it incompatible with having a family. A specialist in pediatrics renounced her specialization in neo-natology because of her children. One of our participants met her husband while a resident in psychiatry; she dropped her training because to be close to him she had to travel long distances. At another level, the same criticism addressed to medical training was repeated as a factor for leaving residency: "My person was under cement, surgery is machist" (GP33) said a respondent who abandoned cardiac surgery. But, the most dramatic account came from a young specialist in orthopedics who said: Was it worth it? I am not convinced. It molded me into something and I have trouble coming out of it. If I had to
Women physicians in Quebec start over again, 1 would not do it because I feel I had to abandon too many other aspects of my personality or interests to concentrate myself just on my profession. ($8) The same type of criteria came into consideration in the decision of which specialty to choose. The possibility of combining it with a satisfying personal life (that is, in most cases, with conjugal life and children) is important. A specialist in neurology said: I didn't want to be just a doctor...l wanted a family, children...l wanted a life that I would call normal...I said to myself, if I go into neurosurgery, I'll never be able to ($29). Some specialized fields are more attractive than others in terms of work conditions. A specialist in internal medicine developed her practice in order to spend her time in the laboratory to get "better schedules". Dermatology, according to our respondents sayings, is the prototype of a specialty where personal and professional life can most easily be conciliated. In fact, it is one of the specialties where women have proportionately been best represented in the last years (Contandriopoulos et al., 1992). Another factor is the length of time required for specialized training which could put off a first pregnancy. Informants pointed out that the age at which women have their children corresponds to the high points in professional life and career advancement.
THE ORGANIZATION OF MEDICAL PRACTICE: BALANCING PERSONAL AND PROFESSIONAL LIVES
The physicians we encountered practice their profession in a variety of regions and settings in Quebec: urban, semi-urban and rural. Personal considerations also play a significant role in women's decisions here, their choice being a strategy to attain their personal objectives. Thus, their professional itinerary is sometimes, in fact, a spouse's itinerary in that the location of their practice (and as a result, the type of practice) is selected in order to follow their spouse, or out of consideration for him. Likewise, the vast majority of women physicians interviewed attempt to organize their daily activities in a way that reconciles family life with professional life. One informant used the expression "made-tomeasure" to describe her work organization. Their choice of a work setting takes into account the number of daily or weekly hours of work, the possibility of taking days off (particularly for a sick child), statutory holidays, fringe benefits (such as maternity leave) and vacations. Many of them said they prefer to practice in local community services centers because it allows them to focus more on patient care than on the production of services while offering greater equilibrium in personal and professional life through regular schedules. However, some other women see
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a private office practice as the ideal context for organizing their work according to their preferences. The professional activities of the interviewed physicians vary. As is the case for Quebec physicians in general (De Koninck et al., 1993), they often work in different settings or combine diverse activities. However, women often put aside activities that present obstacles to a stable schedule and the planned management of their work time, (that is emergency room practice, work on call and hospitalizations). Thus a family physician with two children who practiced some obstetrics said she had to stop even if she enjoyed it because it required too much availability. Another respondent told us how she renounced a career in "urgentology" and traded hospital practice for private practice to take care of an adopted daughter. She reports a male colleague remarked: "You, women, do not plan your career adequately" (GP21). Some professional activities are sometimes excluded from the start by women physicians, or else they are expected to be dropped when it becomes necessary. Therefore, a medical practice which includes hospitalizations and on-call work is not undertaken when one plans to have a family, or else such activities are dropped at the birth of a first or second child. This observation is in keeping with the data on British physicians according to which the most significant differences between the careers of women and men physicians appear at the birth of a first child (Johnson, 1993). Speaking of their schedules, women emphasize considerations related to professional organization, but some also refer to their concern for their own and their family's quality of life. Several participants told us that women do not let their profession take over their lives as much as men do, a fact which shapes their practice in a way which counteracts the criteria of "real" productive medicine. Many of them related this observation to the limits they impose on themselves in order to protect their extra-professional lives. In some cases, respondents explained how their shedules are organized according to the availability of their child care employee, thus making sure their children were getting good care while they were at work. Child care is omnipresent in the discourse of mothers. Strategies differ though. For example, an informant said she constantly has a paget with her making sure her children can always reach her. Some women told us of situations when they brought children with them to work, even on a regular basis for hospital rounds. Strategies may also at some point become collective. A specialist gave us the following example. She is pooled with other physicians, a majority of women. They are allowed a certain number of positions by the hospital. They share these positions among a greater number of doctors so they can
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work part time and enjoy some flexibility. "Moreover", she says, "that way a physician can take a maternity leave without displeasing colleagues" ($6). Noteworthy was the account of a general practitioner who is responsible for medical student training in her hospital. She says she tries to influence them so they will consider their personal life when deciding of their future. Finally, another point that deserves to be raised is physicians' relations with their clientele. Both male and female respondents unanimously maintained that women physicians more easily attract clients than do men physicians. This could be attributed they say to the time women respondents spend with patients and their greater empathy for their clients. They believe that this empathy stems from their ability to share experiences. This element again is, in their own words, related to the combination of their personal and professional lives and the effect the latter has on professional practice. Part of these choices probably result from the division of labor within the family where traditional gendered roles seem to be clearly maintained. As we had found in our survey, women say that they adjust their professional lives and that they are responsible for the majority of household chores and parental work. The survey data indicated that 81.9% of women respondents spent six hours and more per week for domestic chores compared with 42.3% of the men. Moreover, 58.6% of women physicians with children spent 16 hours and more for their care compared with 11.7% of men in the same situation (De Koninck et al., 1993). Women who are married to physicians all said they had adjusted their work to the demands of family life, which is not the case of their spouses. When both partners share the same workplace it is even more obvious that some of the duties, such as the hospitalization of patients, can be transferred by a woman physician to her spouse. According to our interview data, such cases are not exceptions. Most of our women participants, while recognizing the significance of raising their children and giving them a good education, referred to their domestic and family responsibilities as their "personal lives" and as a matter of "personal choice" not as the accomplishment of a social role or as a contribution to society. Here must be raised the issue of the evaluation of professional productivity which occults working hours required in the domestic sphere, since women do, in fact, work less hours as physicians than their male colleagues. But if work was considered as a sum of professional and domestic activities, the figures for productivity of men and women would be quite different since the gendered division of labor persists in the physician population.
BEING A WOMAN PHYSICIAN
Our findings broaden the range of existing hypotheses on the gender differences within the medical profession. Indeed, we find more accurate to conceptualize these differences in the sense of "a different way of being a physician" rather than that of a different way of practicing medicine. "To be a physician" refers to the content of medical practice, but also to what underlies it, that is, personal traits, rationale, and doctors' individual strategies and choices. Throughout the progressive structuring of medical practice, the women physicians we met tend to limit how much of their lives is devoted to their profession. In fact, many of them view their practice as simply one dimension of their life, and not as its defining or central feature. In the words of one respondent, illustrating the opinions of many participants, women would see things in terms of a "life plan" while men tend to think in terms of a "career plan". The structuring of the practices of women physicians are marked by some key moments and choices which have repercussions on later decisions. Admission into the faculty of medicine is the first key moment, followed by training, professional orientation and the choice of a specialized field, and then, the organization of professional practice and personal life. To make these choices, they adopted individual strategies to reconcile their own interests with the constraints associated with the various possible options. The personal characteristics of the participants, their different socialization, their preferences and their experiences acted throughout the course of their development and their decision making. Their medical practice is therefore constructed through these paths and choices, thus revealing the gender variable. This variable plays a more or less important role at each stage of the construction of medical practice (training, career orientation, choices made during one's career). Gender issues appear less in the form of active discrimination than through the constraints that some women accept and others refuse in the name of a desire to be other. Informants' remarks concerning medical practice constantly referred to the existence of gender differences. According to our data, such differences are owing to one key factor: the place occupied by their profession in their lives. The following excerpt synthetizes well what respondents seem to agree upon: Women know from quite early on that there isn't just medicine...and they try to put their energies into other things than work, so of course, they climb more slowly. They may achieve less, but their lives, in the long run, may be fuller... Often men have their children during residency, and it doesn't upset their career...At my age, if I was a man...I would start doing research and 1 could really accomplish a lot...Where am 1 at? I'm planning
Women physicians in Quebec when to get pregnant. It isn't at all the same thing. And yet, 1 did the same number of years of studies ($6). This basic orientation can be traced throughout all stages of their itineraries. Women's discourses we collected are not on renouncing but rather affirming differences. They express these differences all the much more since they counteract standard practice. They criticize training that they believe masks the human dimension of physicians' personalities. They disapprove of work organization that imposes professional schedules without leaving room for a family life. The affirmation of these differences is also manifested through the personal choices made by the women we met regarding training, professional orientation and work organization. These distinctive choices reveal the interconnections between their private and professional lives as well as the reproduction of gender relations in the private sphere. Domestic labour in fact remains the responsibility of women physicians who accomplish it by reorganizing their working hours and/or professional activities over a short or a long period. In the same way, these individual itineraries of women physicians participate in the production, or reproduction, of the institutional traits of medical practice in Quebec. Indeed, the private lives of women physicians appear to determine the organization of their professional lives and as a result, health services. However, the individual nature of the strategies they adopt can have, at a collective level, consequences on the planning and distribution of medical resources and distribution in the Quebec health care system. The accumulation of these individual strategies used by Quebec women physicians may, in the medium-term, pose important problems through the disinterest in some specialized fields, mainly surgery, and by a lower level of participation in professional activities related to hospitalization, on-call work and emergency practice. Finally, we were told that a growing number of young men physicians make more room for personal life in their career. Moreover a recent analysis of physicians' working hours over the years indicate that men tend to reduce them slightly and women to increase theirs (Dedobbeleer et al., 1995). Such an evolution would of course influence the construction of the medical practice. However, even then, unless there are significant changes in gender relations, personal motivations and the division of labour within families will very likely continue to be reflected on medical activities of women.
CONCLUSION
Our research is distinguished from the majority of published work in that its approach makes it possible to go beyond mere description and to suggest an explanation for the observed tendencies
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in the professional practice of women physicians which broadens the existing range of hypotheses. In addition, the proposed interpretation sheds light on both the transformation of gender relations in traditionally male professions and the potential impact of women's presence in the medical profession. To paraphrase the interviewees: to be a physician, must one be only a physician? Our participants answer no and propose another way of being. This other way of "being a physician" is a part of the evolution in gender relations, even though the strategies adopted by women to carve out a space for themselves prove to be essentially individual. The consequences of the strategies adopted by women physicians to succeed in practicing their profession under conditions that take into account their personal objectives are starting to manifest themselves at a time when the proportion of medical staff they represent is becoming larger. Thus, some activities and some specialized fields are increasingly neglected. That being the case, in the context of a publicly managed health care system, should we accept male and female specialized fields with the possibility of shortages in some male specialties, or should women physicians be encouraged to engage in all fields of medical activity? In the latter case, either the professional choices of women physicians would need to be more controlled or a different work organization would need to be favored, one which would make all of medical practice more compatible with women's life plans. These life plans reflect a global perspective which include professional activities, domestic and parental responsibilities and personal accomplishment. The larger issue raised here is the whole question of the gendered division of labor. Acknowledgements--The authors wish to thank H616ne
Guay who carried out the majority of interviews and who participated in coding the data, Marc-Ad61ard Tremblay who participated in the whole research process and MarieAnnick C6t6 and Nancy Legendre. The authors also thank Michel Audet and Abby Lippman for their most helpful comments on previous versions of this article. This study received funding from the Quebec Ministry of Health and Social Services and from the Social Sciences and Humanities Research Council of Canada (#882-910025). REFERENCES
Armstrong, P. and Armstrong, H. (1992) Sex and the professions in Canada. J. Can, Studies 27, 119-135. Bertakis, K. D. et al. (1995) The influence of gender on physician practice style. Medical Care 33(4), 407-416. Cohen, M. et al. (1991) Gender differences in practice patterns of Ontario family physicians. J. Am. Med. Assoc. 46, 49 53. Collin, J. (1992) Les femmes dans la profession pharmaceutique au Quebec: rupture ou continuitY?Recherches f~ministes 5, 31-56. Contandriopoulos, A.-P. et al. (1992) Les effectifs m&licaux au Qukbec: situation de 1972 h 1990 et projections
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pour 1995. Corporation professionnelle des mbdecins du
Qu+bec, Montr6al. CSF (Conseil du statut de la femme) (1993) Desfemmes et des chiffres. D~pliant d'information, Qubbec. Daune-Richard, A.-M. and Devreux, A.-M. (1992) Rapports sociaux de sexe et conceptualisation sociologique. RecherchesfOministes 5, 7-30. Dedobbeleer, N. et al. (1995) Convergence or devergence of male and female physicians hours of work and income. Medical Care 33(8), 796 805. De Koninck, M., Guay, H., Bourbonnais, R., Bergeron, P. and Tremblay, M.-A. (1993) Femmes et mOdecine. enqudte auprOs des mOdecins du QuObec sur leur formation, leur pratique et leur santO. Corporation
Professionnelle des M6decins, Montr6al. De Koninck, M., Guay, H., Bourbonnais, R. and Bergeron, P. (1995) Physical, mental and reproductive health of Quebec women physicians. J. Am. Med. Wom, Assoc. 50, 59-63. Denzin, N. K. and Lincoln, Y. S. (1994) Handbook of Qualitative Research. Sage, London. Diamond, I. and Quinby, L. (eds) (1988) Feminism and Foucault, Reflections on Resistance. Northeastern University Press, Boston. Dufort, F. (1992) La th+orie des interactions symboliques et les enjeux de l'entr+e massive des femmes en m+decine. Recherches J~ministes 5, 57-78. Ferris, L. E. et al. (1995) The quality of life of practicing Canadian women surgeons: results of the population study. J. Worn. Hlth 4, 87 96. Ghiglione, R. and Matalon, B. (1978) Les enqudtes sociologiques, theories et pratiques. Armand Colin, Collection U, Paris. Giddens, A. (1986) The Constitution o f Society. California Press, Berkeley. Gross, E.B. (1992) Gender differences in physician stress. J. Am. Med. Wom. Assoc. 47, 107 113. Johnson, C.A. (1993) Impact of the structure of medicine in Britain on the careers of women physicians. J. Am. Med. Wom. Assoc. 48, 108-113. Kutner, N. and Brogan, D. (1990) Gender roles, medical practices roles, and ob-gyn career choice: a longitudinal study. Women and Health 16(3-4), 99 117. L+pine, 1. and Simard, C. (1991) Prendre sa place dans l'univers organisationnel, l~ditions d'Arc, Montr6al. Levy, R. (1994) Croyance et doute: une vision paradigmatique des m~thodes qualitatives. Ruptures 1, 92-100.
Lorber, J. (1984) Women Power. Stavistock, New Maheux, B. et al. (1989) clinical practices of
Physicians." Careers, Status and
York. The professionnal attitudes and men and women generalists. Canadian Family Physician 35, 59-63. OCDE (1993) Les systOmes de santo des pays de I'OCDE: faits et tendances 1960-1991, Vol. 1, l~tudes de politique de sant6 n~'3. Organisation de cooperation et de d6veloppement 6conomiques, Paris. OCDE (1995) ,~ la recherche de mOcanismes de marchO-Les systOmes de sant~ au Canada, en lslande et au Royaume-Uni. l~tudes de politique de sant+ n°6.
Organisation de coop6ration et de d+veloppement 6conomiques, Paris. Osborn, E. H. S. et al. (1992) Women's attitudes towards careers in academic medicine at the University of California, San Francisco. Academic Med. 67, 59-62. Pineault, R. et al. (1991) Characteristics of physicians practicing in alternative primary care settings: a Quebec study of local community service center physicians. Int. J. Hlth Ser. 21, 49-58. Reinharz, S. (1992) Feminist Methods in Social Research. Oxford University Press, Oxford. Richardsen, A. M. and Burke, R. J. (1991) Occupational stress and job satisfaction among physicians: sex differences. Soc. Sci. Med. 33, 1179-1187. Riska, E. and Wegar, K. (1993) Gender, Work and Medicine. Sage, London. Seidel, J. V. et al. (1988) The Ethnograph, A User's Guide (version 3.0). Qualis Research Associates, Corvallis, OR. Smith, D. E. (1991) The Everyday Day Worm as Problematic. University of Toronto Press, Toronto. Statistiques Canada (1995) Catalogue 71-001 La population active, 3e trimestre 1994. Ottawa. Weilepp, A. E. (1992) Female mentors in short supply. J. Am. Med. Assoc. 267, 739-742. West, C. (1993) Reconceptualizing gender in physicianpatient relationships. Soc. Sci. Med. 36, 57-66. Williams, A. P. et al. (1990) Women in medicine: practice patterns and attitudes. Can. Med. Assoc. J. 143, 194201. Williams, A. P. et al. (1993) Women in medicine: toward a conceptual understanding of the potential for change. J. Am. Med. Worn. Assoc. 48, 115 121.
Soc. Sci. Med. Vol. 44, No. 12, pp. 1825 1832, 1997
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S0277-9536(96)00292-4
~i 1997 Elsevier Science Ltd All rights reserved. Printed in Great Britain 0277-9536/97 $17.00 + 0.00
WOMEN PHYSICIANS IN QUEBEC M A R I A DE K O N I N C K , ' * P I E R R E BERGERON'- and RENI~E B O U R B O N N A I S ~ 'D6partement de m+decine sociale et preventive, Universit6 Laval, Qu6bec, Canada, -'Centre de sant6 publique de Quebec, D+partement de m+decine sociale et preventive et D+partement de management, Universit+ Laval, Qu6bec, Canada and ~D6partement d'ergoth6rapie, Universit+ Laval, Qu+bec, Canada Abstract--This article presents the results of a qualitative study on women physicians in Quebec which aimed to go beyond a mere statistical description of the tendencies observed in their practices. It proposes an interpretation of their discourses on their practice and its context bringing to light the interdependence of individual strategies and structural constraints. We met 30 women physicians and eight men physicians asking them to talk freely about their personal and professional experience. The data reveal how the individual characteristics and interests of women physicians prevail in their decisions at key moments in their lives which have repercussions on the shaping of their practice. These moments include admission into the faculty of medicine, training, professional orientation and the choice of a specialized field, organization of professional practice and personal life. The medical practice of women is constructed through these choices and the gender variable plays a more or less significant role at each stage of this construction. Their distinctive choices reflect how gender relations are reproduced in the private sphere and the interactions between their private and professional lives. According to our participants, a difference lies in the place occupied by their profession in women and men physicians' lives. The private life of women physicians appears to be closely linked to their decisons regarding the organization of their professional life and as a result to the health services they provide, suggesting they have their own way of "being a physician". The individual nature of the strategies they adopt can have, at a collective level, consequences on the planning and the distribution of medical resources in the publicly managed health care system in Quebec while raising the global issue of gendered division of labor. (~: 1997 Elsevier Science Ltd Key words--women physicians, medical practice, medical manpower, health care system
INTRODUCTION
A strong increase in the number of women physicians has been observed in all Western industrialized societies (OCDE, 1993) and the nature and volume of health services they provide tend to differ from those of their male colleagues. This entry of women in medicine is of great interest since, while being meaningful for gender relations in our societies, it may also have important repercussions on health services systems. Indeed, studies of women physicians fall into two major research areas. The first focuses on the evolution of the medical profession and the potential impact of the growing presence of women. The picture painted by these studies reveals similar tendencies in a variety of countries (Riska and Wegar, 1993) and is consistent with the overall observations made in other professions that women have more recently joined, in terms of career progression, distribution within the professions and incomes (Collin, 1992; Daune-Richard and Devreux, 1992; Dufort, 1992). In medicine, as a whole, women tend to prefer general practice and to be unevenly represented in specialized fields (Riska and Wegar, 1993) as in 1o*Author for correspondence.
cations and settings of medical practice, with a higher proportion of women physicians in salaried positions (Cohen et al., 1991; Pineault et al., 1991; Williams et al., 1990). The average number of work hours among women (Contandriopoulos et al., 1992; Dedobbeleer et al., 1995; Gross, 1992; Williams et al., 1990) and the incomes they receive are also lower than men's (Williams et al., 1990). Some studies focus on gender differences in physician practice style (Bertakis et al., 1995; Kutner and Brogan, 1990; Maheux et al., 1989; West, 1993), or in their quality of life (Ferris et al., 1995; Richardsen and Burke, 1991). Others discuss the potential of change for patterns of health services delivery, particularly humanistic orientation (Williams et al., 1993). The second major research trend focuses on the feminization of the medical profession as an illustration of changes in women's status. The medical profession is of particular interest because it requires a high educational level, enjoys high prestige in most societies, and guarantees a good income. The concept of gender relations is usually central to the analytical framework of these studies and different theoretical approaches lead to a range of interpretations (Armstrong and Armstrong, 1992; Lorber, 1984). Among them, recent feminist writings emphasize the ways women deal with gen-
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dered organizations and discrimination and how they either try to change the rules or manage to get through in spite of them (L6pine and Simard, 1991). Both major research trends, that is, the impact of the growing number of women physicians on medical practices and the evolution of women's status, particularly regarding their access to education and professions, refer to social change. Studies of both trends put a focus on aggregated medical and social practices. Few studies aim at obtaining knowledge on women physicians" individual actions and on the relation of these actions with patterns of medical practices and larger social practices. Still, a better knowledge of women's actions, whatever their nature or scope, is crucial to the analysis of social change (Diamond and Quinby, 1988; Smith, 1991) Our research is aimed at increasing this knowledge through a methodological approach centered on women physicians as individual actresses with concrete social practices, and through an analysis taking into account both the production or reproduction of social practices by women physicians and the rationale behind their individual actions (Giddens, 1986). Using data collected from physicians working in the province of Quebec, we show how the practice of women physicians is constructed through their personal itineraries and how these individual paths participate in the production or reproduction of the health care delivery system and of gender relations. METHODOLOGICAL APPROACH
Our research strategy is based on interviews during which physicians were asked to talk freely about their personal and professional experiences. Such a methodological choice provides insight on the rationale behind the actions of individuals, who have both professional and private lives, and on the meaning they give to their reality (Denzin and Lincoln, 1994; Levy, 1994; Reinharz, 1992). It allows for an interpretation which integrates many elements of the practice of women physicians while facilitating an understanding of the interactions between these elements. It also makes room for distinctions between a range of issues (choice of profession, of specialization, of work environment) in the variety of specific contexts structuring their individual practice. Physicians invited to be interviewed were selected from the list of practicing doctors in which available data were exclusively on their professional characteristics; the criteria used for selecting women aimed not to ensure statistical representation but to cover a wide diversity of experiences in terms of number of years in practice, specialization, practice setting (private office, local community services center, hospital) and region. During the interview, standard sociodemographic data were collected.
Since the design of our sample aimed to ensure the heterogeneity of our population but not its demographic reflection of the general population (Denzin and Lincoln, 1994), this information was not used for statistical interpretation of the data collected. A few male physicians, paired with the women interviewed on the basis of specialty and work setting, were included in the study to intersect information gathered from women with information obtained from men and to identify the elements which appear more distinctive of women. A total of 38 interviews were carried out between December 1992 and October 1993; 30 with women and eight with men. Women had been in practice for 1 17 years and men for 4-12 years. Among the women, 21 were general practitioners (GPs) and nine were specialists (anesthesia, thoracic surgery, internal medicine, obstetrics-gynecology, orthopedics, neurology, pediatrics, psychiatry) while the men were equally distributed between general practitioners and specialists (anesthesia, thoracic surgery, internal medicine). Finally, the women interviewed were distributed geographically over most regions of Quebec. This heterogeneity among the subjects gave us access to diverse personal itineraries revealing different forms of interaction between personal choices and motivations and structural constraints. It must be pointed out that most of our informants have been in practice for some years and that the rules governing the distribution of medical manpower were, until recently, globally less strict than they now are. For this reason, the freedom recent graduates and future physicians in Quebec can expect to have as regards the location and context of their practice is without a doubt more limited than it was for the people who participated in this study. The interviews took place in the physician's office, or, in some cases, at their home, and lasted from one and a half to three hours. The number of interviews is relatively small, but during the last few, the data gathered did not add any significant elements to the questions central to the study, indicating we had reached saturation (Denzin and Lincoln, 1994; Ghiglione and Matalon, 1978). Moreover, the information on marginal cases (such as a woman surgeon with a very heavy workload) did not counter the patterns drawn in our interpretation and the content of the interviews with the male physicians also supported our findings. This latter content did not contradict the information provided by the women interviewed and in fact supports, from a different perspective, the material gathered from their female colleagues. Interviews were recorded and transcribed verbatim for content analysis carried out with the computer program Ethnographer (Seidel et al., 1988) that allowed for coding by themes. The themes selected for coding were articulated around broad
Women physiciansin Quebec categories: the choice of profession and specialty; training; the choice of location and work setting; the type of practice including relations with colleagues and clients; and private life. Our analysis of these qualitative data is consistent with the results of a previous study drawing a profile of women physicians in Quebec: their training, practice and health status (De Koninck et al., 1993). This study, carried out through a vast postal survey of 3000 physicians equally distributed by gender, confirmed that tendencies observed elsewhere also apply to Quebec (professional hours, income, work context); it also demonstrated that in spite of the disparities with the situation of their male colleagues, and even though they declare more physical and mental health problems than them, women physicians generally seem to function without major repercussions on their general health status (De Koninck et al., 1995). The results of this study also emphasized the relevance of issues such as the burden of double work, professional and domestic, to understand the personal biographies of women physicians as well as the nature and volume of health services they dispense. THE QUEBEC HEALTH CARE SETTINGS
The Canadian health care system provides universal and comprehensive coverage for hospital and medical services (OCDE, 1995). It is highly decentralized to the provinces for its administration and financing. The Quebec health care system is one component of this system. In general, care is provided by physicians in private practice or in nonprofit hospitals which are managed by a board of directors representing both the population and the establishment. The main distinctive feature of the Quebec system is its administrative decentralization with regional organizations and local community health centers (Centre local de services communautaires, CLSC) that cover both health and social services. These public establishments are spread over the province and, along with physicians" private practices, constitute the main entry point for primary services. They employ salaried physicians under conditions governed by collective work agreements. Women physicians are over-represented in CLSCs (Pineault et al., 1991). Women's admission into medicine in Quebec is relatively recent and their number has grown extremely rapidly. This evolution reflects the democratization of education initiated in the early 1960s, and women's massive integration into high education and the job market. In fact, Quebec women's participation in the job market went from 28.3% in 1961 to 53.6% in 1994 (CSF, 1993; Statistiques Canada, 1995). Whereas they were barely represented at all in medicine in the 1950s and 1960s, by 1992 they constituted 24% of the medical body
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and have composed the majority of the student population since the mid-1980s. Such an increase in the number of women physicians in Quebec constitutes an interesting case of the feminization of the medical profession.
ENTERING MEDICINE: H O W TO REMAIN ONESELF
While the women's motivations to enter medicine, a variety of personal and educational paths, fit in with those of the men interviewed, the majority of our female respondents maintain that they did not take only professional factors into consideration when making career choices. Several stated that when they chose medicine, they promised themselves they would '~remain women". Their accounts reveal that medicine can be perceived as a threat to the possibility of having a "private" life, a spouse or children, and a well-balanced family life, a threat to which women said they are particularly sensitive. This assertion concerning a greater sensitivity of women to events in their private live is confirmed by the data obtained in the survey previously realized. These results indicated that women reacted with greater stress to events such as a divorce or having illness in the family, than did their male counterparts (De Koninck et al., 1993). Preoccupied by aspects other than professional, several of the female participants said they became critical of the training they received, particularly what they qualified as dehumanization and rigidity, as well as what they consider to be a denial of the individual being trained: The system is created by specialists, for specialists, especially in the first few years. It is based mostly on knowledge and on performance, and very little on savoir-~tre (attitudes) (GP 9). Some of the participants draw a parallel between rigidity in their training and the rigidity they sometimes experience in practice. They accuse the profession of placing too much importance on competition and performance: I don't consider it a pleasure to stay awake for 36 hours straight, 1 believe it's completely ridiculous and that that's how mistakes are made and it's very dangerous when dealing with people's health (GP 7). Moreover, some women respondents reject the controlling, disciplinary and even coercive aspect of their training. While they did not openly show their opposition, they claim that they did not want to renounce a part of themselves to take on a purely professional identity: "'What I found difficult, is the negation of one's personality, we did not exist by what we were, our personality traits, we were relatively standardized" (GP 33). Furthermore, the women interviewed point out the lack of role models and mentors, a problem which is shared by other women who enter traditionally male professions (Osborn et al., 1992;
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Weilepp, 1992). They say they could find no model for balancing professional and private lives once they would be in practice. Men we interviewed also recognize the importance of role models during their professional training and stress the role played by those who inspired them, thus confirming their female colleagues sayings. Finally, some women respondents emphasized the sexism in their training. Contrary to what might be expected, the worst cases were presented by women who were trained most recently such as this woman who had been in practice for just three years. If you want to be accepted by tlae boss or by the specialist, I think that as a woman, you have to be genderless. You have to act like they do. They can have a sex, but not us (GP 3). This statement was confirmed by a specialist in anesthesia who said: "I felt as if I were asexual because being a woman made no difference as long as I did not get pregnant" ($6). Sexist practices during the years of training were also pointed out to us by the participants to our initial survey where 23% of our women respondents indicated they had experienced some form of gender discrimination (based on stereotyped professional roles, sexism or harassment) (De Koninck et al., 1993).
PROFESSIONAL ORIENTATION AND THE CHOICE OF A SPECIALIZED FIELD: PROTECTING A PERSONAL FUTURE
Once medical school is over, women and men begin specialty training and the direction taken reflects how they view medicine and how practicing this medicine fits into their plans for a personal life. The notion of a therapeutic relation most often comes up as a characteristic of medical practice, that is, helping or relieving others. It is noteworthy that the verb "to help" was used by 16 physicians in their definition of medicine. Moreover, the limits of medicine in helping and saving others are acknowledged, and both women and men respondents maintain that the recognition of such limits constitutes one of the observable differences between women and men physicians. Thus, we were told that women are more at ease with those limits and feel less challenged as individual by them. One has to learn to have no answers (GP9). I am a doctor in order to "repair" but one cannot always "repair", neither "repair everything" although we can relieve a lot (GPI0). Interesting is the way in which the physicians we interviewed spontaneously refer to what they call "real medicine", used as a standard to evaluate medical practice. However, the definition of "real medicine" does not always involve the same criteria. For some, "real" medicine includes emergency, technical and curative practices; it is highly pro-
ductive, based on intervention aiming at quantifiable performance and requires the physician's complete availability. On the basis of this definition, some of our respondents feel that their practice is not "real medicine", especially if they do not do emergency work or if they work part time. However, some physicians give "real medicine" a different meaning. They believe it is a comprehensive, humanistic approach based on a therapeutic relation and on receptivity which is coherent with the insistence on the need to protect the human dimension while in training. Women participants recognize that there is a continuum between these two poles, nevertheless they are more attracted to humanistic medicine, while we were told that men are closer to a form of medicine based on productivity. What is important for women is not the size of their practice, the income, or publications, but the type of practice, personal satisfaction, fulfilling needs,..women talk about other things than medicine and performance (GP19). A particular aspect of "talk" was often mentioned by our women informants. They insisted on this activity, "to talk about something else than work" when among colleagues, as significant for them and as an evidence they were able to do something else than practice medicine. Personal plans are also at the heart of professional orientation, the decision to specialize, and if so, in what discipline. General (or family) practice was chosen by a certain number of female respondents because it corresponded to what they wanted to do: "Specialized medicine takes care of disease, family medicine takes care of people" (GP9). However, in other cases, the choice was made not only based on interest but on the possibilities this type of practice presented for reconciling personal and family life with professional life. Women respondents explicitly mentioned that when making their decision, they took into consideration the fact that it would allow them to work part time. For the same reasons, some started a specialty but abandoned. One quit an obstetric-gynecology specialty because she found it incompatible with having a family. A specialist in pediatrics renounced her specialization in neo-natology because of her children. One of our participants met her husband while a resident in psychiatry; she dropped her training because to be close to him she had to travel long distances. At another level, the same criticism addressed to medical training was repeated as a factor for leaving residency: "My person was under cement, surgery is machist" (GP33) said a respondent who abandoned cardiac surgery. But, the most dramatic account came from a young specialist in orthopedics who said: Was it worth it? I am not convinced. It molded me into something and I have trouble coming out of it. If I had to
Women physicians in Quebec start over again, 1 would not do it because I feel I had to abandon too many other aspects of my personality or interests to concentrate myself just on my profession. ($8) The same type of criteria came into consideration in the decision of which specialty to choose. The possibility of combining it with a satisfying personal life (that is, in most cases, with conjugal life and children) is important. A specialist in neurology said: I didn't want to be just a doctor...l wanted a family, children...l wanted a life that I would call normal...I said to myself, if I go into neurosurgery, I'll never be able to ($29). Some specialized fields are more attractive than others in terms of work conditions. A specialist in internal medicine developed her practice in order to spend her time in the laboratory to get "better schedules". Dermatology, according to our respondents sayings, is the prototype of a specialty where personal and professional life can most easily be conciliated. In fact, it is one of the specialties where women have proportionately been best represented in the last years (Contandriopoulos et al., 1992). Another factor is the length of time required for specialized training which could put off a first pregnancy. Informants pointed out that the age at which women have their children corresponds to the high points in professional life and career advancement.
THE ORGANIZATION OF MEDICAL PRACTICE: BALANCING PERSONAL AND PROFESSIONAL LIVES
The physicians we encountered practice their profession in a variety of regions and settings in Quebec: urban, semi-urban and rural. Personal considerations also play a significant role in women's decisions here, their choice being a strategy to attain their personal objectives. Thus, their professional itinerary is sometimes, in fact, a spouse's itinerary in that the location of their practice (and as a result, the type of practice) is selected in order to follow their spouse, or out of consideration for him. Likewise, the vast majority of women physicians interviewed attempt to organize their daily activities in a way that reconciles family life with professional life. One informant used the expression "made-tomeasure" to describe her work organization. Their choice of a work setting takes into account the number of daily or weekly hours of work, the possibility of taking days off (particularly for a sick child), statutory holidays, fringe benefits (such as maternity leave) and vacations. Many of them said they prefer to practice in local community services centers because it allows them to focus more on patient care than on the production of services while offering greater equilibrium in personal and professional life through regular schedules. However, some other women see
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a private office practice as the ideal context for organizing their work according to their preferences. The professional activities of the interviewed physicians vary. As is the case for Quebec physicians in general (De Koninck et al., 1993), they often work in different settings or combine diverse activities. However, women often put aside activities that present obstacles to a stable schedule and the planned management of their work time, (that is emergency room practice, work on call and hospitalizations). Thus a family physician with two children who practiced some obstetrics said she had to stop even if she enjoyed it because it required too much availability. Another respondent told us how she renounced a career in "urgentology" and traded hospital practice for private practice to take care of an adopted daughter. She reports a male colleague remarked: "You, women, do not plan your career adequately" (GP21). Some professional activities are sometimes excluded from the start by women physicians, or else they are expected to be dropped when it becomes necessary. Therefore, a medical practice which includes hospitalizations and on-call work is not undertaken when one plans to have a family, or else such activities are dropped at the birth of a first or second child. This observation is in keeping with the data on British physicians according to which the most significant differences between the careers of women and men physicians appear at the birth of a first child (Johnson, 1993). Speaking of their schedules, women emphasize considerations related to professional organization, but some also refer to their concern for their own and their family's quality of life. Several participants told us that women do not let their profession take over their lives as much as men do, a fact which shapes their practice in a way which counteracts the criteria of "real" productive medicine. Many of them related this observation to the limits they impose on themselves in order to protect their extra-professional lives. In some cases, respondents explained how their shedules are organized according to the availability of their child care employee, thus making sure their children were getting good care while they were at work. Child care is omnipresent in the discourse of mothers. Strategies differ though. For example, an informant said she constantly has a paget with her making sure her children can always reach her. Some women told us of situations when they brought children with them to work, even on a regular basis for hospital rounds. Strategies may also at some point become collective. A specialist gave us the following example. She is pooled with other physicians, a majority of women. They are allowed a certain number of positions by the hospital. They share these positions among a greater number of doctors so they can
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work part time and enjoy some flexibility. "Moreover", she says, "that way a physician can take a maternity leave without displeasing colleagues" ($6). Noteworthy was the account of a general practitioner who is responsible for medical student training in her hospital. She says she tries to influence them so they will consider their personal life when deciding of their future. Finally, another point that deserves to be raised is physicians' relations with their clientele. Both male and female respondents unanimously maintained that women physicians more easily attract clients than do men physicians. This could be attributed they say to the time women respondents spend with patients and their greater empathy for their clients. They believe that this empathy stems from their ability to share experiences. This element again is, in their own words, related to the combination of their personal and professional lives and the effect the latter has on professional practice. Part of these choices probably result from the division of labor within the family where traditional gendered roles seem to be clearly maintained. As we had found in our survey, women say that they adjust their professional lives and that they are responsible for the majority of household chores and parental work. The survey data indicated that 81.9% of women respondents spent six hours and more per week for domestic chores compared with 42.3% of the men. Moreover, 58.6% of women physicians with children spent 16 hours and more for their care compared with 11.7% of men in the same situation (De Koninck et al., 1993). Women who are married to physicians all said they had adjusted their work to the demands of family life, which is not the case of their spouses. When both partners share the same workplace it is even more obvious that some of the duties, such as the hospitalization of patients, can be transferred by a woman physician to her spouse. According to our interview data, such cases are not exceptions. Most of our women participants, while recognizing the significance of raising their children and giving them a good education, referred to their domestic and family responsibilities as their "personal lives" and as a matter of "personal choice" not as the accomplishment of a social role or as a contribution to society. Here must be raised the issue of the evaluation of professional productivity which occults working hours required in the domestic sphere, since women do, in fact, work less hours as physicians than their male colleagues. But if work was considered as a sum of professional and domestic activities, the figures for productivity of men and women would be quite different since the gendered division of labor persists in the physician population.
BEING A WOMAN PHYSICIAN
Our findings broaden the range of existing hypotheses on the gender differences within the medical profession. Indeed, we find more accurate to conceptualize these differences in the sense of "a different way of being a physician" rather than that of a different way of practicing medicine. "To be a physician" refers to the content of medical practice, but also to what underlies it, that is, personal traits, rationale, and doctors' individual strategies and choices. Throughout the progressive structuring of medical practice, the women physicians we met tend to limit how much of their lives is devoted to their profession. In fact, many of them view their practice as simply one dimension of their life, and not as its defining or central feature. In the words of one respondent, illustrating the opinions of many participants, women would see things in terms of a "life plan" while men tend to think in terms of a "career plan". The structuring of the practices of women physicians are marked by some key moments and choices which have repercussions on later decisions. Admission into the faculty of medicine is the first key moment, followed by training, professional orientation and the choice of a specialized field, and then, the organization of professional practice and personal life. To make these choices, they adopted individual strategies to reconcile their own interests with the constraints associated with the various possible options. The personal characteristics of the participants, their different socialization, their preferences and their experiences acted throughout the course of their development and their decision making. Their medical practice is therefore constructed through these paths and choices, thus revealing the gender variable. This variable plays a more or less important role at each stage of the construction of medical practice (training, career orientation, choices made during one's career). Gender issues appear less in the form of active discrimination than through the constraints that some women accept and others refuse in the name of a desire to be other. Informants' remarks concerning medical practice constantly referred to the existence of gender differences. According to our data, such differences are owing to one key factor: the place occupied by their profession in their lives. The following excerpt synthetizes well what respondents seem to agree upon: Women know from quite early on that there isn't just medicine...and they try to put their energies into other things than work, so of course, they climb more slowly. They may achieve less, but their lives, in the long run, may be fuller... Often men have their children during residency, and it doesn't upset their career...At my age, if I was a man...I would start doing research and 1 could really accomplish a lot...Where am 1 at? I'm planning
Women physicians in Quebec when to get pregnant. It isn't at all the same thing. And yet, 1 did the same number of years of studies ($6). This basic orientation can be traced throughout all stages of their itineraries. Women's discourses we collected are not on renouncing but rather affirming differences. They express these differences all the much more since they counteract standard practice. They criticize training that they believe masks the human dimension of physicians' personalities. They disapprove of work organization that imposes professional schedules without leaving room for a family life. The affirmation of these differences is also manifested through the personal choices made by the women we met regarding training, professional orientation and work organization. These distinctive choices reveal the interconnections between their private and professional lives as well as the reproduction of gender relations in the private sphere. Domestic labour in fact remains the responsibility of women physicians who accomplish it by reorganizing their working hours and/or professional activities over a short or a long period. In the same way, these individual itineraries of women physicians participate in the production, or reproduction, of the institutional traits of medical practice in Quebec. Indeed, the private lives of women physicians appear to determine the organization of their professional lives and as a result, health services. However, the individual nature of the strategies they adopt can have, at a collective level, consequences on the planning and distribution of medical resources and distribution in the Quebec health care system. The accumulation of these individual strategies used by Quebec women physicians may, in the medium-term, pose important problems through the disinterest in some specialized fields, mainly surgery, and by a lower level of participation in professional activities related to hospitalization, on-call work and emergency practice. Finally, we were told that a growing number of young men physicians make more room for personal life in their career. Moreover a recent analysis of physicians' working hours over the years indicate that men tend to reduce them slightly and women to increase theirs (Dedobbeleer et al., 1995). Such an evolution would of course influence the construction of the medical practice. However, even then, unless there are significant changes in gender relations, personal motivations and the division of labour within families will very likely continue to be reflected on medical activities of women.
CONCLUSION
Our research is distinguished from the majority of published work in that its approach makes it possible to go beyond mere description and to suggest an explanation for the observed tendencies
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in the professional practice of women physicians which broadens the existing range of hypotheses. In addition, the proposed interpretation sheds light on both the transformation of gender relations in traditionally male professions and the potential impact of women's presence in the medical profession. To paraphrase the interviewees: to be a physician, must one be only a physician? Our participants answer no and propose another way of being. This other way of "being a physician" is a part of the evolution in gender relations, even though the strategies adopted by women to carve out a space for themselves prove to be essentially individual. The consequences of the strategies adopted by women physicians to succeed in practicing their profession under conditions that take into account their personal objectives are starting to manifest themselves at a time when the proportion of medical staff they represent is becoming larger. Thus, some activities and some specialized fields are increasingly neglected. That being the case, in the context of a publicly managed health care system, should we accept male and female specialized fields with the possibility of shortages in some male specialties, or should women physicians be encouraged to engage in all fields of medical activity? In the latter case, either the professional choices of women physicians would need to be more controlled or a different work organization would need to be favored, one which would make all of medical practice more compatible with women's life plans. These life plans reflect a global perspective which include professional activities, domestic and parental responsibilities and personal accomplishment. The larger issue raised here is the whole question of the gendered division of labor. Acknowledgements--The authors wish to thank H616ne
Guay who carried out the majority of interviews and who participated in coding the data, Marc-Ad61ard Tremblay who participated in the whole research process and MarieAnnick C6t6 and Nancy Legendre. The authors also thank Michel Audet and Abby Lippman for their most helpful comments on previous versions of this article. This study received funding from the Quebec Ministry of Health and Social Services and from the Social Sciences and Humanities Research Council of Canada (#882-910025). REFERENCES
Armstrong, P. and Armstrong, H. (1992) Sex and the professions in Canada. J. Can, Studies 27, 119-135. Bertakis, K. D. et al. (1995) The influence of gender on physician practice style. Medical Care 33(4), 407-416. Cohen, M. et al. (1991) Gender differences in practice patterns of Ontario family physicians. J. Am. Med. Assoc. 46, 49 53. Collin, J. (1992) Les femmes dans la profession pharmaceutique au Quebec: rupture ou continuitY?Recherches f~ministes 5, 31-56. Contandriopoulos, A.-P. et al. (1992) Les effectifs m&licaux au Qukbec: situation de 1972 h 1990 et projections
1832
Maria De Koninck et al.
pour 1995. Corporation professionnelle des mbdecins du
Qu+bec, Montr6al. CSF (Conseil du statut de la femme) (1993) Desfemmes et des chiffres. D~pliant d'information, Qubbec. Daune-Richard, A.-M. and Devreux, A.-M. (1992) Rapports sociaux de sexe et conceptualisation sociologique. RecherchesfOministes 5, 7-30. Dedobbeleer, N. et al. (1995) Convergence or devergence of male and female physicians hours of work and income. Medical Care 33(8), 796 805. De Koninck, M., Guay, H., Bourbonnais, R., Bergeron, P. and Tremblay, M.-A. (1993) Femmes et mOdecine. enqudte auprOs des mOdecins du QuObec sur leur formation, leur pratique et leur santO. Corporation
Professionnelle des M6decins, Montr6al. De Koninck, M., Guay, H., Bourbonnais, R. and Bergeron, P. (1995) Physical, mental and reproductive health of Quebec women physicians. J. Am. Med. Wom, Assoc. 50, 59-63. Denzin, N. K. and Lincoln, Y. S. (1994) Handbook of Qualitative Research. Sage, London. Diamond, I. and Quinby, L. (eds) (1988) Feminism and Foucault, Reflections on Resistance. Northeastern University Press, Boston. Dufort, F. (1992) La th+orie des interactions symboliques et les enjeux de l'entr+e massive des femmes en m+decine. Recherches J~ministes 5, 57-78. Ferris, L. E. et al. (1995) The quality of life of practicing Canadian women surgeons: results of the population study. J. Worn. Hlth 4, 87 96. Ghiglione, R. and Matalon, B. (1978) Les enqudtes sociologiques, theories et pratiques. Armand Colin, Collection U, Paris. Giddens, A. (1986) The Constitution o f Society. California Press, Berkeley. Gross, E.B. (1992) Gender differences in physician stress. J. Am. Med. Wom. Assoc. 47, 107 113. Johnson, C.A. (1993) Impact of the structure of medicine in Britain on the careers of women physicians. J. Am. Med. Wom. Assoc. 48, 108-113. Kutner, N. and Brogan, D. (1990) Gender roles, medical practices roles, and ob-gyn career choice: a longitudinal study. Women and Health 16(3-4), 99 117. L+pine, 1. and Simard, C. (1991) Prendre sa place dans l'univers organisationnel, l~ditions d'Arc, Montr6al. Levy, R. (1994) Croyance et doute: une vision paradigmatique des m~thodes qualitatives. Ruptures 1, 92-100.
Lorber, J. (1984) Women Power. Stavistock, New Maheux, B. et al. (1989) clinical practices of
Physicians." Careers, Status and
York. The professionnal attitudes and men and women generalists. Canadian Family Physician 35, 59-63. OCDE (1993) Les systOmes de santo des pays de I'OCDE: faits et tendances 1960-1991, Vol. 1, l~tudes de politique de sant6 n~'3. Organisation de cooperation et de d6veloppement 6conomiques, Paris. OCDE (1995) ,~ la recherche de mOcanismes de marchO-Les systOmes de sant~ au Canada, en lslande et au Royaume-Uni. l~tudes de politique de sant+ n°6.
Organisation de coop6ration et de d+veloppement 6conomiques, Paris. Osborn, E. H. S. et al. (1992) Women's attitudes towards careers in academic medicine at the University of California, San Francisco. Academic Med. 67, 59-62. Pineault, R. et al. (1991) Characteristics of physicians practicing in alternative primary care settings: a Quebec study of local community service center physicians. Int. J. Hlth Ser. 21, 49-58. Reinharz, S. (1992) Feminist Methods in Social Research. Oxford University Press, Oxford. Richardsen, A. M. and Burke, R. J. (1991) Occupational stress and job satisfaction among physicians: sex differences. Soc. Sci. Med. 33, 1179-1187. Riska, E. and Wegar, K. (1993) Gender, Work and Medicine. Sage, London. Seidel, J. V. et al. (1988) The Ethnograph, A User's Guide (version 3.0). Qualis Research Associates, Corvallis, OR. Smith, D. E. (1991) The Everyday Day Worm as Problematic. University of Toronto Press, Toronto. Statistiques Canada (1995) Catalogue 71-001 La population active, 3e trimestre 1994. Ottawa. Weilepp, A. E. (1992) Female mentors in short supply. J. Am. Med. Assoc. 267, 739-742. West, C. (1993) Reconceptualizing gender in physicianpatient relationships. Soc. Sci. Med. 36, 57-66. Williams, A. P. et al. (1990) Women in medicine: practice patterns and attitudes. Can. Med. Assoc. J. 143, 194201. Williams, A. P. et al. (1993) Women in medicine: toward a conceptual understanding of the potential for change. J. Am. Med. Worn. Assoc. 48, 115 121.