EQUAL OPPORTUNITIES IN FAMILY MEDICINE
ENAKE PRILOŽNOSTI V DRUŽINSKI MEDICINI
Christina Fabian1 Received: 22.11.2002 - Accepted: 11.3.2003
Review article UDC 614.25
When we think about equal opportunities, most of us think about men and women and the unequal gender differences we may find at home and at work. Inequality, however, is also about other important matters that we may or may not be aware of, such as discrimination based on race, religion, sexual orientation and disability.
During the last 50 years, many things have happened with regard to Equal Opportunities. I am in the position to look back over those years. Fifty years ago most women did not work away from home and, as is also the case now, their work at home was not considered to be work. The reason being, that it was unpaid work. Women took care of the children and, among other many things, took the children to the doctor when needed. Today, fathers often accompany their children to the doctor, and in Sweden, fathers are allowed to have one month at home with their child during the first year. Few men take that opportunity, mostly it depends on the salary differences between men and women. In one year figures showed that men taking one month off from work to take care of their child took that time during the World Football Championship! Today, most women work away from home. If we talk about the private and the public sector, most women 50 years ago only worked in the private sector, i.e. in their homes. Today, they have moved to work in the public sector to a greater extent. Most men have always worked in the public sector, away from home, but have not changed sectors to work with their children and perform household duties to the same extent as women. This is one reason why women have double work to a greater extent than men. Perhaps this is one reason why people divorce so often? A woman is not able to have control of everything, particularly of the most important things in her life; children, work and husband. She chooses what she can take care of, and as a consequence, having children and her work, she leaves her husband . As you all know, there are differences in the stress hormones when a man and a woman come home from
work. When a man comes home his hormones fall to a lower level, while for a woman the hormones rise even more than during the day.
It is important to research the field of equality. Often it is easy to generalise when talking in this field, but the trends are still obvious.
We have had legislation on gender equality in many countries in the European Union, and in Sweden we have had legislation in force since 1992. The law requires that trade unions and similar organisations take measures to actively promote equality in the workplace.
What is equality?
To many of us, working for equality is built on the view that every human being is unique and has their own personal qualities and desires. Traditions and more or less unconscious prejudices ought not to steer the choices of education, work and way of living. Every human being must have the possibility to develop their own choices in life, regardless of sex, race, religion, disability and sexual orientation. As the first European Medical Organisation, the UEMO and its President at that time, our Irish colleague Dr Cormack MacNamara, organised a conference on "Proceedings for Women in General Practice". The inspiration for this conference came because we were increasingly aware of the growing numbers of women graduating from our medical schools. But there was and still is a growing gap between those numbers and the numbers represented subsequently in career posts at the various levels, in senior administrative posts and in senior academic posts.
In the medical faculties, one out of ten associate professors is a woman. Out of the 200 most influential people in Sweden, 26 are women. More and more female medical students do postgraduate research nowadays, but then many of them disappear, and the men are left to continue the research and education. The female students were asked what would
1UEMO (The European Union of General Practitioners), Swedish Medical Association, Villagatan 5, F!O. Box 5610, SE-144 86 Stockholm, Sweden Correspondence to: e-mail: info@uemo.org
be of help, so they could continue with their research. They answered, help at home and support from both family and colleagues. They also replied that there was a glass-ceiling. And what kind of ceiling is it that makes us stop doing what we may want to do? The answers were, that often the glass-ceiling is put there by the women themselves, a kind of psychological ceiling, making an obstacle for a continuing career. This is also what a colleague has written in her book: "Eight Choices for Women's Success". What is holding you back? Another important answer is yourself! Again, the psychological glass-ceiling. The careers of men and women often look different. Women often have a late career. When the children have grown up, it is then that they often start climbing the career-ladder.
Female doctors are more often married to a man with a similar profession, while male doctors are often married to a woman who works part time and has another type of work. This, of course, will affect the workload at home for the male and female doctor. The male world is more hierarchic than the female. This pyramid shows the male way of leadership. At the top is a man. Often the men in this organisation are dressed in the same way as the leader. If he has a uniform, they wear uniforms, if he has a pullover, they wear a pullover. Normally, if a woman reaches a higher level, it is not the top level. No, she stops at a lower level. She is seen by all, and often represents the woman and constitutes a symbol of all females. The world over, the leading positions are dominated by men. Men see men, speak the language of men and build a hierarchy. Also if we suddenly had 90 % women in leading positions , that would not change the way of leading or change the climate in leadership to a more female way. It will take a long time to change this of course, because we have been living in a culture where the male way is the standard. If a woman succeeds in climbing the career-ladder to the top, she is easily criticised for not having been able to change the way of leadership enough, depending on the above mentioned reasons, you cannot change a special culture in a short time. When a woman looks for a senior position at work, she often has to do it in a different way from men. Men usually go directly from their ordinary work to the new position, whilst women most of the time have to demonstrate in several ways how competent they are for the new job, before they are able to take the new position. And of course they must not be too clever in demonstrating this, because that is also a disadvantage! If men build up hierarchies in their way of leadership, women have another way. I am sure that men do not
try to prevent women from making a career. No, when a woman puts her head above the other women at the same level, she is immediately taken back to the same level again. To become a queen is not often accepted by other women. So the obstacles among women themselves are also obvious sometimes. When talking about a late career for women: you are perhaps seeing the staircase of life! Here it is: Starting from childhood, bringing up a family, then at the top at 40-50 when it goes down again until finally they die. Perhaps, we can turn it the other way around. From childhood it goes down, a heavy work load with both family and at work, but after 40-50 it starts getting better, when the career starts and they have their late careers heaven is waiting for them. Are these perhaps examples of male and female staircases of life? I think it is extremely important that we analyse and investigate the way we work together and the attitudes we have towards each other. Men and women need each other, to work together and to learn from each other. And the research has already started, especially the importance of having medical research projects for female patients. Also, here the male way has been the standard. Almost all clinical trials have been focused on men, often for security reasons, but we have to have research on both female and male patients. It has been shown that female patients get less modern drugs when treated. They do not get the new, more expensive ones. One advantage can of course be that the drugs are well-known and their side effects are well known, but this is really not a good explanation. And how do you rehabilitate a male and a female patient who has had a stroke? It is evident that male patients do not have to be able to manage the household work. No, he gets help at home, while a woman in addition also often has to manage the household. When a woman stays in hospital, it is often necessary to give the husband help at home during that time. We know that there is a difference in the way men and women are treated in health care. It has been shown that women are disadvantageously treated in heart-related diseases, tobacco and alcohol related diseases, diabetes and in the psycho-social support of cancer and sexual problems. We have to bear in mind, that when people get older and older, the eldest people will generally be women, often with low pensions, since they have been working with low salaries during their life.
The communication between the patient and the doctor is worryingly asymmetric. A doctor has an enormous advantage when it comes to expertise and possibilities of influencing decisions. Women are at risk of
receiving less favourable treatment here due to their subordinate position. Men and women use different communication strategies and this influences treatment and care.
The role of the doctor has changed during the years and I think that general practitioners and the primary health care sector have started the changes earlier than our hospital colleagues.
Doctors' work in the past was an art of medicine, but now it is built on science. Earlier all doctors were gen-eralists, now they specialise. Before they were authoritarian - now they are being questioned. Before there were a few doctors, now there are many, and not only men, both men and women. Earlier doctors worked alone, now they are interdependent, earlier they were chosen, now they are exchangeable. The empowerment of patients is very important, and respect towards each other is fundamental. I think that a well-informed patient is welcomed, but I am sure that with all the information that is available today, it will make it even more important that the patient has a confidential doctor - patient relationship and, to be guided through all the medical alternatives. It will not give general practitioners less work! No. It will take more time, and the demands from patients will be that their doctor will have time for them - which are the patients' rights. We now live in a multi-cultural society. For example, in Sweden every tenth inhabitant has been born in another country. In our ethical rules as doctors we have to respect all patients, regardless of gender and also with different cultural behaviour. This is very important when we consider that in the future we will have more and more elderly people, where there will be many people from other countries. Thinking about the care at the end of life, where 80 % of our patients will die a slow death, taking some weeks, perhaps months, and where the palliative care will mostly be handled by general practitioners. This is very demanding from the aspect of equality.
We also have colleagues coming from other countries. In many countries there is a lack of doctors and our colleagues are needed in the health care system, something that has not always been the case. Now the National Medical Associations actively work for these doctors, giving them the possibility of having medical and language training.
In the Policy document of the UEMO, developed after the Conference on Women in General Practice, there is the need to provide additional fast-track training for refugees and asylum seekers who are unable to practice because their medical education is not recognised by the regulatory authority in the country in which they
are living as non-citizens.
It is very important to be aware of the way we treat each other as colleagues, and we can question, is there a difference in the co-operation between nurses and male and female doctors? Yes, there is. Often the male doctor does not notice the difference, because he is used to have service from women. As females often tend to keep together this may be a positive thing for a female doctor, but also the male doctors want a good relationship with the nurses, and there we have forces coming into the situation such as power and gender and authority and sexuality that make the nurses help the male doctors more than they assist the females. Male and female doctors often have different methods of working. Female general practitioners are more preventive and patient-oriented and give longer consultations than their male colleagues. Female doctors also prescribe less medication and speak in a more positive way to their patients.
In spite of the fact that the Swedish Medical Association has focused on salary differences between male and female doctors for ten years, we still have gender-related salary differences in Sweden among doctors. The reasons for this may be that male doctors are better in negotiating or they change their workplace more often, so they may have a possibility for a higher salary. These explanations are still no excuse. We are working on it, and there are activities for female doctors to learn how to negotiate and there are networks and mentorship for female doctors. Younger colleagues sometimes say that equal opportunities, are a question of generations and that the younger generation will solve all problems. I am sure it is not that easy. But I am sure we have to do a lot to make the profession of general practice more attractive to both male and female doctors, because we have a lack of doctors in many countries and in many countries only 15 % of young doctors want to become a general practitioner. One of the reasons for this is the heavy work load in general practice. We have to allow part time training for both men and women in certain periods of their lives, not only to take care of children, but also to do some research, or if they become disabled during a period of their lives, or they simply want to work part time.
In the UEMO we are now fighting for general practice to become a speciality, equal to other specialities. In seven countries we have a speciality in Family Medicine /General Practice, with its own academic level and I think this is a way to recruit interested doctors to become GPs.
In many countries, for example Sweden, General Prac-
tice has never got the proper financing and always has had too few doctors compared to hospital care. This is an inequality that has to be changed. The Policy Statement on Equal Opportunities adopted by the UEMO 1998 has now been adopted by the other European Medical Associations. The UEMO has a Standing Committee on Equal Opportunities. The UEMO calls for action to ensure that both men and women practitioners achieve appropriate representation within the National and the European Medical Organisations.
The UEMO asks to look at discriminatory salaries and pension differences, working conditions and working hours, career development, the elimination of sexist language from all contracts and other documentation, the gender distribution within the medical profession and to continue to monitor for new areas of discrimination as they develop and to take appropriate action. Equal opportunities awareness training is an educational programme already in place in some countries,
and "return to medicine" courses available in some countries are activities to work for equal opportunities. We are different as individuals and as men and women, but we will fight for equality to improve our personal and professional lives. Sometimes it helps if you can do it with a smile!
So now I am very interested to know if this is right. Luckily I will never know:
"When a man gets up to speak, people listen then look. When a woman gets up, people look, then if they like what they see, they listen." I also wonder if the young doctors are able to solve all the problems? And sexual harassment, is it a question of age? Or is it only a communication problem?
And I want to quote a woman born 1904 who wrote: "Women have always been the guardians of wisdom and humanity which makes them natural, but usually secret rulers. The time has come for them to rule openly, but together with and not against men."