Discussion

Official statistics and survey data have been used to assess the careers of women in NHS hospitals. The lower proportion of women overall in senior hospital grades to a large extent reflects older doctors coming from cohorts with fewer women medical students; the rapid increase in women medical students in the past three decades is now being reflected as increasing proportions of women at all career levels in most specialties. The curious exception of anaesthetics with its almost constant proportions of women consultants, SRs, Registrars and SHOs is difficult to explain, and requires further exploration.

Disproportionate promotion is absent in psychiatry, pathology, radiology/radiotherapy, the proportion of women being similar at all rungs of the promotion ladder within cohorts. This is strong evidence for the absence of direct and indirect discrimination and differential choice.

Disproportionate promotion from the SHO grade occurs in surgery, O and G and hospital medicine, after which career progression seems to occur proportionately. The possibility that fewer women SHOs have serious intentions of staying in the specialty, using the posts only as part of a broader training, seems unlikely; hospital specialties overall (fig2) show smooth transitions from the SHO grade, implying that women progress equally well in hospital careers overall, so that the specific lack of progress in medicine, surgery and O and G, probably reflects women transferring to other specialties. The data on career preferences in medical school applicants, final year students, and PRHOs suggest there is no lack of career intention in women for surgery, O and G and hospital medicine, so disproportionate promotion is not readily explained as differential choice. The implication is that women are being dissuaded or prevented from entering some hospital specialties.

It has been suggested that women need to achieve a critical mass of about 15% in a career before progressing satisfactorily to the highest level.52 We find little evidence for this overall (see fig2), or in the individual specialties (fig 3); changes with time are mostly smooth, with no evidence of sudden increases at 15% or any other critical value.

There is clear evidence of secular trends in the popularity of particular specialties for women. In particular psychiatry became more popular for women, and hospital medicine and O and G now seem to be behaving similarly; in contrast pathology was disproportionately popular for earlier cohorts. Surgery has always attracted few women, and although numbers have increased in recent years, they are far from equivalent to numbers entering medical school, and there is perhaps a hint of “topping out”. Overall the secular changes probably reflect women choosing between different hospital specialties, rather than between hospital and non-hospital careers, so that career choice must be seen as a dynamic, active process, with women (like men) choosing careers they find attractive and in which success is perceived as possible, with such factors varying between cohorts. The data preclude a static model of career choice, with fixed (or maximum) proportions of women doctors in particular specialties. Instead women (and men) match perceived opportunities and disadvantages in a specialty to their own interests and inclinations, thereby circumscribing their options.53

Our analysis suggests there is no “glass ceiling” for women doctors, and that generally, with a few prominent exceptions, there is no overall disproportionate promotion. However, disproportionate promotion does occur at some stages in hospital medicine, surgery, O and G and anaesthetics, and as it is not easily explained as a result of differential choice, then it probably results from direct or indirect discrimination. The currently lower proportions of women in more senior grades primarily reflects historically lower proportions of women entering medical schools in the 1930s, 1940s, 1950s and 1960s. As older cohorts of doctors are replaced by younger cohorts so the overall proportion of women rises at all levels of hospital practice.

The data from this study are principally quantitative, and derived from official statistics, and therefore it is not straightforward to derive specific explanations of the motivations and drives of the women doctors in the study for their career choices. In particular it is not easy to assess whether they would see themselves as actively making choices, or as passively influenced by circumstances, in the form of career opportunities and lifestyle and living constraints. These are important questions, and would be better considered in part by more qualitative research programmes, rather than the present numerical approach. Such a qualitative approach could be complementary to a more extensive methodology derived from the present type of analysis. The strength of this paper is in the comprehensive nature of the statistics, and the large sample sizes. The weakness is in the fact that it is retrospective, so that its predictive value is limited. In future it may be possible to carry out large scale prospective studies, perhaps based on the type of data collected by the Medical Workforce Research Group,47 54 55 where entire cohorts of doctors, both male and female, are asked not only about career intentions (as at present), but also about motivations, constraints and opportunities. That should allow the teasing apart of the issues raised in this study. A further possibility for further research is to examine comparative data, from the health care systems of other countries. In a recent example, data from Norway56 have shown that despite forceful equal opportunities policies, positive sex discrimination, improved social benefits, workplace creche facilities, and daycare funding, women doctors are still less likely to reach senior positions in medicine; the exceptions are in specialties such as paediatrics in which there is a high proportion of women doctors. The explanation for such findings is not at all clear, although, in a related commentary,57Showalter points to limitations imposed by “the hierarchical system of medicine”, and “the very structure of medical training (which) creates a mystique of stamina, fierce dedication, and stoic endurance, so that deviation from the norm, however licensed, spells weakness rather than leadership potential”. Certainly that description is compatible with Cassell's account of the career barriers experienced by American woman surgeons.13 A further route for future research is to put the data reported here on medicine into a much broader context of education and training in general, where there is a growing number of studies of the choices made by men and women at different stages of school and university education, and subsequent careers.58 As a single example, it has been pointed out that although in the UK the introduction of a national Curriculum has meant that most students at school will study science to the age of 14 or 15, that has not changed the subsequent male excess of students taking science subjects after that age, when students make a free choice of subjects.59 To some extent therefore it has to be accepted that career choices are precisely that, choices, and these are not entirely the result of social forces outside the person, but also reflect their own wishes, needs and desires. Separating those two components has to be a research need for both public health and social policy. People who are working in careers where they wish to be working are more likely to be satisfied, productive, effective professionals, than those who feel that they have been marginalised or coerced into a specialty that is not of their own choosing. As such the career choices of doctors have broader implications for the public health in general.