Women doctors and their careers in a large university hospital in Spain at the beginning of the 21st century

This study shows significant differences between women and men holding permanent/staff medical positions, with differences progressively increasing in relation to the grade of advance in hierarchical promotion, and also in PC promotion. This implies that despite the proportion of women among training specialists having increased up to 50%, the bias in favour of men after completion of their specialist training could be due to the selection criteria for permanent positions. Thus, when women physicians thereafter apply for PC promotion, they have not yet obtained a permanent position, delaying the time for promotion in comparison to that of men physicians with similar years of professional experience. Using a statistical model to evaluate factors associated with the continuous career progression of medical women compared to men over a 13-year study period, the probability of promotion decreased with the year of the application and the age of the applicant, except in women. The absence of a decrease of promotion with the age in women doctors suggests that competitive women have much to offer in the second half of their careers.

The difference in permanent medical positions held by men and women is the basis of the “leaky pipeline phenomenon”, that is, a disproportionately low number of women achieve leader medical positions and advance in their careers. These results add weight to what was suggested in a previous 1-year study carried out in two Catalan hospitals [9].

There is clear evidence of secular trends in the popularity of specialties for women [10,11] to what some authors have pointed to as generic motivations and personality factors. Primary care in family medicine, obstetrics and gynaecology and paediatrics and psychiatry are all related to higher importance from the perspective scale of the measure of empathy and have been widely feminized worldwide [12]. However, the estimated probability of leadership for a 50-year-old female specialist working in hospitals in specialties such as anaesthesia, paediatrics, obstetrics and gynaecology was lower than that of their male colleagues according to a survey of 2,033 Norwegian female physicians [13]. Although the feminization of medicine involves all the medical specialties, general and digestive surgery as well as other surgical specialties continues to be chosen three times more frequently by men than by women physicians [14]. In our study, most hospital specialties registered more men than women among permanent medical positions with an even higher proportion among hierarchical positions. The proportion in favour of men among hierarchical positions is in feminized specialties and in parity specialties, with the difference being significant in masculinised specialties. This may be explained in that women do not want to assume roles in an environment where most of their colleagues are men or that there are unspoken fears that the culture of the profession is too competitive or superiors who decide promotions do not trust women and may subtly lead women far away from the medical hierarchy. A supporting network, especially in terms of a mentor, is crucial for female physicians interested in an academic career to have the opportunity to accomplish their purpose, particularly in the fields traditionally masculinised such as surgery [15].

In the United Kingdom, the proportion of women among hospital consultants represented from 12% in 1983 to 19% in 1995 and reached 25% in 2004 [16]. Our data suggest that internal promotion for women doctors has increased throughout the study, but in 2008, the last year of the study, 70% of consultants and 85% of senior consultants, the top level of the PC, were men. It has been reported that the lack of opportunities for part-time work contracts with the British National Health Service is associated with the lesser advance of women doctors reaching the category of consultant in comparison with men doctors [17]. Whether our doctors had full- or part-time contracts is not yet known. The law for gender equality supporting the reduction of working time to improve the work-family balance was approved in Spain at almost the end of the study period [18]; thus, we assumed that the number of part-time contracts would be negligible.

It has been argued that the dropout rate of women gradually leaving their profession rises as women mature in the medical establishment. If most European university medicine graduates have been women in the last two decades, why does the “leaky pipeline phenomenon” remain unresolved? The differences in personal values and ambitions are reportedly the reason why fewer women than men doctors hold the highest levels of medical positions. The predominant responsibility for child care is still borne by women, and the issue of balancing career and family seems to be of paramount importance among women doctors in diverse disciplines [19-21], or they believe themselves unlikely to be successful in competition. This resignation may reflect fewer women in the high echelons of medical hierarchy and the decline in the number of women applying to the top level of the PC system. Nonetheless, this hardly explains the significant fall at the second level of the PC system shown by our data. The evaluation of merits, according to the rules of the PC system, is confidential and can therefore not be discussed, but the continued difficulty in the advancement of women in comparison with their men counterparts demonstrated throughout the study period is surprising.

Do the significant disparity and lack of equity shown by our data imply that women doctors are not as good as men doctors, or do they reflect continued intangible gender barriers configuring the “glass ceiling” preventing the women from obtaining upper-level positions in hospital medicine? Since the first report from the European Technology Assessment Network in 2000 [22], the subsequent European Guide [23] and the more recent European Research and Innovation [24] show that women’s academic careers remain markedly characterized by strong vertical segregation in the field of science. In 2010, the proportion of women PhD students (38%) and PhD graduates (35%) stood at 32% of academic grade C staff, 23% of grade B and just 11% of grade A. The stable under-representation of women has suggested that subtle gender barriers act synergistically with other obstacles to career goals being achieved by women to advance to higher positions. This may be why women physicians dropout, while a small and highly competitive group of women do continue in their career progression. Gender roles contribute to unconscious assumptions that have little to do with the actual knowledge and abilities of an individual, and they negatively influence decision-making when it comes to promotions. There are differences in perceptions between the genders in relation to the “leaky pipeline phenomenon”, being attributable to subtle discrimination, and this is, suspiciously, denied by those who are well represented in scientific committees, where evaluation rules and selection mechanisms and decisions associated with candidates are made in hospital medicine.

Political government [18] and professional [25] initiatives have demonstrated that they alone are not sufficient to advance the position of women in medicine. Gender equality has an impact on the “feminization of medicine” in hospital medicine. Further evaluation of the underlying factors must be carried out by medical institutions because gender barriers are no longer accepted by women as easily as prior to the 21st century. Recognition of gender inequalities by medical institutions is the first step in helping women to advance in their careers. The gendered nature of the medical workforce worldwide means that the equality impact is quickly felt when restructuring takes place. Following this study, a new rule of the PC system emphasizing the clinical merits regarding patient care, in which women doctors are supposedly excellent [26], will be implemented in brief, hopefully improving these results in the future. The full potential of the increasing number of women physicians will not be achieved without continuing efforts to improve the ways in which they are educated and trained in becoming specialists and the mentoring women receive.