Oxford Medical School Gazette Editorial

Volume 53 (2)

Pushing Things Too Far?

The untimely demise of the male medical student

picture myself 50 years from now. As my good health slowly slips away and the hospital beckons my ageing ailments, I imagine how the medical staff will have changed. My female GP will have referred me. The female A&E medics will assess me. I will enjoy chatting with the female medical students as they practice examining me, then talk seriously about my health with the female house officer as she clerks me. The female consultant will discuss days gone by and explain the newfangled treatments my prehistoric training could never have foreseen. The female registrar will then oversee my transfer and ongoing care on the ward. Fact or fiction? Almost certainly fiction. Yet the meteoric rise in the number of female medical students is starting to raise eyebrows in the profession. Are male medical students at risk of becoming an endangered species? As recently as 1995 females were often under-represented in medical schools, accounting for just over 45% of those receiving offers from Oxford. Seven years later that figure jumps to just under 60%. While Oxford exactly matches the national average figures on this, there are several more extreme examples with some medical schools exceeding 75% female intake. Do the girls beat the boys? So what has happened in the past decade to cause such a turnaround? Are male students discriminated against or simply disadvantaged in todays admission process? Certainly it would be hard to make a case for the former, but given girls on-going success in GCSE and A Levels, it is easy to imagine how girls out-qualify boys in the race for places. Other reasons include the better developed communication skills and maturity that 17 year old girls convey at interview, compared to boys who havent quite left their teenage awkwardness behind. Several commentators have pointed out that girls often look better in person, as well as on paper, and suggest this aesthetic quality could swing the often male-dominated selection panels. If only it were all that simple. Articles on this controversial topic are rare, presumably due to potential authors not wishing to appear sexist in their conclusions. The occasional report suggests indirect discrimination, in that boys may be less likely than girls to meet the initial academic or non-academic criteria for consideration. However, this is not the general experience at Oxford. Fortunately the medical school (perhaps through necessity,

following recent press coverage) has invested heavily in a detailed statistical analysis of applications, offers and admissions based on gender, social class, school type and home region. Their findings paint a very different, if equally concerning picture explaining the disparity. Statistical Truths One notable article researching this area was McManus retrospective study investigating factors affecting likelihood of admission to UK medical schools in 1996/97. His statistical analysis clearly showed that male applicants were disadvantaged. In the fever of correspondence following publication in the BMJ, many highlighted that his study was flawed, as it did not take into account previous exam results or predicted A Levels on which the crucial admissions decisions are made. The Oxford analysis does. The findings are clear. For GCSE results there is no significant difference between male and female applicants. Compared to national figures, there is no significant bias in the number of offers made in relation to gender. For A level results, there is no significant difference between males and females obtaining the grades. However, one major difference stands out like a beacon. Boys just arent applying in the numbers they used to. In 2002 60% of applicants were female, significantly higher than expected compared to national figures for University applications. The number of female students taking up places simply reflects the greater numbers applying in the first place. Sir Lancelot Spratt It comes as a surprise to hear that the number of boys applying is declining. This finding is set against a well reported decline in the number of medical student applications overall. Are these related? Despite an unexpected rise last year, over the past 7 years the total numbers applying have dropped by over 12%. Is medicine declining in its popularity as a career? On the surface it appears there could be a link. But part of the problem is we have no idea of what lies under the surface. Remarkably little is known about the factors that drive todays students to choose medicine, whilst many factors can be identified that might put them off. Compared to careers in the private sector, salaries have been eroded while our workload rises. Negative press publicity is tarnishing the status doctors once enjoyed. The cherished job independence is increasingly controlled by managers. And throughout this the long train-

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ing is becoming prohibitively expensive, with no grants and loans stretched to breaking point. Do these factors disproportionately affect boys and girls? I think they do. Perhaps the boys that were once drawn to James Robertson Justices fiery portrayal of Sir Lancelot Spratt are now drawn to equally machismo business environments. Those boys dont want to play communication skills and clinical governance. They are financially driven in their career choice and for the same workload can claim greater rewards elsewhere. Or perhaps in recent politically correct times medical schools have concentrated too much on portraying the human, caring side of medicine, which while tremendously important to our profession, may turn-off some potential male applicants? Or perhaps the continued negative publicity in the press has dissuaded girls from applying less than it has boys, for whom ego-boosting professional status may count for much more? Does it really matter? There are some who argue that the male and female balance of students simply isnt an issue. After all, who was kicking up a fuss 40 years ago when female students were few and far between? Others argue that there is a natural justice in factors such as sex not becoming predictors of application success. Others argue that medicine is a special case, where patients should be able to see doctors of the gender they choose. The most frequent objection to increasing numbers of female medical students is the effect it will have on future doctor numbers and the balance of hospital versus community doctors. On the basis of this a BMA representative, Dr Peter Holden, last year called for positive discrimination in favour of male applicants. His argument was that you do not get 3540 years service from the females. Many females, burdened with family commitments, leave the profession entirely or at least work part-time. Given the current doctor shortage in the country, Dr Holden predicts that the increase in female doctors will make this shortage even worse. But this takes a very narrow view. What of male students who go on to academia, BMA politics, etc? Should they too be weeded out and discriminated against? Certainly a better way to counter this would be provision of improved support facilities, from part-time training to jobshare schemes and crches. But would this change the number of female doctors staying on as hospital physicians or consultants? Norway is well ahead of the UK in terms of sexual equality, yet a recent study there showed that despite the availability of all of these facilities and more, females still chose not to enter

hospital careers in the numbers that would be expected. This ultimately stems from basic psychological differences between men and women that will take much longer to understand. The study concluded that women appear to choose their personal life over their professional career. Even if women do choose to aim for the top, a glass ceiling still exists, both from fellow workers set against this change in social structure and from society itself. In a commentary on this BMJ article, Elaine Showalter highlighted the continued cultural bias in society, pointing to the popular American TV series ER, which features several female doctors in positions of authority but without husbands, children or family life. Faith in the profession Hopefully as more female students graduate the system will change itself. In the meantime more needs to done to understand what female professionals want from their work and what we can all do to address this, before girls also decide to reject medicine as a career. Perhaps the most important reason for considering this issue is not for the benefit of patients, politicians or UCAS statisticians, but for our own peace of mind. For too long medicine has relied on the surfeit of applicants from which a fortunate few are picked. With sharp rises in medical school places and a continued fall in applications the future may not be so easy. Unless we understand why our fellow male and female students are choosing to study or reject medicine as a career how can we encourage applications? Unless we understand how and why our peers are choosing those students how can we project a meritocratic selection process to applicants? Unless we ourselves have confidence in this being a fair and transparent process how can we believe in the intrinsic tenets of beneficence and benevolence to each other, let alone to our patients? The very same questions must be asked when considering applicants from different cultural, geographical and socioeconomic backgrounds. We owe it to ourselves and the profession. In the words of William Osler: If you do not believe in yourself how can you expect other people to do so? If you have not an abiding faith in the profession you cannot be happy in it. Edward Fitzgerald

McManus, IC. BMJ 1998;317:11117 Griffiths, E. BMJ 2003;326:S4 Kvrner, KJ. BMJ 1999;318:9194

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