Smile!

The myth of choice

Deciding on a specialty is a rite of passage in medical training. Are you a generalist or a specialist? What kind of practice do you want? Often, specialty choice is about the answers to these questions rather than an obsessive fascination with an organ or body system. In my case, family medicine was about flexibility. It was clear to me that no other specialty offered as much practice variety, and it’s something I take full advantage of to this day.

When I started residency, I was surprised to see only a handful of men at orientation. The reasons women disproportionately enter family medicine are varied. Some of it is actually choice. In 2018, the Canadian Resident Matching Service reported that 38% of women ranked family medicine as their first choice of specialty, while only 28% of men made the same choice.² By contrast, family medicine is often used as a backup when first-choice specialties are especially competitive. In the same report, only 55% of women matched to their first-choice surgical specialty compared with 62% of men.³ Given patterns in who gets their choice of specialties, women might be slotted into family medicine out of necessity more often than men are.

Even for those who choose family medicine, the choice does not occur in a vacuum. The culture of medical training is undoubtedly also implicated in specialty choice. When I was a medical student, I distinctly remember a physician telling me that my “excellent bedside manner” made me well suited for family medicine. I wondered why such a quality would be any less desirable in a surgeon. My experience is not unique: women medical students receive more positive feedback about their compassion and empathy than their male counterparts.⁴ If we are drawn to what we are told we are good at, women might perceive themselves as a natural fit for family medicine.

Family medicine as less than

Bear in mind, though, this natural fit comes at the cost of feeling less valued than our peers. There is a sense that as family physicians we are less than other physicians. While I am certain that specialists everywhere would decry such a statement, these sentiments run deep.

The implication that family doctors lack the intellect of other physicians remains a core part of the informal or hidden medical curriculum,⁵ in spite of a study showing that those who choose family medicine are no less capable than other trainees are.⁶ Every family doctor I know has a story of being met with disappointment when announcing family medicine as their choice of specialty. “But,” the conversation inevitably goes, “you’re so smart.” Even when I meet new people at a social function and they learn I’m a doctor, they often ask, “Are you a specialist? Or just a family doctor?” Just a family doctor indeed.

Next come the knowing looks and nods about work-life balance, coded language for my lack of commitment to medicine in favour of domestic responsibilities. My role as a woman, destined to do “woman things,” is supported in family medicine, with the trade-offs of respect, prestige, and even income. In family medicine, there has been a devaluing of the entire specialty. As women have entered the profession in greater numbers, we have watched the income gap between family doctors and other specialists widen. Men in family medicine are less exposed to this difference. They are more likely to enter areas of family medicine that pay better than office practice, like emergency medicine or hospitalist services.⁷

Competent because we’re likeable

There exists a huge body of literature that examines the way women in positions of leadership and authority are perceived. Almost universally, researchers have found a penalty: as women exert more authority, they are considered less likeable. The same is not true among men, for whom perceptions of competence are less tied to their likeability. I’ve been thinking about this in terms of changes in family medicine. As the field has become feminized, we have moved away from the family doctor as an authority figure and toward team-based models, where everyone has equally important domains of care. The increase in numbers of women family physicians has literally coincided with the trend away from paternalistic care. Society is much more comfortable with women as listening caregivers rather than in prescriptive roles.

Family medicine now defines itself as relational: empathy, listening, and comfort giving are key. These traits also happen to be very traditionally feminine. In this way, family medicine offers women a compromise: we can be considered competent professionals but we must conform to gender roles. Indeed, our competence actually comes from our conformity.

Conversely, when we don’t conform, the system moves to correct our behaviour. We can see this as women have entered hospitals, into specialties like emergency and hospitalist medicine. Women doctors feel like they get less assistance and less respect than men in the same positions,⁸ and the research supports the notion that our medical hierarchies are based on gender as much as profession.⁹ In my own case, I’m just reminded that I’m a woman first and a professional second.

Reflecting on responses

If women who don’t conform face criticism, as Kate Manne suggests,¹ surely I’ll receive some for this essay. I imagine my observations and reading of the data will be negated by anecdotes, and I will be accused of suggesting men in family medicine are somehow worse at it than women (they aren’t). But I’ll push back on this. To suggest that the data about family medicine are gender neutral when disproportionate numbers of women are entering the discipline is disingenuous at best. If you’re reading this and your instinct is to reject my argument because it makes you uncomfortable, I invite you to sit with that uneasiness. It reflects what many of our colleagues feel every day. But perhaps more important, working through the discomfort is a step toward changing our system to be more equitable for us all. And that is something to smile about.