Smile!

Dear CFP editor:

I have been moved by the gutsy and heartfelt “Smile” commentary written by Arundhati Dhara in the July edition of CFP. Moved enough to respond with an acknowledgement of her experience to mitigate the risk of minimizing an everyday experience for most if not all female physicians.

I suspect you debated Dr. Dhara whether it was even worthwhile to put your thoughts down- let alone think them. After all you are a practicing family physician and faculty member who role models and teaches future physicians. Why make a fuss, we might all say?
Well, I for one am glad you did. Firstly, you decided to reflect on why this incident got under your skin. That is notable when we as female physicians have become quite accustomed to what Beagan (1) refers to as micro-aggressions, throughout our training. These daily transgressions that communicate that we do not belong, or are not equal, has a cumulative effect that whittles away at self-image. Virtually every female physician experiences these events- none of them “big enough” or egregious enough to comment or complain. Just many - daily.

The coping strategies we employ include self-blame ( I could read this all through your statement) , disengagement, desensitization and finally resignation. We call them coping but with the evidence that female medical students become less confident as their training proceeds (compared to our male colleagues whose self-confidence increases with training), can we really sit complacently and ignore the impact these experiences have on more than 50% of our trainees? You and other readers may find a newly published book, Female Doctors in Canada (2) to be informative and engaging.

You tie your experience of marginalization as a female physician to the issue of career choice and a restriction or narrowing of the career choices of female medical students. I concur that this is a very important consideration in the choices that female students make and how the not so “hidden curriculum” of medicine is a gendered experience. Female and male students have considerably different experiences in their medical education. The result is a horizontal segregation of female students into a narrower career choice than our male colleagues. Moulton and others (3) refer to this a ‘paradigmatic trajectories’ and suggests that female physicians are absent from many discipline’s because they lack opportunities to see and experience that discipline due to gendered exclusion and feel they are not welcomed as legitimate participants in that discipline’s community.

Female medical students when making career choices have a complex and conflicted task. In our study of career choices we identified differences in how male and female students articulated the factors in their career choice.4 Male students appeared to have a very harmonious integration of their personal and professional goals. Female students on the other hand experienced numerous conflicts between the personal and professional. These contextual factors that created dissonance we identified as part of the culture of sexism, including lack of mentorship, inequitable treatment on clinical teams, stereotypes of ‘appropriate’ specialty choices perpetrated by faculty, friends family and the students themselves, expectations and commentary on their appearance and choice of dress and partner and future family influence.

So women do choose family medicine more often than men- and partly this is because of the factors articulated above-perhaps because they “see” themselves in family medicine and the fit feels good.

Certainly, society benefits from having so many capable, competent and compassionate female physicians providing exemplary care. We should be loud and proud about what we bring to the practice of medicine and the care of our patients. Indeed we know the evidence about how health care systems are best when supported by excellent primary care. However, choosing family medicine because it is what we want is different from choosing because other doors are not open to us. Equity in medical education will only come when we begin to address the gendered experiences of female students. Speaking out, as you have will foster a most needed dialogue about all students feeling welcome, included and respected for what they bring to the practice of medicine.

Thank you for your candid comments and your willingness to put it out there.

Sincerely,

Cheri Bethune MD, MClSc, CCFP, FCFP

References

1. Beagan BL. Everyday classism in medical school: Experiencing marginality and resistance. Medical Education 2005; 39(8): 777-7784.
2. Female Doctors in Canada: Experience and Culture. Waugh E, Ross S, Schipper S (eds). Toronto: University of Toronto Press.
3. Moulton C, Seeman N, Webster F It’s all about gender, or is it? Med Ed 2013; 47(6):538-540.
4. Smith V, Bethune C, Hurley K Examining medical student specialty choice through a gender lens: an orientational qualitative study. Teaching and Learning in Medicine. 2018; 30(1):33-44.