Exploring gender differences in doctors’ working lives Laura Anne Jefferson Submitted for the degree of Doctor of Philosophy (Ph.D.) in Health Sciences The University of York Department of Health Sciences February 2013 2 Abstract Background: As the proportion of women in medicine draws towards parity, long- standing questions about gender differences in the way that doctors work become more pertinent. Gender differences in medical working patterns and career choices are well documented; but there is a lack of understanding of everyday differences in the working lives of male and female doctors, particularly in UK hospital medicine. In this thesis, potential sources of gender variations in activity rates, previously reported in the literature, are identified. Methods: Multiple methods were employed to explore potential gender differences in doctors’ working lives. Systematic review methods synthesised existing literature on gender differences in the communication style, content and length of medical consultations. Qualitative methods were used to develop in-depth and contextualised understanding of potential gender differences in UK hospital consultants’ working lives, using observation and interviews. Potential variations in clinic length data were analysed quantitatively and synthesised with the existing literature using meta-analysis. Finally, a pilot questionnaire was designed and tested to build on qualitative findings and investigate variations in a wider sample. Results: Doctors’ gender appears to influence their working lives, and the interface between home and work, and these influences may partly explain variations in activity rates. Specifically, female doctors appear to spend longer on consultations; adopt different styles of communication such as lowered dominance and greater use of psychosocial communication; experience greater barriers in their careers such as gender discrimination and problems with work-family conflict; and may experience lower levels of cooperation from colleagues. Conclusions: This research provides important and timely understanding about the sources of gender differences in the working lives of hospital consultants, which may affect both the quality and quantity of care provided by male and female doctors. 3 Table of contents 1. INTRODUCTION ....................................................................... 19 1.1 THESIS RATIONALE ........................................................................................... 19 1.2 THESIS AIM AND APPROACH ............................................................................ 21 1.2.1 Multiple methods ............................................................................................ 22 1.2.2 Thesis structure .............................................................................................. 23 2. WOMEN IN MEDICINE .............................................................. 25 2.1 HISTORICAL BACKGROUND ............................................................................. 25 2.1.1 Ancient history ................................................................................................ 25 2.1.2 The Middle Ages, witch-hunting and midwifery ............................................... 26 2.1.3 Nineteenth century: nursing ............................................................................ 28 2.1.4 Nineteenth century: medicine ......................................................................... 28 2.1.5 Twentieth century ........................................................................................... 30 2.2 TODAY’S MEDICAL WORKFORCE .................................................................... 32 2.3 TRENDS IN GENDER BALANCE OF PRIMARY AND SECONDARY CARE ...... 35 2.4 CAREER PROGRESSION ................................................................................... 38 2.4.1 The UK medical training system ..................................................................... 38 2.4.2 Gender differences in career progression ....................................................... 40 2.5 TRENDS IN GENDER BALANCE OF PART-TIME WORKING ............................ 42 2.6 TRENDS IN WOMEN’S HOSPITAL SPECIALTY CHOICES ................................ 44 2.7 SUMMARY ........................................................................................................... 47 3. THEORETICAL PERSPECTIVES ............................................. 49 3.1 INTRODUCTION .................................................................................................. 49 4 3.2 ECONOMIC PERSPECTIVES .............................................................................. 51 3.2.1 Family Economics .......................................................................................... 51 3.2.1.1 Becker ..................................................................................................... 52 3.2.1.2 Changing family structures ....................................................................... 53 3.2.1.3 Bargaining theories .................................................................................. 54 3.2.2 Gender discrimination in the workplace .......................................................... 56 3.2.2.1 Gender differences in labour market participation .................................... 57 3.2.2.2 Pay gap in medicine ................................................................................. 59 3.2.3 Summary ........................................................................................................ 60 3.3 SOCIOLOGICAL PERSPECTIVES ...................................................................... 60 3.3.1 Patriarchy ....................................................................................................... 61 3.3.2 Social roles ..................................................................................................... 64 3.3.3 Interactionist approach ................................................................................... 67 3.3.4 Summary ........................................................................................................ 69 3.4 PSYCHOLOGICAL PERSPECTIVES................................................................... 70 3.4.1 Work-life conflict ............................................................................................. 71 3.4.1.1 Stress ...................................................................................................... 71 3.4.1.2 Shift work ................................................................................................. 73 3.4.2 Communication in teams ................................................................................ 74 3.4.3 Communication with patients .......................................................................... 76 3.4.4 Summary ........................................................................................................ 77 3.5 CONCLUSION ...................................................................................................... 77 4. SYSTEMATIC REVIEW OF THE EFFECT OF DOCTORS’ GENDER ON MEDICAL COMMUNICATION ................................ 78 4.1 BACKGROUND ................................................................................................... 78 4.1.1 The importance of good communication ......................................................... 78 4.1.2 Gender and communication ........................................................................... 80 4.2 OBJECTIVES ....................................................................................................... 82 4.3 METHODS ............................................................................................................ 82 5 4.3.1 Criteria for considering studies for inclusion in this review .............................. 82 4.3.1.1 Types of studies ....................................................................................... 82 4.3.1.2 Types of participants ................................................................................ 83 4.3.1.3 Types of outcome measures .................................................................... 83 4.3.2 Search methods for identification of studies .................................................... 84 4.3.2.1 Electronic searches .................................................................................. 84 4.3.2.2 Searching other resources ....................................................................... 84 4.3.3 Data collection and analysis ........................................................................... 85 4.3.3.1 Study selection ......................................................................................... 85 4.3.3.2 Data extraction ......................................................................................... 85 4.3.3.3 Quality assessment .................................................................................. 86 4.3.4 Data synthesis ................................................................................................ 87 4.3.4.1 Narrative synthesis ................................................................................... 88 4.3.4.2 Quantitative synthesis .............................................................................. 89 4.4 RESULTS ............................................................................................................. 90 4.4.1 Description of studies ..................................................................................... 90 4.4.2 Quality Assessment ........................................................................................ 93 4.4.2.1 Problems undertaking the quality assessment ......................................... 94 4.4.2.2 Selection bias ........................................................................................... 94 4.4.2.3 Study Design ............................................................................................ 95 4.4.2.4 Confounding ............................................................................................. 95 4.4.2.5 Blinding .................................................................................................... 95 4.4.2.6 Data collection methods ........................................................................... 96 4.4.3 Findings .......................................................................................................... 98 4.4.3.1 Consultation length .................................................................................. 98 4.4.3.2 Communication content.......................................................................... 100 4.4.3.3 Communication style .............................................................................. 102 4.5 DISCUSSION ...................................................................................................... 105 4.5.1 Findings ........................................................................................................ 105 4.5.1.1 Partnership building style ....................................................................... 105 4.5.1.2 Visit length ............................................................................................. 106 4.5.2 Quality of the evidence ................................................................................. 107 4.5.2.1 Confounding ........................................................................................... 107 6 4.5.2.2 Measurement and blinding ..................................................................... 109 4.5.3 Strengths and weaknesses .......................................................................... 109 4.6 CONCLUSION .................................................................................................... 111 5. QUALITATIVE STUDY TO EXPLORE THE WORKING LIVES OF HOSPITAL CONSULTANTS: METHODOLOGY AND METHODS .................................................................................. 112 5.1 AIMS AND OBJECTIVES ................................................................................... 112 5.2 METHODOLOGY ............................................................................................... 113 5.2.1 The qualitative approach .............................................................................. 114 5.2.2 Philosophical considerations ........................................................................ 114 5.2.3 Quality in qualitative research ....................................................................... 114 5.2.3.1 Triangulation .......................................................................................... 115 5.2.3.2 Reflexivity in the research process ......................................................... 116 5.2.3.3 Transparency ......................................................................................... 118 5.2.3.4 Respondent validation ........................................................................... 118 5.3 METHODS .......................................................................................................... 118 5.3.1 Inclusion/Exclusion criteria ........................................................................... 119 5.3.2 Sampling strategy ......................................................................................... 119 5.3.2.1 Recruiting participants ........................................................................... 121 5.3.2.2 Participant characteristics ...................................................................... 122 5.3.3 Ethical considerations................................................................................... 123 5.3.3.1 Obtaining consent when encountering additional people during observations ...................................................................................................... 124 5.3.3.2 Confidentiality issues ............................................................................. 124 5.3.3.3 Threats to patient safety ......................................................................... 124 5.3.3.4 Data protection and record keeping ....................................................... 125 5.3.4 Data collection .............................................................................................. 125 5.3.4.1 Pilot study .............................................................................................. 125 5.3.4.2 Initial interviews ..................................................................................... 126 5.3.4.3 Observations .......................................................................................... 127 7 5.3.4.4 Main interview ........................................................................................ 130 5.3.5 Data analysis ................................................................................................ 131 5.3.5.1 Managing the data ................................................................................. 132 5.3.5.2 Familiarisation ........................................................................................ 133 5.3.5.3 Identifying the thematic framework ......................................................... 133 5.3.5.4 Indexing the data.................................................................................... 133 5.3.5.5 Charting ................................................................................................. 134 5.3.5.6 Mapping and interpretation ..................................................................... 135 5.4 SUMMARY OF METHODOLOGY AND METHODS ........................................... 136 6. QUALITATIVE STUDY TO EXPLORE THE WORKING LIVES OF HOSPITAL CONSULTANTS: FINDINGS AND DISCUSSION .................................................................................................... 137 6.1 INTRODUCTION ................................................................................................ 137 6.2 GENDER DIFFERENCE FINDINGS ................................................................... 138 6.2.1 Internal factors .............................................................................................. 139 6.2.1.1 Displays of dominant behaviours in interactions ..................................... 139 6.2.1.2 Holism and psychosocial communication in consultations ...................... 145 6.2.2 External factors............................................................................................. 152 6.2.2.1 Feelings of pressure and difficulty achieving work-life balance ............... 152 6.2.2.2 Family commitments and work-family conflict ......................................... 154 6.2.2.3 Gendered culture and barriers in medicine ............................................. 159 6.2.2.4 Patients’ and colleagues’ behaviours ..................................................... 163 6.3 COMMON FINDINGS ......................................................................................... 169 6.3.1 Concerns about the future of the NHS .......................................................... 169 6.3.2 Concerns about the adequacy of current medical training ............................ 170 6.4 REFLECTIONS ON METHOD ............................................................................ 172 6.4.1 Transferability ........................................................................................... 173 6.4.2 Validity ...................................................................................................... 174 6.4.3 Reflexivity ................................................................................................. 175 8 6.5 CONCLUSION .................................................................................................... 177 7. SYNTHESIS OF DATA ON LENGTH OF CONSULTATIONS 179 7.1 INTRODUCTION ................................................................................................ 179 7.2 METHODS .......................................................................................................... 180 7.2.1 Analysis of observational clinic time data...................................................... 180 7.2.2 Integration of time data with qualitative study findings .................................. 181 7.2.3 Synthesising observational time data with existing studies ........................... 181 7.3 RESULTS ........................................................................................................... 182 7.3.1 Observational time data ................................................................................ 182 7.3.1.1 Visit length ............................................................................................. 182 7.3.1.2 Total time per patient ............................................................................. 184 7.3.2 Integration of qualitative findings with visit length data.................................. 186 7.3.3 Synthesis of visit length data with systematic review results ......................... 187 7.4 DISCUSSION ..................................................................................................... 189 7.4.1 Strengths and weaknesses .......................................................................... 190 7.5 CONCLUSION .................................................................................................... 191 8. DEVELOPMENT AND FEASIBILITY TESTING OF A PILOT QUESTIONNAIRE EXPLORING CONSULTANTS’ WORKING LIVES .......................................................................................... 193 8.1 INTRODUCTION ................................................................................................ 193 8.1.1 Existing surveys of medical professionals..................................................... 194 8.1.2 Questions raised from qualitative study findings ........................................... 196 8.1.2.1 Working teams ....................................................................................... 197 8.1.2.2 Gender in medicine ................................................................................ 197 8.1.2.3 Consulting style ..................................................................................... 198 8.1.2.4 Workload, work-life balance and family life............................................. 199 8.2 STUDY AIM ........................................................................................................ 199 9 8.3 METHODS .......................................................................................................... 200 8.3.1 Questionnaire design .................................................................................... 200 8.3.1.1 Themes and item development .............................................................. 200 8.3.1.2 Response modes ................................................................................... 201 8.3.2 Feasibility testing and face validity ................................................................ 201 8.3.3 Final questionnaire ....................................................................................... 203 8.3.4 Sampling strategy and procedure ................................................................. 203 8.3.5 Analyses ....................................................................................................... 204 8.3.5.1 Data cleaning ......................................................................................... 204 8.3.5.2 Feasibility testing.................................................................................... 205 8.3.5.3 Analysis of free text responses ............................................................... 205 8.3.5.4 Statistical analyses ................................................................................. 206 8.4 RESULTS ........................................................................................................... 208 8.4.1 Feasibility testing .......................................................................................... 208 8.4.1.1 Problematic items ................................................................................... 208 8.4.1.2 Item redundancy .................................................................................... 211 8.4.2 Participant characteristics ............................................................................. 212 8.4.2.1 Household characteristics ...................................................................... 213 8.4.2.2 Medical careers ...................................................................................... 215 8.4.2.3 Medical work .......................................................................................... 216 8.4.3 Attitudinal responses .................................................................................... 221 8.4.3.1 Working in teams ................................................................................... 221 8.4.3.2 Gender in medicine ................................................................................ 224 8.4.3.3 Consulting style ...................................................................................... 226 8.4.3.4 Workload ................................................................................................ 227 8.4.3.5 Work-life balance ................................................................................... 228 8.4.3.6 Effect of work on family life ..................................................................... 230 8.4.3.7 Overall satisfaction ................................................................................. 230 8.4.4 Multivariate analyses .................................................................................... 231 8.4.4.1 Feeling well supported in the workplace ................................................. 231 8.4.4.2 Feelings about the importance of engaging in psychosocial communication in patient consultations ...................................................................................... 232 8.4.4.3 Feeling that responsibilities in the home create pressure at work ........... 234 8.4.5 Participants’ free-text comments ................................................................... 235 10