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The role of the doctor has changed drastically since the 1930s and 1940s, when practitioners struggled with unbelievably large numbers of patients in their districts. Today the numbers of patients are much smaller, but their qualitative demands are much higher. At the same time the high status of the doctor has been diminished. These changing patterns of work and position in society are creating new, and damaging, stresses.
Our own studies in the 1980s at the Swedish National Institute for Psychosocial Factors and Health showed that doctors had longer working hours and more exposure to shiftwork schedules (being on call) but also more stimulating work than men and women in most other occupations.1 Doctors also claimed that in relation to most aspects of their work they had reasonable control over their working situation—more than in most other occupations. Since then the situation has changed.
Recent studies of the working population in Sweden show that both female and male doctors report both high demands and little ability to control their work, in comparison with other occupations.2 In the terminology of “demand-control”3 this indicates job strain. Furthermore, the differences between doctors and other healthcare workers have diminished, with most healthcare workers having low scores for ability to control their work. Everyone in health care thus seems to be in the same boat in relation to these demands.4
One of the most important changes in role has to do with gender roles and family pressure. How do doctors combine a very demanding working life with a normal family life? In this issue of BMJ Dumelow et al describe an interview study of hospital consultants in Britain (p0000).5 They have introduced new terminology to describe three different strategies that men and women adopt to try to manage both a family and a demanding career: “career dominant,” “segregated,” and “accommodated.”
The career dominant strategy (15% of the women and 3% of the men) implies a continuous, full time career and a reduced family life—living single or divorced and childless as a consequence of the career. The segregated strategy (55% of the women and 85% of the men) implies a continuous, full time career with family roles organised so as to enable more time to be devoted to the career. The accommodating strategy (30% of the women and 12% of the men) implies that work involvement has been reduced in some way to allow more time for family roles.
Women consultants stated that the segregated strategy was the most successful in terms of both family and career whereas male consultants found this strategy less satisfying for family life. The career dominant and accommodating strategies were assessed in the same way by both men and women—the first good for the career and bad for the family and the second good for the family and bad for the career. The difference in attitude to the segregated strategy reflects gender roles, which are changing very slowly. Female doctors react psychophysiologically, with more arousal than male physicians when they get home after work.6 Analyses of emotional states recorded in diaries during the round of daily life in several occupations show that doctors have more emotional reactions, positive as well as negative, during their working day than those in other occupations,7 and this has been particularly evident in female physicians.
The gender difference may also teach us something about the doctor's role in general because women may be more sensitive than men to emotional demands made on doctors. In the old era, when the numbers of patients were very large, the system allowed very little scope for emotional demands from patients. This is different today: patients demand empathy, and doctors (women more than men, perhaps) feel that demand on them to show empathy. This may be one reason why women doctors have tended to have a higher suicide rate than male doctors.8 In a period of restricted spending on health care, which is occurring in most Western countries, these demands may create insurmountable pressures.9
A study of life events has shown that doctors report more negative life events dealing with deaths and illnesses among friends and relatives than do other working men and women.10 The explanation of this is probably that friends and relatives (who may be relatively distant from the physician socially and would accordingly not be recorded as friends or relatives in life event explorations by other men and women) contact the doctors in their social network when they become ill. This may develop from informal consultations to very close ties, and as a consequence deaths and serious illnesses among these friends and relatives are more often recorded as critical life events.
So far, faced with these pressures, women have tended to select a less career oriented life. Even in the late 1980s the labour market in Sweden was very gender segregated.11 But as the proportion of women doctors increases, other solutions will have to be found: a more humane situation must be created.