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Gender matters in medical education

Alan Bleakley

CONTEXT Women are in the majority in termsof entry to medical schools worldwide and willsoon represent the majority of working doctors.This has been termed the feminising of

medicine. In medical education, such genderissues tend to be restricted to discussions of demographic changes and structural inequali-ties based on a biological reading of gender.However, in contemporary social sciences,gender theory has moved beyond both biology and demography to include cultural issues of gendered ways of thinking. Can contemporary feminist thought drawn from the social scienceshelp medical educators to widen their appre-ciation and understanding of the feminising of medicine?

DISCUSSION Post-structuralist feminist critique, drawn from the social sciences, focuseson cultural practices, such as language use, that support a dominant patriarchy. Such a critiqueis not exclusive to women, but may be describedas supporting a tender-minded approach topractice that is shared by both women and men.

The demographic feminising of medicine may have limited effect in terms of changing bothmedical culture and medical educationpractices without causing radical change to

entrenched cultural habits that are best described as patriarchal. Medical educationcurrently suffers from male biases, such as thoseimposed by andragogy, or adult learningtheory, and these can be positively challengedthrough post-structuralist feminist critique.

CONCLUSIONS Women doctors entering themedical workforce can resist and reformulatethe current dominant patriarchy rather thanreproducing it, supported by male feminists.Such a feminising of medicine can extend tomedical education, but will require an appro-priate theoretical framework to make sense of the new territory. The feminising of medicaleducation informed by post-structuralist frameworks may provide a platform for thedemocratisation of medical culture andpractices, further informing authentic patient-centred practices of care.

gender in medical education

Medical Education 2013: 47 : 5970 doi:10.1111/j.1365-2923.2012.04351.x

Discuss ideas arising from this article at www.mededuc.com discuss

University of Plymouth, UK Correspondence: Alan Bleakley, Peninsula Medical School, Instituteof Clinical Education, Knowledge Spa, Royal Cornwall Hospital,Truro, Cornwall TR1 3HD, UK. Tel: 00 44 1872 252613;E-mail: [email protected]

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INTRODUCTION: THE FEMINISING OF THE MEDICAL WORKFORCE

This article discusses a stream of thought in contem-porary social science that is rarely applied to medicaleducation, but is well established in other academicelds, such as cultural studies: post-structuralist fem-

inism.1,2

This stream of thought, which is fully explained later in the article, offers a valuableperspective for rethinking gender issues in medicaleducation theory and practice, and illustrates how contemporary ideas in the social sciences can shapeinnovation in medical education. Importantly, post-structuralist feminism is an approach that includesmale feminists and challenges habitual patriarchalpractices that have dominated modern medicine andmedical education.

Descriptive demographic studies dominate theliterature on women in medicine, and it is impor-tant to appreciate, understand and then critically address this body of work prior to considering thealternative theoretical framework of post-structuralist feminism that is the concern of the second half of thisarticle.

As more women than men enter medical schools worldwide, in time the medical workforce willcomprise a majority of women doctors. 36 Thisdemographic shift has been referred to as thefeminisation of medicine. 7 The meaning of femi-nisation in medicine, however, can be extended

beyond demographic descriptions to account forcultural processes. Further, it is important to consider what the feminising of medicine might mean not just for the culture of medicine, but also for medicaleducation . In this introductory section, demographicissues are introduced as a platform from which toexplore gender issues beyond demography andbiology, such as gendered ways of thinking.

DEMOGRAPHIC SHIFTS

Demography literally means writing about thepeople and refers to the study of populations ratherthan individuals. Women and Medicine: The Future , a2009 report prepared for the UK Royal College of Physicians, is a good example of descriptive demog-raphy. 5 Written by a female academic sociologist, thereport elaborates on a dataset of descriptive statisticsand includes little in the way of inference, speculationor theoretical modelling. From such descriptive workby social scientists, what do we know about gender in

medicine in post-industrial countries, includingtrends?

Women entering medicine: the numbers

Philadelphia, Pennsylvania has the mixed distinctionof hosting the rst medical school in the USA, but also of hosting the last medical school (JeffersonMedical College) to admit women, in 1960. The rst woman was admitted to a medical school in the USA in 1847. 6 By 2003, Jefferson was admitting a majority of women medical students (51.5%). Although women comprised 10% of practising doctors in theUSA in the late 1800s, by the 1920s women hadpractically disappeared from the medical workforce.However, by 2003, entrants to medical school in theUSA showed a gender balance and by 2005 many schools showed entrance gures comprised of around 60% women and 40% men. 6 Women now constitute the majority of students in medical schools

worldwide and represent an average of 60% of student intake across North America, Europe, Australia and Russia. 310 In the UK, the numbers may have stabilised, having peaked at 62% in 2003 andfallen to 57% in 2007. 5

These statistics have entered the public domainthrough alarmist press articles carrying headlines that include phrases such as the medical timebomb. 10

A front-page article in the International Herald Tribune entitled The changing face of Western medicinedetailed how Across the Western world a generationof young women is transforming the once-malebastion of medicine, swelling medical schools andocking to the front lines of primary care. 3 Therhetoric is carefully chosen: swelling and ockingperhaps signify the emergence of a new family of professionals.

A fear that men are being driven away from applyingfor medicine may be unfounded. For example, in theUK, because of an increase in the absolute numbersof applicants to medical schools, the number of malestaking up places has increased. In 2007, 1200 moremen were accepted for medical school than in 1996

(in comparison with 1760 more women).5

Further, inthe UK, numbers of international students areincreasing and these tend to be more commonly male. 5

Will women be in the majority in the future?

Worldwide, the answer to this question is yes. 3 InEngland, women currently account for approximately 40% of all doctors, 42% of general practitioners

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(GPs) and 28% of consultants. 5 However, womenconstitute 54% of doctors aged < 35 years in the UK,but 58% and 64% of this group in France and Spain,respectively. 3 By 20172022, in the UK, women arelikely to constitute the majority of specialists movingto consultant appointments in all elds other thanradiology, ophthalmology and surgery. 5

Women in specialties

Specialty trends differ across countries. In radiology,for example, women constituted 27% of practitionersin the USA in 2009, but as much as 80% in Latvia,Estonia and Belarus, and 5060% in other Europeancountries. 11 Rinck 11 notes that the feminisation of radiology is good news for patients because womendoctors communicate better with patients and col-leagues and take less risk than their male colleagues.Noting potential dangers of the feminisation of themedical workforce, McKinstry 7 disagrees: Empathy

and communication skills are important, but so areefciency and the ability to live with risk.

Worldwide, women are under-represented insurgery and over-represented in paediatrics andprimary care. 1214 This has led to a concern that there may be a future specialty shortfall. Careerroutes leading to consultant posts, particularly insurgery, have traditionally been harder to pursuefor women who wish to have children. 1517 Womentend to be successful on the career ladder insurgery only if certain structural requirements arefullled, such as the provision of exible hours,child-minding services and supportive mentors. 18 Women may lose interest in surgery as they progressively encounter a strong competitiveelement because in general women doctors prefermore collaborative work contexts. 19

ISSUES RAISED BY DEMOGRAPHICS

Kilminster et al.8 conclude that the raw demographicdata, such as the gures summarised above, raise fourpossible consequences. Firstly, the trend may present

problems for workforce planning as women will workpart-time and leave the profession early, causing apotential workforce shortage. Secondly, the trendmay be a good thing as women bring desirablequalities to practice that differ from those brought by men. Thirdly, gender differences at intake may evenout as graduates enter the workforce. Fourthly,structural inequalities in medical culture may persist,maintaining a male dominance. To this can be addeda continuing problem in equity.

Equity issues

There is not only a structural problem in terms of equality of opportunity in medicine with regard togender, but there also exists an equity, or justice andfairness, problem. Women in medicine are givenpoorer rewards for doing the same job as men 17 and,although women are under-represented in key posi-tions in the senior ranks, medicine continues to fail women with career aspirations through the poorprovision of the resources and infrastructurenecessary to help them achieve their goals. 20 Womendoctors earn less than men in academic medicine,progress through the ranks more slowly and do not readily attain leadership roles, not because of thequality of their productivity or commitment, but because they are subject to structural constraints. 21

Such constraints are then realised at an individuallevel of aspiration: when asked in surveys what their

potential earning power may be, women doctorsreport a ceiling that is around 25% lower than that reported by male doctors. 22 Overall, women doctorsconsistently rate themselves as less capable than maledoctors. 23

Consequences of women doctors working part-time

If a signicant number of women doctors come to work part-time, what will be the knock-on effects forthe workforce, including in leadership and medicaleducation? In comparison with their male colleagues, women doctors already engage in more part-time work (85%) 10 and want more exible working hoursthat will facilitate the opportunity to have children,and women GPs in general plan to retire earlier thantheir male colleagues. 36

A knock-on effect of this is that women doctors areless attracted or committed to seeking clinical andacademic leadership and senior management roles.This gender effect is unlikely, however, to create aleadership decit in the future because, as noted,the absolute numbers of male students enteringmedicine have risen. 5 The issue, rather, is one of

equality of opportunity and equity.12

Dacre12

suggeststhat the feminisation of medicine is creating anopportunity to rethink workforce planning in amanner that may allow leadership roles to becongured differently than they are at present,encouraging women candidates.

Kenneth Ludmerers classic history of Americanmedical education points to the contemporary disappearance of heroes from medicine in a context



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in which academic medicine in particular hasgrown too large and fragmented for heroes toemerge. 24 This may seem like good news to feministsin medical education, in which women doctors areseverely under-represented. For example, in 2007only 12% of clinical professors and 36% of clinicallecturers in England were women, and only two of 34medical schools had women deans. 5 The position issimilar in the USA, where only 15% of women doctorsare appointed as full professors and 11% asdepartment chairs. 12

However, although women medical students tend tomake more effective facilitators than their malecounterparts, 25 women doctors are less likely to takeup academic research 26 and teaching. 7 This presentsa lack of female role models for new cohorts of medical students, despite the disappearance of heroes from the eld. Yet such role models areneeded. For example, in instances in which gender

issues are introduced into the medical undergraduatecurriculum, it is women faculty staff who tend toinitiate this move. 27

CONSULTING STYLES AND COMMUNICATION:KNOCK-ON EFFECTS FOR PATIENTS

A study in junior doctors of role-modelling by respected senior doctors found that women juniordoctors reported communication as the key element they wished to emulate, whereas male junior doctorsconsidered communication to be much lessimportant. 23 Although evidence is equivocal as to whether patients are ultimately concerned about thegender of their doctors, 23 women doctors treat patients with more overt compassion and intimacy than their male colleagues do and are moreconcerned with the psychosocial and communicativesides of medicine. 6,2022,28 Women doctors may bebetter adapted to women patients, who ask morequestions and give more information than malepatients, and check and paraphrase information,thereby forcing the doctor into giving clearerexplanations, and explicitly demand a feelings-

oriented rather than a thoughts-oriented consulta-tion style. 28 Women doctors also rate the provision of a supportive environment, such as one that includesclose friends, as more important to their worksatisfaction than do their male colleagues. 16

The more empathic, patient-centred style of womendoctors, compared with that of their male colleagues,has been shown to result in better patient outcomes. 12 In addition, a UK study of the

suspension of GPs between 2001 and 2010 found that men attracted more complaints than women and were ve times more likely than women to besuspended as a result of investigations intocomplaints. 29 However, McKinstry suggests that efciency and ability to deal with risk are asimportant as empathy and communication. 7 Mc-Kinstry points out that women GPs spend longer withpatients and are more likely to refer, and that womenconsultants see fewer patients than their malecolleagues, and that both of these tendenciescontribute to the stretching of limited resources. 7

This raw descriptive demography does not fully realise the phenomenon of the feminising of medi-cine and certainly offers a limited description of thefeminising of medical education . Something more isneeded. The data clearly need explanation if they areto move beyond description, but also invite innovativeexplorations to rethink elements of medical

education theory and practice. In the remainder of this paper, I will argue how a post-structuralist feminist imagination can achieve such a rethink.

FEMINIST THEORY

From the previous section, the benets of thefeminising of medicine may seem straightforward. As women come to represent the majority of the workforce, a positive change in culture, grounded in women doctors consulting styles, will occur and willbenet patients. However, the situation is morecomplex than this and extends beyond criticism of women doctors as being less efcient and moreresource-dependent than their male colleagues.

Firstly, is the historically formed masculine orpatriarchal culture of medicine simply a result of thedominance of biologically male doctors? Secondly, what are the limits of a biological approach togender? For example, do women have a monopoly onfeminisation, or can men also act as agents infeminising a traditionally patriarchal culture?Further, what are the positions of gay and lesbian

doctors in the feminisation of medicine and medicaleducation? 30,31

The masculine protest

When we talk of the feminine or the masculine, we use these terms in a manner that is not restrictedto the literal description of biological sex essentialism but is cultural. They can be employedmetaphorically. Patriarchy does not relate to a


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cultural context that refers only to men, but refers toa dominant cultural form based on a particular kindof logic that embraces heroism, rationalism, certainty,the intellect, distance, objectication, and explana-tion before appreciation. A key strategy employed by this logic is oppositionalism: for example, the rationalis opposed to the irrational and the former isdominant over the latter. Oppositionalism is a tacticof conict rather than of reconciliation orcollaboration. I will return to oppositionalism later inthe article.

Although it is a truism to say that men havedominated modern medicine and medical education,this is an aspect of the wider cultural form of patriarchy. Michel Foucault has described the specicappearance of patriarchy in medicine as the medicalgaze, interpreted as a variety of the male gaze. 32,33

Bordo 34 argues that the body is the province of thefemale, whereas men, by contrast, want to stand

clear of the esh, to maintain perspective on it,thereby rehearsing a familiar argument concerningthe dominance of an objectifying male gaze.

In Foucaults description, the penetrating eye of thedoctor that sees into the depths of the body in adiagnostic gaze is associated with both the penetrat-ing phallus and a cold logic. This logic extends to thescalpel as a peculiarly masculine extension of theconducting hand and the pointing or probingnger. 35 Further, the medical gaze is legitimated within the sanitised white cube of the clinic, theultimate expression of cold logic in architecture, in which the male doctor has been sanctioned toperform professional intimate examinations of women strangers, as patients, that would be taboo inother contexts. Feminists have come to term thisdominant patriarchal complex phallogocentric. 1

Modern medicines institutional patriarchy is bought at a price, characterising what the psychoanalyst Alfred Adler described nearly a century ago as themasculine protest. 36 The well-rehearsed argument isthat doctors see so much suffering that they must protect themselves, through objectication and

distancing, from carrying this suffering. Psychoana-lytically, they tend to use the stronger ego defencemechanisms of denial and repression. However, thismasculine protest ultimately has a counterproduc-tive effect in the form of empathy decline, whereby medical students learn to objectify patients. 37

Studies of empathy decline in medical students havebeen criticised as exaggerating the effect 38 andpsychometric measures of empathy have been seen to

afford limited utility, such as predictive value. 39 Thereis also debate about the precise meaning of the termempathy, 40,41 which raises questions about what issupposedly being measured. However, robust defences of both denitions of empathy and the validity of psychometric measurement of dimensionsof empathy have been made. 42 Further, plausibleexplanations for the phenomenon of empathy decline have been offered. 43 Although claims aremade that empathy decline has been stemmedthrough explicit curriculum design, measured levelsof empathy remain greater in female than in malemedical students. 44

If empathy is reduced, particularly as medicalstudents progress to clinically based learning, andparticularly amongst men, repressed affect may return in symptomatic form. This includes relatively high rates of substance abuse, burnout, depression,suicide ideation and suicide amongst doctors, who

are unable to resist the infection of the masculineprotest. 45,46 The masculine protest offers a logic that runs through all of medicines procedures andreaches its apex in the culture of surgery.

Two brief illustrative examples of the dominance of patriarchy at work in medical education will round off this section. The rst concerns the rise of theone-sex manikin used for training in clinical skills, 47

demonstrated by the fact that the high-tech SimMandoes not have a female equivalent. The second ishighlighted by the bioethicist Tod Chambers, whosuggests that even the medical ethics case study is written in a way that privileges a male worldview, whereby the person is objectied and analysedthrough an abstract principles-based approach that isinsensitive to the particular individual. 48

THE RISE OF FEMINISMS

In response to the masculine protest, a social move-ment has developed, involving both women and men,and articulating a challenge to patriarchal values. Thesuffragettes of the late 19th and early 20th centuries

were supporters of womens suffrage or the right to vote, previously denied to women. This movement was retrospectively termed rst-wave feminism by those involved in the second-wave feminism of the1960s and 1970s, in which the issues were largely about equality of opportunity, control over thereproductive cycle, and equity or justice in socialmatters (although, for example, women were not ableto vote in Switzerland until February 1971).Second-wave feminists would point to the fact that



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their reproductive cycles, including birth, had beenmedicalised and were controlled by a male-dominated medical profession.

Although the suffragists included men whosupported womens rights, separatist feminism arosein the second wave, from which men were excluded.Third-wave feminism emerged during the 1980s toacknowledge wider issues of ethnicity, gay andcultural identities and allied with sympathetic men tochallenge the dominance of patriarchy to promoteequality of opportunity and equity, or justice andrights, for women.

Third-wave feminism shifted interest away frombiological essentialism to focus, rather, on how aspects of culture produced gender, especially genderstereotypes. The issue here is to debate dominant values, ways of thinking and activities that reproducepatriarchal society. For example, the philosopher

William James presents the idea that there is a tensionbetween tough-minded and tender-minded think-ing. 49 Tough-minded thinking is perceived as moremale and tender-minded thinking as more female incharacter, but this does not mean that all men aretough-minded and all women are tender-minded.

If we apply this to the culture of medicine, although it is true that medicine has been dominated by men andhas also been tough-minded in its values, this does not mean that some male doctors will be tender-mindedand some women doctors tough-minded. James usedthese descriptors originally for schools of philosophy to describe on the one hand the tough-minded schoolof rational empiricists and positivists, and on the otherthe tender-minded school of the romantics, whoelevated feeling and intuition above reason.

POST-STRUCTURALIST FEMINISM

Third-wave feminism is then interested in how genderidentities are produced through cultural discourse.This cuts two ways. Firstly, just because you are born with a female or a male body (and some people are

born with indeterminate gender), this does not meanthat you are destined to act in a particular way.Secondly, that a group of cultural values (such assensitivity and tenderness) can be called femininedoes not mean that these are the exclusive domain of women or mothers.

In 2010, the United Nations Educational, Scienticand Cultural Organization (UNESCO) produced areport on the global social science landscape and

the contribution of the social sciences to interna-tional issues. 50 The report suggested: Never beforehave the social sciences been so inuential. 50

Strangely, in the 400-plus pages of the report, nomention is made specically of the inuence of thesocial sciences on medicine or medical education, but there is one paragraph on the body. This paragraphnotes that the body has, historically, been the domainof study in medicine and biology, but since the1990s, the body has been an interdisciplinary meetingpoint for various social sciences. 50 This turn of thesocial sciences towards the body as an object of study has led to a critique of the medical view of the body asa sophisticated machine and has introduced the ideathat: For some feminist and postmoderntheoreticians, the body is just the effect of discourserather than a stable site of experience. 50

The word just is used rhetorically; it would be betterto suggest that the body is both an effect of cultural

discourse and biology. A key cultural discourse isgender and since the 1960s gender issues have beenof particular interest to feminists. There are twobroad streams of contemporary feminist thinking, Anglo-American and Continental; the latter is oftenreferred to as French post-structuralism. 1 The Anglo-American stream is grounded in the analysis of structural inequalities that can be addressed througheconomic or political strategies; this territory wasintroduced in the rst part of this article. TheContinental stream moves the ground for analysis tothe effects of discourse culturally based languageand thought and argues that addressing structuralsocial issues can be cosmetic if fundamental ways of thinking and valuing, that come to shape activity,remain unaddressed.

What is post-structuralist feminism? 1,2 Structuralism was one of the most inuential theoretical frameworks of the rst half of the 20th century, based onthe linguist Ferdinand de Saussures idea that language is a system, and that all language expres-sions are subject to a universal, underlying structureor set of generative rules. The relationship between a word in any language (such as dog) and the object

itself (the dog) is arbitrary. The word bears meaningonly in its difference from other words (such as cat) inan overall eld of signs (the structure).

Subsequently, structuralists reduced this unseenorganising eld to a code concerning oppositionalcategories. For example, the anthropologist Levi-Strauss reduced complex mythologies across culturesto a basic oppositional category: the raw and thecooked, or nature versus culture; Chomsky suggested


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that language was built on a basic set of unseengenerative rules, and Piaget suggested that humancognitive development followed an invariant,unfolding sequence of stages.

In the latter half of the 20th century, the idea of auniversal organising structure to which culturaldifferences could be reduced was questioned. Moreimportantly, the structures themselves that charac-terised structuralism were seen to be gendered male,as structures of logic. Further, the organisation of structures as oppositional categories was seen to bepotentially violating in its expression in that onepole of the opposition came to dominate and oppressanother, both in language use and in actual socialrelations; for example, Man stands in opposition toand is dominant over Woman.

In the wake of these doubts about structuralism, apost-structuralist philosophical and cultural critique

emerged. This movement has become a dominant form of critique in the arts and humanities but has yet to be employed within medical education. It assumesthat the world is not organised by unseen universalprinciples, but is expressed locally, through idiosyn-cratic cultural rules. Importantly, post-structuralistsargue that difference between these local and pluralexpressions should not only be tolerated, but alsocelebrated.

Where language shapes practices, post-structuralist feminists are particularly interested in the way that language is used to support the dominant culturaldiscourse of patriarchy and why differences betweenthe genders are not celebrated, but, rather, are widened in support of one controlling impulse: that of the male. They are less interested in the foci of traditional post-1960s feminists, such as the liberationfrom male appropriation of womens reproductivecycles, and more concerned with how text is appro-priated by the male voice as a basis for the values that shape social practices. Post-structuralist feminism isoften referred to as French because of the inuenceof three French national thinkers in particular: JuliaKristeva,51 Helene Cixous 5254 and Luce Irigaray. 55

However, other writers such as the American JudithButler have also been inuential in shaping this new wave of feminism.1 Butlers view is that gender is not destiny, but is performed to construct identity, andthis moves gender beyond biological expression tocultural constructions. 1

Post-structuralist feminism is characterised by threenotions: challenging the potentially oppressive logicof binary thinking; respecting and tolerating differ-

ence, and liquid thinking. Each of these concerns will be summarised here.

Challenging binary thinking

Gender studies are compromised by a tendency toutilise binary thinking (such as male versus female), which reduces complex gender issues to essentialismor refers to gender in terms of purely biologicaldifferences. Post-structuralist feminism challengessuch rhetoric, rstly in a critique of oppositionalthinking and secondly in a focus upon language useprior to biological difference. Oppositional thinkingcan be seen as a basic rhetorical strategy with which tocontrol complexity by reducing material to simplisticdescriptive categories.

In oppositionalist thinking and its subsequent prac-tices, one term becomes the positive and comes todominate the other in an asymmetrical opposition,

such as man woman, human animal, adult child, white black. The subjugated term is not only governed, or ruled, but is easily belittled, stereotypedand demonised. Cixous points out that whereverdiscourse is organised it is always the same meta-phor, that of oppositionalism or duality leading tohierarchy, where Western thought has always workedthrough opposition, such as Activity Passivity, andwoman is always associated with passivity.56

Although medicine is riddled with uncertainty, it characteristically controls this by reducing its subject matter to oppositional categories, such as normal versus pathological, health versus illness, and cure versus care.

Kristeva51 suggests that oppositional thinking readily deteriorates to prejudice. Typically, opposition takesthe form of subject object. Whatever I oppose ispotentially de-humanised and de-personalised. Therelegated other can quickly become demonised asthe abject that is considered intolerable. The abject is not only excluded, but pathologised and actively discriminated against, such as by scapegoating.Research has shown that doctors tend to treat theirless ill patients more favourably than more ill

subjects.28

Celebrating difference

Hierarchies need to be countered if we are todemocratise medicine, especially in light of evidencethat horizontal forms of team-working benet patient health outcomes. 57 The possibility of a tran-sition to authentic interprofessionalism is frustratedby professions positioning themselves as opposed and



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hierarchical. Writers such as Cixous suggest that wemust challenge the habit of oppositionalist thinkingthat has historically informed and attempted tonaturalise imperialism and colonialism (producingan us and them mentality) and instead focus upon,and celebrate, multiple differences among persons.Cixous 54 and Clement 58 offer a challenge to thestability of the masculine structure that passed itself off as eternal-natural and naturally dominant theEmpire of the Selfsame that forces others into themould of the protagonists self.

Liquid thinking and the use of metaphor

Irigaray 59 and Cixous 52 suggest that feminism must claim its own language and not be drawn to workthrough the medium of a patriarchal language.Irigaray 59 describes a uid or liquid language that ishighly metaphorical that might be used to capture ways of thinking and knowing that are marginalised

by the dominant patriarchal language. Medicine, likeany complex praxis, is intimately bound with meta-phor. Thinking in medicine works in two ways:literally, as social-realist narrative, and guratively ormetaphorically, as expressive narrative.

By turning the literal into an image, metaphors canhelp us to get closer to the experience of the patient.For example, Vincent Lam describes his grandfa-thers developing tumour: His left ank bulged as if a balloon was being inated under the skin Ipressed the tumour gently with the tips of my ngers.It was rm, hard like cold plasticine. 60 The meta-phors and analogies throughout this text like coldplasticine, as if a balloon was being inated reect those employed in expert clinical judgement throughpattern recognition. Lam (a male doctor) furtherdescribes his grandfathers bloody pee as havingclots like coarse sand. 60 This close noticing andliteral contact clearly illustrate a response to Irigarayscall for tactility 59 to counter the objectifying andabstracting diagnostic gaze that is characteristically male and serves to place the patient in a passiverole.

Susan Sontag notes that metaphors can be employedstrategically on behalf of a patriarchy. 61 Following theprecursor of tuberculosis, contemporary descriptionsof cancer and acquired immune deciency syndrome(AIDS) can move beyond accounts of literal illness tooffer accusatory metaphors. 61 These metaphors bringabout shame and guilt in those suffering from illnessand may prevent them from seeking appropriatetreatment. This resonates with cultures of shamingand scapegoating rather than of supporting and

understanding. In addition, medicine may fail to helppatients to deal with illness in contexts in which it typically employs masculine martial metaphors todescribe its work, such as ghting cancer. Thealready exhausted patient may feel she is not up tothe ght.

Perhaps a feminised narrative sensibility is more likely to read the patient holistically and to grasp thecomplexity of the patient through a uid, dynamicsensibility rather than a formal mechanics. The liquidthinking that is described by Cixous 52 as e criture feminine metaphorically inscribes the world withmothers milk, an elegant metaphor for nourishing,unconditional care that is neither a disguised form of control nor a demand for reciprocity.

THE CURRICULUM AS A GENDER TEXT

Having introduced the basic premises of post-structuralist feminism, the remainder of this article will discuss how this perspective can help us torethink medical education that is currently habitually formed through the discourse of patriarchy and themasculine protest. How might the medicinecurriculum be re-gendered through the framework of post-structuralist feminism? Several illustrativeexamples are considered.

Curriculum design

It would be unusual in medical education to describethe curriculum as a gender text, 62 yet curricula aredesigned, implemented and evaluated through typi-cal patriarchal devices that gender-stereotype to placewoman as the inferior in a male versus femaleopposition. The demographics summarised in therst section of this article note that women are not represented adequately in medical education,although female medical students outperform malestudents as facilitators. Why does this slippage occur?Perhaps current curriculum design consciously orunconsciously reproduces patriarchal forms.

For example, as I have noted, advanced clinical skillsmanikins are gendered male. Biomedical scientistsare notoriously hostile towards what they perceive assoft or tender-minded subjects such as the socialsciences. 63 The current orthodoxy in curriculumplanning, such as behavioural outcomes-based learn-ing expressed as competencies can be seen asrational, technical, instrumental, hierarchical, goal-oriented and cold, 64 thus resembling the classicprole of the masculine protest and the authoritarian


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personality. Such approaches deny process, intuitionand affect as legitimate learning.

The curriculum is a lived experience; it extendsbeyond a mere syllabus or list of content, and serves toconstruct identities. In a medical education, theidentity-associated goal refers to a transition from theidentity of medical student to that of trainee doctor.But what if this identity construction carries with it the classic signs of the masculine protest such asdefence against admitting uncertainty and ambiguity,and the hardening of feelings that can lead tocynicism? Both are signs of the well-documentedphenomenon of empathy decline amongst medicalstudents, which can be read as a largely male-gendered phenomenon. Is Ludmerer 24 correct tosuggest that the days of individualistic heroicmedicine are over?

Andragogy

The widespread uncritical acceptance of andragogy,or adult learning theory, in medical education,disguises an institutionalised gender bias groundedin language and thought. 65 The root of andragogy(Greek: andr- ) means man or male. How might amedical education look if it were a gynagogy?Learning theories that privilege autonomy also serveto mirror medicines traditionally heroic, masculinestance, at the expense of more collaborativeapproaches.

Professionalism, reection and self-knowledge

Although the emphasis upon professionalism andpersonal reection in medical education may seem toreect a move towards a more tender-minded prac-tice, professionalism is subject to the inuence of themasculine protest, including the supposedly rigorousapproach of assessment through stated learningoutcomes, referred to under Curriculum design .

Professionalism in the curriculum is often advertisedas a technique by which students come to know themselves through institutionalised forms of

reective practice. However, this may drive learnersinto individualistic or autonomy-based models of reection that conrm the tenets of andragogy andmove away from collaboration. 66 Kristeva critiquessuch self-knowing as potential illusory, an aspect of mastery, when in reality we are always strangers toourselves. 67

In comparison with their female colleagues, who aremore uncertain about practice, self-image and career

goals, male doctors show assertive condence in theirpractice congruent with strong self-image and aligned with focused career ambitions. 28 This difference canbe read psychoanalytically, where over-condencecan offer defence against recognition of uncertainty.Kristeva suggests that it is through unknowing, orthe recognition of basic instability of self-image, that we paradoxically come to know ourselves. 67 But,again, this is not mastery (another exclusive,masculine term).

Further, professional practice has largely beendened by ethical behaviour based on an approachthat adheres to the upholding of a set of principles,rather than on a situated or contextually sensitiveethics (see Cases ). 68 Principles-based approachesstrive for the more masculine purposes of clarity anduniformity, whereas situated approaches allow for amore feminine tolerance of ambiguity.

Cases

What would such ethics cases look like, or how would they be written up, if medicine were guided by the outlook of e criture feminine , feminine practices of writing, such as those modelled by Cixous, 52 who asks,metaphorically, what it is like to write with mothersmilk? This can be read as (re)inscribing writing, suchas a patient case, with maternalism rather thanpaternalism. Cixouss 52 use of mothers milk as ametaphor opens participation to men also to treat writing and the writing out of our lives as identity performances as nourishing and expressive,expressed as breast milk that stains (in the sense of character or identity formation) as it sustains.

Cixous further describes how a singular, femininevoice might be brought into writing by resistance tothe conventions of a dominant masculine style. Sheshows how writing might not be attened by thestylistic demands of intellectual writing (the scienticreport, the case presentation) so that we might makethetextgasp or form it out of suspenses and silences. 69

Care

For Martha Nussbaum, there is an overarching maleprivileging of issues of justice in health care (such asin the distribution of resources) over a femaleconcern with issues of quality of care. 70 We see thisplayed out in the debate published in the British Medical Journal between McKinstry, a male doctor,and Dacre, a female doctor, in 2008. 7,12 As notedearlier, McKinstry suggests that the focus placed by supporters of the feminisation of medicine on



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improved communication with patients (quality of care) is at odds with justice issues such as pressure onresources because it involves practitioners in spend-ing more time with patients and offering morereferrals. Of course, both orientations are important,but it is typical of the masculine protest to place themin opposition. However, Nussbaum argues that anethic of justice is persistently privileged over an ethicof care, and this can be read as a gender bias leadingto inequalities. 70

Household

Not so long ago, few doctors would have bothered toquestion the meaning of the descriptors rm in thecontext of the ward team, or house ofcer andhouseman with reference to the rst-year juniordoctor (intern progressing to junior resident). In theUK, the notion of the rm has now disappeared andthe term foundation doctor has replaced house

ofcer. The phallic rm is now accid or, rather,exible and liquid as junior doctors learn to becomemore nomadic and less attached.

How will the new female majority of junior doctorsestablish the household, which is, stereotypically, the womans domain? Will they, for example, see domesticcare values as more important than business values(the rm typically describes a commercial venture ora legal set-up) and work against a current discourse of managerialism that frames care as a business andpatients as customers? 71 Will they return the hospitalto its root meaning of a place that offers unconditionalhospitality? Firm, as we know, also means solid, stiff,unyielding and steadfast, characteristics that arereadily linked with the penetrating medical gaze. Willsuch archetypally masculine, or phallogocentric, values be replaced by a different set of values when women doctors are in the ascendant?

Centres

Medical education research continues to emphasisecompetition for resources rather than collaboration. A centre for research is still the most popular descrip-

tor, rather than the more democratic network, whichimplies a structure in which collaborative models canbe seen to be more feminine in tone.

CONCLUSIONS: TOWARDS DEMOCRACY IN MEDICINE

The contribution of post-structuralist feminismtowards medical education can be summarised as thefacilitation of democratic habits in medicine. Medical

education can be described, perhaps controversially,as the means whereby democracy can be brought to ahistorically and persistently autocratic medicalculture habitually grounded in the masculine protest.It is essential that such a democratising process gainstraction so that collaborative teamwork withcolleagues and patient-centred collaborationsbecome the means through which patient safety andthen patient care can be improved.

This project, admittedly, is wider than the employ-ment of post-structuralist feminist thought to medicaleducation. However, such a mode of thought offers aradical platform for rethinking medical education interms of a democratising project that extends beyonda version of feminising that is limited to demographictrends. A future medical education may not be best informed by the conventions of a patriarchal framework, but by a medical education familiar with theelds of contemporary gender studies and critical

feminisms.

Acknowledgements: the author would like to acknowledgethe support of colleagues in the feminist pedagogy groupthat met at the University of Liverpool in the late 1990s, in which he was the only male member. Funding: none.Conicts of interest: none. Ethical approval: not applicable.

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Received 13 January 2012; editorial comments to author 7 March 2012, 9 May 2012; accepted for publication 7 June 2012


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