Perceptions on gender awareness and considerations in career choices of medical students in a medical school in Taiwan
Abstract
The trend of medical career choice in the younger generation has resulted in deficiency of manpower in the four major disciplines of internal medicine, surgery, obstetrics/gynecology, and pediatrics, which will threaten people's health care in Taiwan. However, perceptions of gender awareness and factors affecting the career choices of medical students have not been investigated systemically in Taiwan. To explore the perceptions on gender awareness and considerations in career choices, we recruited 280 1st- and 7th-year male and female medical students at a Medical University for the study. A modified Nijmegen questionnaire using a 5-point Likert scale containing medical curricula (18 items), gender awareness (13 items), and career inclination (9 items) was adopted as the investigation tool in our study. The response rate was 75% (224/280). With regard to gender, the 1st-year male students had greater confidence in being a physician than the female students (p < 0.05), and female students subjectively suggested an advantage to communicate with patients or colleagues (p < 0.05). Faculty attitude in treating students differently by gender was more prominent in the 7th-year than in the 1st-year students (p < 0.001), and they felt male preceptors typically were more enthusiastic to teach and to rank higher grades to female than to male students; however, this was not observed among female preceptors. Both male and female students showed a low level of agreement that clinical skills and performance of a physician were significantly different by gender and “female physicians are more empathetic and provide more communications than male physicians”. Factors influencing career choices of medical students, including “personal interests/talents” and “academic achievement of the specialty,” were not significantly different by gender. Factors included “training and learning environments of the specialty”, “risk of lawsuit”, and “economic incentive” were more appreciated by the senior than the junior students (p < 0.05). Effect of “family” or “spouse” did not differ significantly regardless of gender or seniority. The 7th-year students had experiences in clinical medicine and had different considerations in career choice in comparison to the 1st-year students, and gender played a role in senior students. In addition, the senior rather than the junior students regarded “training and learning environments”, “risk of lawsuit”, and “economic incentive” as more important factors affecting the career choices, and male students paid more attention to these issues. Other factors such as fixed hours of duty with no emergency, easier lifestyle, and more time to take care his/her families were also important factors affecting career choice in medical students regardless of their gender; however, the junior students disclosed lower concern on the issues. In addition, four major misperceptions of gender and health issues were prevalent in the 7th-year students; therefore, we recognized the importance of integrating gender issues into medical curriculum to diminish gender misunderstanding and prejudice, and to provide gender-specific health care is mandatory in Taiwan.
Introduction
Gender roles and responsibilities vary between cultures and can change over time; however, the roles of women tend to be undervalued in nearly all societies [1]. Global mechanisms, such as the Beijing Declaration and Platform for Action [2], have awakened and highlighted the importance of gender awareness. Gender has a great influence on human health and disease, which is a complex interaction among biological, psychological, social, cultural, and societal factors. However, a focus on gender issues between medical students and curricula in Taiwan has been scant. The traditional 7-year medical curriculum in Taiwan has been basically divided into three phases, that is, pre-med for the first 2 years, basic sciences for 2 years, and clinical medicine (clerkship and internship) for 3 years. A fundamental imbalance exists between the science and the humanities in medical education, and gender issues have long been overlooked in medical education [3], and attempts to integrate these topics into medical curricula have been made [4]-[8]. The proportions of gender-related courses of medical programs leading to MD degree are currently approximately 0.4–0.5% in Taiwan's medical schools. How to integrate gender issues into the medical curriculum is a great challenge for medical educators in Taiwan [9]. The aim of the study was to investigate the motivations of medical students to study medicine, their attitudes toward gender awareness, and the effects of their learning experiences in medical schools on gender awareness and the career choices in the 1st- and 7th-year, male and female medical students.
Materials and methods
Development, validity, and reliability of questionnaire
Verdonk et al. developed a questionnaire “Nijmegen Gender Awareness in Medicine Scale (N-GAMS)” to assess the gender awareness in medicine published in 2008 and has been accepted as a valid tool to evaluate perceptions of genderness in medical education. Our study was to explore not only perceptions on gender awareness but factors affecting career choices among medical students; therefore, we developed a modified Nijmegen questionnaire with a 5-point Likert scale in our study [10]. Our questionnaire contained main components on medical curricula (18 items), career inclination (9 items), and gender awareness (13 items), Experts evaluated the content of each item by two rounds, and appropriate revisions were made to the final form and the validity was 0.84. We conducted principal components analysis with varimax rotation to determine the underlying latent clusters within medical curricula, career choices, and gender awareness. Factors were retained if eigenvalues, representing the variance accounted for each underlying factor in factor analysis, were greater than 0.46. Items were assigned to factors based on their largest loading; a simple structure was obtained using factor loadings greater than 1 for this assignment. Reliability analyses were conducted by measuring Cronbach α, which was 0.71, 0.79, and 0.70 on gender awareness, career choices, and medical curricula, respectively.
Statistical analysis
Between June 2009 and September 2009, we enrolled 135 1st-year (men/women = 91/44) and 89 7th-year medical students (men/women = 68/21) in this study. We obtained students' informed consent to fill out the questionnaire in approximately 15 minutes, with a 75% (224/280) response rate. All collected data were strictly confidential. Statistical analyses were performed using the SSPS, version 12.0 (SPSS Inc., Chicago, IL, USA). One-way ANOVA and unpaired Student t test were used to compare the differences of gender awareness between the 1st- and 7th-year male and female medical students. A p value <0.05 was considered statistically significant.
Results
There were 135 1st-year and 89 7th-year medical students, and the proportion of women was 32.6% (44/135) and 23.6% (21/89), respectively. According to the statistics from the Ministry of Education, the ratios of male to female medical students were 2.9 to 1 in 1998 and 2.4 to 1 in 2006 [11], and there has been a trend of gradual increase in the proportion of female medical students in Taiwan.
Motivation to study medicine
The motivation to study medicine was mainly ascribed to personal interest or talent among the 1st- and 7th-year medical students (93% and 75%, respectively). We found that both the 1st- and 7th-year medical students had the same proportions (36%), having at least one physician in his/her family.
Learning experiences from medical curriculum
The 1st-year medical students were not asked to fill out the form because they just entered into medical school in the 2nd week, and were treated as a control compared to the 7th-year students to assess learning experiences from the formal medical curricula. The mean scores of learning experiences in both men and women are shown in Table 1.
| Item (in medical curriculum) | 7th-y male (N = 68), mean (SD) | 7th-y female (N = 21), mean (SD) | p |
|---|---|---|---|
| Societal knowledge level | |||
| I have learned about sexual harassment issues. | 2.68 (1.23) | 2.19 (1.21) | 0.04* |
| I have learned that males are suitable for math and sciences, and females are suitable for artistic development | 2.62 (1.11) | 2.00 (1.00) | 0.02* |
| Psychological level | 4.01 (1.00) | 2.90 (1.58) | 0.01* |
| My preceptor typically showed more kindness to opposite sex students (e.g., female preceptor was more kind to male students) | |||
| My preceptor taught more to opposite sex students (e.g., female preceptor taught more to male students) | 3.49 (0.95) | 2.62 (1.47) | 0.02* |
| My preceptor gave more credit to opposite sex students (e.g., female preceptor gave more credit to male students) | 2.60 (1.07) | 4.43 (0.60) | 0.000*** |
| Female nurses treated male students more kindly and vice versa | 3.37 (0.98) | 2.95 (1.43) | 0.04* |
| Female nurses were more eager to help male students and vice versa | 2.63 (1.05) | 4.33 (0.80) | 0.000*** |
| Clinical skills learning experiences | 3.40 (0.90) | 4.10 (0.77) | 0.001*** |
| I have learned how to examine female breasts | |||
| I have learned how to examine male/female genitalia | 3.35 (1.02) | 1.90 (1.09) | 0.000*** |
- *p < 0.05. *** p < 0.001.
We found four major misconceptions on several important gender issues: (1) men are suitable for the maths and sciences, and women are suitable for artistic development; (2) more women suffer from depression than men; (3) homosexuals are more susceptible to HIV infection; and (4) drug abuse is closely related to homosexuality. The scoring on “men are suitable for the maths and sciences, and women are suitable for artistic development” showed a significant difference between men and women, whereas scoring of other factors was similar among male and female students. In addition, students perceived significant differences between male and female students (p < 0.05) during clinical training. For example, we found female students were more skillful in examining breasts than male students (4.1 vs. 3.4, p < 0.05). Students considered that the attitude of preceptor or faculty was typically kinder and gave higher credit to students of the opposite gender (Table 2).
| Item (in consideration of my gender) | 1st-y male (N = 91), mean (SD) | 1st-y female (N = 44), mean (SD) | 7th-y male (N = 68), mean (SD) | 7th -y female (N = 21), mean (SD) | p |
|---|---|---|---|---|---|
| I am suitable for becoming a physician in consideration of my gender. | 4.07 (0.41) | 3.98 (0.75) | 3.65 (0.94) | 3.95 (0.67) | 0.012*1 > 3 |
| My family suggests that I am suitable for becoming a physician in consideration of my gender. | 3.74 (1.03) | 3.68 (0.98) | 3.31 (0.95) | 3.00 (1.18) | 0.006**1 > 4 |
| I have an advantage communicating with patients in consideration of my gender. | 3.35 (0.94) | 3.80 (0.73) | 3.43 (1.12) | 3.19 (0.98) | 0.041*2 > 4 |
| I have an advantage communicating with other medical professionals in consideration of my gender. | 3.38 (1.02) | 3.04 (0.69) | 3.03 (0.95) | 3.10 (0.83) | 0.000***2 > 34 > 2 |
| Faculty treated men and women students differently. | 2.48 (1.15) | 2.45 (0.90) | 3.19 (0.87) | 3.29 (0.85) | 0.000***3 > 13 > 24 > 14 > 2 |
| I have an advantage in providing patient care in consideration of my gender. | 3.11 (1.00) | 3.59 (0.68) | 3.18 (0.83) | 2.75 (0.81) | 0.02* |
| Consideration of my gender is an important factor in career choice. | 3.12 (1.26) | 3.11 (1.08) | 3.76 (1.14) | 4.19 (0.87) | 0.000***3 > 13 > 44 > 14 > 2 |
| Clinical skill performance of male physicians is better than that of female physicians. | 2.22 (1.14) | 1.80 (0.91) | 2.34 (1.00) | 1.57 (0.75) | 0.003** |
| The performance of male physicians is more efficient than female physicians. | 2.42 (1.36) | 1.66 (0.62) | 2.49 (1.06) | 1.62 (0.74) | 0.000***1 > 21 > 43 > 23 > 4 |
| Male physicians are able to deal with more workload than female physicians. | 2.22 (1.28) | 1.68 (0.69) | 2.75 (0.87) | 1.57 (0.75) | 0.000***1 > 23 > 13 > 23 > 4 |
| Female physicians extend their consultations too far compared to male physicians. | 2.81 (1.42) | 3.14 (0.92) | 2.46 (1.17) | 3.18 (3.19) | 0.014* |
| Female physicians are more empathetic than male physicians. | 2.60 (1.36) | 3.20 (0.83) | 2.47 (1.18) | 3.10 (1.14) | 0.005**2 > 3 |
| Female physicians are too emotionally involved with their patients. | 2.46 (1.06) | 2.43 (0.93) | 2.56 (1.27) | 2.86 (1.46) | 0.04** |
- Note. Modified from “Medical Students' Gender Awareness. Construction of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS)”, by Verdonk P, Benschop YWM, De Haes HCJM, and Lagro-Janssenen TLM. 2008, Sex Roles, 58, p. 229–230. * p < 0.05. ** p < 0.01. *** p < 0.001.
Implications of gender roles in medical students
The implications of student gender roles are shown in Table 2. We found that the 1st-year male students had greater confidence in being a physician than female students (p < 0.05). Female students subjectively suggested an advantage to communicate with patients or colleagues because of their gender (p < 0.05). The 7th-year students complained more on attitude of faculty in treating students differently by gender than the 1st-year students (p < 0.001). Both male and female students showed a low level of agreement that clinical skills (1.57–2.22) and performance (1.62–2.49) of a physician differed significantly by gender, and the level for the 7th-year female students was even lower. Both male and female students showed a lower level of agreement (2.47–3.20; 2.46–3.18) that “female physicians are more empathetic and provide more communications than male physicians”; although more female students subjectively agreed with these notions, male students did not agree that they were less empathetic.
Factors influencing career choices of medical students
We found that “personal interests/talents” and “academic achievement of the specialty” were listed as higher priorities in considering career choice regardless of the gender, and the 7th-year students regarded “training and learning environments of the specialty” as more important than juniors (p < 0.05). “Risk of lawsuit” and “economic incentive”of the specialty were more appreciated by senior than junior students (p < 0.05). Factors of “family” and “spouse” did not differ significantly among male/female students and junior/senior students; however, the 7th-year male students had a higher willingness to suspend medicial practice because of their spouse or family issues. Factors influencing career choices of medical students are summarized and shown in Table 3.
| Item (factors influencing my career choice) | 1st-y male (N = 91), mean (SD) | 1st-y female (N = 44), mean (SD) | 7th-y male (N = 68), mean (SD) | 7th-y female (N = 21), mean (SD) | p |
|---|---|---|---|---|---|
| Training and learning environments of the specialty | 3.85 (0.74) | 3.64 (0.88) | 4.18 (0.85) | 4.43 (0.60) | 0.000***3 > 24 > 14 > 2 |
| Risk of law suit of the specialty | 3.30 (1.00) | 3.57 (0.66) | 3.91 (0.75) | 4.10 (0.77) | 0.000***3 > 14 > 1 |
| Economic incentive of the specialty | 3.18 (1.05) | 3.39 (0.71) | 3.49 (0.97) | 4.38 (0.59) | 0.000*4 > 14 > 24 > 3 |
| I will suspend medicial practice because of spouse or family problems | 2.71 (1.10) | 2.18 (0.84) | 3.22 (1.42) | 2.76 (1.48) | 0.000***3 > 1 |
- *p < 0.05. **p < 0.01. ***p < 0.001.
Discussion
Japan colonized Taiwan from 1895 to 1945, during which people were prohibited to study law and politics, and people were highly encouraged to be physicians, and traditional family expectations played a crucial role for students in career choice [12]. In the study, we found that personal interest or talent was listed as the leading motivation to study medicine among students, and found approximately 36% of the 1st- and 7th-year medical students, regardless of gender, had at least one physician in their family. This phenomenon reflected a traditional view toward physician continuously had great influence on our society and families.
Misperceptions of gender and health issues among medical students have been recognized as important issues in medical education. We found four major misperceptions of gender and health issues in meidcal students: (1) men are suitable for the maths and sciences, and women are suitable for artistic development; (2) more women suffer from depression than men; (3) homosexuals are more susceptible to HIV infection; and (4) drug abuse is closely related to homosexuality. The former President of Harvard University, Dr. Lawrence Summers, caused a stir among academics in 2005 by suggesting that women have less of an innate ability at science and mathematics than men. This is in contrast to Dr. Drew Faust, President of Harvard University, who stated, “I'm not the woman president of Harvard. I'm the president of Harvard”, which provides a good example of gender awareness. The finding disclosed we did not learn the experiences of gender bias from the story of Summers in Taiwan.
Gender bias in the medical profession is derived mostly from the hidden curriculum reflecting the culture of an institution, which is an implicit process embedded in daily clinical practice in the hospital. In our study, we found that male preceptors typically taught more and ranked higher with female students than to male students; however, this phenomenon was not observed among female preceptors. The gender of a student and that of the preceptor affect the level of student-learning experiences on gender-specific skills and procedures, and Levy and Merchant [13] found that the lowest levels of experience occurred in student-preceptor pairs of the same gender seeing patients of the opposite gender.
Our investigation reflected the presence of stereotyped gender blindness or gender bias on issues of depression, HIV infection, and drug abuse in medical students. It has long been ignored that women and babies were potential to be infected by HIV [14]. An association was found between drug use and risk sexual behavior, but unrelated to the gender [15].
Current studies on gender-related issues of medical students lack sexual harassment issues, gender equality laws or regulations, manifestations of coronary heart disease, drug metabolism, and a lecture-dominated teaching strategy to impart medical knowledge to students in Taiwan medical schools. We habitually used the knowledge obtained from the male body as “standard” human characteristics and attributes, ignoring the differences between the male and female bodies [16], [17]. Despite an increase in the medical humanities, gender awareness curriculum has not been systemically integrated into medical education. In our study, female students subjectively suggested having an advantage to communicate with patients and colleagues and supposed that they provide more empathy than male physicians. Female students disclosed higher interests in communication and collaborations with other medical professionals in a medical team [18]. Barnsley et al. [19] found that female physicians spent more time than male physicians in attempting to understand patient's lifestyle, and demonstrated a higher degree of empathy toward patients by smiling, nodding, or making eye contact [18], [20].
Male students hold stronger gender stereotypes perceptions than female students [21]. We found that the 7th-year students complained that the attitude of the faculty in treating students was different according to gender in comparison to the junior students. Gender awareness is critical to provide gender-specific health care, and how to integrate gender awareness and related issues into the medical curriculum to diminish gender misunderstanding and prejudice on health and disease is mandatory, not only in Taiwan, but worldwide [6], [7], [22]. Personalized and advanced courses specifically targeting medical students and physicians of different genders should be developed to improve physician's competency and enhance patient care quality [23], [24].
Medical students prior to the 1980s traditionally favored four major disciplines as their medical career choice, including internal medicine, surgery, obstetrics/gynecology, and pediatrics. The past 2 decades have undergone tremendous changes in career choices by medical students in Taiwan, the United States, and many other countries [25]-[38]. Previous studies have suggested that gender awareness [25], [26], gender stereotype [24], a lack of female role models, lifestyle, and limited hours on duty [28]-[38] influence student decisions of a medical career. Our study demonstrated that despite differences in the career choices between the 1st- and 7th-year female students, the priorities were identical for internal medicine, surgery, and family medicine. The 7th-year students regarded “training and learning environments of the specialty” to be more important than their juniors, which is compatible with the findings by Hauer et al. [35]. “Risk of lawsuit” and “economic incentive” were other important factors that affected the career choices of senior students more than that of junior students. The proportions of men selecting surgical specialties was higher than that of female students, and more female students selected pediatrics, reflecting the insidious effects of gender stereotypes playing an important role in a traditional patriarchal society in Taiwan. However, female medical students have long considered the ob/gyn specialty a suitable career choice, although only two (10%) female 7th-grade medical students selected the discipline in this study, which may have resulted from the low birth rate and high rate of lawsuits in Taiwan. Other factors such as fixed hours of duty with no emergency, easier lifestyle, and more time to care for families were listed as important factors in career choice [39]. Therefore, the trend of more students to select radiology, family medicine, dermatology, ENT, and rehabilitation as a career is not surprising. However, the phenomenon has resulted in the deficiency of manpower of four major disciplines and will threaten people's health care quality in Taiwan.
We recognized that our study has limitations because it was a cross-sectional study, and we did not conduct a follow-up longitudinally. In addition, the study was implemented in a medical school, and the sample size was relatively small. We will subsequently explore a nation-based investigation to provide more meaningful and valuable information on gender awareness and career choice of Taiwan's future physicians.
In conclusion, the 7th-year medical students experienced in clinical medicine made career choices different from those of the 1st-year students, and different considerations were identified among junior and senior, male and female students' career choices. We found that “training and learning environments”, “risk of lawsuit”, “economic incentive” were regarded as more important factors by the seniors than their juniors that affected their career choices. Other factors such as fixed duty hours, low disputes, easier lifestyle, and more time to care for families were also listed as important factors in career choice. However, the trend of our younger generation's career choice has resulted in the deficiency of manpower of four major disciplines (internal medicine, surgery, ob/gyn and pediatics), and will threaten the people's medical care in Taiwan. Moreover, we also found the misperceptions of gender and health issues, and we recognized that gender awareness is critical to provide better gender-specific health care in Taiwan.
Acknowledgments
This study was supported by the Gender and Sciences Research Projects of the National Science Council, Taiwan with grants No NSC 97-2629-S-040-001.
