gender in medical education

Gender matters in medical education

Alan Bleakley

CONTEXT Women are in the majority in terms of entry to medical schools worldwide and will soon represent the majority of working doctors. This has been termed the feminising of medicine. In medical education, such gender issues tend to be restricted to discussions of demographic changes and structural inequalities 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 sciences help medical educators to widen their appreciation and understanding of the feminising of medicine? DISCUSSION Post-structuralist feminist critique, drawn from the social sciences, focuses on cultural practices, such as language use, that support a dominant patriarchy. Such a critique is not exclusive to women, but may be described as supporting a tender-minded approach to practice that is shared by both women and men.

The demographic feminising of medicine may have limited effect in terms of changing both medical culture and medical education practices without causing radical change to entrenched cultural habits that are best described as patriarchal. Medical education currently suffers from male biases, such as those imposed by andragogy, or adult learning theory, and these can be positively challenged through post-structuralist feminist critique. CONCLUSIONS Women doctors entering the medical workforce can resist and reformulate the current dominant patriarchy rather than reproducing it, supported by male feminists. Such a feminising of medicine can extend to medical education, but will require an appropriate theoretical framework to make sense of the new territory. The feminising of medical education informed by post-structuralist frameworks may provide a platform for the democratisation of medical culture and practices, further informing authentic patientcentred practices of care.

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, Institute of Clinical Education, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK. Tel: 00 44 1872 252613; E-mail: alan.bleakley@pms.ac.uk

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medicine in post-industrial countries, including trends? Women entering medicine: the numbers Philadelphia, Pennsylvania has the mixed distinction of hosting the rst medical school in the USA, but also of hosting the last medical school (Jefferson Medical 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 the USA in the late 1800s, by the 1920s women had practically disappeared from the medical workforce. However, by 2003, entrants to medical school in the USA 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 and fallen to 57% in 2007.5 These statistics have entered the public domain through 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 medicine detailed how Across the Western world a generation of young women is transforming the once-male bastion of medicine, swelling medical schools and ocking to the front lines of primary care.3 The rhetoric is carefully chosen: swelling and ocking perhaps signify the emergence of a new family of professionals. A fear that men are being driven away from applying for medicine may be unfounded. For example, in the UK, because of an increase in the absolute numbers of applicants to medical schools, the number of males taking up places has increased. In 2007, 1200 more men were accepted for medical school than in 1996 (in comparison with 1760 more women).5 Further, in the UK, numbers of international students are increasing 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 In England, women currently account for approximately 40% of all doctors, 42% of general practitioners

INTRODUCTION: THE FEMINISING OF THE MEDICAL WORKFORCE

This article discusses a stream of thought in contemporary social science that is rarely applied to medical education, but is well established in other academic elds, such as cultural studies: post-structuralist feminism.1,2 This stream of thought, which is fully explained later in the article, offers a valuable perspective for rethinking gender issues in medical education theory and practice, and illustrates how contemporary ideas in the social sciences can shape innovation in medical education. Importantly, poststructuralist feminism is an approach that includes male feminists and challenges habitual patriarchal practices that have dominated modern medicine and medical education. Descriptive demographic studies dominate the literature on women in medicine, and it is important to appreciate, understand and then critically address this body of work prior to considering the alternative theoretical framework of post-structuralist feminism that is the concern of the second half of this article. As more women than men enter medical schools worldwide, in time the medical workforce will comprise a majority of women doctors.36 This demographic shift has been referred to as the feminisation of medicine.7 The meaning of feminisation in medicine, however, can be extended beyond demographic descriptions to account for cultural processes. Further, it is important to consider what the feminising of medicine might mean not just for the culture of medicine, but also for medical education. In this introductory section, demographic issues are introduced as a platform from which to explore gender issues beyond demography and biology, such as gendered ways of thinking.

DEMOGRAPHIC SHIFTS

Demography literally means writing about the people and refers to the study of populations rather than individuals. Women and Medicine: The Future, a 2009 report prepared for the UK Royal College of Physicians, is a good example of descriptive demography.5 Written by a female academic sociologist, the report elaborates on a dataset of descriptive statistics and includes little in the way of inference, speculation or theoretical modelling. From such descriptive work by social scientists, what do we know about gender in

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(GPs) and 28% of consultants.5 However, women constitute 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 are likely to constitute the majority of specialists moving to consultant appointments in all elds other than radiology, ophthalmology and surgery.5 Women in specialties Specialty trends differ across countries. In radiology, for example, women constituted 27% of practitioners in the USA in 2009, but as much as 80% in Latvia, Estonia and Belarus, and 5060% in other European countries.11 Rinck11 notes that the feminisation of radiology is good news for patients because women doctors communicate better with patients and colleagues and take less risk than their male colleagues. Noting potential dangers of the feminisation of the medical workforce, McKinstry7 disagrees: Empathy and communication skills are important, but so are efciency and the ability to live with risk. Worldwide, women are under-represented in surgery and over-represented in paediatrics and primary care.1214 This has led to a concern that there may be a future specialty shortfall. Career routes leading to consultant posts, particularly in surgery, have traditionally been harder to pursue for women who wish to have children.1517 Women tend to be successful on the career ladder in surgery only if certain structural requirements are fullled, 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 competitive element because in general women doctors prefer more collaborative work contexts.19 Equity issues There is not only a structural problem in terms of equality of opportunity in medicine with regard to gender, but there also exists an equity, or justice and fairness, problem. Women in medicine are given poorer rewards for doing the same job as men17 and, although women are under-represented in key positions in the senior ranks, medicine continues to fail women with career aspirations through the poor provision of the resources and infrastructure necessary to help them achieve their goals.20 Women doctors earn less than men in academic medicine, progress through the ranks more slowly and do not readily attain leadership roles, not because of the quality of their productivity or commitment, but because they are subject to structural constraints.21 Such constraints are then realised at an individual level of aspiration: when asked in surveys what their potential earning power may be, women doctors report a ceiling that is around 25% lower than that reported by male doctors.22 Overall, women doctors consistently rate themselves as less capable than male doctors.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 for the workforce, including in leadership and medical education? In comparison with their male colleagues, women doctors already engage in more part-time work (85%)10 and want more exible working hours that will facilitate the opportunity to have children, and women GPs in general plan to retire earlier than their male colleagues.36 A knock-on effect of this is that women doctors are less attracted or committed to seeking clinical and academic leadership and senior management roles. This gender effect is unlikely, however, to create a leadership decit in the future because, as noted, the absolute numbers of male students entering medicine have risen.5 The issue, rather, is one of equality of opportunity and equity.12 Dacre12 suggests that the feminisation of medicine is creating an opportunity to rethink workforce planning in a manner that may allow leadership roles to be congured differently than they are at present, encouraging women candidates. Kenneth Ludmerers classic history of American medical education points to the contemporary disappearance of heroes from medicine in a context

ISSUES RAISED BY DEMOGRAPHICS

Kilminster et al.8 conclude that the raw demographic data, such as the gures summarised above, raise four possible consequences. Firstly, the trend may present problems for workforce planning as women will work part-time and leave the profession early, causing a potential workforce shortage. Secondly, the trend may be a good thing as women bring desirable qualities to practice that differ from those brought by men. Thirdly, gender differences at intake may even out as graduates enter the workforce. Fourthly, structural inequalities in medical culture may persist, maintaining a male dominance. To this can be added a continuing problem in equity.

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in which academic medicine in particular has grown too large and fragmented for heroes to emerge.24 This may seem like good news to feminists in medical education, in which women doctors are severely under-represented. For example, in 2007 only 12% of clinical professors and 36% of clinical lecturers in England were women, and only two of 34 medical schools had women deans.5 The position is similar in the USA, where only 15% of women doctors are appointed as full professors and 11% as department chairs.12 However, although women medical students tend to make more effective facilitators than their male counterparts,25 women doctors are less likely to take up academic research26 and teaching.7 This presents a lack of female role models for new cohorts of medical students, despite the disappearance of heroes from the eld. Yet such role models are needed. For example, in instances in which gender issues are introduced into the medical undergraduate curriculum, it is women faculty staff who tend to initiate this move.27 suspension of GPs between 2001 and 2010 found that men attracted more complaints than women and were ve times more likely than women to be suspended as a result of investigations into complaints.29 However, McKinstry suggests that efciency and ability to deal with risk are as important as empathy and communication.7 McKinstry points out that women GPs spend longer with patients and are more likely to refer, and that women consultants see fewer patients than their male colleagues, and that both of these tendencies contribute to the stretching of limited resources.7 This raw descriptive demography does not fully realise the phenomenon of the feminising of medicine and certainly offers a limited description of the feminising of medical education. Something more is needed. The data clearly need explanation if they are to move beyond description, but also invite innovative explorations 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.

CONSULTING STYLES AND COMMUNICATION: KNOCK-ON EFFECTS FOR PATIENTS

FEMINIST THEORY

A study in junior doctors of role-modelling by respected senior doctors found that women junior doctors reported communication as the key element they wished to emulate, whereas male junior doctors considered communication to be much less important.23 Although evidence is equivocal as to whether patients are ultimately concerned about the gender of their doctors,23 women doctors treat patients with more overt compassion and intimacy than their male colleagues do and are more concerned with the psychosocial and communicative sides of medicine.6,2022,28 Women doctors may be better adapted to women patients, who ask more questions and give more information than male patients, and check and paraphrase information, thereby forcing the doctor into giving clearer explanations, and explicitly demand a feelingsoriented rather than a thoughts-oriented consultation style.28 Women doctors also rate the provision of a supportive environment, such as one that includes close friends, as more important to their work satisfaction than do their male colleagues.16 The more empathic, patient-centred style of women doctors, compared with that of their male colleagues, has been shown to result in better patient outcomes.12 In addition, a UK study of the

From the previous section, the benets of the feminising 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 will benet patients. However, the situation is more complex than this and extends beyond criticism of women doctors as being less efcient and more resource-dependent than their male colleagues. Firstly, is the historically formed masculine or patriarchal culture of medicine simply a result of the dominance of biologically male doctors? Secondly, what are the limits of a biological approach to gender? For example, do women have a monopoly on feminisation, or can men also act as agents in feminising a traditionally patriarchal culture? Further, what are the positions of gay and lesbian doctors in the feminisation of medicine and medical education?30,31 The masculine protest When we talk of the feminine or the masculine, we use these terms in a manner that is not restricted to the literal description of biological sex essentialism but is cultural. They can be employed metaphorically. Patriarchy does not relate to a

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cultural context that refers only to men, but refers to a dominant cultural form based on a particular kind of logic that embraces heroism, rationalism, certainty, the intellect, distance, objectication, and explanation before appreciation. A key strategy employed by this logic is oppositionalism: for example, the rational is opposed to the irrational and the former is dominant over the latter. Oppositionalism is a tactic of conict rather than of reconciliation or collaboration. I will return to oppositionalism later in the article. Although it is a truism to say that men have dominated modern medicine and medical education, this is an aspect of the wider cultural form of patriarchy. Michel Foucault has described the specic appearance of patriarchy in medicine as the medical gaze, interpreted as a variety of the male gaze.32,33 Bordo34 argues that the body is the province of the female, whereas men, by contrast, want to stand clear of the esh, to maintain perspective on it, thereby rehearsing a familiar argument concerning the dominance of an objectifying male gaze. In Foucaults description, the penetrating eye of the doctor that sees into the depths of the body in a diagnostic gaze is associated with both the penetrating phallus and a cold logic. This logic extends to the scalpel as a peculiarly masculine extension of the conducting hand and the pointing or probing nger.35 Further, the medical gaze is legitimated within the sanitised white cube of the clinic, the ultimate expression of cold logic in architecture, in which the male doctor has been sanctioned to perform professional intimate examinations of women strangers, as patients, that would be taboo in other contexts. Feminists have come to term this dominant 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 the masculine protest.36 The well-rehearsed argument is that doctors see so much suffering that they must protect themselves, through objectication and distancing, from carrying this suffering. Psychoanalytically, they tend to use the stronger ego defence mechanisms of denial and repression. However, this masculine protest ultimately has a counterproductive effect in the form of empathy decline, whereby medical students learn to objectify patients.37 Studies of empathy decline in medical students have been criticised as exaggerating the effect38 and psychometric measures of empathy have been seen to afford limited utility, such as predictive value.39 There is also debate about the precise meaning of the term empathy,40,41 which raises questions about what is supposedly being measured. However, robust defences of both denitions of empathy and the validity of psychometric measurement of dimensions of empathy have been made.42 Further, plausible explanations for the phenomenon of empathy decline have been offered.43 Although claims are made that empathy decline has been stemmed through explicit curriculum design, measured levels of empathy remain greater in female than in male medical students.44 If empathy is reduced, particularly as medical students progress to clinically based learning, and particularly 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 masculine protest.45,46 The masculine protest offers a logic that runs through all of medicines procedures and reaches 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 the one-sex manikin used for training in clinical skills,47 demonstrated by the fact that the high-tech SimMan does not have a female equivalent. The second is highlighted by the bioethicist Tod Chambers, who suggests that even the medical ethics case study is written in a way that privileges a male worldview, whereby the person is objectied and analysed through an abstract principles-based approach that is insensitive to the particular individual.48

THE RISE OF FEMINISMS

In response to the masculine protest, a social movement has developed, involving both women and men, and articulating a challenge to patriarchal values. The suffragettes 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 the 1960s and 1970s, in which the issues were largely about equality of opportunity, control over the reproductive cycle, and equity or justice in social matters (although, for example, women were not able to 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 been medicalised and were controlled by a maledominated medical profession. Although the suffragists included men who supported womens rights, separatist feminism arose in the second wave, from which men were excluded. Third-wave feminism emerged during the 1980s to acknowledge wider issues of ethnicity, gay and cultural identities and allied with sympathetic men to challenge the dominance of patriarchy to promote equality of opportunity and equity, or justice and rights, for women. Third-wave feminism shifted interest away from biological essentialism to focus, rather, on how aspects of culture produced gender, especially gender stereotypes. The issue here is to debate dominant values, ways of thinking and activities that reproduce patriarchal society. For example, the philosopher William James presents the idea that there is a tension between tough-minded and tender-minded thinking.49 Tough-minded thinking is perceived as more male and tender-minded thinking as more female in character, but this does not mean that all men are tough-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 and has also been tough-minded in its values, this does not mean that some male doctors will be tender-minded and some women doctors tough-minded. James used these descriptors originally for schools of philosophy to describe on the one hand the tough-minded school of rational empiricists and positivists, and on the other the tender-minded school of the romantics, who elevated feeling and intuition above reason. the contribution of the social sciences to international issues.50 The report suggested: Never before have the social sciences been so inuential.50 Strangely, in the 400-plus pages of the report, no mention is made specically of the inuence of the social sciences on medicine or medical education, but there is one paragraph on the body. This paragraph notes that the body has, historically, been the domain of study in medicine and biology, but since the 1990s, the body has been an interdisciplinary meeting point for various social sciences.50 This turn of the social sciences towards the body as an object of study has led to a critique of the medical view of the body as a sophisticated machine and has introduced the idea that: For some feminist and postmodern theoreticians, the body is just the effect of discourse rather than a stable site of experience.50 The word just is used rhetorically; it would be better to suggest that the body is both an effect of cultural discourse and biology. A key cultural discourse is gender and since the 1960s gender issues have been of particular interest to feminists. There are two broad streams of contemporary feminist thinking, Anglo-American and Continental; the latter is often referred to as French post-structuralism.1 The Anglo-American stream is grounded in the analysis of structural inequalities that can be addressed through economic or political strategies; this territory was introduced in the rst part of this article. The Continental stream moves the ground for analysis to the effects of discourse culturally based language and thought and argues that addressing structural social 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 on the linguist Ferdinand de Saussures idea that language is a system, and that all language expressions are subject to a universal, underlying structure or 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 meaning only in its difference from other words (such as cat) in an overall eld of signs (the structure). Subsequently, structuralists reduced this unseen organising eld to a code concerning oppositional categories. For example, the anthropologist Le viStrauss reduced complex mythologies across cultures to a basic oppositional category: the raw and the cooked, or nature versus culture; Chomsky suggested

POST-STRUCTURALIST FEMINISM

Third-wave feminism is then interested in how gender identities 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 mean that you are destined to act in a particular way. Secondly, that a group of cultural values (such as sensitivity and tenderness) can be called feminine does not mean that these are the exclusive domain of women or mothers. In 2010, the United Nations Educational, Scientic and Cultural Organization (UNESCO) produced a report on the global social science landscape and

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that language was built on a basic set of unseen generative rules, and Piaget suggested that human cognitive development followed an invariant, unfolding sequence of stages. In the latter half of the 20th century, the idea of a universal organising structure to which cultural differences could be reduced was questioned. More importantly, the structures themselves that characterised structuralism were seen to be gendered male, as structures of logic. Further, the organisation of structures as oppositional categories was seen to be potentially violating in its expression in that one pole of the opposition came to dominate and oppress another, both in language use and in actual social relations; for example, Man stands in opposition to and is dominant over Woman. In the wake of these doubts about structuralism, a post-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 assumes that the world is not organised by unseen universal principles, but is expressed locally, through idiosyncratic cultural rules. Importantly, post-structuralists argue that difference between these local and plural expressions should not only be tolerated, but also celebrated. Where language shapes practices, post-structuralist feminists are particularly interested in the way that language is used to support the dominant cultural discourse of patriarchy and why differences between the 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 liberation from male appropriation of womens reproductive cycles, and more concerned with how text is appropriated by the male voice as a basis for the values that shape social practices. Post-structuralist feminism is often referred to as French because of the inuence of three French national thinkers in particular: Julia Kristeva,51 He le ` ne Cixous5254 and Luce Irigaray.55 However, other writers such as the American Judith Butler 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, and this moves gender beyond biological expression to cultural constructions.1 Post-structuralist feminism is characterised by three notions: challenging the potentially oppressive logic of binary thinking; respecting and tolerating difference, and liquid thinking. Each of these concerns will be summarised here. Challenging binary thinking Gender studies are compromised by a tendency to utilise binary thinking (such as male versus female), which reduces complex gender issues to essentialism or refers to gender in terms of purely biological differences. Post-structuralist feminism challenges such rhetoric, rstly in a critique of oppositional thinking and secondly in a focus upon language use prior to biological difference. Oppositional thinking can be seen as a basic rhetorical strategy with which to control complexity by reducing material to simplistic descriptive categories. In oppositionalist thinking and its subsequent practices, one term becomes the positive and comes to dominate 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, stereotyped and demonised. Cixous points out that wherever discourse is organised it is always the same metaphor, that of oppositionalism or duality leading to hierarchy, where Western thought has always worked through opposition, such as Activity Passivity, and woman 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 takes the form of subject object. Whatever I oppose is potentially de-humanised and de-personalised. The relegated other can quickly become demonised as the 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 their less ill patients more favourably than more ill subjects.28 Celebrating difference Hierarchies need to be countered if we are to democratise medicine, especially in light of evidence that horizontal forms of team-working benet patient health outcomes.57 The possibility of a transition to authentic interprofessionalism is frustrated by professions positioning themselves as opposed and

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hierarchical. Writers such as Cixous suggest that we must challenge the habit of oppositionalist thinking that has historically informed and attempted to naturalise imperialism and colonialism (producing an us and them mentality) and instead focus upon, and celebrate, multiple differences among persons. Cixous54 and Cle ment58 offer a challenge to the stability of the masculine structure that passed itself off as eternal-natural and naturally dominant the Empire of the Selfsame that forces others into the mould of the protagonists self. Liquid thinking and the use of metaphor Irigaray59 and Cixous52 suggest that feminism must claim its own language and not be drawn to work through the medium of a patriarchal language. Irigaray59 describes a uid or liquid language that is highly metaphorical that might be used to capture ways of thinking and knowing that are marginalised by the dominant patriarchal language. Medicine, like any complex praxis, is intimately bound with metaphor. Thinking in medicine works in two ways: literally, as social-realist narrative, and guratively or metaphorically, as expressive narrative. By turning the literal into an image, metaphors can help us to get closer to the experience of the patient. For example, Vincent Lam describes his grandfathers developing tumour: His left ank bulged as if a balloon was being inated under the skin I pressed the tumour gently with the tips of my ngers. It was rm, hard like cold plasticine.60 The metaphors and analogies throughout this text like cold plasticine, as if a balloon was being inated reect those employed in expert clinical judgement through pattern recognition. Lam (a male doctor) further describes his grandfathers bloody pee as having clots like coarse sand.60 This close noticing and literal contact clearly illustrate a response to Irigarays call for tactility59 to counter the objectifying and abstracting diagnostic gaze that is characteristically male and serves to place the patient in a passive role. Susan Sontag notes that metaphors can be employed strategically on behalf of a patriarchy.61 Following the precursor of tuberculosis, contemporary descriptions of cancer and acquired immune deciency syndrome (AIDS) can move beyond accounts of literal illness to offer accusatory metaphors.61 These metaphors bring about shame and guilt in those suffering from illness and may prevent them from seeking appropriate treatment. This resonates with cultures of shaming and scapegoating rather than of supporting and understanding. In addition, medicine may fail to help patients to deal with illness in contexts in which it typically employs masculine martial metaphors to describe its work, such as ghting cancer. The already exhausted patient may feel she is not up to the ght. Perhaps a feminised narrative sensibility is more likely to read the patient holistically and to grasp the complexity of the patient through a uid, dynamic sensibility rather than a formal mechanics. The liquid thinking that is described by Cixous52 as ecriture feminine metaphorically inscribes the world with mothers 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 poststructuralist feminism, the remainder of this article will discuss how this perspective can help us to rethink medical education that is currently habitually formed through the discourse of patriarchy and the masculine protest. How might the medicine curriculum be re-gendered through the framework of post-structuralist feminism? Several illustrative examples are considered. Curriculum design It would be unusual in medical education to describe the curriculum as a gender text,62 yet curricula are designed, implemented and evaluated through typical patriarchal devices that gender-stereotype to place woman as the inferior in a male versus female opposition. The demographics summarised in the rst section of this article note that women are not represented adequately in medical education, although female medical students outperform male students as facilitators. Why does this slippage occur? Perhaps current curriculum design consciously or unconsciously reproduces patriarchal forms. For example, as I have noted, advanced clinical skills manikins are gendered male. Biomedical scientists are notoriously hostile towards what they perceive as soft or tender-minded subjects such as the social sciences.63 The current orthodoxy in curriculum planning, such as behavioural outcomes-based learning expressed as competencies can be seen as rational, technical, instrumental, hierarchical, goaloriented and cold,64 thus resembling the classic prole of the masculine protest and the authoritarian

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personality. Such approaches deny process, intuition and affect as legitimate learning. The curriculum is a lived experience; it extends beyond a mere syllabus or list of content, and serves to construct identities. In a medical education, the identity-associated goal refers to a transition from the identity 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 as defence against admitting uncertainty and ambiguity, and the hardening of feelings that can lead to cynicism? Both are signs of the well-documented phenomenon of empathy decline amongst medical students, which can be read as a largely malegendered phenomenon. Is Ludmerer24 correct to suggest that the days of individualistic heroic medicine are over? Andragogy Cases The widespread uncritical acceptance of andragogy, or adult learning theory, in medical education, disguises an institutionalised gender bias grounded in language and thought.65 The root of andragogy (Greek: andr-) means man or male. How might a medical education look if it were a gynagogy? Learning theories that privilege autonomy also serve to mirror medicines traditionally heroic, masculine stance, at the expense of more collaborative approaches. Professionalism, reection and self-knowledge Although the emphasis upon professionalism and personal reection in medical education may seem to reect a move towards a more tender-minded practice, professionalism is subject to the inuence of the masculine protest, including the supposedly rigorous approach of assessment through stated learning outcomes, referred to under Curriculum design. Professionalism in the curriculum is often advertised as a technique by which students come to know themselves through institutionalised forms of reective practice. However, this may drive learners into individualistic or autonomy-based models of reection that conrm the tenets of andragogy and move away from collaboration.66 Kristeva critiques such self-knowing as potential illusory, an aspect of mastery, when in reality we are always strangers to ourselves.67 In comparison with their female colleagues, who are more uncertain about practice, self-image and career What would such ethics cases look like, or how would they be written up, if medicine were guided by the outlook of ecriture feminine, feminine practices of writing, such as those modelled by Cixous,52 who asks, metaphorically, what it is like to write with mothers milk? This can be read as (re)inscribing writing, such as a patient case, with maternalism rather than paternalism. Cixouss52 use of mothers milk as a metaphor 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, feminine voice might be brought into writing by resistance to the conventions of a dominant masculine style. She shows how writing might not be attened by the stylistic demands of intellectual writing (the scientic report, the case presentation) so that we might make the text gasp or form it out of suspenses and silences.69 Care For Martha Nussbaum, there is an overarching male privileging of issues of justice in health care (such as in the distribution of resources) over a female concern with issues of quality of care.70 We see this played 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 noted earlier, McKinstry suggests that the focus placed by supporters of the feminisation of medicine on goals, male doctors show assertive condence in their practice congruent with strong self-image and aligned with focused career ambitions.28 This difference can be read psychoanalytically, where over-condence can offer defence against recognition of uncertainty. Kristeva suggests that it is through unknowing, or the 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 been dened by ethical behaviour based on an approach that adheres to the upholding of a set of principles, rather than on a situated or contextually sensitive ethics (see Cases).68 Principles-based approaches strive for the more masculine purposes of clarity and uniformity, whereas situated approaches allow for a more feminine tolerance of ambiguity.

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improved communication with patients (quality of care) is at odds with justice issues such as pressure on resources because it involves practitioners in spending more time with patients and offering more referrals. Of course, both orientations are important, but it is typical of the masculine protest to place them in opposition. However, Nussbaum argues that an ethic of justice is persistently privileged over an ethic of care, and this can be read as a gender bias leading to inequalities.70 Household Not so long ago, few doctors would have bothered to question the meaning of the descriptors rm in the context of the ward team, or house ofcer and houseman with reference to the rst-year junior doctor (intern progressing to junior resident). In the UK, the notion of the rm has now disappeared and the term foundation doctor has replaced house ofcer. The phallic rm is now accid or, rather, exible and liquid as junior doctors learn to become more nomadic and less attached. How will the new female majority of junior doctors establish the household, which is, stereotypically, the womans domain? Will they, for example, see domestic care values as more important than business values (the rm typically describes a commercial venture or a legal set-up) and work against a current discourse of managerialism that frames care as a business and patients as customers?71 Will they return the hospital to its root meaning of a place that offers unconditional hospitality? Firm, as we know, also means solid, stiff, unyielding and steadfast, characteristics that are readily linked with the penetrating medical gaze. Will such 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 emphasise competition for resources rather than collaboration. A centre for research is still the most popular descriptor, rather than the more democratic network, which implies a structure in which collaborative models can be seen to be more feminine in tone. education can be described, perhaps controversially, as the means whereby democracy can be brought to a historically and persistently autocratic medical culture habitually grounded in the masculine protest. It is essential that such a democratising process gains traction so that collaborative teamwork with colleagues and patient-centred collaborations become the means through which patient safety and then patient care can be improved. This project, admittedly, is wider than the employment of post-structuralist feminist thought to medical education. However, such a mode of thought offers a radical platform for rethinking medical education in terms of a democratising project that extends beyond a version of feminising that is limited to demographic trends. A future medical education may not be best informed by the conventions of a patriarchal framework, but by a medical education familiar with the elds of contemporary gender studies and critical feminisms.

Acknowledgements: the author would like to acknowledge

the support of colleagues in the feminist pedagogy group that 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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CONCLUSIONS: TOWARDS DEMOCRACY IN MEDICINE

The contribution of post-structuralist feminism towards medical education can be summarised as the facilitation of democratic habits in medicine. Medical

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