Statistics are like a bikini. What they reveal is interesting. But what they hide is vital. – Aaron Levenstein
Last month, I was running late for work and then it started to pour with rain. Last week, the same thing happened. Since then, I make sure that I am always on time because I don’t want to be held responsible for an entire city of miserable, soggy people.
This probably sounds a tad dramatic, but this is a great illustration of how correlation and causation can be confused. To provide a more concrete example, let’s consider Skinner’s superstitious pigeons. True story. You may be wondering what a pigeon could possibly need to be superstitious about. This is a reasonable question, so let me put your mind at rest and tell you that they don’t wear lucky socks when they are about to sit an exam. In 1947, renowned psychologist B.F. Skinner conducted an experiment whereby a food delivery system would release food pellets at random times to caged pigeons. Skinner observed that very quickly, the pigeons started to exhibit peculiar behaviour such as bobbing rhythmically, turning on the spot or twitching their heads. The pigeons had no idea when their food would be delivered so they remembered what they were doing the last time it was delivered and did the same thing again in the hope that food would appear once more.
Amusing as it is to imagine pigeons conducting a feathery likeness of the YMCA, it highlights the point that just because you did something and then something else happened, it doesn’t necessarily follow that the thing you did caused the other thing to happen. Sounds pretty obvious and yet the two are conflated. All. The. Time.
Let’s look at a less plague ridden example. In 2004, the then president of the Royal College of Physicians, Carol Black, caused outrage by saying:
“We are feminising medicine. It has been a profession dominated by white males. What are we going to have to do to ensure it retains its influence?”
If you are a female reader, this statement may be particularly rage inducing, but before your blood pressure becomes unmeasurable on modern equipment, please take a cleansing breath and bear with me.
This statement was not said without foundation. Since the nineties there has been a steady increase in the number of female doctors in the UK, particularly in primary care where they now make up more than 50% of the workforce. This has been met with fierce backlash from some senior medics who claim that too many women in the workforce is bad for business. They highlight that women tend to prefer specialities with predictable working hours and often work part time to accommodate families. At the same time, women tend to avoid the more demanding specialities and roles that involve management as well as retiring early. It is claimed that this has led to a worrying shortage of doctors in areas such as general surgery, orthopaedics and emergency medicine and many male doctors feel that there has been a decrease in the status of medicine as a profession.
It would be understandable, but not forgivable, at this stage to think that women are responsible for our shortage of medics and the decrease in overall medical professional status. That’s certainly an opinion held by some. But Carol Black’s comment didn’t cause uproar simply because it’s outrageously offensive to women; it is also a grossly misplaced conflation of correlation and causation. And she really ought to have known better.
Let’s start with the first point regarding women’s work preferences. The statements above are indeed all true, but let’s take a cheeky look under the bikini for a moment. In the nineties and early noughties, there was a dire shortage of GP’s in the UK and as such, medical students were heavily encouraged to consider it as a career. It was painted as family friendly, predictable hours and the shortest route to specialty. This was going on at a time when female entrants into medical school were soaring, a trend that is continuing, and this was certainly an attractive option for many of them. Women were a disruptive innovation in primary care, whereby the alternative to employing them was to have none at all, but in so doing, the recognised “norm” of primary care as a male dominated area was totally disrupted and a new norm has been embedded. This is not the case in some of the acute specialities where men still dominate in a big way and because women have not been pushed in this direction in the same way that they were towards primary care, along with their male counterparts, this remains the case.
OK, so now we understand a little bit about why women are attracted to primary care, but that doesn’t really help with the shortage in other specialities, so really, it is because of women, isn’t it? Nope. According the 2016 GMC publication The state of Medical Education and Practice in the UK, there was an increase in the number of GP’s on the register between 2011 and 2015 of just 2%. This is compared with an increase in other specialities of 8% over the same time-frame. If that figure is broken down further, we can see that there was an increase in emergency medicine of 22% and general surgery of 7%. And there is still a shortage of GP’s, which is acknowledged as an increasingly complex and challenging specialty. So really, there is a shortage across the medical profession despite the increase of women, certainly not because of them.
So, to the second point. Ask any doctor in the NHS and they will probably tell you that the status of medicine is not what it used to be. Being a doctor nowadays doesn’t come with the perks and benefits in social standing of days gone by and many believe that is partly due to the increasing feminisation of the profession. Certainly the two things appear to have happened simultaneously. But correlation is not causation.
In 2006, the British Medical Association launched a longitudinal study looking at what drives people to enter medicine and what they then go on to do. One of the data sets they gathered was concerned with the differences between genders in motivations to study medicine. For men, status and financial gain were in the middle of the list, but these same motivators were at the bottom for women. Can we therefore establish that the lack of desire for status and money among the increasingly female workforce has caused the collapse of both of these things within the medical profession? I suspect you probably know the answer by now, but humour me anyway as we take a closer look at the history of regulation of the medical profession. The GMC was established in 1858 and until its big reform in the 1970’s, it was the embodiment of self-regulation. This was a model that allowed doctors to decide what was best for patients and they would exercise disciplinary powers in cases of criminal behaviour or poor professional conduct. At that time, the council was made up of Royal Colleges and leading university lecturers and these were predominantly males. This all changed in the late nineties/early noughties when the biggest shake up in the history of the GMC took place. In light of the serious failings at Bristol Royal Infirmary and the Harold Shipman case, it became clear that the GMC could not be governed by insiders and medical colleagues alone and in 2003, the percentage of lay council members increased to 40% (this is now 50%) from having been just one or two. Furthermore, the election process was changed so that medical professionals could no longer vote each other in to be members of the council and in 2012, revalidation was introduced. Whether you love it or loathe it, medicine has become a more tightly regulated and accountable profession where doctors are no longer seen as moral and ethical compasses or totally infallible.
So, what’s this got to do with women? Absolutely nothing. The continued tightening of regulation has been ongoing since the 1970’s and this means that medics as a group no longer wield the independent power they once did. At the same time, the changing regulation and structure has opened the doors for women and therefore the medical landscape has evolved. The decline in power and status and the increasing numbers of women in the profession are certainly correlated, but there is little or no causation to be found. Black’s statement appears to say far more about how she perceives the influential power of men, or perhaps lack of power of women, than it does about any objective evidence.
The fact is, women cannot be blamed for the changes in the medical profession or the broader healthcare landscape, but neither are they independent of it. Complex challenges rarely have simple solutions and never have a single cause. Think broadly. Peek under the bikini.