WOMEN AS HEALTH PROFESSIONALS, HISTORICAL ISSUES OF

Historically, women's roles in healthcare were primarily as caretakers and nurturers; as wives, mothers, and nurses; and in their responsibility for children, the sick, the aged, and the disabled. When instrumental healing roles became more technical and financially lucrative, women met resistance to their assumption of those roles. This attitude often was based on mistrust of their capacities and the departure their work in healthcare represented from their more traditional roles, especially because they might compete with men.

Early History of Women in Healthcare

Women have always been healers as well as caretakers; they have acted as pharmacists, physicians, nurses, herbalists, abortionists, counselors, midwives, and sagae or "wise women." They also have been called witches. In the physician role, however, society rarely permitted them to perform in the same capacities and positions as men.

THE ANCIENT WORLD. Early Egyptian steles refer to a chief woman physician, Peseshet, and in 1500 b.c.e. women studied in the Egyptian medical school in Heliopolis. In the Chinese record in 1000 b.c.e. female physicians were in positions that encompassed activities other than traditional midwifery and herb gathering. There also were medical roles for women in the Greek and Roman civilizations. In Rome physicians were often slaves or freed slaves; it is likely that many were women. Women who entered medicine were frequently members of medical families and practiced together with their family members. The physician husband of a second-century woman physician wrote for his wife's epitaph, "You guided straight the rudder of life in our home and raised high our common fame in healing—though you were a woman you were not behind me in skill" (Anderson and Zinsser, p. 61).

Throughout history women have been special attendants to other women, assisting with labor and delivery, providing advice on the functions and disorders of their bodies, and tending newborns. Because childbirth was considered a normal rather than a pathological process, it was not thought to be part of medicine. Soranus of Ephesus, a first-century c.e. physician practicing in Rome, believed that women were divinely appointed to care for sick women and children. Among the criteria he delineated for those practicing medicine, inluding women, were literacy, an understanding of anatomy, a sense of patient responsibility, and ethical concerns, particularly in regard to confidentiality.

During the first few centuries of the spread of Christianity, women ordained as deaconesses by bishops with the consent of the congregation appear to have played a significant role in healthcare. Although little is known about their work, many of those deaconesses became the first parish workers and district nurses (Shryock, 1959). Among those women were Saint Monica, the mother of Saint Augustine, and Fabiola, who founded a hospital at Ostia in Italy in 398 c.e.

After the fall of the Roman Empire, medicine continued along two paths: monastic medicine, which lost touch with older traditions, and Arabic medicine, which developed in Persia and transmitted the heritage of Greek medicine to Europe. Arabic medicine produced notable practitioners and hospitals run by male and female "nurses." During the Crusades women staffed infirmaries and clinics in Jerusalem and along the European routes to the Holy Land.

THE MIDDLE AGES. Medical scholarship flourished in the ninth century at the University of Salerno in Italy and continued to develop through the tenth and eleventh centuries (Corner). At that time women apparently studied medicine at the university. Although little is known about most of those early women physicians, eleventh-century records reveal the existence of Trotula, a woman faculty member at Salerno who is said to have written important texts on obstetrics and gynecology and to have headed a department of women's diseases. Her most important work, De Passionibus Mulierum, remained the major reference on that subject for several centuries. The authorship of this and other works was attributed to her husband or to other male colleagues (Corner; Achterberg). Trotula suggested that infertility could be attributed to the male as well as the female. In cooperation with the "Ladies of Salerno," a group of women physicians, Trotula established the first center of medicine that was not under Church control.

The M.D. degree was first awarded in 1180, apparently only to men. One of the notable figures of the twelfth century was Hildegard of Bingen, a scientific scholar, abbess, writer, composer, and political adviser to kings and to the pope. She wrote two medical textbooks, Liber Simplicis Medicinae and Liber Compositae Medicinae, presumably for use by the nurses who were in charge of the infirmaries at Benedictine monasteries. Her textbooks described a number of diseases, including their courses, symptoms, and treatment, as well as scientific data on the pulsation of blood and the regulation of vital activities by the nervous system. Hildegard's writings also demonstrated an understanding of normal and abnormal psychology.

In the medieval period affluent women were active in medicine, particularly in Italy, where the universities were accessible to them. In 1390 Dorotea Bocchi earned a degree in medicine from the University of Bologna and followed her father as a lecturer in medicine at that university. In 1423 Constanza Calenda, the daughter of the dean of the medical faculty at Salerno, lectured on medicine at the university in Naples. Women also were qualified and permitted to practice medicine in France, England, and Germany. They generally were limited in practice to specifically defined roles, including bleeding, administering herbs and medicines, and reducing fractures, as well as practicing midwifery. As early as 1292, however, women in Paris worked as "barber surgeons," practicing what was known of surgery. Until 1694 widows automatically were allowed to continue practicing if their specific form of medicine had been their husbands' field.

From the thirteenth to the seventeenth centuries the number of physicians was low, and the role of women healers was particularly important in meeting the healthcare needs of the population. During that period women practiced as physicians, surgeons, bone setters, eye healers, and midwives. It generally was believed that women were better suited for the treatment of women's diseases.

During the fifteenth century women obtained higher degrees by presenting medical theses, and during the fifteenth century and the early part of the sixteenth century women began to excel in innovative techniques and made important contributions to medicine. They served kings, royal families, and even armies in Europe.

Although it is assumed that the number of women in medicine was small, their healthcare work in the Middle Ages caused enough concern that by 1220 the University of Paris succeeded in preventing them from gaining admission to medical school. In 1485 Charles VIII of France decreed that women could not work as surgeons.

By the fourteenth century the licensing of physicians was well established, although women rarely were allowed to sit for licensing examinations. In 1322 university-trained male physicians brought a suit against Jacoba Felicie de Almania in France, claiming that in practicing without appropriate training and licensing, she endangered patients. Patients testified to her skill; Jacoba argued that she was both physician and nurse to her patients. She also emphasized that many women would not seek treatment for their illnesses if they had to see a male physician. Because she did not have the correct university degree, she not only was barred from medicine but also was excommunicated from the Church. Women who practiced outside their licensed specialities, for example, midwives who functioned as physicians, also were condemned.

THE RENAISSANCE AND AFTERWARD. By the end of the fifteenth century, as medicine became an academic discipline and a more established profession in several centers in Europe, the movement to exclude women from the formal practice of medicine gained momentum. That movement coincided with the ideology of misogyny as it was articulated by Heinrich Kraemer and James Sprenger in The Malleus Maleficarum (1486), a treatise on identifying and dealing with witches. Witch-hunting capitalized on the widespread belief in the spiritual and mental inferiority of women, a belief that was fueled by the Church. Even when active witch-hunts subsided, their effects remained. Women were effectively eliminated from performing medical roles other than traditional caretaking and midwifery.

Before the sixteenth century it was not possible for a man to be a midwife; it was a capital offense in some places. As medicine and surgery were differentiated from each other in the fifteenth and sixteenth centuries, some male barber surgeons began to practice midwifery. By the late fifteenth century licensing examinations were given, generally by a doctor and a midwife. Increasingly, concern was expressed by physicians and the laity about whether midwives were knowledgeable enough to recognize when it was appropriate to call for a consultation with male physicians and surgeons.

The sixteenth to eighteenth centuries produced several outstanding female midwives, including Louyse Bourgeois, who in 1609 became the first midwife to publish a work on obstetrics, a book that became the basic text for midwifery in Europe. Nonetheless, with the invention of the obstetrical forceps in the seventeenth century by the Chamberlens, a family of male midwives and barber surgeons, obstetrics was pushed closer to the realm of the male practitioner. In 1634 Peter Chamberlen III attempted to establish a corporation of midwives in England with himself as the governor, a move that was resented by female midwives. Increasingly, men began to participate and compete in that profession, particularly in serving the upper classes. By the eighteenth century men controlled all areas of medicine except midwifery and nursing, and even in those areas women increasingly were required to practice only under male supervision.

By the beginning of the seventeenth century women were denied access to medical training and then prohibited from belonging to professional associations. University training was required, and women were not admitted to universities. Despite exclusion from formal training and practice, women continued to provide for the healthcare needs of family members and others in the community, especially the poor, who had no other access to healthcare.

Women in Early American Medicine

In colonial North America the healing role of women was critical to survival, and many women assumed medical roles. Ann Hutchinson, the early seventeenth-century dissident religious leader, worked as a general practitioner and midwife. Because there were relatively few university-trained physicians and no medical schools in the colonies, medicine was practiced by those who appeared to be particularly talented, and an apprenticeship system began to evolve. Two women listed as physicians in Boston in the seventeenth century later were denounced as witches, and no other woman practiced medicine in Boston until Harriot Hunt, after apprenticeship training, opened a medical office in 1835.

Eighteenth-century American medicine had no unified concept of medical care; a variety of views of practice and training offered various programs of study and concepts of healing. In that setting the role of women was extensive and complex because the medical care of families was frequently the responsibility of women.

Most women practitioners were midwives. Many went to Europe to train, as the first school for midwives in the English colonies was not started until 1762. The early training of midwives was based on the assumption that most obstetrical practice would remain in the hands of women. This did not occur in colonial North America, although it was the case in many parts of Europe.

In 1765 John Morgan founded the first universityconnected, so-called regular American medical school at the University of Pennsylvania. Its formal, scientifically based curriculum departed from the almost exclusive apprenticeship training that existed in the colonies and was more reflective of European standards of that time. By excluding women, it began a tradition of barring them from formal medical training and forcing them into "irregular" training. Many women without diplomas, however, set up flourishing practices. They were trained in the homeopathic, eclectic, or "irregular" traditions, which tended to be less prestigious.

Women in Nineteenth-Century Medicine

In 1847 Elizabeth Blackwell became the first woman to be admitted to a "regular" medical school in the United States; she graduated first in her class at Geneva (New York) Medical School in 1849. The New York State Medical Association promptly censured the school, and when her sister, Emily Blackwell, applied a few years later, she was rejected. Emily subsequently received an M.D. from Western Reserve Medical College in Cleveland after her acceptance to Rush Medical College in Chicago had been rescinded in response to pressure from the state medical society.

Ann Preston began her medical studies in 1847 as an apprentice to a Quaker physician. After two years she applied to and was rejected by four medical schools. In 1850 she established the first regular women's medical college in the world, the Women's Medical College of Pennsylvania. She and her students recalled their experiences at the Pennsylvania Hospital: "We entered in a body, amidst jeerings, groaning, whistlings, and stamping of feet by the men students. On leaving the hospital, we were actually stoned by those so-called gentlemen" (Alsop, pp. 54–55). This account was corroborated by the Evening Bulletin of Philadelphia.

In 1847 Harriot K. Hunt, who earlier had established an irregular practice in Boston despite her lack of an M.D. degree, applied to Harvard Medical School. Although supported by the dean, Oliver Wendell Holmes, she was rejected for admission. After hearing about Elizabeth Blackwell's acceptance, she again applied for admission and was accepted. However, she was denied a seat when the all male class threatened to leave if women or blacks were admitted. Not until almost a hundred years later, in 1946, did Harvard Medical School begin to admit women.

By 1850 two additional all-female medical colleges were founded, one in Boston and one in Cincinnati. Both were "irregular" schools. The Boston Female Medical College was designed primarily to prevent male midwifery, which its founder, Dr. Samuel Gregory, felt trespassed on female delicacy. The school was founded in 1848 and offered a medical degree by 1853, but it was always financially troubled and did not have a good reputation. In 1856 it changed its name to the New England Female Medical College and began to recruit new faculty members, including Marie Zakrzewska, who helped develop a pioneering clinical training program. In 1873 the school merged with Boston University.

In 1855 the National Eclectic Medical Association formally approved the education of women in medicine, and in 1870 it became the first medical society to accept women as members. Traditional medical societies, however, continued to be closed to women. In his 1871 American Medical Association (AMA) presidential address Alfred Stille criticized female physicians for being women who seek to rival men, who "aim toward a higher type than their own" (Ehrenreich and English, p. 26). Negative attitudes toward the presence of women in medicine appeared to be supported by accumulating "scientific" evidence that supposedly supported the inferior status of women on biological grounds, including the idea that their brain capacity was less than men's. A book published in 1873 by Edward Hammond Clarke fueled the controversy: In Sex in Education: or, A Fair Chance for the Girls he stated, "Higher education for women produces monstrous brains and puny bodies" (Clarke, p. 41). It echoed Charles Meigs's 1847 statement, "She [woman] has a head almost too small for the intellect but just big enough for love."

The debate about women's intellectual capacity induced Harvard Medical School to offer the Boylston Medical Prize in 1874 for the best paper on the topic "Do women require mental and bodily rest during menstruation and to what extent?" The winning research was submitted by Mary Putnam Jacobi. When the judges discovered the sex of the author, they hesitated about awarding the prize but finally did so (Walsh). Putnam Jacobi had found, contrary to prevailing views, that the majority of women in her sample did not suffer incapacity. Her study was followed by several others, all with similar findings. Despite such work and evidence, the barriers to women did not fall.

Even women who managed to obtain medical training were refused admittance to medical societies, and hospitals denied them appointments. Female physicians in the United States began to open their own hospitals and clinics. In 1857 Elizabeth and Emily Blackwell founded the New York Infirmary for Women, where they cared largely for indigent women, and in 1865 the Women's Medical College of the New York Infirmary opened. Paternalistic attitudes coupled with the difficulty women had in obtaining hospital privileges led Marie Zakrzewska in 1862 to found the New England Hospital for Women, owned and operated entirely by women.

The role of women in medicine, including the productivity and lifestyle of female physicians, continued to be debated vigorously. In 1881 Rachel Bodley, dean of the Women's Medical College of Pennsylvania, surveyed the 244 living graduates of the school and found that despite persistent beliefs to the contrary, the overwhelming majority were in active practice. Those who had married reported that their profession had had no adverse effect on their marriages and that marriage had not interfered with their work.

By the end of the nineteenth century women physicians were being accepted into many medical societies. The Massachusetts Medical Society admitted women in 1884, and the AMA seated a woman delegate in 1876 but did not accept women formally until 1915 (Morantz-Sanchez, 1985). Women physicians began to form their own associations. There were several attempts to build a national organization of women physicians, beginning in 1867. The Women's Medical Journal was started in 1872. In 1915 the National Women's Medical Association was founded. It was renamed the American Medical Women's Association (AMWA) in 1919 and was condemned by many male physicians. To alleviate people's fears the AMWA required that its members also join the AMA, and it held its meetings together with that organization.

Female separatism was a double-edged sword. Although it gave women a special place in the care of women and children, it also was used to exclude women from more extensive roles in medical education and from the increasing influence and prestige of the profession.

Financial contributions from women philanthropists (such as M. Carey Thomas, Mary Elizabeth Garrett, Mary Gwinn, and Elizabeth King) forced the Johns Hopkins Medical School in 1889 to accept women on the same terms that it used for accepting men. However, this did not result in large numbers of women being admitted and did not appear to increase the number of appointments of women to faculty and leadership positions (Walsh).

Following Johns Hopkins's lead, however, 75 percent of other, already existing medical schools began to accept women as students. By 1894 over 66 percent of women medical students were enrolled in regular medical schools (Walsh). The student body at Tufts Medical School was 42 percent female. Women also received a disproportionate number of the academic honors in their graduating classes.

Women Physicians in Europe and Canada

In 1859 the American Elizabeth Blackwell was placed on the British Medical Register; in the following year the British Medical Association ruled that persons with foreign medical degrees could not practice in Great Britain. In 1865 Elizabeth Garrett Anderson became the first woman to qualify to practice medicine in that country. She did that by passing the apothecaries' examination; the regulations of that guild did not exclude women. The rules were changed shortly afterward. In France, although women were allowed to study at the Faculty of Medicine in Paris, they could not become interns and thus could not complete their training.

The Royal College of Physicians in Edinburgh attempted to exclude Sophia Jex-Blake in 1869 by stating that a single woman could not attend medical school. Jex-Blake organized a group of seven women, and together they completed the first year of training. Attacks on female students from male peers, however, prompted some public support from people who were outraged that these "indelicate and ungentlemanly" men would be seeing female patients. Four years later the university won a lawsuit allowing it to refuse to grant degrees to women. Women in other European countries also experienced hostile and even violent attacks by their male peers.

The first continental European university to accept women was the University of Zurich in 1865. By the 1870s other Swiss universities had followed its lead. In Russia women were allowed to attend medical schools in 1872, partly because a number of Russian women already had studied medicine in Zurich. Negative attitudes toward women were fueled by the assassination of Czar Alexander II by a woman. After that event, from 1881 through 1905, universities in Russia were closed to women.

Many of the women who graduated from medical schools in those countries were from middle-class or upperclass backgrounds. Often they had fathers or other family members in medicine; they entered the profession to join the family practice.

The first woman doctor to practice medicine in Canada, James Barry, a graduate of the University of Edinburgh, was a British Army medical officer who became inspector general of hospitals in Canada in 1857. She was able to practice because she was thought to be a man. After her death Dr. Barry was discovered to have been a woman (Hacker).

Nineteenth-Century Midwifery

There was considerable opposition to the practice of midwifery by women in the mid-nineteenth century, particularly in the United States. In 1820 John Ware, a Boston physician, is said to have written Remarks on the Employment of Females as Practitioners of Midwifery, in which he raised objections that were based on his view of women's moral qualities. He stated: "Where the responsibility in scenes of distress and danger does not fall upon them when there is someone on whom they can lean, in whose skill and judgement they have entire confidence, they retain their collection and presence of mind; but where they become the principal agents, the feelings of sympathy are too powerful for the cool exercise of judgment" (p. 7).

In addition, economic and class issues played a role in women's exclusion from medicine. Midwives came primarily from working-class, rural, and poor backgrounds. They charged less than physicians did for their services and were more likely to care for the poor. With the beginning of obstetrics as a medical discipline, physicians feared economic competition from midwives.

Some physicians objected to midwives on the basis of the allegedly lower quality of healthcare they provided. However, in the 1840s two physicians, Oliver Wendell Holmes and Ignaz Semmelweiss, reported on the spread of puerperal sepsis (childbirth infection). Semmelweiss found that there was a lower incidence of it in women who were assisted in delivery by midwives. He deduced that because medical students and physicians did not wash their hands when they moved from the autopsy room to the delivery room, they spread disease. The warnings of both doctors were ignored by most of the medical profession, and controversy continued about the adequacy of midwives.

By the turn of the twentieth century about 50 percent of all babies in the United States were delivered by midwives. Midwives were held responsible for childbirth illness and puerperal sepsis, as well as neonatal ophthalmia (inflammation of the eyes generally related to maternal gonorrhea), because it was believed by many people, especially in the medical profession, that they were not sufficiently trained to prevent those illnesses. Under mounting pressure, many states began to pass laws forbidding midwifery, many of which remain in effect.

Evolution of Nursing in the Nineteenth Century

The practice of nursing was sponsored primarily by the Church until the mid-eighteenth century, when the London Infirmary appointed a lay nurse. Nursing was seen as a low-status occupation; records show long working hours and low pay. Dickens's novel Martin Chuzzlewit (1844) focused attention on the quality of the nursing care given by pardoned criminals, aging prostitutes, and other women of questionable morality and interest who functioned as nurses.

At the time of the Crimean War Florence Nightingale responded to the need for nursing reform and established military and then civilian nursing. In 1860 she founded a school for nurses in London that had a rigorous curriculum and specific guidelines for nursing as a profession. She met opposition from the medical profession, many of whose members felt that "nurses are in much the same position as housemaids and need little teaching beyond poultice-making and the enforcement of cleanliness and attention to the patient's wants" (Dolan, p. 230).

The first nursing schools recruited upper-class women who were "refugees from the enforced leisure of Victorian ladyhood" (Ehrenreich and English, p. 34). Despite their aristocratic image, nursing schools began to attract more women from working-class and lower-middle-class homes. Those advocating the nursing profession saw the nurse as the embodiment of Victorian femininity and nursing as a natural vocation for women, second only to motherhood. Nightingale viewed women as instinctive nurses, not physicians: "They have only tried to be men, and they have succeeded only in being third-rate men" (Ehrenreich and English, p. 36).

Women in Twentieth-Century Medicine

By the beginning of the twentieth century women were seeking admission to medical schools in increasing numbers. Because of an oversupply of physicians, however, salaries and prestige were diminishing. Some people blamed the situation on the "feminization" of the profession, and many schools began to decrease the number of women they accepted. Women also had more difficulty obtaining internships and residencies. Because all but one of the female institutions (the Women's Medical College of Pennsylvania) had consolidated or closed, many women had nowhere to train.

The conviction that women were not able to perform effectively as physicians and the belief that women would be damaged by pursuing a difficult career intensified. Women physicians seemed to be unable to develop a consolidated and effective strategy to resist that negative attitude. In 1905 Dr. F. W. Van Dyke, the president of the Oregon State Medical Society, stated, "Hard study killed sexual desire in women, took away their beauty, brought on hysteria, neurasthenia, dyspepsia, astigmatism and dysmenorrhea. Educated women could not bear children with ease because study arrested the development of the pelvis at the same time it increased the size of the child's brain and therefore its head. This caused extensive suffering in childbirth" (Bullough and Voght, pp. 74–75).

At that time academic medical schools were developing formal medical curricula. Proprietary medical schools also were increasing in number. The education they provided was focused primarily on an apprenticeship model, and there was little monitoring of the quality of the education. Because of the oversupply of doctors produced by those two systems, with consequent competition for patients as well as a lack of mechanisms to assess quality and monitor performance, the AMA asked the Carnegie Foundation to investigate the condition of medicine and make recommendations for dealing with the situation. The foundation commissioned Abraham Flexner, a schoolteacher with no medical expertise, to perform the study. In his 1910 report Flexner stated: "Medical education is now, in the United States and Canada, open to women upon practically the same terms as men. If all institutions do not receive women, so many do, that no woman desiring an education in medicine is under any disability in finding a school to which she may gain admittance. Now that women are freely admitted to the medical profession, it is clear that they show a decreasing inclination to enter it" (Flexner, pp. 178–179, 296).

Flexner's report concluded that medical education required higher standards for training and provided an important impetus for establishing medicine as an academic discipline. It resulted in the closing of many medical schools, especially the proprietary ones; unfortunately, because women continued to have difficulty gaining admission to many of the university-affiliated and more prestigious medical schools, the schools that were closed were the ones that traditionally had admitted substantial numbers of women and members of minority groups. This had the effect of lowering the numbers of women physicians in the United States.

Women physicians gained some status as a result of their patriotism during World War I, when the AMWA campaigned to have women physicians commissioned on the same basis as men. Although that effort was rejected by the government, the AMWA urged women physicians to contribute to the war effort. Fifty-five women physicians practiced medicine by signing specific contracts with the military. They received neither military status nor benefits (Walsh). At Johns Hopkins the percentage of women medical students dropped from 33 percent in 1896 to 10 percent in 1916. At the University of Michigan the percentage of women medical students dropped from 25 percent in 1890 to 3 percent in 1910 (Walsh).

The number of female physicians in the United States continued to be low until the 1970s. Other countries continued to report greater percentages of female physicians. In 1965, for example, women accounted for 7 percent of allU.S. physicians. The Soviet Union reported 65 percent female physicians; Poland, 30 percent; the Philippines, 25 percent; the German Federal Republic, 20 percent; Italy, 19 percent; the United Kingdom and Denmark, 16 percent; and Japan, 9 percent (Lopate).

Medicine was viewed as a male profession in the United States more than it was in most other countries. Some scholars hypothesize that this occurred because medicine had higher prestige and income than did many other professions and therefore interested men more. Others believe that the dominance of men adds prestige and that men demand better compensation. The reasons for the gender stereotyping of professions, however, is complex and has cultural as well as political determinants. Many areas of work are sex-role-stereotyped. This occurs because of the perception that men or women are better at certain functions. For example, in the United States women were considered to be more suited to caretaking roles and men were considered to be better in more instrumental and technological activities. Thus, although medicine presents a melding of these stereotypes, women were not considered capable of performing in the increasingly technological aspects of the field. Even in a revolutionary society such as Cuba, where these stereotypes are disparaged, there is a persistence of traditional roles for women in healthcare; 30 to 40 percent of Cuban physicians are women, but virtually all nurses and midwives are women.

In the United States the choice of a specialty and the specific positions held by women in their fields of expertise reveal a pattern that has held since women began to be admitted to medical schools. In the 1970s the fact that women would assume primary care roles was used as an argument for increasing their numbers in medical schools. This has proved to be correct. Women characteristically have entered primary care fields including pediatrics, internal medicine, family practice, and obstetrics and gynecology, as well as psychiatry, pathology, and some medical subspecialties. There has been more diversification in the choice of medical specialties for women in recent years, but the numbers in the higher-paid technically oriented surgical fields continue to be low. (Accreditation Council on Graduate Medical Education).

In the United States and other countries academic and administrative appointments as well as other decision-making positions are held almost exclusively by men, whereas the majority of women physicians tend to be involved in direct patient care. Women continue to constitute almost 30 percent of full-time medical school faculty, but they are concentrated in the lower academic ranks and do not advance at the same rate as do their male colleagues (Bickel).

In countries where women have made significant progress in terms of their influence in the healthcare fields changes have occurred most often in times of war, physician shortages, or major cultural reorganization. In Russia midwives proved to be effective as doctors in the Russo-Turkish War of 1870, beginning the influx of women into medical schools. However, after the 1917 revolution, as the prestige of medicine declined, women were admitted in greater numbers. By 1940, 62 percent of Soviet physicians were women, and by 1970, that number had risen to 72 percent. As in the United States and other countries, however, Russian women held a disproportionately small number of senior positions. The feldschers (semiprofessional health workers) in the Soviet Union were primarily women.

The rise of female health professionals in China occurred along with the reorganization of the medical-care system and of Chinese society under the People's Republic after 1949. About half of Chinese physicians were women. In the countryside "barefoot doctors" (peasants, primarily women, with basic medical training) provided medical care without leaving their regular work to meet the needs of fellow workers (Sidel and Sidel).

Women's Evolving Role in Healthcare

The blurring of roles and the overlapping of areas of function in a healthcare have raised important questions about roles and responsibilities, for example, among primary care physicians, physician's assistants, and nurse practitioners as well as among psychologists, psychiatrists, psychiatric social workers, and psychiatric nurses. In the United States economic factors rather than specific expertise, experience, or skills have become important determinants of decisions about which practitioners will provide care. Less well trained practitioners may be favored by payers because their services are less costly. Many of these healthcare providers are women. There are few objective guidelines for determining the scope of practice. For example, in providing routine physical examinations, obstetrical care, anesthesia, psychotherapy, and minor medical and surgical procedures, professionals of varied backgrounds and training may provide similar services. There are insufficient data assessing the outcomes of this practice.

Since 1945 there has been more regulation of medical practice in the United States, and healthcare increasingly has been paid for or subsidized by governments and/or private insurance companies. Health maintenance organizations and other managed-care models have evolved. With this has come a diminution in physicians' authority and, more recently, income. At the same time there have been fewer white men applying to medical school and more women and minority group members; as a result, almost 50 percent of medical students are women and increasing numbers are from minority groups (Lorber).

The demands of work and family life as well as the nature of the process of attaining medical leadership positions continue to result in the presence of few women in major healthcare policy decision-making positions. As a result, less has changed and women have had less of an impact on practice, research, and education in medicine than was predicted in the 1970s, when the demographic shift began. There has been evidence of some changes in practice with the increase in the number of women physicians; for example, some preventive tests are more likely to be performed depending on the sex of the patient and the physician, and there are differences in practice styles related to gender. Most of the changes in the practice patterns of physicians appear to be related more to economics and political factors than to gender. However, the development of a focus on women's health and an emphasis on gender biology, including an expansion of research in this area, have been fueled largely by women physicians and scientists and by the women's movement, beginning in the 1960s. This has been important for women's health and represents a substantial contribution by women to medicine.

carol c. nadelson

malkah t. notman (1995)

revised by authors

SEE ALSO: Alternative Therapies: Social History; Care; Feminism; Medical Education; Nursing, Profession of; Paternalism; Sexism

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