Doing gynaecology today : a qualitative study from the area of Basel, Switzerland

Background The framework of this PhD thesis is the feminisation of medicine since the 1970s and the change of the medical culture over the same period. While in the 1970s mostly men were gynaecologists, today the majority are women. At the same time, a change in the physician-patient relationship has occurred which is often attributed to the increase in female doctors and depicted as a transition from physician-centred to patient-centred care. A shift of power in the direction of patients was at the heart of the feminist women’s health movement too. This movement developed in the early 1970s and critiqued men as medical doctors, specifically in gynaecology, for deciding over women’s bodies and their health. Following this, women’s health centres were established with the objective to empower women through educational support and self-help approaches so that they are enabled to take care of their own health. The feminist movement prompted the growth of gender studies, which fed into the rising debate in the 1990s about whether female and male doctors would care for patients in different ways. Since then, research efforts have focused largely on gender and communication in clinical encounters. These types of studies found that female gynaecologists talk in a more emotional manner and apply a more patient-centred communication style than male gynaecologists. However, they have not revealed how the observed gendered patterns may come about or what they might mean to gynaecologists and their patients. Moreover and as a consequence of the changes in conventional healthcare, a number of studies have questioned whether women’s health centres still differ from mainstream care settings. They have neither provided a conclusive answer nor addressed the area of gynaecology, although it was a former cornerstone of the feminist women’s health movement. Objectives The aim of this PhD thesis was to explore how working approaches are understood and practiced across different gynaecological care settings, including a women’s health centre. Drawing on social constructionism and under consideration of gender, the objective was to provide an in-depth understanding of (a) gynaecologists’ viewpoints on empowerment; (b) relational aspects of shared decision-making, and (c) professional identities based on gynaecologists’ perspectives on their career paths. Methods This PhD thesis is based on the qualitative part of the SNF-funded mixed methods project ‘Women and Gynaecology in Evaluation’ (WAGE; SNF No. 32003B-121358). Research combined a set of qualitative methods: Semi-structured interviews with 18 female patients and 11 physicians (three men and eight women of which three were expert women from the women’s health centre) as well as 33 observed consultations. The data was collected in the following six gynaecological outpatient care settings located in the Basel area, Switzerland: The outpatient department of the university’s women’s clinic; four privately run gynaecological practices with varying sub-specialisations (two led by female and two led by male gynaecologists) and one women’s health centre born out of the women’s health movement. Data collection was conducted between August 2011 and December 2012. Findings Variations of working approaches between female and male gynaecologists across all included settings were evident and appeared as rooted in the interrelations of gynaecologists’ gender, their past and present socialisation and their physician-patient relationships. Gynaecologists’ career paths were gendered and influenced their working approaches as well as integration into gynaecology, thereby exposing the constructions of professional identities in feminised gynaecology. Gynaecologists’ stances towards empowerment A semiotic, interpretative perspective was applied to analyse gynaecologists’ interpretations of a pelvic pain vignette built into qualitative interviews. This approach revealed gynaecologists’ variations in medical reasoning and varying stances towards empowerment. Furthermore, it showed that their gendered socialisations in work settings affect their medical reasoning: Female gynaecologists across all settings strongly valued the integration of patients’ voices. This enabled them to produce new ways of understanding symptoms and devise treatment options that extended beyond biomedical approaches, thus supporting empowering processes. Female doctors of the women’s health centre stressed to a greater extent than other female gynaecologists the importance of focusing on women’s societal life circumstances, thereby going beyond purely individual based care approaches. This created greater opportunities for handling women’s well-being from varying viewpoints. They thus displayed the most comprehensive approach to women’s care. Male gynaecologists displayed a greater interest in technical and biomedical aspects, declared to apply standardised diagnostic procedures to exclude physical risks, and understood functional pelvic pain as a sign of psychosocial distress. This being said, both female and male gynaecologists showed dangers of stereotyping patients. Therefore, a self-reflexive approach to gynaecological practice is warranted. This would not only (Kristi Malterud, 2000) foster empowerment and patient-centred attitudes in clinicians, but would also give them the leeway to deliver women’s health care in conformity with their own ideas, experiences and personalities. Bearing in mind that care approaches develop from physician-patient relationships, relational aspects of shared decision-making were explored next. Relational aspects of (shared) decision-making The triangulation of interviews with gynaecologists and patients as well as participant observation of clinical consultations uncovered how decisions arise in physician-patient relations through a co-production of meanings and practices. Variations in decision-making emerged from contextual experiences and clinical interactions. Congruency in behaviour and meaning production appeared to be more important in making patients feel supported in decision-making than did gynaecologists’ styles of communication. Shared decision-making was only observed in female physician/female patient relationships. It was grounded in sameness in female gender which was portrayed to facilitate reciprocal exchange. In these relationships the combination of medical expertise and womanhood produced feelings of closeness, empathy and support for the patients. In male gynaecologist/female patient constellations, reciprocal bonds were also constructed, but were based on an unequal distribution of medical knowledge with patients favouring direct medical advice. Clear advice made these patients feel supported. Female patients who did not receive medical advice considered to change to a female gynaecologist with a more biopsychosocial perspective, revealing the expectation of gynaecologists’ gender-congruent behaviour in clinical relationships. Thus, it is deemed important that relational and gendered aspects of care approaches are acknowledged. Because gender is central to the variations in empowerment and decision-making, close attention was paid to how gynaecologists reasoned about what has influenced their present working approach and how gender appears in these accounts. Gynaecologists’ professional identities An embodiment perspective with theories of un/doing gender was used to analyse gynaecologists’ views on their careers which largely started in the 1980s when they acquired their first work experiences in gynaecology. This disclosed that gynaecologists internalised the past hierarchical gender order of gynaecology in very different ways due to their differing gendered experiences. These processes set the course for the differentiation of female and male gynaecologists’ career socialisations and care approaches, uncovering gendered constructions of professional identities. Female gynaecologists reverted to their own (bodily) experiences as women and female doctors so as to create solidarity with female patients and thereby distanced themselves from past hospital gynaecology which they portrayed as not having treated women well. They moved into private outpatient practices to have sufficient space for engaging in a more feminine way of providing gynaecological care, uniting their own embodied knowledge with conventional medical expertise. Male doctors emphasised their past experiences as senior physicians, researchers and surgeons. In that way they presented a cultural affinity to conventional biomedical care settings and care approaches. They distanced themselves from female doctors by assigning work aspects associated with women a lower profile. Thus, men seemed to be challenged by the feminisation of the profession. They made almost no reference to their own bodily experiences, hinting at men’s challenging position in gynaecology wherein they need to perform pelvic examinations. They coped with this institutionalised situation by dissociating themselves from transgressive, sexualised behaviours through adopting the position of the neutral medical expert or the caring father figure. By distancing themselves from each other, female and male gynaecologists reproduced gender differences and engaged in intra-professional boundary work. The female body appears as a central site upon which the gendered differentiation of gynaecology and professional identity is constructed. However, some forms of undoing gender were also observed, implying that socio-cultural changes in the profession may be under way. Conclusion Gendered past and present socialisations of female and male gynaecologists influence the ways in which they practice gynaecology. In our study, female gynaecologists were more inclined than male gynaecologists to integrate patients for sense-making of symptoms and devising treatment options, thereby showing a more pronounced stance towards empowerment and shared decision-making. Female doctors from the women’s health centre presented the most inclusive and holistic approaches towards women’s health care, implying that women’s health centres still deliver care that cannot easily be obtained elsewhere. Care approaches, as exemplified by shared decision-making, arose from relational physician-patient interactions, through constructions of meanings and dependent upon gender-congruent behaviours. Accordingly, relational aspects of care approaches should be taken into account in medical training. Relation building skills based upon a self-reflective learning approach should be integrated into (postgraduate) training courses. This could help gynaecologists to offer best possible and responsive support to women, fostering an empowerment perspective and taking into account the intimate and sensitive nature of gynaecological relationships