Soc. Sci. & Med,. Vol. 12. pp. 305 to 309. I)O:~7-7856 7~ I)7111-I}~05$0211{I II

© Pergamon Press Ltd. 197"8. Printed in Great Britain.

RESEARCH NOTE

SEX D I F F E R E N C E S IN MEDICAL PRACTICE IN ARGENTINA*

JORGE SEGOVIA and JACK ELINSONt

Division of Community Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada A IB 3V6

Abstract--This report presents some data about demographic and professional characteristics of a sample~-454 males and 98 females--of physicians in the city of Buenos Aires, Argentina. The analysis of the age structure showed women as younger and as an increasing component of the profession. Female physicians tended to be limited in their selection of specialties, mainly in the older groups. The earnings of women were less. and a larger proportion of women had their income from salaries: they also were more dissatisfied with their incomes. The representation of women in teaching was smaller and mostly in lesser positions. A question about desirable attributes in an ideal personal physician was answered similarly by both groups. Women were less likely to think that sex, religion and national origin made a difference in the quality of medical care, and were less likely to feel that prestige and authoritarianism were desirable attributes.

I N T R O D U C T I O N

This paper presents some descriptive data about the practice of medicine by male and female physicians in the city of Buenos Aires, Argentina. The data were collected as part of a larger study, a replication of a sociometric measure of the quality of medical care [1]. The study was done in the last semester of 1970, at the Centro Latinoamericano de Administracion Medica, CLAM:[: (Latin American Center for Medical Administration).

A questionnaire was applied, by personal inter- views, to a sample of physicians in the city of Buenos Aires, and to all physicians living in a suburban county of the Great Buenos Aires and a rural section of the Province of Buenos Aires. Because the absolute number of women in t h e county and rural section was too small, only data from the Buenos Aires sample will be presented. The sample frame was a master list of physicians in the city of Buenos Aires, prepared for a Manpower and Health Utilization Study [2]. A 5Yo systematic random sample was drawn from the master list. The total number of cases is 552; 454 (82%) are males, and 98 (17%) are females [3].

F I N D I N G S

The main purpose of the study was a sociometric assessment of the quality of medical care.

Data about the practice of medicine were collected

* Presented at the Fifth International Conference on Social Science and Medicine, Nairobi, Kenya, August 1977.

"t Professor of Sociomedical Sciences, Columbia Univer- sity School of Public Health, New York, NY 10032, U.S.A.

:~ In addition to the authors of this paper, the study team was composed of Dr. Omar J. Gomez, Dra. Maria Teresa Beas, and Ms. Maria A. Rivero Penaloza. We are grateful for the encouragement and support provided by the Director of CLAM, Dr. Hugo Enriquez (deceased) and the Deputy Director, Dr. Placido Nosiglia.

as background. The small absolute number of women in the sample precludes many statistical operations with the data. The findings are, therefore, mainly de- scriptive.

Analysis of age composition by sex shows very clearly how females are a growing component of the medical profession. Table 1 (and Table AI in the appendix) shows the age distribution. Female phys- icians had a very young age distribution; almost 70% of them are under 39 years, and only 4% are 60 years old or more (Table 1). The % for men, for the same age groups, are 41 and 17%, respectively. On the other demographic variable available, marital status, there are also differences. Women are in a larger pro- portion, single, and they are more likely to be widowed. For both sexes, the separated class--there is no legal divorce in Argent ina--amounts only to 1% of all cases.

In terms of professional variables, and as expected from common knowledge, the degree of specialization was very high. Only 15~o of all physicians are engaged in general practice. For physicians practising a spe- cialty, Table 3 shows the distribution of specialties by sex [4]. There are obvious differences, which are statistically significant, even when the categories with small absolute numbers are discarded. In some spe- cialties, the participation of women is relatively small, as in surgery. Only 6% of female physicians reported a surgical specialty (29% for men) and then they were concentrated in only two subspecialties: pediatric sur- gery and ophthalmology. Men practised ten different subspecialties within surgery. In the appendix, Tables A2 and A3 show how the distribution of specialties is affected by the age distribution. The figures, though severely limited, point clearly to the need for further research to verify whether it is true that women graduated in the 40's were constrained to practise only four subspecialties, 2 in medicine, and pediatrics and gynecology. An interesting finding is that there" are no women obstetricians in the sample, nor

305

306 Research Note

Table 1. Age distribution (grouped) by sex--CLAM study, Buenos Aires, 1970

Age groups < 29 3(k 39 40-49 50--59 60-69 70-79 80 +

Sex N ",, N ",, N ",, N ",, N ",, N '!o N '!o Total

Males 36 8 152 33 99 22 89 20 50 I 1 26 6 2 454 100 Females 16 16 52 53 19 19 7 7 2 2 2 2 0 - - 98 100

Total 52 9 204 37 118 21 96 17 52 9 28 5 2 - - 552 100

X2:31.29 ~0.001). For a table with the age groups 50 and over collapsed tto avoid the small frequencies): X]: 31.12 (0.001).

Table 2. Marital status, by sex--CLAM study, Buenos Aires, 1970

Sex Male Female Total

Marital status N ",~ N ° o N '~o

Single 77 17 35 36 112 20 Married 359 79 55 56 414 75 Widowed and separated 17 4 8 8 25 5

Total 453* 100 98 100 551 100

* One case without information in males X2:23.07 t0.001).

homeopaths (the major marginal specialty in Argen- tina. somehow comparable to osteopathy in the U.S.). This could be an artifact of the sample, since the ~o for those specialties are small for all cases and there- fore, it is possible that in the small sample of women those specialties were not represented just by chance.

With respect to teaching in medical schools (Table 4), we find that women are more likely to have non- academic appoin tments [5] but the difference is not significant. We are relegating to the appendix (Table A4) an analysis of teaching activities, in academic and non-academic positions, by sex and age groups, again

Table 3. Specialties practised by sex--CLAM study. Buenos Aires, 1970

Sex Male Female Total

N "<, N '~,, N ".

Medicine* 123 32 18 22 141 30 Surgery* I 12 29 5 6 117 25 Pediatrics* 32 8 23 28 55 12 Gynecology* 38 10 15 18 53 I1 Obstetrics 9 2 0 - - 9 2 Psychiatry* 38 l0 17 21 55 12 Homeopathy 7 2 • 0 - - 7 2 Others* 15 4 3 4 18 4 INA 9 2 1 1 10 2

Total 383 99 82 100 465 100

[For a table prepared using the data in the rows marked*, the X]: 47.746 0.001.)

as an indicat ion for further research into the partici- pat ion of women in teaching activities to confirm a trend toward an increase in the number of women engaged in teaching activities, and to verify that they are more likely to be accepted in non-academic pos- itions.

The quest ionnaire included two questions related to an interesting part of professional practice: income. Since this is a very sensitive point, the questions were indirect. One was aimed at the propor t ion of income from fee-for-service and from salary, and the other was an indirect measure of satisfaction with their in- comes (we asked the physicians to say whether, in their opinion, their income was below equal or above the average income for physicians). The results, in terms of sex differences, are again significant (Table 5). Women are more likely to have a larger propor- t ion of their income from salary. This fact is not easy to interpret without addit ional information about type of practice, t ime devoted to office and to salaried positions, type of positions etc.

Table 6 shows that women tend to be more dissa- tisfied with their incomes which is not surprising since physicians, both as individuals or in the organized profession, consider salaried work to be highly unde- sirable. One factor in the dissati.sfaction of women is related to their age distribution. An analysis of satisfaction by age distr ibut ion in the 'total sample, and in males, shows that there is a relation. Younger and older physicians tend to be more dissatisfied with their incomes. This is undoubtedly a factor in the

Table 4. Teaching positions grouped in academic and non-academic, by sex--CLAM study, Buenos Aires, 1970

Male Female Total Position [4] N ° o N "o N "o

Academic 46 47 6 33 52 45 Non-academic 52 53 12 66 64 55

Total 98 100 18 99 116 100

Research Note 307

Table 5. Type of income by the proportion of fee-for-service and salary by sex--CLAM study, Buenos Aires, 1970

Males Females Total Type of income N % N '~o N ?o

Only fees 87 20 20 22 107 21 Up to 505o salary 266 62 40 45 306 59 More than 50~o salary

to all salary 78 18 29 33 107 21

Total 431" 100 89t 100 520 101

* 23 cases not responding. t 9 cases not responding. X22 : 11.244 0.01,

women sample with a younger distr ibution. Of course, we do not know what is mot ivat ing the dis- satisfaction of w om en- - w he t he r it is the type of in- come or the total amount of income. Da ta about this will be interesting for bo th sexes, in order to have a base for possible changes in professional practice related to a more efficient use of physicians [6]. Note that the number of cases not responding to these questions is impor tan t and could affect the analysis.

The last finding will be related to the opinions of physicians about the at t r ibutes desirable in an ideal personal physician. Fifty-two attr ibutes were pres- ented for selection in two stages: first, to sort the desirables, indifferent and undesirables; and second, to select from the desirables the ones connected with a good quality of medical care. Table 7 presents the results, in four groups of at tr ibutes (Table A5), related to personality, communicat ion, quality of medical

Table 6. Opinion about own income in relation to the income of all physicians by sex--CLAM study, Buenos Aires, 1970

Opinion about income Males Females Total

N % N % N !~';;

Above average 81 18 5 6 86 16 Average 220 50 45 51 265 50 Below average 141 32 38 43 179 34

Total 442* 100 88t 100 530 100

* 12 cases not responding. t 10 cases not responding. X~: 10.024, 0.01.

Table 7. Attributes of an ideal personal physician by sex--CLAM study, 1970

°' o Selecting Grouped attributes* Males Females

I. Personality# 84 85 II. Communication 79 80

III. Quality of medical care 68 68.5 (a) Objective attributes 58.5 57 (b) Subjective attributes 82.5 85

IV. Prestige 18 11.5 V. lntragroup 17 9

* See Table A5. t Excluding the "negative" attribute (authoritarian) which was chosen

by 9.5% of males, and 2To of females.

Table 8. Opinions of males and females (in Yo) about certain attributes in an ideal personal physician-- CLAM study, Buenos Aires, 1970

Males Females Related to Related to

Attribute Desirable quality of care Desirable quality of care

Same sex 33 23 11 5 Same religion 11 8 2 2 Same national origin 11 7 2 2 N 454 98

308 Research Note

care, prestige and intragroup [7]. The results are simi- lar for both sexes with one exception: women seem to be less influenced by intragroup and prestige attri- butes. Specifically, it is worth stressing the attitudes of men and women toward three attributes of the intragroup class, as they are presented in Table 8.

The attitude of men toward the sex of physicians could be an important factor in many of the variables analyzed, such as acceptance or rejection in certain specialties (surgery for example), a somehow inferior status in teaching activities and a disconformity with income which could arise from the fact that females may be forced to accept less important positions. It is interesting to note that 23°0 of all male physicians think that the sex of a physician is related to the quality of medical care that he (or she) could provide, but 5~/o of female physicians think so.

CONCLUSIONS

As is generally known, women are a small propor- tion of all physicians practising in the city of Buenos Aires. They are much younger, an indication of the recent trend toward accepting medicine as a suitable career for women. Their selection of specialties is affected, in all probability, by the position of power of male physicians. Since one-third of male physicians consider the sex of a doctor as an important attribute, it is not surprising that in certain specialties, such as surgery, there is a formidable barrier in the accept- ance of women. The data indicate that women are also in a somewhat worse position with respect to income. They are more likely to have a large propor- tion from salary and they are more dissatisfied with their incomes.

While male and female physicians are in general similar with respect to what they regard the attributes of an ideal personal physician to be, they differ on several interesting points. Male physicians attribute more importance to being of the same sex, religion and national origin than do female physicians. Males also are more likely to feel that prestige and authori- tarianism are important attributes.

It is only fair to say that the main conclusion from these data is to indicate the need to pursue further studies in this direction. Lack of funding for research of this type in Argentina and the poor records about physicians are major problems to overcome, but the need to have a solid base of data about the current practice of medicine in order to be able to plan ahead is unquestionable.

field work, and analysis of some data. Although printed, those reports were not circulated by CLAM.

4. In 1970, when the study was done, there were not clearly defined criteria to ascertain the practice of a specialty. Only a few specialties had officially approved postgraduate training. Of all physicians reporting the practice of a specialty, approximately 85"0 restricted their practices to that specialty.

5. There are two major paths toward a teaching career in Argentinian medical schools. One is highly insti- tutionalized and with almost bureaucratic regulations and the only accepted route to professorial status. It includes the following stages {starting with the most important): Professor, Associate Professor, Adjunct Professor, Adscript. The other is what we call non- academic positions. It involves selection through examinations and regulations which are managed by each Professor in each chair. It includes Chief of Laboratory, Instructor and Lecturer in hospital units (clinical lecturers). The different positions are not simi- lar to the U.S. career.

6. For a description of the health care system in Argen- tina, see Segovia J. and Gomez O. J. Implicit vs expli- cit goals: medical care in Argentina. In Topias and Utopias in Health {Edited by Ingman S. R. and (Thomas A. E.). Mouton, The Hague, 1975. Of course, there are many papers in Spanish about this subject. See especially the collection of Medicina Administra- tiva, a journal edited by the Centro de Investigacion y Adiestramiento en Salud Publica (CLASP), Buenos Aires, from 1967 to 1971.

7. For another analysis of the attributes of a personal physician, see: Elinson J. and Segovia J. What phys- icians think of physicians in Argentina. Presented at the 1971 meeting of the American Association of Pub- lic Opinion Research, Pasadena. California. Abstracted in Puhl. Opinion Q. 35, 469. 1971.

APPENDIX

Table AI. Age distribution grouped, by sex CLAM study. Buenos Aires. 1970

Age Groups < 39 40-49 50 + Total

Sex N ",, N ",, N ",, N ".,

Male 188 73 99 84 167 94 454 82 Female 68 27 19 16 I1 6 98 18

Total 256 100 118 100 178 100 552 100 g~: 30.15 10.01)

Table A2. Specialties practised by age groups in males CLAM study. Buenos Aires. 1970

REFERENCES

1. For a description of the original study', see: Maloney M.D.. Trussell R. E. and Elinson J. Physicians choose medical care: a sociometric approach to quality ap- praisal. Am. J. puhl. Hlth 50, 1678. 1960.

2. The sample was a major problem. We were fortunate to be able to use the master list developed for a Man- power and Utilization Study which was prepared by a computer check of lists of the Ministry of Health and major drug companies. Although we had some problems with it, it was the best list available.

3. Two preliminary reports were prepared in 1971 with descriptions of the study, results and problems of the

Specialties

Age Groups <39 40-49 50+ Total

N ",, N ", N ",, N ",,

Medicine 52 32 29 34 42 31 123 32 Surgery 48 29 19 22 45 34 112 29 Pediatrics 16 10 6 7 10 7 32 8 Gynecology 10 6 13 15 15 11 38 10 Obstetrics 4 3 4 5 I 1 9 2 Psychiatry 24 15 6 7 8 6 38 10 Homeopathy 2 1 4 5 I I 7 2 Others 5 8 2 2 8 6 15 4 INA 2 1 3 3 4 3 9 2

Total 163 100 86 100 134 100 383 99

Research Note 309

Table A3. Specialties practised by age groups in females- - CLAM study. Buenos Aires, 1970

Specialties

Age Groups <39 40-49 50+ Total

N '~'o N ",, N % N %

Medicine 12 22 4 22 2 25 18 22 Surgery 2 4 3 17 0 5 6 Pediatrics 16 29 3 17 4 50 23 28 Gynecology 10 18 3 17 2 25 15 18 Obstetrics 0 0 - - 0 - - 0 - - Psychiatry 12 21 5 28 0 - - 17 21 Homeopathy 0 - 0 - - 0 - - 0 - - Others 3 5 0 0 - - 3 4 INA 1 I 0 - - 0 - - 1 I

Table A4. Contr ibution of academic and non-acadcmic positions by sex to the specific age group in percentages

C L A M study, Buenos Aires. 1970

Age Groups Type of teaching < 39 40-49 50 + positions M F M F M F

Academic 24 5 44 7 74 4 Non-academic 56 15 41 7 18 4 (N of the age group) (59) (27) (27)

Total 56 100 18 I01 8 100 82 100

Table A5. List of groups of attributes*

I. Communica t ion (1) Good explanations to patients (2) Good relations with patients (3) Personal interest in each patient (4) Tends to form friendships with patients

I1. Personality (I) Honest and sincere (2) Authori tar ian (3) Good temper (4) Deliberate and unhurried

III. Quality of Medical Care A. Objective

(I) With a teaching appointment at a medical school (2) Affiliated with a hospital (3) Member of Scientific Societies (4) Involved with research work (5) One who keeps good medical records (6) Working on a team with other physicians

B. Subjective (I) With contacts with a group of specialists of good reputation (2) One who keeps up with the latest development in his field (3) Able to recognize own limitations (41 Skillful at diagnosis and therapy

IV. Prestige (1) One charging higher than the average fees to patients (2) Earning more than Arg. 5300,000 a year (3) Many papers published (4) Recommended by physicians with prestige 15) One with prestige 16) With studies abroad (7) With many patients

V. ln t ragroup (1) Same religion (2) Same national origin (3) Same sex (4) Graduated from the same University (5) Attending the same hospital

* For various methodological reasons. 27 attributes were not included in this analysis.