It was a national roundtable, and the Tasmanian chair of the RACGP had a question for one of the key visitors.
“I don’t want to answer that,” he told her, “I want to talk about your beautiful eyes.”
Dr Clare Ballingall was taken aback. “I’m nearer 50 and I’d just done 12 hours of work.”
General practice these days is a far cry from her early hospital rotations where sleazy comments like “whose bed did you fall out of” and goading to wear shorter skirts were not unusual. But sexism still “rears its head every so often”, Dr Ballingall says.
A recent US survey of 5700 female doctors who were mothers found that four in five felt they had faced discrimination. Around two-thirds felt that the discrimination was based on gender, and more than one in three felt they had suffered maternal discrimination.
It can be as subtle as a throwaway comment.
Dr Elizabeth Sturgiss, lecturer in general practice at the Australian National University, says that in her experience sexism is more prevalent in the hospital setting than in general practice. But she remembers starting at a new practice many years ago where she shared a room with a male colleague.
“The room was always in a complete state of disarray whenever I started my day,” she recalls. Then one of the staff told her it was good she was now sharing the room because “he needs a woman in there to help him keep it tidy”.
“This is a small but concrete example of gender stereotypes in the workplace,” Dr Sturgiss adds.
For the mothers in the survey, the key complaints were disrespectful treatment by nursing and support staff, not being included in administrative decision-making and unequal pay.
Right now, women account for around half the general practice workforce and that proportion looks set to grow.
Nevertheless, the popularity of other specialties is outstripping general practice. Nearly 10 medical graduates will choose another specialty for every one going into general practice.
The passion is evident in Dr Ballingall’s voice when she explains why she recommends general practice to young women. It’s hard work, it’s not an area where you get to play with flashy machines or use cool drugs, but the complexity and intimacy of general practice is powerful, she says.
“With the trust our patients put in us, I feel so uniquely privileged to work in this area.”
Dr Sturgiss is equally enthusiastic, describing her joy in the variety and nature of the work and the rewards of looking after patients over the course of their life.
“I haven’t regretted my decision to become a general practitioner one bit. Although it’s not perfect, we’ve made big inroads into making general practice a welcoming place to practice as a woman,” Dr Sturgiss says.
Female representation is strong in academic primary care, where Dr Sturgiss spends much of her time. That said, senior and leadership roles within academia tend to be held by men.
Similarly, only two women are members of the RACGP Council, compared with eleven men, and GP practice ownership also appears to skew male.
Which raises the question, is there something standing in the way of female leadership?
“There’s growing evidence that diversity leads to better decision-making and outcomes,” Dr Sturgiss says, and that more diversity on boards translates into a broader mix of ideas in a group and a better ability to recognise potential problems and solutions that a group of similar people might not have foreseen.
The fact that the RACGP leadership has included so few women is “abysmal”, she says.
“Our current RACGP Council falls well below the ASX average, and the ASX average is considered to be pretty poor.”
Figures on 200 ASX-listed organisations show only 23% of the boards of these companies are women.
Over the last eight years, the RACGP Council has been made up of 41% women on average. These figures still reflect well compared with other colleges such as the surgeons’ and physicians’ which had only around one in five women council members in the last four years.
But in the last two years female representation has swung back in favour of a more male-dominated leadership.
A number of different factors are put forward to explain this discrepancy, including a confidence gap, financial disincentives, lack of mentorship and systemic discrimination.
Simple and subtle things like the fact that meetings are often held in the evening means mothers may struggle to attend.
Dr Magdalena Simonis, the College’s co-chair of Women in General Practice, emphasised the importance of mentorship to overcoming barriers to leadership.
“Today and historically, leadership roles have been assumed by males because they have got the confidence, and they have got the role models and mentors going back generations.”
She says a College-run pilot study on mentorship was welcomed by women early in their career who found it useful to speak with a more experienced woman in the medical world.
Women make up only 18% of the RACGP Council which is less than the ASX average for boards.
The study also revealed younger women had concerns about how to balance family and career, how to navigate an academic career and owning practices.
Leadership roles can also be isolating, with some women compelled to adopt more blokey behaviours, the immediate past president of the Victorian Medical Women’s Society says.
“So even when you do get into those upper echelons you might find that it’s actually not as friendly an environment as you were hoping it would be.”
For this reason, a support network is important. This support doesn’t necessarily come from a spouse, Dr Simonis cautions, noting career goals can sometimes be contrary to family dynamics or family needs.
A major drawcard of general practice has been its flexibility, which can be appealing for women who want a career that complements a family.
But this can be a double-edged sword.
“Women can be as brilliant, or more brilliant than a man, but when it comes to the family life, they are perceived as responsible for raising the kids,” Dr Simonis says. “And that, I think, is a significant barrier.”
“The reality is that in order to take on leadership roles, you need to be able to say ‘I’m not going to be home tonight, I’m not going to have dinner ready for you all and I’m going to be interstate for the next two nights’ How many women with families and working husbands can easily do that?”
Even in 2017, the bulk of domestic duties statistically falls to women. An Australian Institute of Family Studies report found that even stay-at-home fathers did an average of only 19 hours of childcare per week compared to the 21 hours performed by women already working 35-hour-weeks at a job. These dads still only did slightly more hours of housework than the working mums, at 28 hours compared to 23.
“I see it all the time in my practice,” Dr Simonis says. “A lot of these women with stay-at-home husbands will still come home and cook, or they’ll come home after a week overseas or interstate to a mountain of laundry.”
To make matters worse, women who work in general practice get paid less than their male counterparts.
Regardless of the number of hours worked or experience, female GPs earned on average $11 less per hour – equivalent to around $21,000 per year – than their male counterparts in 2014-2015, according to BEACH data.
The findings, presented at the Primary Health Care Research and Information Service in Canberra in June last year, showed the women offered better value for the healthcare system.
Female GPs were spending longer in consultations with patients, and covering an average of 1.63 problems per encounter, 1.51 for male GPs.
This translated into better outcomes for patients as female GPs were less likely to visit their GP in the course of a year but had no differences in hospitalisation rates.
Christopher Harrison, a senior analyst with the BEACH team, said his findings showed that the gender pay gap was the result of multiple factors beyond simply the number of hours worked, and this inequity needed to be tackled under the Medicare Benefits Schedule item review.
A US study on academic doctors in medical schools echoed these findings, showing that even when years of experience, age, specialty, seniority, age, research productivity and amount of work with patients were accounted for, men still earned an average of US$20,000 more than women annually.
“We do see more problems per consult, spend more time with patients, and as a consequence they see us less frequently,” Dr Simonis says. “Female GPs are very cost-effective for the healthcare system, but the remuneration needs to be reflective of what we contribute.
“So if you consider these women put that amount of effort into their daily work, then go home and have that amount to do on top, you are dealing with a situation where burn-out and dissatisfaction creep into general practice,” she adds.
Regardless of the number of hours worked or experience, female GPs earned on average $11 less per hour – equivalent to around $21,000 per year – compared to their male counterparts.
Dr Karen Price, co-chair of the Victorian Faculty’s Women In General Practice Committee, agrees that substantial structural changes will be required to even the playing field.
“We don’t want a Band-aid solution,” she says.
For example, every college should be campaigning for more taxpayer-funded childcare funding. “No employer or cottage practice owner should have to fund a creche in their general practice.”
Affordable childcare and paid time off are major barriers to gender equality, and the emphasis should be on making the field supportive for parents of both genders, Dr Price adds.
The flexibility and part-time nature of general practice also has some hidden downsides.
“People pitch part-time as a choice…but it’s precluding us from education. The costs of medical education continue to go up and up and up so we continue to be deskilled.”
She argues that programs such as childcare funding for conferences should be a central feature inimproving gender equality. If nothing is done, general practice is going to continue to lose experience, skills and the valuable voices of women who limit their exposure to education and leadership roles.
Because a woman’s career has already been interrupted by childbirth, she may be getting paid a lesser rate than her partner who has continued working. This income penalty affects the decision who should stay home for the childrearing, meaning women are further limited in their trajectory into senior and leadership positions.
“I believe the College needs to pay the senior contributing GPs appropriately for their expertise,” Dr Price adds. “Because if you’re not going to pay them at appropriate rates the only way to support that role is to have external income; for example, a practice owner has passive income that you don’t have as a contractor.”
Improved childcare options would mean that the tasks of working and childcare wouldn’t be left to one person “simply because of their biology”, she says.
Dr Karen Price is quick to stress that it isn’t women who need fixing, but structural impediments in the workplace. “We are not going to change anything with a moral argument,” she says.
For Dr Ballingall, life is at times reminiscent of circus shows she used to watch as a kid where the performer spun plates on the top of a pole.
“That’s what I’m like, I’m running around keeping those plates spinning on the top of poles, and they all get a bit wobbly at times,” she says.
“It’s a 24-hour role, being a mother, being a doctor and having a leadership role. There are lots of positives obviously, but I have to sacrifice quite a few things, time with children sometimes being one.”
References available on request