Despite the increasing proportion of women in medicine and the changes they have brought to medical practice, they are still grossly under-represented in areas such as surgery. Barbara Millar reports

Jenny Jaeger, the greatest juggler of all time, who was born in Odessa, Ukraine, in 1909 could juggle 10 balls at once and was the only performer ever able to do this in a stage act.

Unsurprisingly, her feat is invoked in the recruitment literature of the Medical Women's Federation, which was founded soon after her birth. 'The skill of juggling remains an art form for many working women today, ' says Dr Mollie McBride, the MWF's honorary secretary. 'All women wanting to pursue a career in medicine are well advised to acquire the knack of juggling their personal and professional lives for job satisfaction.'

The MWF, set up in 1917 to work for women doctors, wants to see gender barriers in the medical profession removed and for women doctors to be available in all branches of medicine.

While women represent a growing force in medicine their numbers are by no means evenly distributed among the branches of the profession. More than half the entrants to medical school and a third of GPs are women, compared with a quarter a decade ago. But they account for only a fifth of hospital consultants, and in some specialties the proportion is even lower. Only 5 per cent of consultant surgeons are women.

The flexible training initiative, set up in 1969 to encourage the provision of part-time, educationally approved posts for hospital doctors who could not train full-time because of family commitments or other circumstances, has grown in popularity. The number of doctors training part-time in London has increased five-fold over the past five years, from just 40 to more than 200, of whom 80 per cent have children.

In 1998 over 15 per cent of those undertaking flexible training were in psychiatry and over 18 per cent were in paediatrics, compared with just 7.5 per cent in the surgical specialties.

'Women are still experiencing problems fitting in with the male culture in surgery, ' says Dr Gillian Markham, a consultant radiologist at Whiston Hospital on Merseyside and chair of the British Medical Association's Mersey consultants committee. 'I have doubts about whether this will ever change very much.'

'Theatres have a peculiar atmosphere, ' says Dr Markham. 'They are highly charged, for obvious reasons, and those who work in them often have short tempers. It needs an exceptional human being to work in this environment and it does not suit many women. It doesn't suit a lot of men, either.'

Increasingly, surgeons are becoming technicians, Dr Markham adds. 'And this is not usually the reason people have for going into medicine.'

Dr Markham enjoyed surgical work but chose radiology because she needed more sleep. She believes both male and female doctors now look on medicine much more as a job than was previously the case. 'It used to be that medicine was your life and you accepted that, along with the one-in-twos and the seven-day working. People now expect a life outside work and often they can see a better life in general practice.'

The increasing number of women in the workforce has had an impact on general practice, believes Glasgow GP Dr Barbara West. 'Women started the trend for part-time working and now lots of men, particularly the younger ones, are opting for it.'

This, combined with the advent of out-ofhours co-operatives, has 'completely changed' the pattern of service delivery from the personal touch to the team approach, she adds.

Women are also now building up portfolio careers, combining general practice with research, hospital sessions and employment as facilitators in various settings. 'This adds up to a satisfying career but can cause conflicts of interest and make you feel as if you are shortchanging one or more of the jobs.'

Dr Jane Richards, who has now retired from general practice, but is still a member of the British Medical Association council, believes women had more impact in the 1980s on the way general practice was run and services were delivered. Most women worked full-time then. But when the number of women GPs working part-time increased dramatically 'they sidelined themselves', she says, and had a negative impact on the continuity of care.

'Part-time may be the future, but it is sad. Women have had a good effect on making men spend more time with their own families, but now things have gone too far the other way.'

Dr Richards has remained single. 'Out of 10 of us in my year at medical school almost all married late. We felt we had to keep our end up and make sure we were established in our careers. One of our year got married while we were training and we thought she hadn't a hope in hell. I am not the only one of my year not to have been married - a number of us missed out.'

Dr Irene Weinreb chose to go into general practice 'for all the wrong reasons', she says. 'I married a career paediatrician and we had a family. It was impossible for us both to work in hospital medicine.' She started training as a neurologist and then 'fell into' general practice. But in her practice of five partners, the three full-timers are all women, the two part-timers are men.

She is also involved in her local primary care group and says that there, all the 'softer qualities' normally associated with women are expressed by the men.

'They talk about wanting peer support groups because general practice has become so stressful. Would they have raised this 20 years ago? I doubt it very much. It seems that women have brought these so-called 'touchy-feely' issues to the fore and now men feel just as easy about expressing them. Women in medicine have allowed a more open debate on subjects such as family responsibilities, paternity leave and sabbaticals that were previously taboo.'

According to Dr Judy Gilley, secretary of Bedfordshire and Hertfordshire local medical committees, general practice has traditionally been more flexible than hospital medicine as a career and has become even more popular with women over the past 20 years.

The doctors' retainer scheme, set up in the 1960s and renegotiated last year, has had a real impact on recruitment and retention of women, she adds. 'The new scheme allows GPs to do four sessions a week within a quality practice and also offers seven education sessions a year which are subsidised.'

Just over 1,000 doctors, mainly women, are currently participating in the scheme and hospital doctors are looking at building on the format, too.

But a return-to-work scheme is also needed, argues Dr Gilley.

'General practice now moves so fast that when you have a break from it it can be difficult to get back in.'

She would like to see a scheme established whereby a doctor wishing to get back into practice after a break spends time with an established principal, observing practice and gradually doing a few sessions, building up until they feel ready to go back to work.

'If they have been out of general practice for, say, five years it might take a year to get up-to-date, but if they have only been out for one year they might be ready after a month. Such a scheme would need financial backing from the Department of Health as the doctors would have to be supernumerary. I think this has to be the next move as we get a workforce with more and more women in it.'

The Royal College of Surgeons last year announced its plans to increase the number of women consultants so they represent 10 per cent of the total number of consultant surgeons within five years, and at least 20 per cent by 2009. Currently there are 210 women surgeons - less than 5 per cent of the total of 4,190 working in the UK.

RCS president Barry Jackson has called the targets 'ambitious, but realistic'. To achieve them the number of women at the training grades would need to grow so that within five years at least 30 per cent of all basic surgical trainees are women.

Leela Kapila, chair of Women in Surgical Training, set up in 1991 by the RCS and the DoH in response to the under-representation of women in surgery, points out that, despite a 9.6 per cent annual rise in the number of women at consultant grade over the past 10 years, only 5 per cent of consultant surgeons are women, compared with an average of 21 per cent in the other medical specialties.

'These figures are a grave cause for concern when we look at them in the context of the number of women at medical school, ' says Miss Kapila. 'Fiftysix per cent of the new intake in 1998 were women, and, if the current trend continues these figures could be nearer 60 per cent in the future. If surgery continues to be a male-dominated profession, the surgeons of the future must come, by default, from the increasingly small proportion of male graduates.'

Initiatives such as job sharing, flexible training and reasonable working hours would make it easier for men and women to combine family life with a surgical career, she adds.

Women doctors who believe moving into medical management might offer a more tempting working environment should think again, according to Jenny Simpson, chief executive of the British Association of Medical Managers. 'Nineto-five working just doesn't happen. If anything, working hours are even worse, with lots of evening meetings, ' she says.

But there are satisfactory elements, too. 'One of the greatest satisfactions for women working in medical management is multitracking - thinking about and working on several different things at once, ' says Dr Simpson.

'Women tend to like the complexity of the job, the management of uncertainty, the broader picture. It is a very satisfying career option, but it does not really lend itself to being familyfriendly, as generally, people carry on with their clinical commitments as well.'