Women are fast overtaking men in student numbers at South Africa's medical schools, but their failure to specialise has serious implications for the future of health service delivery.

When they do specialise, their top three choices are psychiatry, paediatrics and obstetrics, leaving potential for a shortfall in the more "difficult" specialities the men traditionally choose, including medicine and surgery.

This so-called "feminisation of medical schools" is examined in a Human Sciences Research Council study by senior researcher Dr Mignonne Breier.

She focuses on the University of Cape Town medical school where she says that in the five years from 1999 to 2003, the university has seen an average of 40 percent men to 60 percent women admitted as undergraduates.

These numbers, according to Breier, are "a cause for concern, because of their potential impact on provision of services in the medical profession".

Quoting Professor Gonda Perez, former acting dean of UCT's faculty of health sciences, Breier says the proportion of females has since risen further to 65 percent.

The faculty is concerned, and is attempting to correct the balance by looking for male applicants.

Breier quotes Perez as saying that it would be "problematic if medicine became a female-only profession".

"Women would inevitably leave it at some stage, if only temporarily, to have babies, therefore there have to be males in the profession, particularly as there is a need for men in certain specialities," she said.

Breier also says the proportion of women who graduate falls short of the proportion who enrol.

Of 800 UCT medical school graduates between 1999 and 2003, 55 percent were women and 45 percent were men.

"Since males formed 40 percent of the enrolments, and women formed 60 percent, the proportion of male graduates (which translates into lower 'graduation rates' for women) could indicate that male students are performing better," Breier says in the document.

When it comes to specialising, Breier points out that while the demographics of UCT undergraduate students have changed considerably, at postgraduate level few black and women students go on to specialise, although the numbers are increasing.

Although women enrolments for specialisation are disproportionately low, the figures from 1999 to 2003 show a rapid rise - from 28 percent to 37 percent.

From 1999 to 2005, the top five specialisation choices for men were: medicine, surgery and anaesthesiology, with paediatrics, orthopaedic surgery, obstetrics and gynaecology, and psychiatry featuring less prominently.

Women's top three choices are psychiatry, paediatrics and obstetrics and gynaecology. Medicine, anaesthesiology, pathology (anatomical) and public health feature less prominently.

Breier says common specialities such as surgery, medicine and anaesthesiology will always feature relatively prominently, and that given the predominance of men at postgraduate level, it is also not surprising that there are relatively large numbers of men in these specialisations.

"What is significant is that the male-female proportions in these disciplines do not reflect the gender proportions across the specialisations as a whole.

"If they did, then women would constitute between a quarter to more than a third of enrolments in each speciality," she says.

Breier ponders whether these trends are in line with the international view that women are attracted to specialisations that are particularly suited to traditional concepts of their gender.

She questions whether women are attracted to specialisations in tune with traditional feminine roles and strengths, or which are less physically demanding, with more predictable hours and less overtime.

There were virtually no women students in orthopaedic surgery in the period studied, and they also accounted for a very small proportion of surgery enrolments.

Very few women at UCT were studying surgery in the study period.

Professor Leslie London, the faculty's transformation officer, is quoted by Breier as saying that the university is aware that while graduates had been predominantly women for many years, students entering specialisation had been predominantly men.

He suggests "the unwelcoming environment" as one of the reasons for women not specialising in surgery.

"If you're a woman in surgery, you're automatically seen as somebody who's going to create trouble for everyone else."

"You know, you're going to get pregnant, so they're going to have to cover for you."

"There are no provisions for locum support if a woman, a surgical trainee, goes off for maternity. So the rest, men and women, have to cover," Breier quotes him as saying.

Breier concludes that the feminisation of undergraduate classes has not yet translated into similar proportions at postgraduate level.

Health system planners are concerned that women doctors, who need to care for their children, are choosing part-time work and avoiding "difficult" specialisations, she says.

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