FEMALE SURGEONS' ALCOHOL USE: A STUDY OF A NATIONAL SAMPLE OF NORWEGIAN DOCTORS

JUDITH ROSTA1,* and OLAF G. AASLAND2,3

1 Norwegian Institute for Alcohol and Drug Research, Oslo, Norway, 2 The Research Institute, Norwegian Medical Association, PO Box 1152 Sentrum, N-0107 Oslo, Norway and 3 Department of Health Management and Health Economics, University of Oslo, Norway

* Author to whom correspondence should be addressed at: Department of Sociology, Johann Wolfgang Goethe-University, Robert-Mayer-Strasse 5, D-60054 Frankfurt am Main, Germany. Tel.: +49 (0)69 798-22052; Fax: +49 (0)69 798-28009; E-mail: Rosta{at}soz.uni-frankfurt.de

(Received 2 May 2005; first review notified 1 June 2005; accepted in revised form 27 June 2005)


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aims: This study was designed to describe the alcohol use by female surgeons and the hazards of their drinking habits for them compared with the habits of female doctors from non-surgical specialities, and with those of their male colleagues in surgery, and to identify the variables associated with hazardous drinking. Methods: The data were collected in 2000 from a representative national sample of 1120 Norwegian doctors. Alcohol use was measured using a modified version of the Alcohol Use Disorders Identification Test. A score of 9 or more was used as an indicator of hazardous drinking. Results: Female surgeons compared with female non-surgeons had tendencies for more frequent moderate alcohol consumption accompanied by more frequent consumption of larger amounts of alcohol, and a significantly higher rate of hazardous drinking (18 vs 7.6%). Being a surgeon (OR = 1.7, 95% CI 1.2–2.4), male (OR = 2.7, 1.7–4.1) and aged 45 years or over (OR = 1.5, 1.1–2.2) were significant predictors of hazardous drinking. With separate gender analyses, being a surgeon was a significant predictor for both females (OR = 2.8, 1.2–6.6) and males (OR = 1.5, 1.0–2.3). Conclusion: Female surgeons practising in Norway drink more frequently and more hazardously than other female doctors. There are a number of possible explanations for this. Surgical culture may be an important factor.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
There is growing concern about women in medicine because of the persisting gender-segregation within the medical field, particularly in a traditional male-dominated area such as surgery (Flottorp, 1993Go; Baxter et al., 1996Go; Dresler et al., 1996Go; Lambert et al., 1996Go; Casswel, 1998Go; Hinze, 1999Go; Searle, 2000Go; Gjerberg, 2001Go, 2003Go).

In Norway, as in many Western countries, there has been a marked increase in the number of women in medicine during the last four decades (Gjerberg, 2001Go), from 10% in 1960 to >30% in 2000 (Historisk legestatistikk, 2004Go) (http://www.legeforeningen.no/index.gan?id=1458). However, only a small minority of women seek a career in surgical specialities (Flottorp, 1993Go; Gjerberg, 2001Go, 2003Go), especially general surgery, where only 5% are females (Den norske lægeforening, 2002Go) (http://www.lægeforeningen.no/index.gan?id=1442). The low proportion of females in surgical careers is due both to individual preferences and to work opportunities (Baxter et al., 1996Go; Gjerberg, 2001Go). Women traditionally choose specialities that have to do with children's and women's health and those that have a high degree of patient-contact, such as family medicine and psychiatry (Gjerberg, 2001Go). Surgery is beset with long and unpredictable hours, being frequently on call, and few part-time work opportunities, factors that make it difficult to balance work and family (Hofoss and Gjerberg 1996Go; Decker et al., 1997Go; Casswell, 1998Go; Gjerberg, 2003Go). The absence or low representation of female role models in surgical specialities has also been described as a reason why women tend to choose other specialities (Baxter et al., 1996Go; Casswell, 1998Go). Moreover, the existence of unofficial networks among men, discriminatory behaviour and different exclusively male practices are also mentioned as reasons for making it difficult for women to choose a surgical speciality (Dresler et al., 1996Go; Oancia et al., 2000Go; Gjerbeg, 2001Go, 2002Go).

An important issue in alcohol research is the relationship between cultural setting and drinking behaviour (Gmel et al., 2003Go), which was also verified among doctors (Aasland and Wiers-Jenssen, 2001Go; Rosta, 2002Go). It has been shown that male professionals have a culture that weakens the influence of women's traditional values and attitudes, including attitudes concerning alcohol. For example, in predominantly male occupations both male and female employees are more likely to drink and to have alcohol-related problems than employees of both genders in female-dominated occupations (Wilsnack and Wilsnack, 1991Go, 1992Go; Kraft et al., 1993Go; Davey et al., 2000Go). Plant and colleagues (1991)Go have shown that female nurses in a speciality with the highest percentage of male nurses were significantly more likely than other female nurses to drink heavily and to experience alcohol-related problems. Representative studies of the drinking patterns of female doctors are few, but they support the picture of a relatively low alcohol consumption (McAuliffe et al., 1991Go), less frequent drinking (Aasland et al., 1988Go), and lower prevalence of heavy or hazardous drinking (Aasland et al., 1988Go; Juntunen et al., 1988Go; Gulbrandsen and Aasland, 2000) compared with male doctors. We found one study of female surgeons' drinking habits, unfortunately without comparative data for female non-surgeons, or for male colleagues (Frank et al., 1998Go). In Frank's study the alcohol measures were too general to identify hazardous drinkers. In addition, one of the author's (J.R.) working experiences of 10 years as a nurse in surgical specialities was a strong factor to initiate this study.

Our research question is whether alcohol use and hazardous drinking of female medical doctors differ for doctors in surgical and non-surgical specialities, and the role of gender in this picture.


    MATERIALS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In 2000 a representative sample of 1616 Norwegian doctors was surveyed using postal questionnaires. The survey was part of a current prospective longitudinal study administered by the Research Institute of the Norwegian Medical Association. Part of the survey in 2000 was an assessment of smoking and drinking habits. Drinking was identified using a slightly modified version of the Alcohol Use Disorders Identification Test (AUDIT, Saunders et al., 1993Go).

For the purpose of this analysis, the specialities have been categorized into surgical and non-surgical specialities. Surgical specialities include general surgery, vascular surgery, gastroenterological surgery, orthopaedic surgery, thoracic surgery, urology, paediatric surgery, neurosurgery, plastic surgery and obstetrics, and gynaecology. Doctors in training were coded according to their future speciality.

Data on alcohol use, frequency and amount, and possible negative consequences of drinking were obtained using a slightly modified version of the AUDIT (Gulbrandsen and Aasland, 2002Go), see Table 1. The modification is a more detailed registration of the frequency of drinking and the frequency of drinking ≥60 g of ethanol (questions 1 and 2). Each question was scored from 0 to 4, giving a possible summary score between 0 and 40. A cut-off of 9 points or more was used as an indicator of hazardous drinking. In accordance with previous findings that older doctors are more frequent drinkers (Juntunen et al., 1988Go; Gulbrandsen and Aasland, 2000), age was categorized into two levels, 44 years or younger, and 45 years or older.


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Table 1. The AUDIT questions

 
Categorical differences were tested using Pearson {chi}2 test, and simultaneous effects with logistic regressions. Most analyses were performed for females and males separately.


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The response rate was 86% (1385/1616). All doctors with data on gender, age, speciality, and alcohol use were included (1120) of which 347 were female. Of those surveyed 226 doctors were surgeons and 56 were female, the majority working in obstetrics and gynaecology. The median age was 38 years for female surgeons and 40.5 years for female non-surgeons, as opposed to 50.5 years for male surgeons and 48 years for male non-surgeons.

Table 2 summarizes alcohol use and levels of hazardous drinking. Compared with female non-surgeons, female surgeons were less likely to abstain from alcohol and were more likely to drink 2–3 times a month or more. They also reported more frequent consumption of large amounts of alcohol, and showed a significantly higher rate of hazardous drinking on the basis of a score of 9 or more on the AUDIT (18 vs 7.6%, {chi}2 = 5.57, df 1, P = 0.02). Male surgeons were also more likely to drink frequently, and had a significantly higher rate of hazardous drinking (AUDIT 9 or more) compared with male non-surgeons.


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Table 2. Alcohol use and hazardous drinking (AUDIT-score 9 or more) among Norwegian doctors in 2000 (Percentage)

 
In a logistic regression model (Table 3) being a male, surgeon, and 45 years or older were all significant independent predictors of hazardous drinking. With separate analyses for females and males, being a surgeon was a significant predictor in both models.


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Table 3. Logistic regression models with hazardous drinking (AUDIT 9 or more) as response variable

 
By using the two separate regression models (males and females) to estimate the probability of hazardous drinking (Table 4) we found that both female surgeons (0.12–0.17) and male surgeons (0.26–0.34) of both age groups have higher probabilities than female doctors (0.07–0.11) and male doctors (0.17–0.24) from non-surgical specialities. Female surgeons aged 45 or older compared with male non-surgeons aged 44 or younger appear to have similar probabilities of 0.17.


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Table 4. Estimated probability of hazardous drinking for eight different categories of doctors

 

    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The study describes the alcohol use of female surgeons in relation to female non-surgeons, and to male doctors. The results suggest that female Norwegian surgeons differ from other female Norwegian doctors with regard to alcohol use and possible hazardous drinking. Female surgeons were less likely to abstain from alcohol, more likely to drink weekly, and more likely to to engage in hazardous drinking than other female doctors. These findings are inconsistent with some earlier studies suggesting that female or male surgeons are not significantly different from doctors in other specialities with regard to alcohol use (Frank et al., 1998Go; Hughes et al., 1999Go; Storr et al., 2000Go). However, our results are not fully comparable with the results from these earlier studies because medical specialities were classified differently, and the analyses were performed either for both genders or for females only. The finding that within surgery as a male-dominated speciality men and women tend to practice more hazardous drinking, corresponds with earlier observations that in a predominantly male occupation both sexes are more likely to drink and to have alcohol-related problems (Plant et al., 1991Go; Wilsnack and Wilsnack, 1991Go; Kraft et al., 1993Go; Davey et al., 2000Go). Tendencies for more frequent drinking and more frequent consumption of large amounts of alcohol, that may by associated with hazardous drinking (Gmel et al., 2003Go; Rehm et al., 2003Go), were also detected in this study.

The higher rate of hazardous drinking among female surgeons compared to other female doctors may reflect a number of possible factors, including working conditions and personality traits (Wilsnack and Wilsnack, 1991Go; Brook, 1996Go). Thus, one explanation might lie in the sensation-seeking that was found to be a prominent factor in recreational alcohol drinking among doctors in training, including surgical specialities (McAuliffe et al., 1984Go). Another explanation might be the stressful nature of surgical specialities. Revicki and Whitley (1995)Go have described how daily confrontations with medical crises that require an immediate decision about diagnosis and treatment were perceived as stressors among emergency doctors, and this may also apply to surgeons (Casswell, 1998Go). Although some studies suggest that surgeons are more resistant to stress (Linn and Zappa 1984Go; Chambell et al., 2001), excessive workloads of surgery such as very long hours, sleep deprivation, and exhaustion in relation to nights on call may be important stressors. One manifestation of stress is burnout, which was defined as an important problem for actively practising American surgeons (Campbell et al., 2001Go). Both stress and burnout have been associated with the use of alcohol and heavy drinking of medical staff (Juntunen et al., 1988Go; Plant et al., 1992Go). It is also important to note that heavy drinking is associated with other risks such as suicide (WHO, 2004Go), which was found to be more prevalent among doctors (especially among female doctors) than in the general population or among other academics (Hem et al., 2000Go, 2005Go). Whether female surgeons in accordance with their tendency to hazardous drinking have more suicidal thoughts and attempt suicide more often than their female colleagues, still remains to be answered adequately.

Shore (1992)Go suggests that employment may influence women's drinking norms through the gender composition of the workplace rather than through work-related stress. In fact, studies show that women who gain access to traditionally male environments have a higher risk of alcohol abuse (Wilsnack and Wilsnack, 1991Go, 1992Go). This view is supported by the results of the present study. Affiliation to surgery as a largely masculine field was the strongest predictor of hazardous drinking among females. Because of the tendency for women to choose non-surgical specialities, women who indicate even a passing interest in surgery may differ systematically from their female colleagues (Oancia et al., 2000Go). Indeed, female surgeons differ in their social characteristics from other female doctors: female surgeons have a stronger professional interest and a lesser interest in traditional families, i.e. they are more likely to be single and childless, they work more hours, have more nights on call, and spend more time on continuing medical education than other female doctors (Casswell, 1998Go; Frank et al., 1998Go). These characteristics of female surgeons may be signs of role deprivation, that can increase women's risk of hazardous drinking (Wilsnack and Cheloha, 1987Go). Although the surgical culture may well change women (Cassel, 1998Go; Oancia et al., 2000Go), it is also possible that surgery selects out a group of women who probably ‘have more masculine traits’ (Cassel, 1998Go). If these observations are also valid for Norwegian female surgeons, they may explain some of the differences found in this study.

Although female and male surgeons were more likely than their non-surgical counterparts to use alcohol hazardously, expected gender differences in drinking, and that females are less likely to drink and less likely to be heavier drinkers (Wilsnack and Wilsnack, 1991Go; Ahlström, 1995Go) are also present within surgery. In this study, female surgeons were also less likely to be abstainers than male surgeons. This could, however, be an age effect. As noted, in earlier surveys carried out in 1985, 1993 and 2000, Norwegian doctors in younger age groups were found to be less likely to abstain from alcohol (Aasland et al., 1988Go; Gulbrandsen and Aasland, 2002Go). However, it was not the younger age group (as was shown within the general population studies), but the older age group that reported more hazardous drinking. Our results support the previous findings of doctors' drinking (Juntunen et al., 1988Go; Aasland et al., 1988Go; Gulbrandsen and Aasland, 2002Go). This age-effect among doctors is explained by the fact that younger doctors place increased emphasis on the dangers of alcohol, which will hopefully contribute to an increased risk-awareness concerning personal consumption. This has also been the case with the change in doctors' smoking habits in many Western countries (Harrison and Chick, 1994). A support for this explanation could be the finding of a Norwegian study of doctors, that younger doctors are more aware of the danger of alcohol use as a public health problem (Aasland et al., 1988Go).

This comparative analysis has some limitations and strengths that deserve attention. A clear strength is the validity of anonymous self-administered questionnaires using AUDIT to assess quantity, frequency, and adverse effects of alcohol use (Aasland et al., 1988Go, 1990Go; Saunders et al., 1993Go; Davey et al., 2000Go; Gulbrandsen and Aasland, 2002Go). A weakness of this study is the relatively small group of female surgeons, but there is only a small minority of women who seek a career in surgery. Therefore, the understanding of the nature of surgical specialities and the factors related to drinking might be improved by closely studying the specialities with diverse gender distributions, for example, general surgery and its sub-specialities having the lowest percentage of females, and child psychiatry and adolescent psychiatry having the highest rate of females (Den norske lægeforening, 2002Go). In the future, it might also be interesting to analyse whether and how the alcohol use by female surgeons will change with the expected growth in the proportion of women in surgical specialities (Casswell, 1998Go; Frank et al., 1998Go; Gjerberg, 2001Go). In addition, since data from other Western countries suggest similar gender segregation in medical specialities (Baxter et al., 1996Go; Lampert et al., 1996Go; Decker et al., 1997Go; Searle et al., 2000Go) there may be common conditions for a higher rate of hazardous drinking among female surgeons compared to female non-surgeons that could be addressed using comparative data from other countries for further analyses.

In general, paying more attention to the alcohol use by female doctors is important, because of their health, the potential adverse effects on their clinical practice (Frank et al., 2000Go), and their function as role models in the population with regard to lifestyle and drinking (Aasland, 1994Go).


    ACKNOWLEDGEMENTS
 
This study was supported by the National Institute for Alcohol and Drug Research and the Research Institute of the Norwegian Medical Association, Oslo, Norway. The authors acknowledge the helpful comments of Dr Ingeborg Rossow on an early version of this article.


    REFERENCES
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 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
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