Still far to go – An investigation of gender perspective in written cases used at a Swedish medical school

Abstract

Objective: Given decisions to implement a gender perspective in medical education, this study investigated gender perspective in written cases used at a Swedish medical school.

Method: All course organizers on terms 5–11 were asked to submit the case descriptions used in 2005. The 257 cases collected were subjected to content analysis focussing on sex of author and patient; whether there were any guidelines for tutors; and whether the case touched on biological sex differences, psychosocial and gender aspects.

Results: The majority of cases were written by male teachers. The proportions of male and female patients were equal. There were instructions for tutors in 20% of the cases. Sex differences were mentioned in 7% of cases. Psychosocial data were meager. Ten cases (4%) contained gender aspects and four of them presented gender as a main issue.

Conclusions: The lack of instructions for tutors and overall scant interest in psychosocial issues were important obstacles for gender implementation. Actually, ignoring psychosocial conditions means that a gender perspective is also neglected. The results illuminate the importance of monitoring and follow-ups for a successful implementation of gender. Our method of scrutinizing written cases might be useful also for other medical schools.

Introduction

During the last decades there has been a growing awareness about gender disparities in health and disease. For many diseases prevalence, risk factors and treatment outcome may differ between men and women, and such differences are important to consider in healthcare and medical education (Lorber 1997). Explanations for the disparities are sought in biological sex-differences, psychosocial conditions, and communicative behaviour, as well as in gender bias.

Biological differences between men and women were previously ascribed to reproduction, reproductive organs and sex-hormones. Research has now shown that biological sex-differences are also significant in many conditions that lack a reproduction connotation, and that affect both men and women. Examples are cardiovascular diseases (CVD), immunological diseases, HIV, diabetes, and irritable bowel syndrome (Legato 2004). This is a lively research field that involves the creation of new knowledge and the need to revise guidelines for the prevention and treatment of diseases. To date the largest body of evidence concerns CVD, and it is, for instance, now acknowledged that myocardial infarction without plaque is more common in women than men, which has consequences for the investigations required to secure the patient's diagnosis (Pinn 2005). Recently, the American Heart Association presented evidence-based guidelines for CVD prevention in women (Mosca et al. 2007).

Table

Practice points

This study investigated the implementation of gender perspective in written cases used during the second-half of medical school (terms 5–11). Only 4% of the 257 cases touched on gender aspects and this lack of gender was related to a neglect of psychosocial issues and their impact on health and disease. In no more than 20% of the cases there were written instructions for tutors, although such instructions are important when new perspectives are introduced in the curriculum. Our way of scrutinizing the cases might be useful in gaining an overview of gender in cases in other medical schools. Investigations involving several countries are suggested to make it possible to compare, learn from each other, and expedite the implementation of gender in case education.

Differences in men's and women's health are often related to psychosocial circumstances. Research has shown that different conditions in daily life, environmental experiences, risk behaviours, and different responses to stressful events may all contribute to variation in health and well-being in men and women (Lorber 1997; Hammarström 2007). A recent report from the UN concluded that gender inequality damages the health of millions of girls and women across the globe because they are deprived of necessary resources, power, authority, and control of their everyday life at home and work (Sen and Östlin 2007). Violence against women in intimate relationships is one utterance of gender inequality and is recognized as a significant threat to women's health. Gender inequality can also be harmful to men's health since the many benefits it gives to men come at a cost to their own emotional and psychological health, often translated into risky and unhealthy behaviours and reduced longevity (Courtenay 2000; Payne 2004). One explanation for the high death rates among young men compared to young women in the Western world is the risk-taking seen among men, such as driving fast on roads, engaging in potentially dangerous leisure activities, or using more drugs and alcohol.

Gender affects patient–doctor interaction and the outcome of consultations as well. Disparities in communicative behaviour can be seen. Research focussing on physicians in consultation indicates that male and female physicians differ when comparing time, content, and communication patterns (West 1993; Elderkin-Thompson and Waitzkin 1999; Roter et al. 2002; Zaharias et al. 2004). Women doctors have longer encounters and they include more proposals, partnership building, and emotional support. Male doctors tend to be more dominant and they give more advice. The communicative behavior of the patients and their wishes also contribute to the interaction. Female patients are, for example, reported to tell more and disclose more information, both biomedical and psychosocial, than male patients (Roter et al. 2002). Female patients also more often seek care for symptoms that do not fit into the medical schoolbooks and such patients are often seen as difficult to help (Johansson et al. 1996; Malterud and Hunskaar 2002).

Gender bias, the fourth explanation for gender differences in health, is demonstrated when physicians and healthcare staff treat men and women with the same health problems and the same severity of symptoms in different ways – unintentionally and with no scientific evidence to support their doing so (Ruiz and Verbrugge 1997). Gender bias is considered to be caused by stereotypical and normative expectations of, and conceptions about, men and women. In several common diseases, research has documented bias disfavouring women patients, for example, coronary artery disease, Parkinson's disease, neck pain, irritable bowel syndrome, groin hernia, psoriasis and tuberculosis (Hariz and Hariz 2000; Hamberg et al. 2002; Hamberg et al. 2004; Koch et al. 2005; Chang et al. 2007; Karim et al. 2007; Osika et al. 2008). Still, there are studies indicating that gender bias in some situations affect men negatively (Hamberg et al. 2002; Kempner 2006), and there are important reports indicating that elucidating gender bias might be a step forward in reducing it (Johansson et al. 1999; Hamberg 2008).

All in all, research shows that sex- and gender-aspects are highly relevant in many fields of medicine.

Sex and gender

In gender research, sex and gender are distinct concepts. Generally, while sex signifies biological differences between men and women, for example, in chromosomes and reproduction, gender describes the variability between men and women that is attributable to society and culture. The concept of gender refers to the constantly ongoing social construction of what is considered ‘feminine’ and ‘masculine’, based on power and socio-cultural norms about women and men (Connell 2002). Gender is constantly created in interaction between people – we are all ‘doing gender’.

For physicians, the dichotomy between sex and gender might cause problems. Biological and social aspects are related and the explanation of a patient's health problem can seldom be ascribed to one of the categories (Williams et al. 2003). Teenage girls who exercise are doing gender differently than girls who are not physically active and the two groups will develop bones and bodies that differ. Many girls who exercise will probably have heavier bones than boys who do not exercise (Fausto-Sterling 2005). A gender perspective in medicine implies that life conditions of men and women, life styles, positions in society, and societal expectations about ‘femininity’ and ‘masculinity’, must be considered along with biology. Thus, research and education about biological differences between men and women (i.e., sex differences) does not per se imply that gender is investigated. To justify the use of the term gender, socio-cultural conditions of men and women have to be considered and biological differences discussed in their social context.

Gender in medical education

Knowledge about the impact of gender aspects in healthcare, implies that attention has been paid to recognizing gender as an essential component in medical education (Lent and Bishop 1998; Phillips, 2002).

To date most research about gender in medical education has revealed weaknesses that need correction. In a Swedish study, gender bias was found in most of the literature recommended in medical schools, and the researchers were worried about the stereotypical sex pattern that was consolidated in the texts (Alexanderson et al. 1998). A study of the cases used in problem-based learning at a Canadian university revealed that the content presented men as equivalent to people and women as other (Phillips 1997). Descriptions of patients were stereotyped, for example, nearly all depressed patients were women and feelings were commonly omitted in descriptions of male patients. A recent examination of the inclusion of women's health and gender-specific information in the curricula of US medical schools revealed that few schools offer such courses, or sessions within courses, despite a decade of official recommendations to do so (Henrich and Viscoli 2006). A current Dutch study showed that sex and gender differences beyond reproduction were mostly ignored in the medical curricula (Verdonk et al. 2006), and an inventory at a Swedish medical school produced similar results (Hamberg 2003).

Efforts to implement current knowledge about gender into medical curricula have been initiated in some medical schools (Zelek et al. 1997; Lent and Bishop 1998; Lawless et al. 2005; Verdonk et al. 2005; Henrich and Viscoli 2006; Verdonk et al. 2006). Traditionally, such endeavours are often grouped under the heading ‘women's health’, but in recent times concepts like ‘gender perspective in medicine’ or ‘sex and gender sensitive curricula’ are often adopted. Analyses and reports from such pioneer work signify that achievements are being made but also describe slow progress. Problems reported are lack of gender-knowledgeable teachers, institutional barriers, and the need for more obvious acknowledgment and support from faculty leadership (Jacobs, 2000; Henrich and Viscoli 2006; Verdonk 2007). However, to date not much research exists on how the implementation of gender is traced in medical education material itself. Gender in medical education is a new field and further research is crucial.

Case methods

During the last few decades, medical schools throughout the world have changed their curricula to include more self- or group-directed learning. In ‘problem-based learning’ (PBL) and ‘case method’ (CM) the education starts from a written case about a medical problem or a biochemical process (Towle and Jolly 1998). Both methods require the students to work in small groups, discuss the case, and search for the answers in relevant literature. Teachers are available as tutors and are usually present at the introduction and at the final session when the students present their new knowledge to each other. CM can also be performed by way of discussing and finishing several short cases during the same session (Tärnvik 2002). Case methodology is widely used in courses traditionally seen as comprising ‘the core of medicine’, that is, internal medicine, surgery and infectious diseases (Towle and Jolly 1998; Tärnvik 2002; Lawless et al. 2006). The cases presented to the students during each course are intended to highlight the most important diseases and relevant approaches to diseases. By presenting symptoms and diseases in the context of an individual patient, the possibilities that the students remember might increase. Inasmuch as the content of such courses has a great impact on what students regard as significant knowledge for their future, gender aspects have to be integrated into the cases.

At the Umeå University medical school in Sweden where this study was conducted, the curriculum was changed in 2000 and most courses now have CM mixed with lectures. As part of the new curriculum the faculty board also decided that a gender perspective should be integrated into all courses, when relevant.

Aim

The aim of this study was to investigate whether a gender perspective could be traced in the written cases used during the clinically oriented terms in the Umeå medical school, at the time when the new curriculum was implemented for all terms.

Method

Data collection

All teachers responsible for planning and organizing the various courses during terms 5–11 were contacted by e-mail. The largest course in term five was pathology, while the other terms were mainly clinically oriented. The course organizers were informed about the study and asked to contribute copies of all written cases used in their course during autumn 2005. Guidelines for teachers were also requested. Those who did not respond were reminded twice. Discretion was promised in that no names of responsible teachers or case authors would be revealed and no copies of the cases would be seen by anyone other than the researchers.

A few courses used PBL instead of CM. In this article no distinction is made between the methods and all written case descriptions are labelled cases. A few courses (professional development, orthopaedics, and a course in research methods) did not use written cases and are not part of this study.

Analysis

Content analysis was performed (Hungler and Polit 1999). After reading and discussing 20 cases, a preliminary coding schedule was devised. The guide was then modified after another 20 cases were coded. Both authors participated in this work. Thereafter, the second author coded all the cases and when any difficulties arose both authors discussed to find a reasonable interpretation. The variables coded were:

1. Guideline for teachers: yes, no, no information.

2. Sex of case author(s): male, female, no information. (In cases with several authors of the same sex the number of authors was not counted – e.g., three male and one female author was coded as ‘male’ and ‘female’.)

3. Sex of case patient(s): male, female, no information.

4. Sex of case doctor(s): male, female, no information.

5. Sex-specific problem or disease: yes, no. (Sex-specific implied that the problem/disease affects only one sex, i.e., abundant menstruation or prostate cancer. Breast cancer was seen as sex-specific for women.)

6. Biological sex-differences mentioned: yes, no. If ‘yes’, the biological factor mentioned was noted.

7. Psychosocial information about the case-patient's family situation, work, leisure activities, or lifestyle (food habits, smoking, alcohol, and drugs): in each factor yes, no.

8. The word ‘gender’ mentioned: yes, no.

The results of this coding were summarized and compared.

Finally, both authors reread all the cases to make a qualitative evaluation of gender in each one (Graneheim and Lundman 2004). Cases touching upon gender aspects were ‘gender-marked’. In line with the definition in the introduction, a gender-mark implied that at least one of the following aspects was considered and given some weight in the case text or teacher manual: life situations of men and/or women, their life styles, positions in society and societal expectations about ‘femininity’ and/or ‘masculinity’. The gender-marked cases were then categorized according to the importance given to gender in each case.

Results

All invited course organizers responded and 257 cases were collected. Based on the reports from the course organizers, the number of missing cases was estimated to be a mere handful.

Written manuals for teachers were available in 51 cases (20%), reported as non-existing in 168 (65%), and in the remaining 38 (15%) no information was found about whether or not there was a teacher manual.

Information about the sex of the case authors was found in 138 cases. Of these 107 (78%) had only male authors, 18 (13%) had exclusively female authors and 13 (9%) cases had both male and female authors.

The distribution of male and female patients in the cases was fairly equal. Altogether 247 patients were described: 120 men (49%), 112 women (45%), while in 15 patients (6%) the sex was not specified.

The descriptions of the doctors were most often gender neutral, such as ‘‘You are a doctor at the X-clinic and this patient comes to see you …’’ The sex of the doctor was defined in eight cases, two were women and six were men.

Most cases dealt with health problems affecting both sexes (237, 92%). Thirteen cases (5%) focussed on conditions affecting only women and seven (3%) dealt with conditions that are sex-specific for men.

Biological sex differences were touched on in 17 cases (7%). In two of these, dealing with length of life and tiredness respectively, biological as well as psychosocial and cultural aspects were discussed and given some weight. In the other 15 cases, there was only passing references to biological sex-differences (Box 1).

Table 1.  Proportion of cases containing information about the case-patients’ family situation, paid work, lifestyle, and leisure activities

	Total (N = 247)	Female patients (n = 112)	Male patients (n = 120)	Patients sex not defined (n = 15)
Family situation	112 (45)	57 (51)	50 (42)	5 (33)
Paid work	80 (32)	35 (31)	39 (33)	6 (40)
Lifestyle	69 (28)	32 (29)	34 (28)	3 (20)
Leisure activities	53 (21)	21 (19)	26 (22)	6 (40)

Note: Number and column per cent (%).

Box 1 Cases mentioning biological differences (or similarities) between men and women

Seven cases touched upon sex differences related to fertility and childbirth: investigation of infertility, disease post partum, pregnancy and breast-feeding as contradiction to trombolysis, prophylaxis against malaria during pregnancy, hepatitis during pregnancy, abuse of drugs in a pregnant woman, low stomach pain in women.

Ten cases brought up biological sex differences in the following: heart disease, iron deficiency, glaucoma, side-effects of medical drugs, increased levels of androgens, prevalence of diabetes, length of life, dangerous consumption of alcohol, urinary tract infections, and growth disturbances in children.

The facts given about the patients’ psychosocial contexts are summarized in Table 1. The information was generally sparse regarding content and few words were used. It resembled the way a medical record is written. Typically psychosocial data were presented as ‘a 38-year-old mother of three children’ or ‘a retired 72-year-old farmer.’ As the manuals for teachers and questions to the students did not relate to the psychosocial information, it was not presented as being important. The amount of psychosocial information was fairly similar for male and female patients. Data about family and work were the most common. For a few case patients (18/247, 7%) all four categories family, work, lifestyle, and leisure activities were mentioned (not shown in Table 1). In 97 patients (39%) there was information about one of the four categories. Seventy-nine patients (29%) were presented without any psychosocial information.

The word ‘gender’ was mentioned in one case text and in two teacher manuals.

When scrutinizing the gender perspective in the individual cases, four cases were identified where it was obvious that knowledge about gender was seen as being a priority and important for the students to discuss. (Box 2, cases 1–4.) These cases seemed to be written with an aim of stimulating a discussion about gender and were thus categorized as ‘cases with a clear gender perspective’.

Box 2 Cases with a clear gender perspective

Case 1. This case concerned long-term pain and was written so that the patient's sex was not revealed. The teacher manual calls for a discussion about whether the management would differ in male and female patients and also in relation to the sex of the physician. The word gender was mentioned in the teacher manual.

Case 2. One-third of the students were instructed to collect knowledge about ‘‘gender aspects in depression’’ and later present the results to their fellow students. The other students worked with other aspects of depression.

Case 3. The main discussion in this case was why women live longer than men in many countries.

Case 4. A middle-aged woman complained about tiredness. The description pointed at her responsibility for family and relatives, risk factors for heart disease in women, and the higher frequency of pharmaceutical side-effects in women.

In ‘cases with gender as a partial aspect’, gender was not a main issue, but appeared as one of several secondary questions (Box 3, cases 5–10).

Box 3 Cases with gender as a partial or minor aspect

Case 5. This case posed many questions about anxiety, among them one about the fact that anxiety is regarded more common among women than men.

Case 6. This case focussed on a disease of the eye but gender aspects of the reception of a male patient was also considered. The word gender occurred twice in the teacher manual.

Case 7. A young woman encountered due to uro-genital symptoms. In the teacher manual it was underlined that one should reflect on whether the patient might have suffered sexual abuse.

Case 8. This case concerned fertility/infertility and as a part of this topic the question was raised about who in the relationship took the responsibility for contraception.

Case 9. A young woman sought help for acute abdominal pain and the students were instructed to reflect on whether rape or battering might have occurred.

Case 10. The case concerned statistical methods for determining prevalence and proposing preventive measures. The health problem used as an example in the case was violence towards women.

The analysis also revealed four ‘cases offering a possibility for gender discussions’. In these cases the texts indicated that the authors might have had gender in mind but there was nothing in the questions to the students or in the teacher manuals clarifying that it was important or relevant to consider gender (Box 4).

Box 4 Cases with a possibility for gender discussions

Cases 11 and 12. Both cases had male patients described as stoic, calm and autonomous. One was portrayed as a ‘'real Northlander’’ who for a long time abstained from seeking care and the other didn’t want to go to the doctor but agreed to go because his wife wanted him to. Here it would be possible to discuss knowledge and prejudice in our beliefs about men's and women's healthcare-seeking behaviour.

Case 13. Abuse of alcohol is presented as one reason for the patient's health problem and some biological differences between men and women involved in alcohol abuse were discussed. Here it is possible to also discuss social, psychological, and cultural aspects of alcohol abuse in men and women.

Case 14. The focus here was on uro-genital symptoms in a middle-aged woman. The students were asked to reflect on the psychological and social significance of menopause.

Discussion

Constructing written teacher manuals is an easy way to ensure that all students are offered an equally good education. It was therefore surprising that two-thirds of the collected cases lacked a tutor's guide. Such guides seem to be especially important and valuable for teachers when new approaches such as gender perspective and case method are introduced. At best, leaving the teachers without manuals and practical ideas might be a sign that the course organizers have great confidence in the teachers’ abilities or respect their autonomy, but it could also be a sign of neglect and lack of support.

The analysis revealed four cases with a clear gender perspective, constructed with a focus on gender, and six cases where gender was included as a partial aspect. Considering that the faculty board had decided that a gender perspective should be mainstreamed into all courses, the result was discouraging. It is reasonable to believe that more cases dealing with gender are needed for students to become accustomed to identifying and reflecting on gender as an important determinant for health and disease. Furthermore, we believe that it is important that questions about and references to gender form part of the instructions to students and are not reserved for teacher manuals. Well-prepared students, who are informed about the issues that are prioritized, are a prerequisite for good discussions.

Our study revealed that the patients’ psychosocial conditions were often omitted or neglected in the case texts. Such was the case although the study foremost concerned clinically oriented terms, where an important goal is that the students shall learn to see the patient as an individual with his or her personal history, experiences, and needs. There were a few cases that clearly focussed on ‘the whole patient’ and the person in context, but generally social information seemed to have been included more as padding. Nor did the questions posed to the students direct attention to socio-cultural aspects. These results are in line with findings in a Canadian study of PBL cases where accepting the metaphor of the body as a machine, with its implicit endorsement of the idea that the whole is no more than the sum of its biological parts, was central (Phillips 1997). However, since gender perspective implies seeing health and disease as an interaction between biological processes and life situations of men and women, putting the spotlight on biology alone has serious consequences. Inasmuch as socio-cultural aspects are marginalized, a gender perspective is precluded. In an article concerning putting principles about gender and culture into practice in medical education, the authors underlined the importance of incorporating such dimensions into the mainstream of the curriculum, that is, into the case studies (Lawless et al. 2005).

What might be the reason for the lack of gender perspective in the cases despite the official school policy about integrating gender? A lack of knowledge about health-related gender issues among medical school teachers is reported in previous studies conducted in Sweden and elsewhere (Phillips 1997; Risberg et al. 2003; Westerståhl et al. 2003; Verdonk 2007). Methods are needed to support and educate the staff and deficiencies in implementation strategy and monitoring are possible reasons for the low number of cases that consider gender. Providing support to the teachers in the form of educational material, such as problem-based cases and audio-visual material, was shown to provide a better opportunity for integration of gender in a project involving Dutch medical schools (Verdonk et al. 2005; Verdonk 2007). It is shown that to succeed in tempting lecturers to participate in courses, the faculty leadership must show in practice that such education is important (Jacobs et al. 2000), for example by participating themselves in the course. A precaution worth testing might be to reward teachers who attend gender courses. Several studies have exposed that female teachers are more aware of gender than male (Risberg 2003; Westerståhl et al. 2003), and this underlines the importance that male teachers should also be encouraged to increase their gender awareness.

Parallel to the lack of knowledge, resistance toward the implementation of gender due to political–ideological connotations of gender issues is reported in several studies (Westerståhl et al. 2003; Risberg et al. 2006; Risberg et al. 2008). Such resistance might be expressed as negative attitudes and downgrading of the relevance of gender for medicine. This downgrading will serve as an excuse for not participating in further education and for not implementing gender in the education. Although handling resistance toward gender is a delicate problem, a key question is that the leadership is distinct about the importance of gender, not only in words but also in the allocation of financial resources and time (Beck Weiss et al. 2000; Jacobs et al. 2000; Verdonk et al. 2006).

We did not ‘gender mark’ cases that touched on biological differences between men and women, unless they also saw the patient's health problem in a broader socio-cultural context (Box 2, cases 3 and 4). Deciding which malaria prophylaxis should be prescribed to a pregnant woman is important but can be discussed on a restricted biological level, considering for example, the risks of foetal damage, and is therefore not gender discussion per se. This being said, it is important to underline that there were a few cases related to recent research about biological sex-differences in, for example, heart diseases, immunological diseases, and the side-effects of drugs (Legato 2004). A few cases with focus on ‘sex-differences in disease’ would be an achievement. In such cases,students might become acquainted with established knowledge and contemporary research about sex differences but would also be offered a chance to discuss risks that might result from exaggerating sex differences. A strong focus on sex-differences, in prevalence of diseases for example, might in fact cause bias and lower quality of treatment in the sex in which the disease is less common (Ruiz and Verbrugge 1997; Hamberg et al. 2004).

In a qualitative study about medical students’ attitudes to gender education, some students complained that teachers lacked insights and that the low theoretical level in the discussions risked strengthening stereotypical ideas about men and women (Hamberg and Johansson 2006). This problem has to be considered. Repeatedly describing male patients as robust and patient as in cases 11 and 12 (Box 4), while using female patients as examples of worry and anxiety, might bias perceptions (Risberg et al. 2006). Women with serious diseases might then be misunderstood and their healthcare needs neglected. Similarly, in men, anxiety as a reason for seeking healthcare might be overlooked resulting in unnecessary investigations and treatments. This illustrates that the question of gender in case texts is not limited to whether men and women show up in cases, but also how they are described. As shown in Table 1, there were no or small differences regarding how often psychosocial information occurred in male and female patients. For example, information about paid work occurred in about 30% of both male and female patients, while comments about the family were a bit more frequent in women (42% in men and 51% in women). We have received few examples of good or bad case texts with regard to gender stereotypes since one, a main finding in this study, was the deficiency of psychosocial and contextual information, and two, the existing information was short and condensed.

Including psychosocial and cultural aspects in the case texts, making gender issues visible in doing so, and formulating questions for the students that actualize gender without reinforcing stereotypes, requires teachers who have insights into gender issues. The importance of the teachers’ competence regarding gender is also underlined in earlier research (Phillips 1997; Lawless et al. 2005; Verdonk et al. 2006; Risberg et al. 2006; Hamberg and Johansson 2006). On the one hand, there is a need for a few experts who are skilled and have expert competence in gender research; on the other, the large majority of teachers need sufficient competence to manage a gender discussion in their own area.

But how can then the ‘ordinary teachers’, without expertise in gender, secure that gender stereotypes are not reinforced in their cases? One measure is to outline the case texts in joint sessions, which include teachers from different courses and some who are skilled in gender. Another way is to discuss and evaluate potential gender stereotyping in the case material with students who have participated in the case discussions. They can report about the associations and discussions that developed in their own case groups and in that way the preconditions for improvements of the case texts increase. Among the students there might be some who are knowledgeable about gender issues and their competence can be taken into account.

Methodological considerations

Due to the available resources we could not investigate all terms 1–11. We chose the later part of medical education, terms 5–11, because the studies during these terms concern diseases and ill-health in patients rather than normal anatomy and function of single organs or basic biological processes, like urine production or the life-cycle of blood cells. Inasmuch as a gender perspective was implemented and mainstreamed in the education it should be visible in the cases during the more clinical terms.

This study concerned gender in the written cases and is not an investigation of the gender perspective in the education as a whole. Gender aspects might have been discussed despite their absence from the case text, or neglected in discussions even when included in case texts. In addition, gender might have been presented during lectures, seminars, or in the literature. We also do not know whether knowledge about gender was examined. This study illuminates whether gender was included in the written cases, that is, in educational material that all students were required to work with, but to obtain a more complete picture of the implementation of gender, interviews with or enquiries to students and faculty are suggested.

There were many cases that lacked information about the author. Thus the proportion of cases with male and female authors must be treated with caution.

Previous research shows that the very process of evaluating gender in education might stimulate new ideas and lead to improvements (Verdonk et al. 2005). We had the same experiences in this study. The involvement of the course organizers in collecting the cases made them aware of the study. Preliminary results were presented to them and their comments, explanations, and questions helped us in writing this article. The discussion was also a way to deepen the teachers’ awareness and knowledge of gender.

This study involved one Swedish medical school. Since the implementation of gender might show great variation among individual schools, even in the same country, the transferability of our findings is restricted concerning numbers and figures. However, case methods are common in medical education, and the tendency to downgrade the importance of psychosocial aspects is a widespread feature in medical work (Pauli et al. 2000). Likewise, several studies report about a lack of knowledge about gender among medical teachers, and even a resistance toward the implementation of gender (Risberg et al 2008). Thus we suggest that: (1) despite official decisions about gender implementation, there is a need to examine if gender is addressed in the educational material that is used; (2) our way of scrutinizing the cases might be useful in gaining an overview of gender in cases in other medical schools; and (3) our conclusion, that marginalizing psychosocial and cultural issues implies hindering the implementation of gender issues, is transferable to other medical schools.

In addition, we suggest that further research on gender in case methods should involve medical schools from several countries to make it possible to compare, learn from each other, and expedite the implementation of gender in medical education.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Katarina Hamberg

KATARINA HAMBERG, MD, PhD, is a general practitioner and associate professor at the Medical Faculty, Umeå University. Her research includes studies on women with chronic pain, gender aspects in the patient-doctor relationship, and gender bias in medicine. She is engaged as a Senior Lecturer and her teaching is foremost within the course ‘Professional Development’.

Marie-Louise Larsson

MARIE-LOUISE LARSSON, is medical student at Umeå University.