The bad news is that hospital medicine remains a male-dominated, macho profession
A QUIET revolution has taken place in the NHS over the last 20 years. It may be termed the feminisation of medicine. In some ways it could be more significant than all the managerial and market reforms of recent decades put together.

In the last 10 years the number of women hospital doctors has risen by 72 per cent. They are still in a minority, accounting for one in three of all hospital doctors, but that is a striking improvement on the situation a decade ago when they accounted for only one in four.

Increasing numbers of women are also moving into the top career posts. The proportion of consultants who are female has risen by almost half in the last decade, from 14 per cent to 20 per cent. In five specialty groups, including paediatrics, obstetrics and surgery, the number of female consultants has more than doubled in a decade.

That is the good news. The bad news is that hospital medicine remains a male-dominated, macho profession where performance on the golf course and in the locker room may count as much as in the operating theatre.

Take surgery. It is true that the number of female consultant surgeons has more than doubled in a decade, from 75 to 180. But before you applaud, consider that male consultant surgeons number more than 3,800. The women account for less than one in 20 of the total.

This is worrying for every patient faced with an operation - and not just for reasons of gender politics. Unless more women are recruited to surgery, standards will inevitably decline.

Simple arithmetic shows why. Women account for more than half the number of students now admitted to medical schools and the proportion has been above 40 per cent for more than a decade. If surgery draws on only half the student pool - the men - then the quality of its recruits is bound to fall relative to those specialties that draw from the whole pool of talent.

There is another reason why women are needed in surgery. In some specialties, such as orthopaedics, which involves the manipulation of large bones and joints, it has been thought that a degree of physical strength was required which would be beyond most women.

That is almost certainly another macho myth - but we will let it pass.

More importantly, modern keyhole surgery, which requires dexterity and good hand-eye co-ordination, is more akin to sewing than to carpentry and may in fact be better suited to women, who often acquire skills in fine hand movements from an early age.

There are some signs that women are becoming more interested in wielding the surgical knife. At the junior doctor level 22 per cent of surgeons are women, but by the time they become specialist registrars only 9 per cent are female. The rate of attrition is high.

Seven years ago the Royal College of Surgeons established a specialist unit to encourage more women into surgery, but it has had limited success.

A spokeswoman said that it took a minimum of seven years to train a surgeon.

"We have moved from a very poor situation 10 years ago to one that is not quite so poor," she said.

The lack of a role model is felt keenly by women surgeons who are struggling to make an impact in a world where male values prevail.

"It is the loneliest feeling in the world when you are operating alone late at night on a patient who is rapidly going downhill, and the anaesthetist looks at you and asks how long you are going to be,'' said one female surgeon. "Everything hinges on you. You go to bed wondering whether you have done all right, and if next morning the patient is doing badly you take it all on yourself.''

Senior surgeons like to see people with the "right stuff'' coming up the ladder, and patronage is important. Playing golf with the consultant is recognised as something that junior surgeons do to further their careers.

Women, on the other hand, are more often patronised - seen as someone who can provide the male surgical staff with tea and the patients with succour.

Although opportunities for part-time training have increased, most women medical students fear that a career in surgery will be incompatible with motherhood and a normal domestic life. More provision needs to be made for women doctors to train and work flexibly. They also want to be valued more highly for their skills, not just seen as a shoulder for the patient and their relatives to cry on.