Shows the existence of differences by gender in dental students' expectations.
Suggests that women prefer working with people, while men are concerned about professional status.
Suggests that the teaching process is still based on the technicism of the biomedical model.
Introduction With the significant increase of women in dentistry, the profile of the dental professional has been altered.
Aim To investigate the discourses of future dental surgeons, of both genders, from public and private universities of Curitiba, Paraná, Brazil, to detect whether gender profile differences can influence training and intended future practice.
Methods The problem is approached using a qualitative design, with the strategy of collective interviews in focus groups followed by a discourse analysis.
Results Women choose dentistry mainly because they like working with people and want to have formal employment in the future. Male discourses show a desire for professional status, worthy business prospects, and the flexibility of being self-employed. The analysis of the university education process revealed that men desire learning that is more technical, besides knowledge on business management, whereas women still complain of current prejudices in the personal relationships that exist with teaching staff and colleagues.
Conclusion The teaching process, based on the technique-driven biomedical model, has not reached an ideal standard for the female gender in terms of training, which would be a model based on empathy and good relationships with human beings.
Published research and official government data have shown an unprecedented change in the last two decades. It is characterised by the rise in the number of female workers in several fields of the labour market worldwide.1 As such, it is related to the expansion of schooling and women's access to universities.2 In dentistry this change has been particularly noteworthy, with the majority of women being able to gain recent access to dental schools in many countries.3,4 In Brazil, progressive feminisation of the workplace is undeniable.5,6,7
The literature highlights some of the motivations for following a career in dentistry such as: financial benefits, good business connections/prospects, working in a socially connected environment, and timetable flexibility.6,8,9 The literature also exemplifies that for men, the biggest motivation is job security, good business connections/prospects, professional status, and regular working hours, while for women it is the possibility of a stable, interactive environment, working with people.10,11
In the contemporary world, women's professional practice still needs to be investigated in the light of a possible persistence of a family model that influences women's social roles as well as choices in their personal lives. There is a perceived constant cycling between family and professional roles,8,12,13 reflected in the reduction of hours worked by female dentists, which is sometimes less than those worked by men.4,14,15
There is evidence of differences in the degree of job satisfaction among dental surgeons of both genders, regarding the amount of personal time and moral/ethical issues surrounding the profession. In practice, women say they are frustrated as the dentistry they undertake does not fulfil the objective of being a profession which serves the needs of a human being.16,17 They instead consider the most important component of working to be for moral gain/benefit and not commercial.16,17 Women dentists in the public sector reported that they do not have an influence on important managerial decisions, and there is a lack of interaction with their superiors and other colleagues; they hold lower positions on the hierarchy in the service;18 and have lower salaries.19 In dentistry, the male hegemony seen in many countries in faculties and dental education has since undergone a shift towards female predominance,20 however, academic administration remains a male-dominated field.3,20,21,22
The stereotyping which, at times, appears in areas such as the surgical practice,23 as well as the relative absence of examples of females in surgery, appears to negatively affect women's choice of dedicating themselves to oral and maxillofacial surgery. In addition, the time required to qualify and the lack of time for cultural activities and a social life are indicated as obstacles for women.24,25
There are also concerns about the characteristics of females and their position as university students. According to Gilligan,26 the 'ethics of care', as a female mentality, stems from a normative ethical theory that holds interpersonal relationships and compassion as a fundamental advantage of moral action, which prompts the professional women's way of being. Kfouri et al.27 concluded in a literature review that the reasons that led Brazilian women to choose dentistry seem to be related to traditional notions (in the context of culture and biopolitics) of a natural feminine inclination to care for and be sociable with other people. The ability to communicate and open a dialogue,28 along with the humanisation of care,29 are considered relevant aspects commonly associated with women according to service users. On the other hand, the long-standing profile of dental schools should also be considered. In the biomedical teaching paradigm, following the successive reforms of Flexnerian/Giesian inspiration, curricula and disciplines have resulted in the prevalence of the cognitive domain and the instrumental aspects of the clinical-surgical practice, with emphasis on mechanicism, biologism and individual assistance.5 Interpersonal relationships, education/prevention and concern for the community were not considered important in universities where the traditional biomedical model is still highly valued despite the many historical movements directed toward promoting these ideals.30 Based on these theoretical grounds and rationale, the aim of this study was to investigate the discourses of future dental surgeons from public and private universities of Curitiba, Paraná, Brazil, seeking to detect whether the differences in gender profile can influence aspects of the way they intend to practise the profession in the future.
Materials and methods
This study used a focus group, a qualitative research technique derived from group interviews that collects data through group interactions.31 It seeks to gather information that can provide an understanding of the perceptions, beliefs, and attitudes about the theme chosen for this work. Data were collected from four groups which were intentionally formed so they would embody the diversity of the educational experiences of the sampled subjects. The groups shared common experiences that are associated with the central theme under study. Therefore, they were homogeneous in terms of characteristics that interfere in the perception of the focused subject.
The groups of students in Curitiba, Paraná, Brazil, were formed as follows: two focus groups from a public, institution-free dental school, one made up of women and one group of men; and two other groups with the same previous characteristics, but made up of students from a private university. Six participants were invited to participate in each of the four groups, making a total sample of 24 subjects. In each group, the six students were subdivided between three students in the first year and three of the last year, in their respective undergraduate courses. All subjects signed a free and informed consent form prior to the focus groups being held. The study was approved by the Research Ethics Committee of the Pontifical Catholic University of Paraná under number 5957.
The interview script was elaborate, containing only a few essential 'triggering questions' emanating from theoretical assumptions and the literature review. Granting the requirement that the moderator has substantial knowledge of the topic under discussion so that the group is led properly, the task was assigned to the first author of this article. The subjects were directed to the object under investigation: a) the motivations that influenced their choice of profession; b) future plans and outlooks regarding the profession; c) the strategies and attitudes which should be adopted in the professional relationship with future patients; and d) suggestions on the teaching/learning of dentistry, capable of leading to an improved university education.
The focus group dialogues were digitally recorded using two recorders (to maintain a backup), and were then transcribed and imported into the ATLAS.ti 5.0 software (visual qualitative data analysis). It stores, handles and analyses qualitative data, consequently the focus group's transcribed text files were generated for use in ATLAS.ti and are referred to as 'hermeneutical units'. Such units are processed by coding mechanisms – 'code' meaning that the keywords that summarise themes and points of view are related to the script of the interviews. As participants' citations relate to certain topics relevant to the research, they are classified under the same code. ATLAS.ti has a tool for grouping codes into larger units, called 'code families', which have some conceptual affinity. For example, a code that categorises men in an interview (M), and a code that categorises women (F), was grouped into a family called 'gender'. Finally, we use the 'network editor', which is the means to construct interpretive models, giving a heuristic and intuitive touch to the qualitative analysis, without losing the systematicity. With the help of this program and the triggering questions used in the interviews, the data were organised into four categories of analysis to facilitate the interpretation/comprehension of the discourses, as well as subsequent discussions based on the theoretical references.
The discourse analysis strategy was used,32 taking a pragmatic approach, thus contemplating two complementary moments: specific analysis of each group, and cumulative and comparative analysis of the set of groups performed.
The organisation of the discourses followed the plan previously designed for the groups, that is, the interview script with four driving questions with correspondent interpretative categorisations or repertoires.
1) The motives that influenced the choice of profession
In this first interpretative repertoire, the majority of the men spoke about their motivation in choosing dentistry as it is a profession that provides financial return, confers respect and trust in general, and allows for flexible working hours. Many reported that they would have preferred medicine, and that dentistry was a second option because of the family patronage in getting on the course and conducting the career: 'My father's a dentist [...] I thought it would be easier this way' (R8, male).
Other excerpts of discourses, such as 'What matters today is working for yourself. The respect for professionals [...] I think that's what it comes down to' (R12, male); or 'I already work as a prosthesis technician, but I want to gain more professional respect' (R1, male), illustrate the remainder of what the male focus group members said.
The first year students also listed their choice as being down to its existence as a health-related profession, which helps people to regain their smile and improve their quality of life; thus demonstrating a degree of idealism and altruism more evident than the final year students. It stands out that younger male students are primarily concerned with financial expectations and professional status and, secondly, with personal and technical dimensions: 'I think that what you earn, you being able to decide your own salary, being able to help someone [...] to provide a good service' (R11, male).
With regard to the female gender, the contents of the interviews reveal that working in the area of health was always their first choice: 'I've never imagined myself outside the area of health'(R22, female). Even when asked by their parents to study medicine, some women opted for dentistry and had thought of this possibility ever since they were children. In this sense, female vocation seems to be more evident. The statement 'Ever since I was little I wanted to be a dentist [...] my father wanted me to study medicine [...] but I wouldn't change it for anything' (R17, female), illustrates this interpretation.
The ethics of care, as quoted in the introductory section, appears in the statements on the motivation behind the choice of career: 'I was motivated by contact with dentistry professionals [as a patient][...] the way I was treated' (R14, female); or 'The way I was treated and the care I had from my dental professional' (R24, female), and 'When I was little I heard people speaking well of dentists' (R24, female). Again, working with people was much valued among females. Some of them said: 'I really like working with people' (R14, female); or 'What matters to me is dealing with people [...] chatting [...] interacting with them [...] giving full attention [...] not just taking care of teeth' (R18, female).
The flexibility which this profession can provide was also highlighted by the women and was evident in their discourses in the following way: 'The fact of being my own boss [...] of me being able to decide my working hours' (R18, female); or 'The fact of dependent [sic] only on yourself [...] a doctor depends on the team' (R21, female).
2) Future plans and perspectives regarding the profession
The expectations of the male gender as to their professional future include studying more, as illustrated by this statement: 'I intend to carry on studying and afterwards set up my dental practice' (R2, male). The option for private practice was mentioned in several male interviews, although the possibility of working in the public health sector was not entirely discarded. One of the focus group participants said: 'I think that in public services the procedures are simpler and I'll manage to get the financial means [to set up a private practice]' (R5, male).
The financial element and the prospect of earning a significant amount of income are clues in the dialogues of the male interviewees. The examples are: 'There's a sort of uncertain expectation about what you'll earn' (R7, male); 'You need to be patient to build up a client base and become known where you are. Earning decent money depends on you, on your dexterity' (R9, male); 'I don't recommend working with health plans. You're going to be totally exploited' (R10, male).
The female gender shows itself to be divided. Students from the public university are more inclined to formal employment in the public health service: 'Working in the public service provides stability. Working in private practice doesn't, [it's better] to be employed and to take a postgraduate course' (R16, female). Although most female students from private universities demonstrate the intention to choose private practice, they do not reject working in the public service. However, they are just deciding the direction of their professional careers after taking postgraduate courses or acquiring greater skills: 'At the moment I don't want to work as a dentist. I want to take a specialisation course [...] orthodontics' (R15, female); or: 'Take a master's degree and a PhD' (R20, female).
3) The strategies to be adopted for professional relationships with future patients
Here, the students spoke of marketing resources such as mailing lists and intensive networking, personal appearance and the appearance of the workplace, as well as detailed technical instructions to patients regarding treatment.
The question of personal relationships denoting affection was not evident among men: 'In addition to having a good relationship with the patient, you [need] to be a good professional [...] there's no point in being someone highly considerate that everyone likes, if you're an irresponsible professional or if you haven't got sufficient technical capacity to carry out the procedures [...] so I think that having technical ability and knowledge is very important for the patient to trust in you. To accept your treatment [...] your price [...] if you want to make money [...] but if you don't know how to explain, to provide information [...] the patient won't trust you enough to use his money to pay you' (R1, male). This statement is emblematic and is a very good summary of the other male testimonials.
Regarding the female students, gaining patient fidelity is a synonym of affection and personal relationships. Even when they mention a relationship based on technical skills, they add that a whole-hearted, welcoming approach is necessary. The illustrative statements are: 'Respect comes in first place [...] meeting his [the patient's] needs' (R14, female); or 'Honesty, being very clear with the patient' (R21, female); and 'Conversation puts the patient more at ease [...] that's the main thing' (R22, female); culminating in 'He's not merely a patient [...] there's an entire person [...] an entire life'(R13 female). Contrary to the men, the women did not mention financial gains as motivating this more affectionate approach.
4) Suggestions as to the teaching of dentistry leading to improved university training
The men were said to have spent more hours on clinical practice, learning more about consulting room administration, greater emphasis on political issues through participation in student organisations and dental professional defence movements, integration between dental knowledge and other health sciences, as well as more socialising in the university environment. Testimonies such as: 'People who graduate from here are going to set up a private practice and need a discipline that better explains how a consulting room works [...] We lack practical approach [...] we have had very little contact with certain clinical situations [...] when we get out there the teacher won't be with us any more' (R3, male); or 'More emphasis on the defence of dentistry rights [...] training professionals who are more responsible to put over a good image of the profession' (R6, male).
For the women, the most important point for improving professional training was teachers' commitment, attention, interest in coaching, understanding and respect for the students. The figure of the teacher was the most mentioned among the female interviewees, demonstrated by the statements: 'The teachers could be more polite' (R19, female); 'Male teachers [should] respect the number of women in the room and see that they are going to be future dentists' (R22, female); 'If we don't treat them well [the teachers], there'll be no smile' (R20, female); 'They explain things sort of superficially' (R17, female).
Two testimonies stood out; a male one and a female one, which provide clues as to the place women may occupy in the view of the students. One male student said: 'The female teachers say that the majority of students are women but that the male students are the best' (R11, male). A female student reflects: 'Yes, but at the dental implant congress there were more men than women [...] how strange! Aren't there more women than men?' (R19, female).
In general, the discourses do not show important differences between students of public and private schools. Some first year male students in both schools did show themselves to be considerably more committed to humanitarian objectives, than their final year male counterparts, although, generally on the key issues, the groups were very homogeneous.
This qualitative study aimed to investigate the discourses of future dental surgeons to detect whether gender profile differences can influence training, attitudes and intended future practice.
The results showed that women choose dentistry mainly because they like working with people and want to have formal employment, as suggested in the literature.18,19,33 The majority feel attracted by the clinical area and several mention aesthetics and orthodontics as specialities they would like to practise, as found in previous studies.33,34,35 In Brazil, recent literature shows that female dentists taking postgraduate courses do so mainly in the area of paediatric dentistry, followed by public health, aesthetic dentistry and endodontics.33,34 Brazilian women dentists' disposition to work in the public health sector suggests that they prefer not to opt for the competitiveness of private practice. Women make up the majority of Brazilian professionals working in public services.33 With regard to the presence of female professionals in hospitals, cases have been reported of sexual harassment from their male colleagues.35
In the study undertaken by Garbin et al.29 the majority of service users interviewed consider that the aspects relating to humanisation are the most relevant during dental care. As to their personal life, the women were unanimous in stating that they intend to have a family, which reflects the tendency of working fewer hours a day.4,14,15,36
The men, in turn, emphasise a profession aimed at financial gain and do not discard practising the profession outside of the large urban centre in a clear statement that they value profit.29 The female students' answers show that they value working with people and conversing with patients among the most important characteristics of the profession, which is also in agreement with the literature.10 Female dentists believe that personal interaction can, undoubtedly, create trustworthiness between the patient and the professional. This fact can be favourable to the more humanised provision of services, thus meeting the expectations of patients who, according to the literature, value above all the personal characteristics of professionals.17,29,37,38
The men demonstrated greater concern with the technical quality of their professional practice and with studying specialties. When they refer to personal interaction with the patient, this allusion is always made in relation to information about treatment and financial returns. The need to communicate is always accompanied by the concern about being a good technical professional. This did not appear in the female discourse, either in this study or in other findings in the literature.28,39
In the male and female students' discourses relating to the quality of university training, differences emerge in their perceptions. Whereas male students are concerned with improving technically and in becoming specialists, female students consider the personal characteristics of the teachers to be a determining factor in their education. This finding, obtained through the male and female interviews, is contrary to the results of Kelsey et al.40 who demonstrated that there is no difference in the perception of dental students of either gender in relation to university training. The women interviewed in this study always refer to personal interactions, especially with teachers, demonstrating that the way in which the teaching process is being conducted is not in keeping with the female consensus.41 They were unanimous in stating their discontent with the type of relationships that are built at university42 and encounter discrimination, even from teachers.
The mainstays of the education process and of professional practice continue to be technicism and entrepreneurialism,5 and in the view of the male students, the curricular contents taught on these questions remains insufficient. These characteristics of dentistry courses have been reinforced historically, without significant redefinition of goals. Some reforms in curricula, the growth of awareness of health promotion and of the needs of a diversified population can be felt in what is taught currently, but the biomedical paradigm is still prioritised.42,43 Women, who make up the majority of students, have some advantages in their social relationships, but the teaching process in dentistry courses tends to deny these advantages, instead favouring students whose skills lie in executing techniques.43 Female students feel the implicit prejudice in the attitude of male teachers in relation to them and consider them not to be very welcoming. This is a scenario that can also be observed in professional practice in several contexts.3,16,35
If the ability to work with people leads women to seek dentistry as a profession, this enthusiasm may be stymied at university when their relationships with people do not turn out the way they idealise and desire. To this end, male needs and aspirations are perhaps more valued and women end up adjusting to them, sublimating the attributes inherent to the female nature.26 Professions exist and last to satisfy a social need and although dentistry is commonly characterised as a vocational profession, internal issues cannot always explain the orientations, attitudes, and beliefs of its students, faculty members and graduates. Behind the educational structure of a dental course or a professional practice environment, there is the dental equipment and materials industry, externally influencing a direct relationship with the demands of the market. Based on the general trends observed, a market dentistry, characterised by private production and consumption of goods and services under market regulation, has been consolidated and will continue to advance for the next few decades in Brazil and many other countries. Dentistry has not overcome the technical concerns of a highly sophisticated and elitist professional practice. In many countries, there is excessive regional training and a concentration of dentists, most of whom provide only private services in cities, with partial insertion (in most cases) in part-time public services.. Dentistry often does not reach citizens residing in more remote areas. In some countries, the professional plethora is already generating tensions and underemployment, with a high-cost human resource being underutilised. Simultaneously, there is a recent decline in government spending in the social sector, due to structural adjustments and austerity policies. The growth of specialisations within dentistry, while resulting in profitable practices for the specialist, does little to improve public oral health. In the future, it would be necessary to gain clarity on the quality of the courses, especially in guaranteeing an egress with a professional profile that is linked to the needs of the population. The methodological strategy of using focus groups, as in this study, have been indicated as useful when the intention is to explore the opinions and values of the respondents.31 As such, the richness of the qualitative information that a focus group may provide comes from group interaction.44 Through this method, it was possible to create an interpretation of the issues being studied, converging on the social construction32 of the meaning of dental training based on the student perspective of gender.
Among the limitations of the study, it should be remembered that the approach does not allow for identifying more precise causal and correlational links between variables, since it is a qualitative cross-sectional technique with low variable control. Moreover, the intentional composition of the sample limits the possibilities of generalisation for the population under investigation.
The results could suggest that:
Women choose dentistry mainly because they like working with people and wish to have formal employment
Women appear to be more concerned with the humanisation of practice and components of their discourse reinforce the guidelines of the public health service
Men make this choice because they desire professional status, good business opportunities and the flexibility of being self-employed
In their discourse men also practise a form of dentistry marked by a past tradition, that of being a qualified and profitable profession.
In the analysis of the process of education at university, men were shown to want more technical learning and knowledge regarding business administration, whereas women were often shown to be unhappy with the personal relationships.
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da Graça Kfouri, M., Moysés, S., Gabardo, M. et al. Gender differences in dental students' professional expectations and attitudes: a qualitative study. Br Dent J 223, 441–445 (2017). https://doi.org/10.1038/sj.bdj.2017.810
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