Not a week goes by that I don’t have a conversation with an amazingly successful women physician who states: “I’m thinking of quitting.” They are succeeding in all their goals: leadership, family, practice improvement, the highest level of patient care, contributing meaningful research and/or teaching, and even getting some homemade muffins or a bottle of cherry wine from patients on occasion.
Why would someone in this situation feel so dissatisfied to consider leaving the profession they have dedicated their life to? The data continues to accumulate that maybe, just maybe, it could be all about their gender. We are a data-driven group, and complex problems rarely have simple explanations or simple solutions. However, complex issues often have a common theme that travels through and is often a difficult theme in plain sight. Acknowledgment may make us feel powerless. Instead, we claim that it isn’t as bad as we are experiencing it to be. This disconnect is either internal (cognitive dissonance) or external (gaslighting). We will explore some data around pay, daily practice, expectations of female physicians, and the domestic division of labor. Odds are, you already have a hunch of the gender issues at hand, but I’m an internist; I need data.
A 2022 study of 54,479 academic physicians demonstrated that women physicians are offered lower starting salaries right out of training in 93% of 45 different subspecialties. This concerning trend only worsened; after ten years, 96% of subspecialties have lower women’s salaries with the same training in the same specialty. This easily extracts millions of dollars over certain careers for no other difference but one demographic feature.
It is unanimously accepted that physicians tolerate the EMR (electronic medical record) but often feel abused by it. Something that few are aware of, the EMR is used differently by women physicians. Women primary care physicians (PCP) receive 26% more messages from patients and 24% more from staff than male PCPs. As a hepatologist, I often received patient messages: “So sorry, doc, I went to a wedding and drank too much; I thought you should know.”
I know of a female orthopedic surgeon who has a fabulous bedside manner. A patient saw her for the initial consultation. The patient decided to have the surgery by one of her male colleagues. Post-operatively, the patient continued to message the female: “Because you are so much easier to talk to than Dr. X.” She kindly let the patient know that her operating physician was the one she should direct her questions toward. Now guess who’s Press Ganey scores suffered at the end of the month? Guess who missed out on surgical RVUs?
As a female gastroenterologist, the reality of the patient mix also feels like a setup. 60% of gastroenterology patients are female and are more likely to request a female to do her colonoscopy (only 13 to 18% of gastroenterologists are women). That’s all wonderful, except for a few key facts: female patients have longer colons with more twists and turns due to pregnancies, hysterectomies, and more “parts” to navigate through anatomically. It takes more time to complete a single female patient scope vs. a male colon scope. Therefore, we do fewer colonoscopies on the same 8-hour day, and, interestingly, women patients form fewer polyps (RVU/reimbursement is higher with polyps to resect). Therefore, we do more technically challenging procedures, take several minutes longer per procedure, and have lower reimbursement than our male colleagues. This is not a level playing field.
“We all have the same 24 hours in a day.”
The evidence shows that, for women and men in an opposite gender partnership as physicians or scientists, women do 8.5 more hours per week on domestic activities vs. their partner. A recent Lebanese study surveying 3,866 physicians found that full-time physicians (male vs. female) spend the same long hours at work (60.2 vs. 58.3). However, those women physicians spend 23.5 hours/week on parenting vs. men physicians 10.4 hours and women physicians spend 8.9 hours per week on household work vs. 6.0 hours per week for men.
As with everything except Zoom and Amazon, the pandemic has only worsened. Multiple studies have documented what we have lived, the domestic inequality of parenting and other non-money generating work greatly worsened for women. A large U.S. study revealed that during the first year of the pandemic, women had primary responsibility for childcare 56 to 72% of the time compared to men 11 to 33% of the time. Even when both parents pivoted to working from home, women did 84% of children’s education while men did 50%.
In conclusion, we cannot change societal norms, gender biases, childhood needs, the education system, or stop a pandemic. But, we can stop gaslighting 50% of the population. We can start acknowledging that the simple fact of gender does greatly affect patient and support staff expectations, time, power, compensation, and career trajectory. Women physicians have gained much ground, but this world and life are nowhere near a level playing field yet. When we all work together to allow our women physicians some flexibility in schedules, 10 to 20% more administrative time, transparent salary offerings, remote work options, extra “flex days” for children’s medical appointments, on-site childcare, and considerate timing of “mandatory” meetings we can set us all up for success. These are radical proposals that are not “fair and equal,” but they address the reality of unequal experiences. Maybe then we can stop the hemorrhaging of women physicians from health care. When we acknowledge and tweak current systems and structures to accommodate the 50% of medical students graduating, we are setting ourselves up for success.
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