Women in Health

Being a Doctor Is Hard. It’s Harder for Women.

Female medical residents and physicians endure bias and a larger burden with home duties. They also face a greater risk of depression.

By Dhruv Khullar

Happy medical residents are all alike. Every unhappy resident would take a long time to count.

It’s no secret that medical training is grueling: long hours, little sleep, rigid hierarchies, steep learning curves. It’s unfortunate but not surprising, then, that nearly one-third of residents experience symptoms of depression, and more than 10 percent of medical students report having suicidal thoughts. But is it worse for women than men?

A new study in JAMA Internal Medicine suggests yes. Dr. Constance Guille and colleagues analyzed the mental health of more than 3,100 newly minted doctors at 44 hospitals across the country. Before starting residency, men and women had similar levels of depressive symptoms. After six months on the job, both genders experienced a sharp rise in depression scores — but the effect was much more pronounced for women. A major reason: work-family conflict, which accounted for more than a third of the disparity.

Despite large increases in the number of women in medicine, female physicians continue to shoulder the bulk of household and child care duties. This unequal distribution of domestic labor is not unique to medicine, of course, but its manifestations are particularly acute in a physically and emotionally demanding profession with a lengthy training process that allows few, if any, breaks.

Despite large increases in the number of women in medicine, female physicians continue to shoulder the bulk of household and child care duties.CreditKaren Bleier/Agence France-Presse — Getty Images

The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties. Support for those trying to balance home and work life hasn’t kept pace with changing demographics, nor has the division of domestic labor shifted to reflect the rise of women in the medical work force. Today, women account for more than one-third of practicing physicians and about half of physicians-in-training. In 1966, only 7 percent of graduating medical students were women.

There’s a saying that you can’t take good care of patients unless you take good care of yourself, but as a colleague recently told me, “Try taking care of patients, yourself and two kids at home — while working 80 hours a week.”

Female physicians are more likely to cut back professionally to accommodate household responsibilities. Among young academic physicians with children, women spend nine more hours per week on domestic activities than their male counterparts, and are more likely to take time off when a child is sick or a school is closed.

Households in which both spouses are doctors are particularly illustrative: Women in dual-physician households with young children work 11 fewer hours per week (outside the home) compared with women without children. There’s no difference in hours worked by men, and this disparity hasn’t narrowed in the past two decades. Female physicians are also more likely to divorce than male physicians — and working more is associated with higher divorce rates for women but not for men.

These work-family conflicts are crystallized by the intensity of medical training, but gender bias within hospitals — both subtle and overt, from patients and colleagues — may be just as pernicious.

As a man of Indian descent, if I’m mistaken for anything, it’s for a cardiologist. (Which I am not — much to my mother’s chagrin). But for many female physicians, just getting others to call you doctor can be a daily struggle.

“I wear a white coat; I introduce myself as doctor,” said Dr. Theresa Williamson, a neurosurgery resident at Duke. “But patients still assume I’m a nurse or medical assistant or pharmacist. If there’s a man in the room — even if he’s a medical student and I’m the doctor — he’s the one they make eye contact with, tell their story to, ask questions of.”

It’s not just patients. A recent study explored how physician speakers were introduced at formal academic lectures, known as Grand Rounds. Female introducers almost always referred to the speaker as “doctor,” regardless of his or her gender. Male introducers used the formal title only two-thirds of the time — and were much more likely to use “doctor” for men than women. They used a woman’s professional title less than half the time.

“I remember being on a panel with all men, and the moderator thanking Dr. X, Y, Z — and Julia,” said Dr. Julia Files, an associate professor at the Mayo Clinic in Arizona and lead author of the study. “It happens all the time.”

After her study came out, Dr. Files said, “we heard from women across the world who said: ‘Thank you, this is our shared reality.’ ”

These biases can bleed into the way we do business. A new working paper by Heather Sarsons, a Ph.D. candidate at Harvard, examines whether surgeons’ gender affects their referrals after a good or bad patient outcome. Ms. Sarsons finds that physicians are much less likely to refer patients to a female surgeon after a patient death, but barely change their referrals to a male surgeon.

A bad experience with one female surgeon also makes physicians less likely to establish referral relationships with other female surgeons. There was no similar effect for men.

“That individual men and women are treated differently is obviously not a nice result,” Ms. Sarsons said. “But what’s really concerning is the broader spillover effects to other women.”

Medicine styles itself as both art and science. The science creates new knowledge and treatments. The art helps us recognize another’s humanity. But it also creates space for bias — conscious and unconscious — in how we treat patients and how we treat one another. These biases influence who is respected, who burns out and who is promoted.

By these measures, we’re not doing well. Female physicians are more than twice as likely to commit suicide as the general population. They earn significantly less than their male colleagues. They’re less likely to advance to full professorships — even after controlling for productivity — and they account for only one-sixth of medical school deans and department chairs.

There are steps that might help. A pilot program at Stanford, for example, allows physicians to “bank” hours they spend mentoring others or serving on committees. Those hours can then be used as credits for child care, dry cleaning pickup, ready-made meals, housekeeping and handyman services. Preliminary results are promising, and suggest that the program has increased job satisfaction, improved work-life balance and reduced turnover.

As these initiatives evolve, they could be evaluated to see not only if they improve physician well-being, but also if they promote career advancement, cut medical errors or improve patient satisfaction.

We can all also examine our own biases. Those of us evaluating medical students and residents, for example, could make it a point to ask ourselves whether a trainee’s gender — or race or ethnicity or accent — might have affected our assessment.

And more women in leadership and mentorship roles may help with the larger cultural shift that seems necessary. It’s possible that gaps in gender pay, promotion and mental health will narrow as medicine shifts from a boys club to one with more women. It’s also possible they will not. Disparities don’t close on their own. They close because we close them.

Dhruv Khullar, M.D., M.P.P., is a physician at NewYork-Presbyterian Hospital and a researcher at the Weill Cornell Department of Healthcare Policy and Research. Follow him on Twitter at @DhruvKhullar.