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.
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.
