Gender Differences in Physician Burnout: Driving Factors and Potential Solutions

Abstract

Introduction

Burnout among physicians has reached an epidemic level, with substantially higher rates among women. In this brief report, the authors evaluate recent literature to identify major factors leading to gender differences in physician burnout.

Methods

The authors review data on gender within each of the key drivers of burnout, including workload and job demands, efficiency and resources, control and flexibility, organizational culture and values, social support and community at work, work–life integration, and meaning at work.

Results

Women physicians face a higher workload, spending more time in electronic health records, and more time per patient. Women physicians also receive fewer resources and report less control over their workload and schedules. Organizational culture factors, such as a lack of women in leadership roles, compensation disparities, lower rates of career advancement and academic promotion, as well as gender bias, microaggressions, and harassment, also play a key role in gender disparities in burnout. Disproportionate responsibilities outside of work, including childcare and elder care, contribute to less satisfaction with work–life integration. Additionally, women physicians report lower self-compassion and perceived appreciation. These factors ultimately lead to decreased professional fulfillment and higher burnout rates among women physicians. Finally, the authors present proposals to address each of these factors at an organizational level, to effectively address the high burnout rate among women physicians.

Conclusion

Burnout among women physicians is substantially higher compared to men and stems from multiple factors. It is crucial for organizations to evaluate the gender differences within each burnout driver and develop sustainable strategies to reduce disparities.

Introduction

Burnout among physicians has reached an epidemic level in the United States, particularly among women physicians. According to a 2021 study, 62.8% of physicians reported at least 1 manifestation of burnout, an increase from 43.9% in 2017.¹ There is a dramatic gender difference in physician burnout rates: in 2020, 51% of US women physicians reported burnout vs 36% of men physicians.² In 2021, Burnout increased among both women and men physicians, to 56% and 41%, respectively.³ International data show a similar pattern during the Covid-19 pandemic, with higher burnout and psychological distress for women primary care physicians.⁴ These observations are consistent with prior studies that found a 30% to 60% higher odds of burnout in women compared to men physicians.⁵

According to World Health Organization, “burnout” is an occupational phenomenon, which is a syndrome resulting from chronic workplace stress that has not been successfully managed and is characterized by emotional exhaustion, depersonalization, and feelings of decreased personal achievement.⁶ These components manifest differently by gender, with higher rates of emotional exhaustion for women, and more depersonalization for men.⁷ Age differences may exacerbate gendered patterns of burnout, as younger age is associated with higher rates of burnout, and the mean age of women physicians is younger than that of men physicians.⁸ Additionally, it is possible that reported burnout rates may reflect socialized gender norms of willingness to discuss difficulties and seek support.

The key drivers of burnout and engagement in physicians, as described by Dr Shanafelt and colleagues, include: workload and job demands, efficiency and resources, control and flexibility, organizational culture and values, social support and community at work, work–life integration, and meaning at work.⁹ In order to explore the gender difference in physician burnout, the authors review data on gender’s role in each of these drivers (Figure 1).

Figure 1:

Driving factors for higher burnout in women physicians. Figure depicts contributory factors for higher burnout in women among key drivers of burnout in physicians, such as efficiency and resources, workload and job demands, work–life integration, control and flexibility, organizational culture and values, social support and community at work, and meaning at work. Icon created by Bernd Lakenbrin from the Noun Project. EHR = Electronic health record; esp. = especially.

Workload and Job Demands

Clinician well-being and burnout reflect the relationship between the demands of work and the resources available to meet those demands.¹⁰ Burnout can be understood as a primarily “system-level problem driven by excess job demands and inadequate resources and support, not an individual problem triggered by personal limitations.”¹¹ Thus, to address the disproportionate burnout levels experienced by women physicians, it is crucial to understand the ways in which gender impacts workload and job demands.

Workload refers to the expected quantity or time of work, while job demands encompass the physical, cognitive, and emotional components of this work. Accumulating evidence suggests that women physicians face a higher workload and greater job demands than their male colleagues.

Women physicians spend on average 10% more time per patient during in-person office visits.^12,13 In the Physician Work Life Study, women doctors reported having more psychosocially complex patients, fewer resources, and the need to spend more time with their patients to provide high-quality care.¹⁴

In addition, women physicians devote more time to work in the electronic health record (EHR) than men, including time after work hours, on weekends, and during “pajama time.”¹⁵ Based on data that burnout correlates with work hours it is not surprising that these extra hours take their toll on well-being.^8,16

Evidence suggests that increased communication from patients contributes to the extra workload experienced by women physicians. Reflecting gendered expectations of physician accessibility, patients communicate more with women physicians during visits, and women physicians spent 15.7% more time with a patient in direct patient care.^17,18 Similar patterns can be seen in recent studies of the EHR. Patients are more likely to address women physicians by first name rather than by their professional title.¹⁹ Patients send approximately 25% more electronic messages to women primary care physicians.²⁰ However, it is important to note that the increased level of patient-doctor communication with women physicians may have benefits for patient outcomes.²¹

In addition to differences in the number of hours, there is evidence that the content of work differs according to physician gender. During medical visits, women physicians engage in more psychosocial question asking, psychosocial counseling, and emotionally focused talk; and patients expect more empathic behavior from women physicians.¹³ These emotional demands can result in both positive consequences, such as job satisfaction and feelings of accomplishment, but also in negative consequences, such as emotional exhaustion and depersonalization, key components of burnout.²²

Efficiency and Work-Related Resources

Physicians may find that physically and emotionally demanding work can be rewarding and meaningful, but supportive and resourced work environments are needed to make this work sustainable.¹⁰

Clinical practice support, such as distribution of workload including paperwork, documentation, and triage across team members, is an important factor in how much work falls on the physician. Women primary care physicians are less likely to report having staff support for documentation such as scribes, team-based documentation, or novel technologies.²³ Informal support from staff may also differ by physician gender. In addition to more patient messages, women physicians receive more staff messages; one potential explanation for this finding is that staff have lower threshold to contact women physicians, while taking care of tasks for men physicians without requesting their involvement.²⁰

Financial support and mentorship comprise additional important resources for physician professional well-being. Men and women academic physicians receive different levels of financial support at the beginning of their careers and experience disparities in mentoring and sponsorship.²⁴

Control and Flexibility

Lack of autonomy contributes to burnout among female physicians. In a 2022 Medscape survey, 32% of physicians reported "lack of control and autonomy" as the most important contributors to their burnout, while 36% of physicians stated that increased control and autonomy would help the most to reduce burnout.³

The increased time that women physicians spend with patients may make it particularly challenging to meet institutional productivity requirements. Women physicians report less control over their workload and schedules and less “sufficient” time to see patients during office visits; furthermore, lack of workplace control predicted burnout in women but not in men.¹⁴ A recent survey that showed higher burnout among women general surgeons compared to their men colleagues found that male surgeons reported a higher degree of control over their schedules. Moreover, the observed gender difference in burnout was explained by gender differences in professional fulfillment and control over schedules.²⁵ Furthermore, schedule rigidity has major implications for work–life integration for physicians who are mothers, which is highlighted in a separate section.

Organizational Culture and Values

An organizational culture committed to gender equity must address persistent disparities and bias facing women physicians. There are several aspects of organizational culture and values that may lead to gender differences in burnout rates among physicians, including compensation disparities, fewer career advancement opportunities, and experiences of bias, discrimination, and harassment.

Women physicians on average receive less compensation than their male colleagues. An electronic survey study of trauma surgeons found that despite women surgeons reporting more work hours than their men colleagues, they reported lower incomes.²⁶ Similarly, the 2022 Medscape physician compensation survey showed that male primary care physicians are paid 25% more than their female colleagues, and male specialists 31% more than female specialists.²⁷

Women physicians additionally face disparities in academic and leadership promotion. Female physicians have lower rates of promotion in academic rank despite similar academic productivity. In a recent large meta-analysis of 218 studies, which included 24 specialties across 16 countries, men were 2.8 times more likely to be full professors than women, even after adjusting for experience, academic productivity, and specialty; furthermore, men physicians had higher salaries, received more federal research funding and were more likely to be departmental chairs.²⁸ Although there has been some improvement over the years, substantial gender disparities have persisted.²⁸ Women are less likely than men to be speakers at grand rounds, losing the benefits that these opportunities provide for career advancement.²⁹ Despite similar work and levels of academic productivity, women are less likely to be promoted and compose a small minority of leaders in medicine.³⁰ Furthermore, women from ethnic and racial minority groups face additional discrimination at all levels of their careers.³¹

Gender discrimination may include sexual harassment as well as bias toward physician mothers. Many more women physicians than men experience sexual harassment at work. In a survey of K-award recipients, 30% of women reported having experienced sexual harassment at work compared with 4% of men.³² Physicians who are pregnant and/or mothers report gender discrimination.³³ These experiences of workplace bias can negatively affect well-being and career advancement and have been shown to be associated with higher rates of self-reported burnout.³³

Work–Life Integration

Long hours and on-call responsibilities can make work–life integration challenging for both men and women physicians. However, women physicians in the US report lower satisfaction with work–life integration.¹ Disproportionate responsibilities outside of work may contribute to this difference: for example, women who are employed full time spend 8.5 additional hours per week on childcare and other domestic activities, including care for elderly parents.³⁴ In dual-career couples, women report more household work than men.³⁵ These challenges became more pronounced for women physicians during the COVID-19 pandemic.³⁶

Medical careers pose particular challenges for women physicians who are mothers. As noted above, one-third of physician mothers noted experiencing discrimination related to their role as a mother, primarily related to pregnancy or maternity leave. Exposure to maternal discrimination was associated with an increased incidence of self-reported burnout.³³ Physician mothers report being held to higher standards, a lack of support, and limited opportunities for career advancement.³⁷

Social Support and Community at Work

Social support and community at work are essential to the well-being of health care professionals. When physicians experience social isolation, conflict, and disrespect in the workplace, they become more susceptible to burnout.³⁸ Women physicians in certain subspecialties, especially surgical, may experience professional isolation. A sense of community and belonging in medicine can be undermined by microaggressions, from patients, colleagues, and staff. Women physicians are more likely than men physicians to experience microaggressions from patients, most often related to questioning their role as a doctor and assuming their expertise to be inferior.³⁹ Gendered microaggressions are associated with burnout and negatively associated with job satisfaction.³⁹ The presence of impostor syndrome may also impact a sense of community and impair self-esteem. Women medical students are twice as likely to report impostor syndrome as their men counterparts.⁴⁰

Meaning at Work

Meaning and purpose in work are fundamental to professional fulfillment and engagement—the antithesis of burnout.³⁸ In multiple studies, women physicians report substantially lower rates of professional fulfillment than men physicians.^25,41,42

System factors contributing to the development of meaning at work include matching work to individual talents and interests, opportunities for faculty education, research, leadership and professional development, transparency of leadership, and the ability to influence organizational decisions.⁹ Women physicians are less likely than men to report a sense of common purpose and belonging, and to report fair access to opportunity and rewards within organizations.⁴³

In addition, individual factors such as doctor-patient relationships and personal recognition of positive events may affect physician experience of meaning in work.⁹ Women physicians report lower ratings for self-compassion and multiple culture-of-wellness factors, including perceived appreciation, schedule control, and work environment diversity and inclusion; perceived appreciation attenuates the substantial relationship between gender and professional fulfillment.⁴¹ These findings suggest that both self-compassion and culture-of-wellness factors may contribute to gender differences in burnout and professional fulfillment.

Proposed Strategies to Promote Gender Equity in Professional Well-Being and Burnout

To successfully decrease burnout among all physicians, gender differences must be considered. Leaders can play an important role in addressing this challenge by requiring leadership education in the areas of burnout and gender disparities in the workplace. Organizations should develop an internal accountability measure for leaders to achieve desired targets of physicians’ well-being and burnout. In order to do this, organizations should utilize a validated method to measure physician burnout and wellness on a regular, routine basis. To understand the contributors to burnout, leadership should analyze burnout with their institution’s data on physician demographics, including gender, inclusive of gender minority categories, as well as race and ethnicity.

In addition, organizations should develop interventions to reduce burnout and improve wellness. These efforts can potentially be system-based or individualized; however, evidence has shown that organizational interventions are expected to lead to higher benefits.⁴⁴ Interventions can address gender disparities in each of the domains critical to burnout: workload, resources, control and flexibility, organizational culture and values, work–life integration, social support and community, and meaning at work.^8,9

To reduce workload disparities, health care organizations can set fair productivity targets that take into account all aspects of patient workload, including time requirements and volume of communication within the EHR. Duty hour limits should be implemented and consistently enforced. Efforts can be made to develop an interprofessional team-based approach to patient care, which can promote a more equitable and sustainable distribution of workload.

To improve efficiency and provide a fair distribution of resources, efforts to optimize EHR are crucial. Staff support should be monitored to ensure equity, and guidelines and protocols developed, so that nonphysician staff members can contribute to the work equally across the system. Leadership must ensure equal access to resources for their physicians, equal opportunities for faculty development, and equal support for academic and leadership promotion. For example, a formal mentorship program could assist and support equality in career development and advancement, leadership training, and academic promotion.

In order to increase autonomy and flexibility in the workplace may have beneficial effects on burnout, organizations can implement policies to promote physician control over their schedule and flexibility in their workdays. These policies may include providing part-time or shared work opportunities, flexibility in vacation and medical leave policies, remote work options, as well as parental leave. In addition, organizations might increase options for work schedule flexibility such as clinic start and finish times, to allow personalized work schedules while maintaining organizational targets.

In order to create a climate of equity in which all people can thrive, organizations should develop a robust system to address concerns of gender bias and discrimination. Leaders should address gender differences in compensation, support fair policies for parental leave, and work to systematically prevent and respond to episodes of harassment and bullying. Institutions can implement interventions to minimize gender-based microaggressions, such as clear role labels on ID badges.

It would benefit all physicians if organizational leaders would create a supportive system to address physician work–life integration, call schedule structure, night/weekend coverage, post-call time off, and cross-coverage policies for time away.

Institutional policies can promote social support and community at work. These include support for social gatherings to promote community, as well as programs specifically targeted to women physicians, such as women’s interest groups or women’s employee resource groups. Peer communities and women groups in professional societies can provide opportunities for women to work together to address institutional policies and to discuss common issues such as bias and work–life integration.

Finally, a sense of meaning at work can be fostered by interventions that demonstrate that an organization values the contributions of all of its members. These efforts may include a mix of the following, or others that an organization identifies as the particular needs of its members: interventions to reduce the effects of gender bias and discrimination and to improve awareness about the influence of gender bias on feedback and promotion; career development and promotion support for women; placing women on appropriate committees while providing administrative support and fair compensation for this work; mentorship support and peer communities; matching work to individual talents and interests; and improving equal opportunities for education, research, and leadership.

All of these domains offer rich opportunities for institutions to conduct quality improvement projects across divisions and practice settings, targeted to eliminating gender differences. Each specialty and practice location will have its own unique method of approaching these issues and has the opportunity to develop specific solutions to the challenges of burnout that can yield tangible rewards.

In order to truly address the high burnout rate among women physicians, organizations must evaluate the contributors to burnout at their institution, including gender and racial disparities, and develop timely and adequate responses that span each of the key drivers of burnout.