Women in medicine

The number of women choosing medicine as a career continues to grow. In 1960, women made up 6% of all physicians; in 2000, they comprise about a third of the physician population. Almost half of the students in medicals school are female. Women are reshaping the way medicine is practiced. Women physicians generally report being satisfied with their career, but many would not become a physician again if given a choice or would choose a different specialty.¹ Female physicians experience all the stressors that their male colleagues face, but deal with additional stressors unique to them.

METHODS

I searched MEDLINE from 1980 to the present, using the search terms women, medicine, and physicians. I included English-language reviews and original research papers. I have also based this review on my own experience and research.

WORK-RELATED STRESS

There are differences in the practice styles of male and female physicians. Women are more likely than men to practice in primary care fields and to pay more attention to preventive medicine, health education, counseling, and the psychosocial needs of their patients.² They spend more time with patients, but feel a sense of time pressure, because they often take more than the allotted time to deliver care. They earn less or are often in salaried positions.

The work environment offers few supports for women physicians. Women often feel that they have too much to do, with not enough resources and authority, leading to stress and burnout.

There can be harassment at work. Women experience inappropriate sexual comments or behavior, which may not be overt or intentional, but which is still demeaning.

A senior colleague sat across the table from me at a psychiatry departmental meeting. He looked at me and then said, “I bet that all you have to do is to bat those big brown eyes at your patients, and they feel better.” I am sure that he would never diminish our male colleagues' therapeutic skills like that.

—Psychiatrist

Women physicians are vulnerable to high rates of verbal abuse and physical assault by male patients as well as by other health care workers.³

Academic medicine poses further stresses for women physicians. Women are significantly more likely than men to pursue an academic career. But the number of women who advance to the senior ranks is much lower than the number of men.⁴

Women are more likely to be in part-time positions, which often precludes tenure. They are often in clinical positions and so have less time and resources to carry out and publish research. They are less likely to understand the promotion and tenure criteria and process. Women value patient care and local recognition, while male physicians place greater value on scholarship and national recognition.⁵

Fewer women than men advance in medical faculties, leading to too-few role models for women and inadequate mentoring. There is a sense of isolation and a lack of a supportive network for women. They may not access pertinent information or gain needed skills to advance in their careers. Women are excluded from the “old boys network.”⁶ This may be unintentional on the part of men—perhaps they schedule late evening meetings or make decisions among themselves at sporting events, in hallway conversations, or at all-male lunch tables. Some women feel that they are devalued, ignored, overlooked, or not given appropriate credit.

HOME-RELATED STRESSES

Balancing the demands of work and home effectively is the top priority for most women physicians. Sometimes, it is difficult to define these separately.

I try hard to assess just how many hours I work. I found that I could not. The hours swirl together, and I can't actually divide them up into allotments of professional activity and unwaged work. What happens when my patient dies and I hold a family member in pain...is that work or is that a privilege? What happens when I am discouraged and I ask my 5-year-old to come and look at a book with me? “Mommy is tired and she would like you to keep her company.” Is that child care or is that communion? What happens when I do circle after circle around a parking lot on my roller blades, thinking hard about the 3 trauma patients who arrived at once, the 1 who died, the cardiologist I got into a big fight with because he wouldn't take over the care of a patient with hypotensive undifferentiated chest pain so I could attend to the traumas? Is that leisure, or is that work?

—Emergency department physician

Single women physicians usually enjoy their flexibility and independence, but they often find it difficult to meet potential partners. There are social barriers for physicians, who may feel as if they live in a “glass house,” having high visibility and little privacy in the community. This is especially so in small or rural communities.

I feel lonely a lot. I don't have much in common with the other women who live here and so do not have friends. As 1 of 3 docs here, usually I am too busy to have much free time. Even so, there is no chance of meeting anyone. Every potential candidate is a patient and off-limits!”

—Primary care physician

Women physicians in same-sex relationships may feel intensely lonely and isolated. They are often reluctant to openly acknowledge their homosexuality and experience difficulty in coming out. This leads to a lack of social support. The medical environment, especially in smaller communities, can stigmatize gay relationships.

Although marriage correlates with less stress for male physicians, it leads to increased stress for women who retain the primary role for managing the household (cooking, cleaning, shopping). If they delegate these duties, they are still usually responsible for the delegating, such as interviewing, hiring, and managing the assistants. Problems in marriage for women physicians include domestic abuse and a deep sense of guilt because they are so busy, low self-esteem, difficulty with intimacy and sexuality, and resentment because they feel responsible for all the “worry-work” of the relationship.⁷

More and more women are having children during their medical training.⁸ This is because students are entering medical school at an older age, and they have more role models for balancing home and family life, as well as more maternity leave and supportive benefits.

During their pregnancy, physicians may feel guilty because their colleagues will have increased work burdens in covering for them. Some physicians experience criticism and disapproval from male colleagues.

I was pregnant as a resident and later during my fellowship. Now, years later, I still envy people whose announcements of their pregnancy are not met with “Oh, no.”

—Oncologist

Women physicians who have children have a huge amount of role strain. Although the compulsive aspects of their personality—a strong sense of guilt, chronic self-doubt, and an excessive sense of responsibility⁹—can help lead to professional success, these traits can also cause personal distress. There is a never-ending list of things to do. Women may feel that they have tried to please everyone, and end up feeling they have pleased no one.

I have 3 young, busy sons. I put in a load of laundry every morning before I head out to the office. At the end of my work day, I come home, take the laundry from the washer and put it in the dryer before I even take my coat off. Then, it's time to get the homework done, make dinner, eat quickly, and clean up in time to get the boys to Cubs. While they are there, I get an hour to get the groceries. I return to pick up the kids and head home. We launch into the bedtime routine—showers, snacks, stories, cuddles. Finally, they're in bed and I can unload the car, put away the groceries, fill out the kids' pizza forms for school, and make lunches for the next day. By 9:30 PM, I sit down for the first time in hours—to fold the laundry.

—Primary care physician

Women physicians are usually the ones to organize the child care. When children are ill, it is usually the women who adjust their work schedules. Indeed, having children and raising them is one of the pivotal issues that separate women's and men's career experiences.

PERSONAL STRESSORS

With all of the above responsibilities, women physicians find that their personal needs are last and, often, lost. They put their needs at the bottom of the list of priorities and rarely get to them. There is no time to consistently take care of themselves, even the basics such as exercising, eating well, getting enough sleep, and spending time alone or with friends.

THE END RESULT OF STRESS

Ultimately, stress leads to burnout with its associated physical problems and illnesses, relationship difficulties, negative thoughts and feelings, and exhaustion. Women physicians are 60% more likely than male colleagues to report burnout.² Almost 20% of women physicians have a history of depression,^{3, 10} with an estimated 1.5% reporting a suicide attempt.

SOLUTIONS

Women physicians need to monitor their stress level and address it productively. We do have choices. Balancing our lives involves taking control and setting priorities about what we want. Women who are happy and thriving in their careers have adopted the following strategies.

At work

Office management. Take control of working hours by scheduling breaks and days off, varying the type of work, keeping up with paperwork, and personalizing the office with pictures and photographs.

Time management. Learn to be better organized and set priorities about what needs to be done. Use the FLAG method: file it, let someone else deal with it through delegation, act on it, or put it in the garbage. Schedule realistically, and do not overcommit yourself.

Work environment management. Lobby effectively for work equity policies, parental leave policies, flexible hours, child care, safety measures, workshops on assertiveness training and leadership skills, and mentoring programs.

Network management. Use colleagues for support, and share stresses and successes with them. Seek mentors, and actively reach out to them. Add fun to work activities. Learn to set boundaries. Say “no” if appropriate, and stop trying to please everybody.

Transition between work and home

Stop before you start. Stop rushing at the end of the workday; take a few minutes to take a deep breath and relax. Consciously prepare to be home: consider what is ahead, what will be required, and how to best deal with it. Plan to say “hello” to people at home.

At home

Don't take work home. If there needs to be an exception to this rule, set definite limits on when and where in the house to work, and stick to them. Give your family your undivided attention when you are with them.

Housework. Ask for help, and be specific. Share both the thinking and the doing of the jobs. Allow children to help from an early age. Group chores together to enhance productivity. Consider options, and delegate if possible. Prioritize the chores, and let go of things not at the top of the list.

Child care. Consider the options and pool resources. Say “yes” to help, and “no” to extra demands and interference. Spend less time trying to make the children perfect. Spend more time with your children, enjoying them, and celebrating the pleasures of parenting.

Partners. Take care to maintain the connection, emotional attachment, and intimacy with your partner. A good relationship takes constant work. Learn to resolve conflicts productively. Time together is the glue for all relationships.

Personal life stresses

Take care of your own needs. Eat well, and get adequate rest, sleep, and exercise. Set limits, relax, and slow down. Indulge regularly and spontaneously. Learn something new. Learn to “waste time.”

Solo time. Time for yourself is essential. Balance time alone and with your partner. Feel comfortable asking for solitude, and offer it to the other. Consider it as an investment in all other relationships.

Make friends. Friends provide support, escape, and laughter. Humor is therapeutic; surround yourself with fun and humor daily. Keep friendships alive—even voice mail messages, e-mail, or cards can help to maintain contact.

Table 1.

Resources for women physicians

Books

For career advancement and success What's Holding You Back? 8 Critical Choices for Women's Success by Linda Austin. New York, NY: Basic Books; 2000. For work/life balance Sanity Savers: The Canadian Working Woman's Guide to (Almost) Having It All by Ann Douglas. Toronto, Ontario: McGraw-Hill Ryerson Limited; 1999. For marriages/relationships The Medical Marriage: Sustaining Healthy Relationships for Physicians and Their Families. Revised edition by Wayne Sotile and Mary Sotile. Chicago: American Medical Association; 2000. For general physician health The Handbook of Physician Health: The Essential Guide to Understanding the Health Care Needs of Physicians by L Goldman, M Myers, and L Dickstein. Chicago: American Medical Association; 2000.

Organizations

Medical Women's Associations: These are dedicated to the personal and professional well-being of members and provide continuing medical education, support, advice, mentoring, and networking. They have national offices with many local branches.

In the United States: American Medical Women's Association 801 N Fairfax St, Suite 400 Alexandria, VA 22314 Phone: (703) 838-0500 Fax: (703) 549-3864 www.amwa-doc.org

In Canada: Federation of Medical Women of Canada 107-1815 Alta Vista Dr Ottawa, Ontario K1G 3Y6 Phone: (613) 731-1026 Fax: (613) 731-8748 www.fmwc.ca

Association of American Medical Colleges: This has excellent resources and training for senior women in (academic) medicine.

Association of American Medical Colleges 2450 N Street, NW Washington, DC 20037-1126 Phone: (202) 828-0400 Fax: (202) 828-1125 www.aamc.org

Others

MomMD — Connecting Mothers in Medicine: www.mommd.com Women in Medicine Magazine:www.womeninmedicine.com

Finances. Learn to manage finances. Live within your financial means. Pay off non-tax deductible debts. Money (or lack of it) is a major cause of stress. Money problems often prevent physicians from making the very changes needed to better manage their stress.

Phases. Remember that life has many phases. As you make choices, you may have to sacrifice something (eg, having children instead of pursuing an academic career). It helps to remember that this is only for now, for this phase—not forever. Moving into the next phase enables you to reassess, make new choices, and set new priorities.

Attitudes. Be aware of the attitudes that help perpetuate a sense of stress. The 2 key ones are guilt and perfection. Guilt is what you feel when you think you are not meeting expectations. Learn to acknowledge this guilt and let it go so it does not prevent you from meeting your personal needs. Perfection is an illusion, and striving for it can be a block to happiness. Accept that you will not be perfect. Good enough is good enough.

CONCLUSION

It is difficult to make the changes necessary to manage our stress because change itself is stressful and we try to make too many changes at once. Make a list in order of your priorities. Start with the top item on the list, make the change, then move on to the next one.

Women physicians need to monitor their stress level and address it productively

We also want change to happen too quickly. Be patient. We make more changes than we need to, so try to just focus on the necessary ones. People who liked what you used to do will want you to change back to your former self—identify that they are doing this and resist!

Monitor regularly to see if you are still on track or if this is the track you want to be on. I personally do this by consciously putting time aside. Each year on my birthday, I take the day off work and spend it indulgently, including sitting and considering where I am in all parts of my life—work, home, relationship, children, friends, financial, personal—and deciding on adjustments if required. I maintain this with an hour each month to monitor where I am in life. This seems to be regular enough to stay on track.

Medicine can be an enjoyable, enriching career. Women physicians enter it full of hope and promise. It is worth making the effort to better manage the associated stresses, so that you can maintain overall satisfaction.

Summary points

• More women than ever are choosing medicine as a career

• The stresses for women physicians come from their work environment, their home life, and the role strain they experience as they struggle to balance these competing demands

• The end result of this stress over time is burnout, which can lead to serious physical and emotional problems.

• Women physicians can do many things to actively address their level of stress, successfully manage it, and thrive in their careers

Figure 1.

^{Women physicians can thrive and be happy in their careers© Malcolm Willett}

Figure 2.

^{Women physicians must juggle domestic and professional stressors© Tony Stone}