Where have they gone? – A discussion on the balancing act of female doctors between work and family

Abstract

Goals: The increasing number of vacant positions for doctors increasingly puts the issue of reconciling work and family into the spotlight in companies, hospitals and universities, as increased expectations of a better work-life balance are seen as one of the reasons for these vacancies. Highly qualified professionals are trained, but not available to the labour market. The aim is to summarise what difficulties doctors who want to have a family and their potential employers must face.

Methods: The following articles show the current state of research and potential starting points for an optimisation of the medical profession from a family-friendly perspective and intend to stimulate debate.

Results: Some basic steps towards better work-life balance have already been taken, such as the provision of childcare places and the increasing availability of more flexible working patterns. But it seems that these measures, since they have been implemented neither sufficiently nor universally, do not suffice to secure the next generation of staff. Especially women in leadership positions are still rare to find.

Conclusions: Both male and female doctors want better quality of life by achieving a better work-life balance. The expansion of family-friendly services is seen as a necessary step to allow female doctors to successfully combine work and family.

Introduction

“It would be an untold disaster which could destroy universities if the number of female students were to exceed that of male students”

This fear, expressed by a Swiss professor of physiology in 1872 (Ludimar Hermann, 1872, quoted from: [24]) seems to have become reality in Germany in recent years: The feminisation of medicine is progressing rapidly in Germany. About 70% of approximately 80,000 medical students in Germany are women and amongst new graduates, close to 60% are female [22], [16]. But as yet, the “disaster” predicted by Hermann in 1872 is only happening at the “base”, as one can only really speak of female medicine when the percentage of female doctors in management positions corresponds to the proportion of female doctors who graduate from university. This is far from the case, the proportion of women in W3 professorships in Germany only stands at 13,3 [21] (other Data shows only 5,6% [18], only a few women are found at the management level of healthcare and women are extremely underrepresented at top positions at hospitals [17]. And that even though maintaining comprehensive healthcare is becoming increasingly difficult [5]. Slightly older figures from 1999 show that 48% of female doctors registered with state medical associations are currently “not engaged in medical activity”, with the unemployment rate at 8.3%, about twice as high as that of their male colleagues [2]. The relevance of a good balance between work and family has grown among male and female doctors alike [9]. Clinics, universities, medical associations and professional organisations are now faced with the task of meeting these expectations to address the changes in the workplace.

An inventory of possible factors which could improve family friendliness is essential to ensure that in the long-term, highly skilled female workers are not lost to the labour market. This article will give an overview over the current state of research and encourage a discussion of potential causes for the unequal distribution of men and women in medicine.

The Current State of Affairs

In 2009 there were about 2,800 students at the Faculty of Medicine in Ulm of which 66% were women and 34% were men, amongst the 249 doctorates 153 (61.4%) were women and 96 (38.6%) men. When it came to professorships, the dominance of women was reversed in 2009 as only four (14.8%) of the 27 post-doctoral theses were by women, with the ratio of female professors of medicine standing at 15% in 2009. Other universities have reported very similar figures. The GWK (Gemeinsame Wissenschaftskonferenz, engl.: Joint Science Conference, [20]) reports that although the proportion of women in Germany has increased at all levels of qualification in medicine, the share of female W3/C4 professors in medical subjects in 2008 was only about 13.3%. Looking at the so-called leaky pipeline of past years, it becomes clear that a relatively large proportion of women embark on a professional career but a large share of these are lost over time. Some researchers suggest that this phenomenon has to do with the severe difficulties of reconciling work and family life to date. Some 86% of people in medical school would like a family but 79% of medical students, however, assume that there it would be (very) difficult to combine children with a medical career [6]. This phenomenon is also commonly seen amongst other student groups. The Federal Ministry for Family Affairs, Senior Citizens, Women and Youth [10] indicates that only 25% of all female students have planned their life purely around the family (as opposed to 50% amongst non-student women). 39% of female students assume that until their child is three they will neither be able to study nor work. This results in a trend where women who start an academic education also plan to complete this promptly in order to embark on a career. Only 6-7% of the students are parents [10]. The average age at graduation is about 27-28 years, even amongst medical students. From then onwards, the deck appears to get reshuffled completely. Putting it bluntly, women at this point are at a crossroads. The path to becoming chief physician means many privations, long working hours and few options for individual flexibility. The conservative image of the selfless and always ready doctor is still anchored in the minds of colleagues but also the general population. Raising a family is hard to reconcile with the demands required by this career option. One can assume that the groups split here, into those who start a family and give up their career and those who shelve any plans for children and fully commit to a medical career. A survey by Claus Goworr Consulting in 2006 [12], for example, showed that about 40% of female academics remain childless for professional reasons. This number has even increased slightly in the last few years and female doctors, compared with their male counterparts, are even less likely to have a partner.

First of all it must be said that the last few years have seen efforts to make up for the failures of enabling better reconciliation of work and family.

There are various audits on the subject of the compatibility of career and family (for example, the berufundfamilie audit of the Hertie Foundation, http://www.beruf-und-familie.de) with which both hospitals and universities, and thus medical faculties, can be reached. Various publications show that the Federal Government has also woken up to the issue, such as Career Planning for Female Doctors by Dettmer and Colleagues [14], published by the Federal Ministry for Education and Research and the German Medical Association, Family-friendly workplaces for Doctors by von Bühren and Schoeller [5] which was supported by the Federal Ministries for Families, Senior Citizens, Women and Young people and Health and the German Medical Association. The authors include checklists on “family-friendly hospitals”. The Federation of German Female Doctors since its founding has been addressing the issue of compatibility and has been successful in enabling part-time training and obtaining legal provisions for job sharing in established surgeries [7]. Political measures such as parent benefits, parental leave care leave or guarantees for childcare places are just a step in the right direction. Other steps must follow. Political measures such parent money, parental leave, care leave or guaranteed care places are not only a step in the right direction and necessary as part of educational policy but also, according to Bühren, necessary from an economic and equality point of view. More steps must follow. For the clinics in order to ease the shortage of doctors in these times of staff shortages and for the physicians in order to be able to realise their own plans for lifestyle, family and career. As the study by Kommission Klinika (2007) shows, the proportion of women between 2001-2005 in any of the studied levels of qualifications (assistant physician to C4 professorship) has not increased significantly. The federal and state target of 40% of new employees being women was not met by a long way. What are the reasons?

Despite many efforts by the Klinika, most clinics still do not offer adequate child care facilities such as crèches, kindergartens or day-care even if some family-friendly models show, in particular privately run clinics (such as the Murnau Trauma Centre) that comprehensively flexible childcare offers and family-friendly working hours can indeed be compatible with economic objectives [7]. But across Germany, neither their number nor the services hours are adequate for the requirements of clinical routines. Working hours also remain family-unfriendly, with the prevailing working hour models offering only 10% part-time opportunities and thus little flexibility [3].

The traditional role of wife and mother in German society sees women almost “naturally” responsibly for caring for and raising children. In comparison with other European countries, this picture is particularly extreme in Germany (compare [25]). It is still common for women to stay home after the birth of a child with the husband providing for the family (compare [15]). If a woman does not comply, she is quickly branded a “raven mother” - a name for a bad mother which does not even exist in many other languages than in German. In this context, Bühren [7] speaks of a significant internal and external career barrier. Astrid Bühren [8] published a study on surgical departments of German university hospitals. In this survey of 103 heads of departments a conservative gender role model proved a possible cause for the discrimination of women at the executive level. Dettmer and colleagues [14] speak of traditional career logic at the medical faculties in this context. The above mentioned ideological expectations of mothers in terms of all-round services for women by society have recently been supplemented by additional demands of highly-skilled for successful professional activity and their readiness for moulding careers, thus leading to conflicting goals and motives with which young women are faced.

The value of work: Approximately 70% of waking hours we spend working. Climbing the career ladder often means having to increase that percentage even more. Hard work and perseverance are just as important as a good education. Mothers cannot afford purely focussing on employment, however, and often cannot supply any expected overtime as the opening hours of childcare facilities do not normally cover periods of 12 or more hours per day and important committee meetings which take place after 4.30pm are not doable for most mothers. But by having a family they acquire additional skills which may be of importance in the labour market. Yet acknowledging this also entails abandoning the view that full-time workers pay penalties for others working part-time and that a management position must mean private life taking a hit.

That the lack of equality in medicine is not only down to the lack of a family-friendly environment, as Regine Rapp-Engels (President of the German Female Doctors Federation) points out, as female doctors without children also often hit a glass ceiling (press release of the German Female Doctors Federation dated 03.08.2011, [17]).

Eagly and Karau’s role (in-)congruity theory [18] could also apply to the under-representation of female doctors in management positions. According to this theory, many people perceive a discrepancy between the typical characteristics of successful leaders and the typical role behaviours/characteristics of women. This means that the leadership potential of women is often underestimated because leadership skills tend to be associated with male rather than female gender stereotypes. So women tend to be judged less qualified for leadership positions and women’s leadership will tend to be assessed less positively because they are women.

Ley and Kaczmarczyk [22] speak of a lack of female role models as a brake on the transfer of management responsibility. Only 20% of female workers in Europe are managed by women and only 10% of male employees have a female boss. Role models are important in choosing a particular way of life. If the perception is that many women in one’s vicinity can combine children and work, this has a motivating and encouraging effect. But if you have the impression that climbing the corporate ladder is associated with not having children, this is a deterrent should one have a desire for children.

As far back as the 70s Kay Deaux [13], based on extensive studies, had a suspicion that too modest self-assessment and self-representation impaired women’s careers. Several recent studies have confirmed this assumption. Buddeberg-Fischer and colleagues [4] found, for example, an internal barrier amongst female medical students in the form of a discrepancy between subjective career concepts and self-concepts.

Discussion

Medicine is faced with the challenge of making itself more attractive as a career option. The increased desire of physicians of either gender for better balance between work and family should be seen as a starting point for restructuring. In future medical schools will depend especially on young women, if only to be able to recruit enough young talent in clinical practice, research and teaching. Flexible and family-friendly working conditions are a decisive factor in this. The question is, how institutions, universities, hospitals and businesses can meet the challenge of providing employment conditions which allow space for family and career (Oldenburger Beiträge zur Geschlechterforschung, [11]). Possible starting points are:

1. In principle, a willingness to see the issue of reconciling family and career as a gender-independent problem, which affects mothers and fathers (in terms of childcare) as well as daughters and sons (in terms of care for elderly parents).

2. More flexible and more care provision: Working mothers and fathers need to know that their children are cared for safely and reliably. Either in a fixed care institution such as a kindergarten or crèche or in flexible care services provided by childminders, babysitters, community support, etc. for exceptional appointments outside regular working hours. For older children longer school hours should be considered. In many European countries, children do not finish school until 4pm. The governmental measures for expansion of nursery places represent an important step. In 2005 approximately 71% of clinics offered childcare places, although often not meeting demand [21].

3. Flexible working hours, such as part-time arrangements, working life models and, for example, new shorter shift-work models that take into account not only the needs of mothers but also fathers or young couples. Pregnancy, parenthood, as well as caring for relatives may no longer be regarded as disruptive to labour organisation but must be included early in long-term planning and work schedule models.

4. Safe jobs: The majority of scientists are on short-term contracts, often for less than a year. The uncertainty of what comes after keeps many couples from starting a family under these conditions and families or couples who opt for children, from an academic career.

5. Loosening regulations on age limits (cf. Prof. Kempen in Forschung & Lehre, [19])

6. New, more flexible career paths: Prof. Winnaker, Secretary General of the European Research Council in Brussels [19] speaks of attractive small research departments as an alternative to the big chairs which are overburdened with administrative tasks, which could be particularly attractive for scientists in the family phase.

7. Mentoring programs for young doctors, where more experienced colleagues are available for professional contacts and career-technical issues of reconciling work and family (see [1]) and

8. especially in specialisation, increasing the flexibility of the maternity leave arrangements must be considered to minimise the amount of time lost through work prohibitions (e.g. work in surgery, lab etc). Adapting the maternity leave policies to the needs of the medical field seems necessary.

9. Intensification of women-specific and family-friendly support programs and scholarships as well as dual-career programs.

10. Building networks with female role models and mentors.

11. Change in thinking: Women and men must examine traditional gender roles and reflect on new concepts of self and family. Women should learn to develop consistent career concepts even without role models. Fathers should take more active roles in raising children, even if this is often difficult in practice due to lacking acceptance and feared career disadvantages.

12. Providing financial support: Universities and hospitals should be supported in introducing more family-friendly structures by increasing funding.

13. Redesigning corporate culture: Companies should be aware of the benefits arising from family-friendly personnel policies.

Undoubtedly there are many more aspects which need to be discussed. And that is precisely the aim of this short essay. What else can be done to help women bring a career in the medical profession and family life into balance?

Conclusions

For women of our generation quality of life means family and a career in their chosen field [6]. Balancing work and family is often difficult to realise in the medical profession, as is the case in other academic professions, as patients also need medical attention at night, on weekends and on the birthday of a son or daughter. If one wants to tackle the growing shortage of physicians, a sensible and helpful step would be to establish comprehensive services for families with children.

To obtain an accurate assessment of care needs, we would like to encourage staff surveys at this point. The status quo for staff at the University of Ulm and Neu-Ulm, for example, will be captured and optimised in a 4-year longitudinal study, starting in 2012. The intention is not only to capture the need for measures in detail to facilitate better compatibility of career and family of employees but also to produce a statistical analysis of parameters of workplace satisfaction, stress and health via the collected data. In the following, concrete measures will be implemented and their effectiveness measured in longitudinal studies. The effectiveness of such an approach has already been demonstrated in a survey of medical students [23]. The University of Ulm study is able to demonstrate family-friendly organisation [5].

Competing interests

The autors declare that they have no competing interests.