Am Fam Physician. 2001;64(1):174-178
Since the beginning of time, women have been healers. Female healers, including hedge-witches and nuns in mediaeval times, the sangoma of southern Africa, the curanderas of New Mexico and shamans in native healing rituals, have impacted the history of the ancient and new worlds.1,2 Today, women are continuing this great medical legacy. More women are entering medical schools now than ever before. In 1999, a record 45.8 percent of first-year medical students were women,3 a number that is dramatically higher than the 9 percent reported only 30 years ago.4 The American Medical Association (AMA) has projected that this upward trend will continue and by 2010, 30 percent of all physicians in the United States will be women.5
Women have come to be accepted in all fields of medicine including clinical specialties and subspecialties, research, administration and academia. Moreover, the demand and respect for female physicians is rapidly growing because society is increasingly becoming aware of the benefits of recruiting female physicians. For example, the increasing numbers of women in medicine have resulted in a better distribution of physicians across the United States, because women contribute more than men to underserved areas.6 Results from one study7 showed that twice as many female as male medical students plan to practice in socioeconomically deprived areas. Results from another study8 showed that female physicians were more likely than male physicians to work in generalist or primary care fields and to have a higher proportion of patients in managed care. Furthermore, increasing numbers of female patients are actively seeking and requesting female physicians.7 This is particularly significant because women make about three fourths of the health care decisions in the United States, and they spend two thirds of health care dollars.9
Women's impact on health care has also been noticed internationally. In fact, the World Health Organization has proclaimed that women currently play a far greater role than men in the delivery of health care in most countries: “Equally important is the role of women in the formal health systems of many countries, where they often constitute the majority of health care providers. Whether within or outside the family, whether in a formal or informal setting, women outnumber men as providers of health care, including physicians, nurses and midwives.”10
Although female physicians of the past led the way for women in medicine today, many gender-based issues still exist. In one large national questionnaire11 (sample size: 4,501), 47.7 percent of female physicians reported experiencing gender-based harassment and 36.9 percent reported experiencing sexual harassment. Harassment was reported to occur more commonly during the early training years and in specialties that are traditionally male dominated. Female physicians who reported feeling in control of their environment, satisfaction with their careers and would choose to become a physician again reported a lower prevalence of harassment, possibly indicating that harassment affects job satisfaction.11 In another poll,12 73 percent of female physicians in practice reported experiencing verbal abuse at work with 71 percent reporting the harassment as having occurred within the previous year.
These statistics are even more significant for female physicians who belong to underrepresented minority groups. The prevalence of ethnic harassment at various times during medical training and practice is high and not decreasing, according to the study11 that analyzed surveys of 4,501 female physicians. In that study, 62 percent of African-American female physicians reported experiencing ethnic harassment, and 25 percent reported that it occurred during at least three different phases of their careers.11 These findings could have serious consequences for the medical profession's stated goal of developing a more diverse physician workforce.
Inequities in financial compensation have historically existed between male and female physicians. In a recent study of internists in Pennsylvania,13 women reported being more likely than men to spend fewer hours seeing patients, practicing in the least lucrative settings and choosing lower paying specialties as salaried employees. Yet, even after adjusting for these differences, hourly earnings were significantly higher (14 percent) for men. Men's earnings substantially exceeded women's earnings among physicians with no academic affiliation, in high-income specialties and in general internal medicine.13
Maintaining a balance between multiple roles while under the pressure of societal expectations is another issue that may trouble female physicians, although this may vary within specialties. Female physicians report deriving more satisfaction from their personal relationships with patients and, therefore, report greater dissatisfaction with the decreasing amount of time they have to spend with patients.7 Women who are surgeons differ from other female physicians in that they are likely to be younger, unmarried, childless and work more clinical hours and call nights. But, they are not more likely to report feeling they work too much, experience too much stress or have less control over their lives. Their reported satisfaction with their specialty is greater.14 Female physicians in academia earn less, report having less control over their work and working too much, but they are also less likely to want to change their specialty.15
Women with children and families at home sometimes face a more difficult dilemma because they struggle with child care issues, working-mother guilt and isolation from their spouses. In a survey16 of married female residents, the majority reported having communication difficulties with their partners, not having enough time to spend with their partners and arguing about domestic responsibilities. Results from one study12 showed that approximately one half of 200 female physicians who were polled reported experiencing continual high stress levels because of their multiple roles, 44 percent felt mentally tired and 17 percent took antidepressant medications. It is no wonder, then, that in this study17 of 4,501 female physicians, 31 percent indicated that they would not become a physician again or would choose another specialty if given the choice.
Motherhood in Medicine
More than one half of female physicians have their first child duringresidency,18 which has led to research regarding the safety of pregnancy in residents. Results from one study19 showed increased rates of preterm labor (11 percent versus 6 percent) and higher rates of preeclampsia (8.8 percent versus 3.5 percent) in pregnant residents when compared with pregnant women who were not residents. However, no increase in preterm deliveries was indicated, and preeclampsia was not shown to be associated with adverse outcomes. Another study20 showed increased rates of spontaneous and induced abortions among resident physicians.
In a study21 of family practice residents, the average length of maternity leave was eight weeks, and it was derived from multiple sources including vacation, sick leave and home-based electives. Residents reported that after returning to work they experienced sleep deprivation, difficulty arranging child care, guilt about being absent from their children and difficulty continuing breast-feeding.21 These results show that although flexibility in training is increasing, more understanding and support is needed for residents and physicians who are pregnant.22
Female physicians who have children also face greater obstacles in career progression. In a study23 of 1,979 full-time academic medical school faculty members, women with children reported facing major obstacles in developing academic careers. They reported producing substantially fewer publications, feeling that they had slower career progress and less career satisfaction. Notably, no differences were found in academic career progression between men and women who did not have children.23
Logistics of “Having It All”
As the saying goes, there is no right time to have a child in medicine. Having children while still in medical school presents dilemmas about finances and child care and means that women will have toddlers during their residency programs, which is the least flexible period of training. Yet, the benefits of having children while in medical school include greater flexibility in taking time off and having no commitments to a practice. Having a supportive partner is essential, and the partners of medical students should be knowledgeable about the complexities of this decision when the couple is contemplating pregnancy. Many women and their partners feel that by beginning their family and career simultaneously, they are choosing to make their children a priority.
Having a child during residency can be physically and emotionally demanding, although the demands are impacted by the particular training program and the director's willingness to be flexible. Being pregnant during residency also impacts other residents' schedules, which can result in feelings of resentment.24 Speaking with other mothers in the residency program can provide insight, as can reading literature published by the American Medical Women's Association and the Association of American Medical Colleges, which outlines options and legal rights regarding pregnancy and child care. Information about residency programs that offer part-time positions should be sought. Although this is typically a less flexible period of training, the benefits of having children during residency include paid maternity leave and a modest income.
Much more latitude for childbearing exists after completing medical training, although advancing age may preclude it. As attending physicians, women have the benefits of a sizable income, more time, control and flexibility greater support systems and the power of a contract (which can include a pregnancy clause).24 Many options are available. Income can be used to hire household help, for example. Working from home is another option. Many female physicians, especially those in specialties such as psychiatry, have set up offices in their homes. Women might also choose not to work in their profession for a few years or limit their practices to part-time when their children are young.
Women have been central to the development of the compassion and intellect of the practice of medicine. Out of necessity and will, women have woven themselves throughout the profession of medicine and the bedside of communities for centuries. In recent years, the numbers of women physicians have radically increased, causing numerous studies about women in medicine to be undertaken. If fully utilized, this information may provide greater insight into the challenges and successes of female physicians.