NYT: Women are ruining medicine

Jun 12 2011 Published by under Medicine, Uncategorized

(I should note that some of this text appeared in a previous piece on an older blog of mine.  The issue just won't die.  --PalMD)

I've written before about many of the challenges faced by women in medicine.  As more and more women enter medicine, there is a cultural shift struggling to be born.  In the early 1960's, about 5% of medical American medical students were women. Now about half are. Women are first authors on more medical papers than ever, yet fill only about 11% of department chairs, and fill about 15% of full professorship positions.

There is literature studying the trends in academic and clinical medicine. But an Op-Ed piece in today's New York Times sums up nicely the barriers facing women in medicine, dragging out the same old tropes.

I frequently hear that women in medicine are likely to take time off for kids, and to work part-time, and that this somehow renders them less valuable. I'm not sure how this reasoning works. After all, doctors treat people of all ages, genders, and ethnicities, and doctors of different backgrounds often have different experiences and skills to bring to the table.

But I can see how some of these ideas are perpetuated. Slots in medical schools, residencies, and fellowships are quite limited, and it costs much more to create a doctor than tuition could ever cover. Some take a false utilitarian view that because it costs so much to create a doctor, only those who can give back the most as measured in time and money should be trained.

Residencies are limited in both the number of residents they can take, and in how many hours these residents can work. When one becomes pregnant, it can burden the entire program.

Well, this is the real world, and in the real world, half of us are women, and women are the ones who bear children. Also, the prime years for physician training are prime child-bearing years. Get used to it. If we think women have at least as much to offer as physicians as men, we better get used to the fact that they have "lady parts" and that this has real effects. Are we to limit the contributions women are allowed to make because a short period of their lives may or may not involve child-bearing?

In clinical medicine (as opposed to academic medicine), there seem to be many more opportunities to work part-time than in the past. The less you work, the less you get paid, but the pay is still pretty good. But academia is still about productivity, and gaps are not acceptable.

As a society and a profession, we have to decide to take the role of women seriously. If we demean women's role in our profession, we may be more likely to demean our female patients and family members.

27 responses so far

  • sciwo says:

    Thank you, Pal. That op-ed annoyed the heck out of me. And as @nparmalee pointed out on Twitter, it totally ignored the role of fathers in raising children.

  • scicurious says:

    Thanks so much for covering this, I read that op-ed with my jaw on the floor, and I was hoping you'd get on it!

  • WhizBANG says:

    Glad to see someone with a Y chromosome calling out these asshats. I daresay my productivity by any measure has exceeded some of the d00ds in my department, even though I took off a few weeks with newborns.

  • Melissa (DrSnit) says:

    Love your post! And I will say that academia needs to change too. EVERYTHING needs to change. Our inability to fit various life needs and work desires into our needs is endemic to the US overworked/inequality based system.

    Rock on you.

  • Julie Stahlhut says:

    Entirely too many people believe that having a life makes one a mediocre worker. Which is totally ridiculous, since having happy relationships and other outside interests gives us the emotional stability that we need to perform at our best in all aspects of life.

  • becca says:

    So... when it is women who fill more of the urgently needed primary care slots (NOT anesthesiologists, last time I checked), and we can't get enough people into such slots... the correct answer is NOT to make the slots more appealing (by providing better provisions for work-life balance) but to berate the women for not being dedicated enough? uhmhmm. Apparently, some of those drugs that make people numb cause hallucinations as well....

  • Jim Thomerson says:

    I go to a specialist clinic, which, as far as I can tell, is all female. My surgeon there is female, and I scheduled my last surgery around her doing maternity leave. I was referred there by another all female operation. I was referred to that operation after I said I had no problem with female MD's. I'm happy with the situation.

  • Alexis says:

    I hated that piece. It also ignored the generational shift: I've seen data showing that younger physicians in general want to work fewer hours, and that matches up with what I've seen from friends who went into medicine. (I'm 33, for what it's worth.) Isn't dermatology the most oversubscribed residency? I also don't see many younger solo practitioners. They want groups with coverage. The only solos I see now are boutique/no insurance practices, which are a niche market, or older physicians who are near retirement. The younger physicians are all in groups of at least 3 and usually more. My friends want to be employed and not run their own business. They've gone into academia, become hospitalists, joined HMOs.

    I don't see anyone signing up to work surgeon's hours at primary-care pay. "Part time" can often still mean 40 hours a week. She didn't propose any solutions, just "suck it up, because I did."

    Also: What is the real data on women taking leave? I only have anecdata here, and it suggests that female physicians are not taking long maternity leaves--I'm seeing 6-8 weeks. They're not taking European 1 year leave.

  • David Dobbs says:

    Oh wonderful. We have thousands and thousands of doctors who won't or can't (b/c of where they work) see would-be patients who are uninsured or underinsured -- an ENORMOUS inefficiency and sickening injustice — and our problem is that women doctors won't work 60? Poppycock. Address the real problems.

    The family practitioner who treats my wife and children works half-time, splitting a position with her husband. In reality they each work about 30 hours a week. They have other lives, too: they spend time with their daughter, Dr. Jonna plays the bassoon in a community orchestra. And most of all, Dr. Jonna has a better sense of life outside the clinic than most doctors do, and that shows in the way she treats the whole patients, asking my wife all kinds of questions about her LIFE and environment, those things that so affect one's health. She also takes more time with her patients than any doctor I've ever known, because she feels less harried. She's a better doctor for her schedule.

    Our shortages of primary care physicians are not due to women working part-time. Most of our problems exist because our medical system has become not a system for creating and distributing healthcare but a system for redistributing wealth and income from a large array of people, those lucky enough to be insured, into a very few hands. This is not to question the motives of all physicians -- though the motives of many, it's clear, have become wildly warped and corrupt, where their first filter on whether to deliver care to a sick person is whether the person is insured. But anyone looking from the outside would note clearly that the delivery depends more on money moving up than care moving down. Which is, quite frankly, sick.

  • Gerty-z says:

    Ugh. What a freaking load. Thanks for calling this out, Pal.

  • A. Marina Fournier says:

    Two attitudes I dislike hit me upon reading this article: sour grapes and "If I had to, you have to". Chinese (and other Asian cultures) MiL/DiL dyads have done this last throughout the centuries, and it doesn't make it right or desirable.

    There's a certain amount of QueenBee-ism here, too--why should you get what I couldn't at your stage of the game? Was it you who wrote of an oncologist who felt if you weren't working to fight cancer 80 hrs/week, you weren't doing enough?

    Imagine you're a patient of an OB/GYN, and she needs medical leave for a massive tumor, or for her own high-risk pregnancy. What are you supposed to do, leave in a huff because she's human? I've spent a fair amount of time escaping physicians and psychiatrists with god-complexes, and I WANT a practitioner with a good work/life balance, as well as a good use of time & resources in their daily work. The latter ought to be made possible by a good office manager. Emergencies happen, and the on-call setup is supposed to distribute the workload that imposes.

    I also want a physician who appreciates an inquisitive and informed patient, and can communicate well without feeling attacked. I'm much more likely to stay with that physician or mental health professional.

    You ask if we are to limit the contributions women are allowed to make because a short period of their lives may or may not involve child-bearing. I was hoping we were leaving that all behind. You made great points--thank you for writing this.

  • Tiercelet says:

    I'm glad I'm not the only one who was driven mad by that article.

    Doctors of the present generation are like most people in that generation -- they want to be able to have good lives, which includes but is not coterminous with good jobs. The expectations and the burdens on doctors have been far too great to support for far too long. I'm sorry for this woman that she's sacrificed too much of her life that can never be restored, only to see up-and-coming physicians force a cultural change, but she should be cheering them and fighting for them, not insisting that medicine be a form of indenture.

    I'd be a doctor today if it weren't for the 80-hour workweeks. And like many of my cohort, if I were going to work banker hours, I'd expect banker pay. Raise taxes, fund more residency positions, make more doctors, make doctors' lives better (and their patients' too).

  • RachelW says:

    "If we think women have at least as much to offer as physicians as men, we better get used to the fact that they have "lady parts" and that this has real effects." - Yes, this, thank you. Not to mention that at the same time, we're getting messages that women who work at all, or are poor while raising children (contradiction, much?), or or delay childbearing are also ruining it for themselves and other people.

  • WcT says:

    A few random slightly related thoughts:
    "I frequently hear that women in medicine are likely to take time off for kids, and to work part-time, and that this somehow renders them less valuable. I'm not sure how this reasoning works. After all, doctors treat people of all ages, genders, and ethnicities, and doctors of different backgrounds often have different experiences and skills to bring to the table."
    Well she explicitly says in the article that she's talking about productivity, a part time physician is less productive than a full time physician, it's just simple math, 40 hours a week of doctor time is WAY less patients than 80 hours a week. I heard similar arguments about admitting older people to medical school - over a career a 22 year old med student will practice longer, see more patients over their career than an 45 year old med student, and is thus a better investment of subsidized medical education dollars. Overall I'd say we get more from having the most qualified people in medical school, so I certainly don't agree with this sentiment, but it exists, and isn't just aimed at women.

    "...(by providing better provisions for work-life balance)..."

    Just to play devil's advocate here, speaking as a physician currently in residency
    How are programs supposed to provide for better work life balance? We have a physician shortage. If you want a little time to spend with your family, there still need to be doctors covering the hospital! There isn't enough money to hire additional attending physician faculty to somehow cover resident resposibilities, nor is there money or availability for enough midlevel providors such as NPs or PAs to help cover all of theses.
    At the institutions my residency covers in the ER, overall residents see around 1/3 to 1/2 of the flow of patients to the ER. If someone needs off for some reason, family related or otherwise, some doctor needs to cover that, or the waiting room goes from manageable to "people are dying while waiting for you to take care of them."
    Healthcare is already expensive, CMS is unlikely to want to provide extra money for us to cover people for work life balance, we aren't in a position to negotiate higher prices, and hospitals are already struggling to keep doors open.

    And as already mentioned, we have a big shortage of doctors, so how are we supposed to provide care for everyone? By and large doctors job satisfaction is decreasing along with their pay, so yea going into medicine we want more work life balance - because work isn't all it's cracked up to me. Further, when programs TRY to be family friendly, because of the need to have doctors in the hospital, it just turns into dumping those extra responsibilities on those physicians who DON'T have families, which isn't really any more fair.

  • Cloud says:

    But is the doctor who is working 80 hours a week doing high quality work? If I try to work 80 hours a week I make stupid mistakes. My own personal productivity curve tops out at about 45-50 hours/week.

    Personally, I'd rather have a well-rested doctor who is making good decisions for fewer patients than a stressed out, overworked doctor who is making so-so decisions for more patients.

    I'll give you that the current system isn't set up to allow that for all doctors, but that doesn't mean it has to stay that way. You doctors are smart people. Surely you could design a better system if there was enough pressure to force a change?

    • Nicole says:

      I know there's been legislation limiting the number of hours residents can work. Maybe a step in the right direction...

    • WcT says:

      "But is the doctor who is working 80 hours a week doing high quality work?"
      Over 80, my quality absolutely declines, but up to 80, pretty top notch. What gets sacrificed is personal time. When I'm working 80 hours, I get enough sleep, eat ok, exercise fine, have a liiiittle bit of time with my family, and spend alot of time at work. Now when I was on a bad rotation and hitting 100-110 hours a week consistently, yea, my work wasn't top notch, and the program had to make adjustments to make sure we weren't doing that anymore (that's the hours restriction being referred to below, we're capped at 80 hours a week).

      And frankly, if you offered me 80 or 45 right now, I'd take 80. To get to be competant in my field in the 3-4 years residency offers me, I need to work 80. Cut me down to 45 and I won't have seen enough patients, done enough procedures, taken care of enough complex issues to be able to handle it in the real world without at least 1-2 more years of training. I'm already in grade 20sometihng, I'd prefer to be done training and have a real job before i lose all my hair!

      Now in the real world, I'll be working 35-45 hours, in shiftwork, but in training, less hours equals more years.

      We've already seen this in general surgery, as hours restrictions have directly lead to surgeons having done significantly less surgeries prior to the end of residency than previous years. I'm sure it's true for other specialities, but at my institution, they were the first people to point this out as an issue.

  • daedalus2u says:

    @ Cloud, I think the whole point is to keep the number of doctors low, to keep them overworked, so they can't realize what a crappy deal they are getting, and don't have time to do anything about it, so the insurance companies can continue to make money hand over fist while screwing over patients, the government and health care providers.

    Continue to nickel and dime the MDs, nurses, med students and patients so the insurance companies can have big profits just for being the choke-point in the middle.

    If the problem is not enough doctors, the solution is not to bully doctors into working longer hours or to bully them into giving up the life that many people want to have. The solution is to make it easier and more pleasant to be a doctor. Remove the BS hoops that doctors have to jump through which are there just to hassle them.

    Doctors didn't cause this problem, doctors don't have a magic wand to fix the problem. Is this a problem in other countries? Why or why not? Every other country spends less on health care and achieves better results.

  • Nicole says:

    @daedalus2u -- NPR had a fascinating series (still available on their webpage) on how medical professionals are reimbursed (and how insurance and medical care in general works) in other developed countries a few years back. If you're really interested in whether or not this is a problem in other countries, it offers some fascinating answers. Different countries keep costs low (and health high) with different methodologies, whether by depressing MD wages, rationing care, etc. Japan is very different from Germany which is very different from England.

  • DrugMonkey says:

    I would be very curious to hear about the groundswell of doctors and doctor organizations advocating new med schools be opened and for existing ones to figure out how to train more doctors. Can anyone point to such efforts?

  • DrugMonkey says:

    According to Wikipedia, Oral Roberts Med closed in 1990, last ones to close before that were in the 1920s.

    There are 13 new MD programs listed as planning to open in the next few years or "in discussion". It will be interesting to see how many open.

    There appear to have been 9 MD programs to open since 2000.

    So where is the doctor supply bottleneck? Going by undergrads claiming to be premed and seeking ref letters for med school there doesn't seem to be any lack there either. Or is this recent expansion in capacity arriving too late in the game?

    • Nicole says:

      Don't forget DO degrees.... Also NP (especially nurse midwives).

      • DrugMonkey says:

        Those are not MD programs. They are perhaps more of a symptom than a remedy

        • WcT says:

          The bottleneck is at least partially graduate medical education - the funding to open up residency programs is more limited than funding available to open medical schools, and frankly, the number of hospital systems that can sustain residency programs is limited - a small ER that sees 20,000 visits a year can't really sustain an ER residency for example, you really need an ER big enough to see a higher volume of sick patients.

          On top of that the residency review committees are only gradually increasing the number of allowable residents in a given program - appropriately, because it takes time to make sure increasing the number of residents doesn't decrease the quality of education. In my own field the "old" cap on number of residents at an ER program was 14 residents per class, they are currently piloting some programs as many as 20 residents per class, and results of that will be a few years in coming before that kind of expansion becomes more widespread.

  • PalMD says:

    It's not so much a doctor shortage as a "type of doctor" shortage, and our current education system is designed to shunt american medical grads to high paying subspecialties.

    • WcT says:

      I don't really agree with you... Discounting a few highly paid subspecialities like derm, ophtho, plastics, ortho, ENT, which acount for a small percentage of a given medical school class, there are still shortages in EVERY primary care subspecialty, OBGYN, ER, and general surgery, programs that account for a higher percentage of a given med school class.

      I agree the education system is set up to favor those highly paid subspecialties, but there is an absolute doctor shortage in addition to a relative doctor shortage.