When the doctor is a lady

More women in medicine may mean a healthier balance between patient care responsibilities and lifestyle - for all physicians.

By Gail Garfinkel Weiss, SENIOR EDITOR

During the last 40 years, women have become physicians in ever-increasing numbers. In 1964, according to the American Association of Medical Colleges, 6 percent of medical school graduates were female. By 1984, that number had risen to 28 percent, and by 2004 it was 46 percent.

The trend is as inexorable as it is unsurprising. Medicine is, after all, a line of work in which practitioners take care of people. And if stereotypes are at least partially grounded in fact, women have long been seen, and see themselves, as nurturers. Once women started entering the professional world in large numbers, the business of medicine—especially family medicine, pediatrics, and obstetrics/ gynecology - seemed a natural fit.

Females, however, aren't represented equally throughout the medical profession: Gastroenterology, neurology, and most of the surgical specialties remain male bastions. And men still dominate the profession as a whole. In 2003, according to the AMA, women comprised just 26 percent of the total physician workforce. But that's up from less than 8 percent in 1970. Indeed, according to the AMA the total number of physicians in the US increased by 86 percent between 1980 and 2003, while the total number of female physicians increased by 315 percent.

What does this mean in terms of patient care and the future of medicine? We looked at studies and anecdotal information to get some answers.

Does gender influence practice patterns?

In their study on the effects of physician gender on patient care, FPs Klea D. Bertakis and Peter Franks of the University of California Davis School of Medicine found that female physicians spent more time with patients and were more likely to order certain preventive services such as Pap tests and blood pressure checks. They were also more prone to offer counseling, and make follow-up arrangements and referrals. Male physicians, the researchers found, devoted more time to "technical" issues: doing a history and physical, and focusing on the problem at hand. (The study was published in the January 2003 issue of the Journal of Women's Health.)

Surprisingly, when Bertakis and Franks controlled for patient gender and health status, they found that differences in the amount of time spent with patients were statistically insignificant. "Female physicians have more female patients," says Bertakis, "and female patients report themselves as being in poorer health than males and require more time. Women physicians also see more new patients, and we all know that first visits are longer than follow-ups."

That's certainly the experience of Karen B. Weinstein, an internist in Oak Park, IL. Weinstein spends more time with patients than her two male partners do, but 80 percent of her patients are women, so naturally she does more Pap tests and breast exams.

Other physicians think that differences in visit duration reflect personality more than gender. "I know of many male and female doctors who are in and out of the exam room quickly, and several of both sexes who take the time to sit and listen," says Rivka Stein, a pediatrician in Brooklyn, NY. Stein, who likes to spend time with patients and their parents, educating and just chatting, adds that she thinks patients gravitate toward physicians who are like them. "I have had patients leave my practice because they prefer not to spend much time on a visit," she says.

Sherri L. Morgan, a family physician in Yellow Springs, OH, believes that patients expect women doctors to be more conversational and empathetic. Those who meet these expectations, Morgan says, do so because it comes naturally to them or because they've learned how to be better listeners. In her own case, if a patient, say, complains of stomach problems, she'll do her usual workup and at the same time ask about the patient's family, marriage, and work situation to determine if the problem has emotional components.

Patient satisfaction and physician gender

When Klea Bertakis, Peter Franks, and statistician Rahman Azari observed over 500 physician-patient interactions in a study designed to measure the effects of physician gender on patient satisfaction, they found that patients of female physicians were significantly more satisfied than patients of male physicians. This held true even after the researchers controlled for patient characteristics such as age, sex, income, education, and health status. (For the complete study, see the Spring 2003 issue of Journal of the American Medical Women's Association.)

The researchers attributed the women physicians' higher patient satisfaction scores to female doctors' tendency to engage in more positive talk and partnership building, and to provide more information. Bertakis acknowledges that patients' gender-based notions might play a role in the physician-patient relationship. "For example," she says, "patients may presume female physicians are more compassionate, empathetic, and nurturing. The patients may consequently respond with more self-disclosure and greater satisfaction at having been able to express themselves."

Nonetheless, some patients remain uncomfortable with women doctors. "Male patients tend to be less comfortable with women examining them, but women don't mind being examined by men," says Rivka Stein. "The only time I've really seen a difference is in rape cases."

Shannon Oates, an endocrinologist with Arnett Clinic in Lafayette, IN, doesn't take it personally if she gets the brush-off from a male patient. "When one gentleman told me he wouldn't do what I asked because I was a ‘girl'—I was 43 at the time—I laughed and referred him to a male internist. That doctor later called to complain that the patient wouldn't commit to any lifestyle changes or take his insulin. So I guess it wasn't me."

Sherri Morgan has had similar experiences. "Some older male patients don't feel comfortable talking to me because they don't think I can understand where they're coming from," she says. Morgan refers these patients to male colleagues, but if no male doctor has room on his schedule, Morgan says that she and the patient "work it through." Other women physicians report problems with younger men: For instance, FP Mary Wirshup of Glenmoore, PA, says older men are happy to see her, but men under 40 are sometimes hesitant.

Even rank-and-file medical workers are sometimes reluctant to accept women physicians. FP Katherine Martin of Harrisonburg, VA, says that employees - usually women - will tolerate criticism from a male physician, but not from a female. Martin recalls that when she corrected an RN on a work-related matter, the nurse angrily replied, "You're not my mother." Martin finds that nurses overreact or act irritated if she criticizes their work, "while male physicians are rarely taken to task, no matter how egregious their behavior."

Getting a foothold in medicine's upper echelons

As much as the number of women has increased in the physician community, female physicians continue to be underrepresented at medicine's higher levels. For instance, of the 21 people on the AMA's Board of Trustees, just four are women. The situation is much the same in the specialty societies—even for those specialties in which women are making significant inroads. Four of the AAFP's six officers are male, as are eight of the 12 members of the board of directors and four of the five vice presidents (one vice presidency is unfilled). The American Academy of Pediatrics has a woman president and president-elect, but men hold eight of the 10 board of director spots. In academic medicine, too, women are scarce at the top. Eyeball any list of full and associate professors and you'll see mostly male names. Ditto for the top positions in group practices.

"I think it comes down to families," says Rivka Stein. "Most women physicians I know want to have a life outside the office, and that doesn't leave time for board and committee work."

Pediatrician Jennifer Shu, who teaches at the Dartmouth Medical School in New Hampshire and is director of the Normal Newborn Nursery at Dartmouth-Hitchcock Medical Center, sees the issue as a generational one that will change as more women mature in the profession. She may be onto something. Shu, who finished her medical training nine years ago, was chair of the young physicians sections of the AMA and the AAP. This year, three of the seven members of the governing council of the AMA's Young Physicians Section are female, including the chair and the chair-elect. And half of the executive committee of the AAP's Section on Young Physicians are female.

That leaves the question, "What happens when female physicians opt for parenthood?" Most who combine career and family earn less than men,* sacrifice promotional opportunities, and face a delicate balancing act when determining how to share call with full-time colleagues. Mary Wirshup, for one, worked part time when her children were young, but her 16-doctor group had a pay formula that offered bonuses only to physicians who worked more than full time.
*For more on how much female physicians earn vs. men, and how they handle their finances, see our Financial Survey article, "Women are holding their own," on page 00 of this issue.

Still, many applaud the trend away from punishing work schedules, and see signs that male physicians are following the example set by their female colleagues. "A large percentage of pediatricians entering practice plan to work part time at some point in their careers, and many of the doctors are men," Jennifer Shu says. Indeed, the AAP reported in a 2002 study that 58 percent of female residents and 15 percent of male residents hoped to work part time within five years of completing residency.

Regardless of how much time women physicians spend in the office, their growing presence will make the profession more patient-friendly, says FP Sherri Morgan. "Traditionally, women are caregivers," she says. "As we continue to enter medicine and move into leadership positions, we'll see more of a ‘patient comes first' philosophy."

Some doctors hope that female physicians will reach that goal and loftier ones. San Diego, CA, general practitioner Liza Shiff would like to see the profession move toward addressing women's health issues in ways that are specific to females. "For instance, cardiovascular disease management in women shouldn't mirror the way the disease in managed in men; there's a need for a different protocol. Such a trend will benefit the profession as a whole, because it'll result in better patient outcomes and fewer malpractice suits."

Power Points

• Studies show that female physicians are more likely than males to order certain preventive services, offer counseling, and make follow-up appointments and referrals.
• Female physicians, on average, spend more time with patients, but that's because female doctors see more patients who report themselves as being in poorer health.
• According to a 2003 study, female physicians garner higher patient satisfaction scores.
• Women doctors are underrepresented on the executive boards of organized medicine and in positions of influence in academia and medical groups.