Think about your own experiences—you’re at a party or a restaurant, and someone you’re with says something obviously racist. You cringe, but given the setting, you can’t decide how to react; after a pause, you probably decide to say something. Now imagine you’re at meeting for work, and a senior partner says something racist. You want to say something, and you even know that under some circumstances there are laws behind you, but you don’t want to get branded a trouble maker and risk subtle (or not-so-subtle) discrimination.

Now imagine you are sitting in the doctors’ lounge, and a senior physician says that sending women to medical school is a bit of a waste. The people sitting around the table make decisions every day about who to accept and reject to medical schools and residency programs, who to hire, who to promote, but hey, it’s just a group of guys having a cup of coffee. How would you react?

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.

What’s behind this?

There is literature studying the trends in academic and clinical medicine. I’ll point you to the reference below as a starting point, but I’d like to give you a front-line perspective.

Something I hear every week is that women 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 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.

Things are getting better, but we still have a long way to go.

References

Reshma Jagsi, M.D., D.Phil., Elizabeth A. Guancial, M.D., Cynthia Cooper Worobey, M.D., Lori E. Henault, M.P.H., Yuchiao Chang, Ph.D., Rebecca Starr, M.B.A., M.S.W., Nancy J. Tarbell, M.D., and Elaine M. Hylek, M.D., M.P.H. The “Gender Gap” in Authorship of Academic Medical Literature — A 35-Year Perspective. NEJM 355(3); 281-287. July 20, 2006.

Comments

  1. #1 Chris H.
    April 13, 2008

    FWIW, this is a huge problem in law too. I tell my students before they interview to ask the various law firms how many of their partners are women.

  2. #2 Abel Pharmboy
    April 13, 2008

    As one who works with many academic MDs, men and women, and I cannot agree with you more that women bring incredible gifts to medicine and medical research. I’m also married to one and see firsthand the grief and other indignancies women must endure in academic medicine. I wrote a few words on this issue when the first female dean of a top 10 medical school was appointed last year. Last year, man?!?

    We can, and must, do better.

  3. #3 Aotus
    April 13, 2008

    The major problem that exists in this gap is the same problem that people of color and feminist groups have been pointing out for years. Racism and sexism are no longer appropriate when they are blunt, but institutionalized racism and sexism are perfectly fine when they can be linked to “productivity.” When you measure “productivity” strictly by how much an upper class white man with loads of societal priviledge can accomplish, you immediately deduct a certain amount of that measure from any other group and negate anything extra they might have brought. If we’re judging people purely by the amount of hours they work and not by the quality of service they provide, then someone without child bearing capacity and a strong financial background is going to win every time.

    I want to thank you for taking a stance on this. I love the “get used to it” attitude. It’s rough to be able to call out that the rules favor a certain group, especially these days when no one wants to think of themselves as having benefited from racism or sexism. Great post!

  4. #4 Katharine
    April 13, 2008

    This is part of why many of us elect to just not have children. My wants and my career come first, and I’m not going to jeopardize them by having a child. In fact, I’m planning on having my uterine lining removed as soon as I can afford it. (That, and I’m not fond of children anyway.)

    I suspect this, and other sexist policies, would be moot if both sexes were able to have children.

  5. #5 CeCe
    April 13, 2008

    In a normal pregnancy the amount of time that women are physically unable to work is short compared to the amount of time needed to care for dependent infants and children (even if said kids are in childcare). If fathers would equally share the responsibilities for childcare, this would be a moot point. This would include parental leave, regular childcare, staying home with sick kids, arranging doctor’s appointments, school appointments, etc. If employers knew that fathers were just as likely to miss time as mothers, then the bias against women would fade, perhaps to be replaced with a bias against parents, but then at least it would be gender neutral.

  6. #6 Anonymous
    April 13, 2008

    I’m familiar with the argument that has been made which appear to represent the time that women spend bearing and rearing children as somehow having no economic value. The problem of course is that “women’s work” (which is slowly starting to balance out between the sexes) is one of the major driving forces of any economy. Not only are parents producing and training the next generation of workers (as a rule, employers expect their staff to be toilet-trained) but the industries that financially benefit from child rearing activities provide countless jobs (and tax revenue). Just someone is not earning an income doesn’t mean that the work has no economic impact.

  7. #7 N.B.
    April 13, 2008

    The interesting counterbalance to this is the fact that a huge percentage of recently graduating pharmacists are women. 46% of currently practicing pharmacists are women; roughly 60% of my class is female, and two out of the three pharmacists that I work with on a regular basis are female as well. This isn’t quite in-line with the national average, but the best statistics I could find are from a 1980 survey that suggests roughly 1/3 of pharmacy students are female.

    The oft-cited reasons behind this is that pharmacy provides an opportunity for a job that offers excellent compensation even for part-time employees.

    I may have to do a bit more thorough probing into the gender dynamics of pharmacy here in the near future.

  8. #8 Joe
    April 13, 2008

    The “lost time” argument sounds spurious to me, at least concerning private practice. I have known people in their thirties who were accepted to med school. That’s a whole decade lost, full time. Somebody once told me the occasional 40-yo is accepted.

    If the shortage of women in academic med is self-selection, one can hardly complain. (As long as it comports with personal priorities, rather than fear of rejection.) I strongly support recruiting women in public service professions (medicine, law, politics, journalism, etc.). In academia/research, I don’t think it matters much if you are male, female or Republican. (I do think that women may find problems that are less likely to occur to men; but I doubt they need equal representation to do that.)

  9. #9 Ruth
    April 14, 2008

    My C-section was done by a woman 6 months pregnant. She belonged to an all woman practise, and several of the partners had young children.

    Are we screening the male med students to see which ones will die before age 50 of heart disease? Why pay for expensive training for someone with less life expectancy?

  10. #10 FutureMD
    April 14, 2008

    Its kind of funny that the high speed lifesytle is encouraging our best and brightest women not to have children. Its a selection pressure against intelligence.

  11. #11 Dave Munger
    April 14, 2008

    Its kind of funny that the high speed lifesytle is encouraging our best and brightest women not to have children. Its a selection pressure against intelligence.

    Well, affluence will do that regardless of the social status of women. Wealthier people have fewer babies because babies cramp their lifestyle and compete for resources. In poorer families children are often seen as an economic benefit because they can be put to work, and will take care of the parents as they age.

    Nonetheless, nice post, PalMD!

  12. #12 Stephanie
    April 15, 2008

    Frankly I think sending men to medical school is a bit of a waste. I may be misremembering the mortality breakdown by age and sex, but aren’t they more likely than women to die during their prime doctorin’ years?

  13. #13 Tinuz
    April 15, 2008

    Well, I definitely feel that discriminating against women is a bad thing, regardless of their likelihood of taking a prolonged break due to motherhood. However, I do feel that if you accept a position with a certain responsibility then you accept the limitations that come with it. If that means you cannot take a three month break, then you shouldn’t, whether it is because you want to go on a long holiday or because you want to have children.
    So, in the end, if you want to have children, that represents a certain limitation in jobs you are able to perform (at least for a certain period). If you think that’s unfair because men can’t have children…well, I guess it is, but we didn’t make the rules on reproduction. ;)

    PS. I am thoroughly against contractual obligations of not getting pregnant or something like that, so I acknowledge the lack of enforceability of this notion (perhaps for the best :p )

  14. #14 geetha
    April 15, 2008

    Interesting post PalMd. In india such discrimination exists in most of the fields not only medicine though it is subtle.

  15. #15 rjb
    April 15, 2008

    Grrrr, I already commented over at The Intersection about this, but…

    intelligence and genetics are only loosely correlated!! Experience is a much much larger variable than genetics. So the fact that “smart” women aren’t having as many children should have a minor, if not nonexistent, effect on the intelligence of the next generation…

  16. #16 Dianne
    April 15, 2008

    If the shortage of women in academic med is self-selection, one can hardly complain.

    The decision to enter academia or not is not made in a vacuum. Women in medicine are subtly and not-so-subtly pointed at family practice as a “family friendly” (but mostly non-academic) specialty, encouraged to “consider their priorities” in ways male medical students are never asked to, subject to open harrassment and discrimination (cough…surgeons…), and have to do far more work to be considered “good enough” than their male colleagues. These factors play into the decision as well as simple questions of “is academia where I want to be”. Which is why simply saying, “Oh, well, what can we do, it’s self-selection” isn’t valid in this situation.

  17. #17 Tlazolteotl
    April 15, 2008

    Yes, rjb, but at the same time, children from privileged families tend to do better, have better opportunities, etc., and these are precisely the women who are choosing not to have children because they interfere with their careers.

  18. #18 T
    April 15, 2008

    intelligence and genetics are only loosely correlated!! Experience is a much much larger variable than genetics. So the fact that “smart” women aren’t having as many children should have a minor, if not nonexistent, effect on the intelligence of the next generation…

    What’s the correlation? If the correlation is anything above 0, then the effect *cannot* be nonexistent. Further, parents are *part* of experience, so if we assume that intelligence is 100% environmental, it still means the next generation will have a lowered intelligence relative to this generation based purely on environmental factors.

  19. #19 Coriolis
    April 15, 2008

    Isn’t the “solution” here fairly simple, although admittedly socially very hard to get to? If we lived in a society where it was socially mandatory for the husband to also take a similiar amount of time off for taking care of the kid, as the woman does (after breast-feeding is done most likely), then the practical discrepancy would dissapear. If the man’s career was similiarly interrupted like the woman’s due to child-bearing than there would be no reason (other than actual pure sexism) for discrimination.

    Of course I’d guess even the wildest feminist would never think that could happen, but I wonder if it would really be that hard if women really demanded something like that and changed the expected social obligations of men.

  20. #20 Dianne
    April 15, 2008

    Its kind of funny that the high speed lifesytle is encouraging our best and brightest women not to have children. Its a selection pressure against intelligence.

    So? That is to say, if we take as a given that you are right, what is your proposed solution? How should we encourage smart women to have more children?

  21. #21 Joe
    April 15, 2008

    Dianne wrote “Which is why simply saying, “Oh, well, what can we do, it’s self-selection” isn’t valid in this situation.”

    Thanks for that thoughtful response.

  22. #22 MMOToole
    April 15, 2008

    Hey, I lived through that era. Still am, to some degree.

    I started medical school in 1975. I had professors who said that to some of us women students flat out. (Interestingly, my med school appointed a woman as dean, someone who had been one of my teachers, years ago; she’s retiring this year. The “Top 10″ are way behind on that one.)I have colleagues who are still fossilized in the 1960s and not in a good way, not at the hospital at which I primarily practice (which is the unusual free-standing OB-GYN/neonatal hospital), but next door at the large general teaching hospital. Fortunately, they’re mostly retiring, and their younger colleagues are—surprise!—marrying other doctors, so the attitudes are not being perpetuated.

    My own hospital’s (university medical school affiliated) OB-GYN residency is now, and has been for many years, heavily female. At this point we have one male resident (we graduated one last year, out of seven graduating). Our residency program, from what I can gather, is fairly accommodating (probably because almost always somebody’s pregnant), although the Am. Board of OB-GYN insists that past a certain amount of time off, the time must be made up before graduation, which is reasonable. Four years isn’t a lot of time in a specialty which is heavily surgical and changing rapidly.

  23. #23 outeast
    April 16, 2008

    What a bizarre attitude to hear expressed. Of the doctors that my family and I use regularly (including GP, paediatrician, OB/GYN, optometrist, etc) or have had cause to rely on recently (medical geneticist, pediatric orthopaedic surgeon, etc) more than 2/3 are women (and FWIW at least two of those are mothers – very likely more, but I don’t run family background checks on doctors we use!).

  24. #24 TK Kenyon
    April 16, 2008

    Excellent post, PalMD.

    I had to quit my postdoc because I was pregnant. Because postdocs are considered “temporary workers,” they aren’t afforded protection under the family leave act, common decency, etc. I read the university’s materials that stated that, if I saved up all my vacation and sick leave, I could take up to two weeks off.

    Because I have an interesting immune system, I knew that they were going to slap me on bedrest at around 5 months, so I had to quit. It’s too bad. I was creating some very interesting cells to screen Alzheimer’s drugs.

    And yeah, I felt like I was at a disadvantage because I had “lady parts.”

    TK Kenyon, http://www.tkkenyon.com
    Author of RABID (http://www.amazon.com/gp/product/1601640021) and CALLOUS (http://www.amazon.com/gp/product/1601640226): Two novels about science and religion, with some sex and murder.

  25. #25 Lisa
    April 16, 2008

    I am glad to know that as a female physician I am not superfluous. It is interesting that even though I work less hours then the male partners in my practice, I bring in just as much if not more revenue. The economics are not to totally tipped in the male physicians favor.

  26. #26 Abel Pharmboy
    April 26, 2008

    PalMD: So sorry to miss this post in my discussion yesterday about the BMJ essays on women physicians hurting/not hurting medicine. I appreciate your comments and will add this link to my post. Thanks so much for your thoughtful contributions.

  27. #27 medstudentgirl
    May 6, 2008

    Reading this post, I was so worried that you were going to conclude with some conciliatory nonsense. Until I got to the part where you said “Well, this is the real world, and in the real world, half of us are women.” That’s so exactly right on, and it’s incredibly refreshing to hear that attitude expressed by a current doctor. Thanks for the encouraging words.

  28. #28 Tiffany Bracelets
    November 1, 2009

    I am glad to know that as a female physician I am not superfluous. It is interesting that even though I work less hours then the male partners in my practice, I bring in just as much if not more revenue. The economics are not to totally tipped in the male physicians favor.

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