Career resources content posted on NEJM CareerCenter is produced by freelance health care writers as an advertising service of NEJM Group, a division of the Massachusetts Medical Society and should not be construed as coming from, or representing the views of, the New England Journal of Medicine, NEJM Group, or the Massachusetts Medical Society
The number of women in medical school, residency, and fellowship are dramatically increasing. Gender equality can be found in primary care, but disparities persist in ophthalmology, radiology, and a host of surgical specialties. Mentors, either male or female, and early career activities in departmental and organized medicine can be invaluable as part of a strategy for women to enter and achieve leadership roles in intensive specialties.
—John A. Fromson, MD*
Demographics Continue to Shift, Albeit Slowly in Some Areas, and Certain Disparities Persist
By Bonnie Darves, a Seattle-based freelance health care writer
The past three decades have witnessed dramatic and increasingly visible change in the realm of women entering the physician workforce. In the big picture, the gains have been impressive: Women now make up close to half of all U.S. residents and fellows — 45.4 percent in 2010, up from 21.5 percent in 1980; and in 2010 female physicians numbered nearly 300,000, a 447 percent increase over 1980. Last year, 48.3 percent of U.S. medical school graduates were women, and female physicians comprised 33.8 percent of all physicians and surgeons.
These aggregate numbers, and women’s increasing prominence in the medical profession overall, might signal that historical gender disparities will soon be a thing of the past. Data suggests that this is the case in primary care — women physicians now outnumber men in pediatrics, family medicine, and obstetrics-gynecology, and comprise nearly half of internists. But change is coming more slowly in other specialties. Women remain highly under-represented in ophthalmology, radiology, and urology, and are still a distinctly small minority in many of the other surgical specialties.
Cardiothoracic surgeon Virginia Litle, MD, an associate professor of surgery at the University of Rochester in New York, suspects that the slow rate of change in her specialty — fewer than 5 percent of cardiothoracic surgeons are women — is largely attributable to the training commitment and certain practice realities. “There has been this perception that cardiothoracic surgery is not for women because it’s too intense, and it’s a difficult lifestyle,” said Dr. Litle, who is president of Women in Thoracic Surgery.
Dr. Litle doesn’t deny that the long residency — and often grueling — surgery schedule warrant considerable consideration by anyone looking at the field. But she thinks that women aren’t encouraged enough to look at these time-intensive specialties, or given the message that “it’s doable” to pursue the fields provided they plan ahead. Her organization is attempting to do just that, through grass-roots efforts, mentoring and, as she puts it, “by being an example.”
“I think the best way to attract women to our field is to make them realize that they can have a life outside of surgery,” said Dr. Litle, who has three young children. “We’re trying to get that message out that women can have a family and do this. It’s hard, and it’s not for everyone, but it’s possible. And I do think women have to accept the fact that someone else will help raise their children.” On the positive side, an article in the July 2009 issue of Archives of Surgery reported that the hard work and balancing act pays off eventually; 85 percent of women among the 900 established surgeons surveyed said they would choose their career again, compared with only 77.5 percent of participating men.
Dr. Litle and others interviewed for this article stressed that it’s vitally important for women considering intensive specialties to find a mentor, and to start that process early. Ideally, she advises, women should seek out multiple mentors — in both the career and “life” aspects, and if feasible, both inside and outside their training program or organization. “Don’t just try to do it all on your own,” she said. “I think a lot of women probably make that mistake because they’re independent minded. I’ve made that mistake myself, thinking, ‘I know what I am doing. I can do this,’ when it might have been better to stop and ask someone for help along the way.”
New York City neurologist Gayatri Devi, MD, president of the American Medical Women’s Association (AMWA), agrees with Dr. Litle on both the importance of mentorship and the perception that women often don’t avail themselves of mentors — particularly ones that they themselves choose — early enough in their careers.
“Mentorship by women physicians in positions of power is absolutely crucial, I think, particularly for women who want to be in academic practice,” said Dr. Devi, who is a clinical associate professor at New York University School of Medicine and serves as director of the New York Memory and Healthy Aging Services. “It’s there, but we have to look for it.” AMWA is working to help more such mentors connect with female medical students and residents, she reports, but the relative paucity of women in leadership in medicine means that there are far fewer mentors than are needed.
Krystal Tomei, MD, MPH, a sixth-year neurosurgery resident at the University of Medicine and Dentistry of New Jersey, has sought out mentors of both genders and found their assistance invaluable in helping her craft her career path to date. At the same time, she thinks it’s important for women to operate from the assumption that any surgical specialty — in 2008, only 10 percent of neurosurgery residents were women, compared to 30 percent of all surgery residents — is open to receiving them, if they’re willing to put in the time. And being resilient doesn’t hurt, she notes.
“In my experience, I think that there’s more of an outside perception about [how it is] for women in neurosurgery. The reality is that we are a minority, but we’re not really made to feel like one,” Dr. Tomei said. “I think it may be somewhat personality dependent, though. I am the kind of person who doesn’t mind hanging out with the guys. Sometimes people make comments, but frankly, nothing gets under my skin.”
In ophthalmology, another traditionally male-dominated specialty, the picture has been changing quickly in recent years. Ruth D. Williams, MD, president of the American Academy of Ophthalmology (AAO) and an Illinois glaucoma specialist, observes that just 5 years ago, 84 percent of AAO members were male. By 2011, 24 percent were women, and 42 percent of all members in their first 5 years of practice were women. “The demographics have been changing dramatically. What we predict, based on what we’re seeing now, is that eventually 40 percent of ophthalmologists will be women,” she said.
One possible reason is that ophthalmology has a high rate of professional satisfaction, in part, she suspects, because it offers diversity of practice-focus areas and, increasingly, career-planning flexibility. “It’s a great career, especially for women. We all work very hard, but ophthalmologists can choose different aspects of the profession — from the retail setting to plastic surgery — and most of us can pretty much control what our day looks like,” Dr. Williams said.
Fast-paced recent change is also occurring in urology, where more than 25% of the specialty’s residents are women. That’s a dramatic change from 1999, when only 11.8% were female. But as with other surgical specialties, the long training period and paucity of women in leadership roles remain formidable challenges to enticing more women to the field, according to Melissa Kaufman, MD, PhD, president of the Society of Women in Urology.
“Trying to reach out to our resident contingent to give them role models and mentors to look to has been problematic — and remains a big issue to this day,” said Dr. Kaufman, an assistant professor of urologic surgery at Vanderbilt University in Nashville, Tennessee. “Despite the gains of our predecessors, there is still a need for mentoring, and for professional societies that advocate for the advancement of women in the field because there’s certainly not [gender] equity in our academic systems. There are still many residency programs without female faculty members.”
Women are making inroads in to the specialty despite these barriers, Dr. Kaufman reported. Her own experience at Vanderbilt is a case in point. “Vanderbilt has a long history of having women faculty members in urology and in many other specialties. I was fortunate to always have women faculty members as mentors during my training here, and that surely influenced my decision.”
On the work-life balance front, women urologists are managing to make the most of combining a time-intensive specialty with family life. Dr. Kaufman cites a recent survey of female urologists, which found that more than 60% had children. “Clearly, the long training hasn’t stopped women who wanted to proceed on with family life from doing so,” she said, adding the surveys also tend to find high career satisfaction among women urologists.
Seattle neuroradiologist Yoshimi Anzai, MD, MPH, also remembers well what it was like to come up in a male-dominated specialty. Dr. Anzai, now chief of neurology at the University of Washington, was a rarity in her residency program at the University of Michigan. Today, one fourth of medical school graduates entering radiology training programs are women, but in the late 1990s, when she trained, fewer than 5 percent of radiology residents were women. Like Dr. Tomei, Dr. Anzai reports that she “got along well with [her] male colleagues, and felt accepted overall.”
She credits both her hard work and her mentorship experiences with her career progression. “I would say that my mentors—all men, actually—have actually made the biggest impact on my career advancement,” said Dr. Anzai, who is vice president of American Association for Women Radiologists. “I do think, however, that I have had to work harder than my male colleagues to be recognized as a competent radiologist and to move into leadership. I hope that is changing.”
Continuing Disparities in Academia Perplexing
Unfortunately, although progress is clearly occurring in that regard, those sentiments are still echoed by many women physicians who have made their way into top positions, Dr. Devi notes, based on AMWA’s observations and recent research on the subject. “The sheer number of women going into medicine is the most reliable evidence that change is occurring, but the disparities—in pay and in the number of women who advance to top positions—are still there,” Dr. Devi said.
A study published in the Journal of the American Medical Association in June 2012* on findings from a 2009–2010 survey of 1,729 National Institutes of Health grant recipients, found that male recipients earned $13,399 more than their female counterparts. That difference remained even after researchers adjusted for differences in specialty, institutional characteristics, academic productivity, academic rank, and work hours.
Another recent study, published in Health Affairs in February 2011, found a pay gap of $16,819 between men and women, among newly trained physicians. The study looked at starting salaries of New York state physicians who had left training programs between 1999 and 2008. As with the JAMA study findings, the researchers** determined that the gender pay gap could not be explained by specialty, practice setting, work hours, or other characteristics. Surprisingly, the gap in 2008 was wider than in 1999, when the difference was $3,600, the researchers reported.
“It’s not clear why this pay inequity persists, or why it is actually widening,” Dr. Devi said, “but it appears that it’s not just a matter of women working fewer hours.”
Robert Gebhard, DO, a Jamestown, New York, hospitalist who chairs the department of family medicine at WCA Hospital and co-chairs the AMWA Gender Equity Task Force, thinks that in recent years women have been “lulled into a false sense of confidence” that the disparities are going away. “Half of the medical students may be women now, but half of the leadership positions in medicine are not held by women—and that’s the area that needs the most attention now,” she said. She added that AMWA recently received a grant to study the issue of the perception of women physicians in leadership.
“One issue we have found is that women often question their skills,” Dr. Gebhard explains, and therefore may be initially reluctant to accept a leadership role when it’s offered. “If a male physician is asked to be chair, most will say ‘sure,’ whereas women will often step back and say they need to ‘think about it.’”
Those behavioral characteristics may play some role in the disparities, Dr. Devi and other sources agreed. But other factors, notably medicine’s hierarchical structure and persisting societal bias about women physicians, may be at issue as well, researchers have concluded—although their effect is hard to tease out. Although women accounted for 28 percent of promotions to full professor in 2009, in 2010 only 13 percent of deans and department chairs, and 21 percent of division chiefs, were women, according to data from the Association of American Medical Colleges. In addition, in several specialties—otolaryngology, orthopedic surgery, physiology, and surgery—10 percent or fewer of full professors are women.
Several sources interviewed for this article cited two possible factors that may be involved in the relatively slow pace of advancement: Generally speaking, female physicians don’t do as good a job at self-promotion as their male counterparts do; and many think that if they simply work harder they’ll get ahead by virtue of their qualifications and track record.
“Many women physicians have this idea that unless they give 120 percent, they can’t do the job well, or that they don’t have time to take on roles outside of practice,” said Linda Brodsky, MD, a Buffalo, New York, otolaryngologist and former head of pediatric otolaryngology at Children’s Hospital who co-chairs the AMWA Gender Equity Task Force with Dr. Gebhard.
“I think that what’s actually holding some women back is the networking. Women need sponsors to help them get on editorial boards, for example, or to become director of education for their [professional] societies,” said Dr. Brodsky, who also advocates for and counsels women physicians on career advancement through her firm, Women MD Resources. “But often they don’t where to look for sponsors.”
Strategies for Getting Ahead
Besides securing mentors, one of the most effective and time-honored ways to move forward in medicine, for physicians of either gender, is to become actively involved in both the workplace and their specialty. Women physicians are making headway in this area of health care in general, as evidenced by the fact that they are far more present on committees and executive boards than in the past. In medicine, however, getting ahead requires a very concerted effort — and a willingness to “put in the time” in department (or practice) and specialty initiatives, many physician leaders point out.
Dr. Tomei exemplifies that strategy. She has been involved in organized medicine since she was a medical student and in the neurosurgery professional associations throughout her residency. She thinks that such involvement is a good way to ensure that younger surgeons, regardless of their gender, influence activities their specialty undertakes, while also gaining a sense of what they’ll encounter in practice. She has, for example, worked on the American Medical Association’s Council on Medical Education and with the AMA’s Surgical Caucus and Women Physicians Congress; and she now serves on the National Board of Medical Examiners Advisory Committee. “Sometimes it means that I spend my weekend off doing this [volunteer] work, but I think it’s important — and I actually enjoy it,” she said.
In her own specialty, both the Congress of Neurological Surgeons and the American Association of Neurological Surgeons have been particularly receptive to providing gratifying avenues for resident involvement, she reports. And that’s something she thinks organized medicine in general should do more. “I think there’s something to be said for just improving involvement for residents in these organizations, beyond the typical one-year opportunity, to keep them invested,” she said.
Women in the specialties also need to operate a bit more like their counterparts in the business world, Dr. Litle suggests, by being extremely motivated, resilient and, as the situation dictates, somewhat entrepreneurial.
“I think that women have to be prepared for the possibility that someone may not come along and guide them,” said Dr. Litle, “which means that you’ll have to do a bit of work on your own, because it’s less likely that people will feed anything to you than they might a male counterpart,” she said. “But that doesn’t mean you won’t get ahead. What I say to women is, ‘if your dream is to become a chief or a chair, don’t give up!’”
Online Resources and Organizations for Women in the Specialties:
Association of Women Surgeons
American Association for Women Radiologists
American Medical Women’s Association
Ruth Jackson Orthopaedic Society
Society of Women in Urology
Women in Endocrinology
Women in Neurosurgery
Women Physicians Congress (AMA)
*Jagsi R, Griffith KA, Stewart A, Sambuco D, DeCastro R, Ubel PA. “Gender Differences in the Salaries of Physician Researchers.” JAMA. 2012;307(22):2410–2417. doi:10.1001/jama.2012.6183.
**Lo Sasso AT, Richards MR, Chou CF, Gerber SE. “The $16,819 Pay Gap for Newly Trained Physicians: The Unexplained Trend of Men Earning More than Women.” Health Affairs (Millwood). 2011 Feb;30(2):193–201
*Dr. Fromson serves as the editor for Career Resources and is Vice Chair for Community Psychiatry, Brigham and Women’s Hospital; Chief of Psychiatry, Brigham and Women’s Faulkner Hospital; Associate Professor of Psychiatry, Harvard Medical School.