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WOMEN PHYSICIANS:

An Increasing Influence in Health Care

By By Rajam Ramamurthy, MD

“We need to take a good, introspective look at ourselves, the people we are, and the people we wish to become. The path to successful health care reform must begin with care. Only by caring about each other can we learn how best to care for each other”. Dr. Steven A. Wartman, AAHC President and CEO.

The health sector accounts for fifteen percent of our nation’s economy, and 11 percent of the total US workforce is in the health care area. According to the Bureau of Health Statistics, by the year 2014, one of every five new jobs will be in health care. In 1970, women comprised only 7.6 percent of the physician workforce and were a negligible number in dentistry. However, between 1995 and 2005, female enrollments rose from 36.7 percent to 44.3 percent in dental school; 42.7 percent to 48.5 percent in medical school; and, 63.8 percent to 64.2 percent in pharmacy school.

In Texas in 2009, of the 43,692 licensed physicians practicing in-state 12,674 (29%) are women. In the great County of Bexar, of the 4,302 practicing physicians, 1223 (28.4%) are women. There is a rising proportion of women physicians and it is incumbent upon us to have a great deal to say about shaping health care delivery in the country.

Women physicians need to have a strong voice in women’s health care issues. In the US, 51 percent of the total population is women, and they make 75 percent of the health care decisions in the household. In the nation, 50 percent of workers are women and 50 percent work more than one job. Women account for 60 percent of the physician visits and medication prescriptions, and spend two of every three dollars on health care. Studies have shown that women are less likely to be screened for serious illness by male doctors. For example, they are less likely to be screened for heart disease, but are more likely to die from a heart attack. Women have a great deal at stake as our nation prepares to overhaul its health care system. They are more likely than men to be insured through their spouse. Almost 12 million women in the US have no health insurance of any kind. As the primary caregivers to children and dependent elderly, often fulfilling this role alone, a lack of coverage for women often translates into a lack of coverage for entire families. Vital preventive screening services, such as mammograms and Pap smears, are not covered by many private insurance companies. Women patients present a myriad of health concerns which are unique to women (such as pregnancy). Ailments such as osteoporosis or depression are predominant in women or manifest differently in women, such as heart disease. Women's family roles must be recognized as potential barriers to their receiving care. Women need the security of health care for themselves and their family regardless of the job status of the spouse or themselves, the freedom to be entrepreneurial and the assurance that they can care for their family’s health.

Women Physicians in the Workforce:

The Institute of Medicine predicts that by the year 2020, our country will have a shortfall of 50,000-100,000 physicians. The Institute of Medicine, a federal advisory body, just reported that in a mere three years, senior citizens will be facing a health-care workforce that is "too small and woefully unprepared." Let us take a look at the growth of women physicians in the workforce. From 1970 until 2000, the number of women applying to medical school increased from 10 percent to 48 percent; and in 2004, for the first time women exceeded their male counterparts at a rate of 51 percent. This curve almost parallels the number graduating. The number of practicing women in the workforce increased from 7 percent in 1970 to 22 percent in 2000.

Women physicians are typically choosing two primary care specialties over the others (Figure 3). Fifty-two percent of the pediatricians and pediatric subspecialists are women; and, 41 percent in obstetrics and gynecology are women. A third of the physicians in Internal Medicine, Family Medicine and Psychiatry are women. Although women are seen in all specialties of medicine, less than 14 percent go into surgery and surgical specialties. For the average woman doctor, 85 percent will have encountered gender discrimination and/or sexual harassment at least once during her career. She will earn only 63 cents on the dollar that a male physician earns (after all variables are considered), and she will likely be segregated into clinical areas that have less prestige and earning potential. Diminishing the worth of women physicians is a loss that our ailing health care system can ill afford.

The mere increase in the numbers enrolled in medical schools isn’t the only factor that determines women physicians’ fit in the workforce. Between 2005 and 2020, the overall supply of physicians is projected to grow by 16 percent, while the FTE (full-time equivalent) supply is projected to grow by 14 percent. Part of this discrepancy is due to the increasing proportion of women in the workforce, and partly due to the aging of the physician workforce. Several studies have found women doctors tend to work 20 percent to 25 percent fewer hours than their male counterparts. Women doctors in the US work less — 47 hours per week on average, versus 53 for men. They also see about 10 percent fewer patients and tend to take more time off early in their careers. Women physicians also want more flexible hours. Women need to balance many things in life: pregnancy, raising children and caring for aging and or ailing parents and relatives.

It is significant that women are willing to enter lower-paying specialties that male doctors are moving away from, such as primary care, pediatrics and obstetrics. Since 1996, there has been a 40 percent jump in the number of women choosing primary care, offsetting the 16 percent decline in men entering the field. A lighter workload also has its advantages. "Lots of studies show that doctors who work fewer hours have less burnout," says Dr. Joseph Flaherty, dean of University of Illinois College of Medicine. "There is a strong association between long hours and medical errors.” The rising proportion of women in medicine and the higher propensity of female physicians to practice in metropolitan areas could hinder the national goal of improving physician supply in rural areas. In the table below, note that the work hour gap closes in the 56-65 age group for obvious reasons, an age at which women find more time to devote to work.

Earnings by Female Physicians:

Several studies have focused on the discrepancy in earnings between male and female physicians. In a study involving 455 internists in Pennsylvania, it was found that male internists earned 53 percent more than female internists (Ness et al., 2000). The authors identify several differences between men and women to explain the disparity in earnings. Compared to their male colleagues, on an average, female physicians:

• Are more likely to practice in lower-paying medical specialties, • Have fewer years in practice, • Are less likely to be in a partnership, • Work fewer hours per week in professional activities, and • Are more likely to take time off or work part-time.

As per one report (Ness et al., 1998), female physicians had average annual earnings of approximately $149,000 compared to $208,000 for male physicians. This difference of over $59,000 (29 percent) per year can be partially explained by differences in average hours worked. Female physicians in this sample worked 11 percent fewer hours per year, on average, compared to male physicians (2,412 versus 2,725 hours); and after adjusting for hours worked, the difference in annual earnings falls to $45,000 (or 21 percent). Comparing many of the systematic differences between male and female physicians in terms of practice patterns and medical specialty results in female physicians still earning $38,000 (18 percent) less than male physicians.

There will be greater pressure on the health care systems as the population ages and the realities of funding will force cost-containing measures. It is estimated that physicians directly account for 20 percent of health care expenditures, and indirectly account for the majority of health care spending. Any change will have an impact on physicians. The proportion of US allopathic medical school graduates planning careers in primary care decreased from 53.4 percent in 1997 to 35.1 percent in 2004. This is an economic reality. The median income for primary care physicians increased by 9.9 percent from 2000 to 2004, compared with a 15.8 percent increase in income for specialists. The current provision in the healthcare reform bill to increase compensation for primary care will in the right direction to attract more physicians to go into primary care specialties.

Women Physicians in Leadership Positions:

A survey of 126 US allopathic medical schools showed that women in general have an uphill battle in medical settings. Although 30 percent of faculty members are women, at least 18 schools have no women serving as department chairs. Women are less likely than men to be promoted to the levels of associate or full professor and less likely to be appointed to search committees, which influence future faculty representation. Women comprise only 14 percent of tenured faculty and 12 percent of full professors; and, the average number of female department chairs in the United States is just 1.7 per medical school" (King and Cubic, 2005). Cohort studies comparing men and women medical school faculty have found that, “Even after adjusting for number of publications, amount of grant support, tenure versus other career track, number of hours worked and specialty, women remain substantially less likely than men to be promoted to the senior ranks." (Yedidia and Bickel, 2001). However, women are more successful in moving into management positions in the health care industry where women in management positions increased from 13 percent to 36 percent in a 8-year span of time from 1993 to 2001 (Neubert and Palmer, 2004).

Cultural Competency:

Women appear to value different components of care than men. Both sexes place a high value on time spent with the doctor. But for women, satisfaction with the doctor's ability to answer questions clearly, with how well the doctor knew what happened at other visits, and with nursing care are significant predictors of overall visit satisfaction. These items might be construed as reflecting, respectively, the technical content of communication, continuity of care, and the multidisciplinary nature (i.e., the importance of non-physician providers) of the care process. For men, satisfaction with the personal interest shown in them and their medical problems significantly predicts overall satisfaction. Research suggests that there is a strong tendency for minority patients to use minority physicians as their usual care providers. What is not clear is whether this is a supply or demand phenomenon. In a study investigating the relationship between physician race and the care of minority and medically-indigent patients, Moy and Bartman (1995) determined that more than a third of minority patients are treated by minority physicians. Only 11 percent of non-Hispanic, White patients are treated by minority physicians. The authors also find that minority physicians, in particular Asian and Black physicians, are more likely to care for patients outside their own minority group than are non-Hispanic, White physicians.

A modicum of research has focused on the issue of culturally competent care, which argues that more effective care is provided when clinicians and patients have similar cultural backgrounds and speak the same language. Arguably, this will segregate minority physicians to the poorer, underserved areas with greater burden of providing uncompensated care. Although women physicians are less likely to work in rural areas, according to the study by Bickel and Ruffin (1995), women are more likely than men to work in clinics providing health care to medically indigent patients. Ideally, physicians should serve and share the burden of underserved populations in lower socio-economic sectors equally.

Conclusion:

The World Health Organization’s World Health Report 2006: Working Together for Health revealed an estimated worldwide shortage of almost 4.3 million physicians, nurses, midwives, and other health personnel. An early 2007 projection anticipates a shortfall of 340,000 registered nurses by 2020. Dentist-to-population ratios have been dropping for the past decade and are expected to decline further, to a rate of 52-55 dentists per 100,000 people by 2020. The Health Resources and Services Administration (HRSA) estimates that approximately 50 million Americans live in underserved areas. The number of women entering medical schools equals men. As a profession, we have to make the necessary changes to facilitate their participation in the delivery of health care or we will be left with a great deficiency in our ability to care for our patients.

It was around 9:00 p.m. on March 21, 2010 when, as I was writing the concluding paragraph to this article, the historic Healthcare Reform Bill was passed. I thought about how liberating this would be to millions of Americans. I thought of little Arturo, a less than 3-pound birth weight, premature infant in my clinic who did not show up for a whole year for his developmental assessment or intervention because his father got a better job and he no longer qualified for Medicaid. His father’s better income was not large enough to afford the insurance premium for this preemie, “a pre-existing condition”. His speech was significantly delayed. It took substantial speech therapy and other interventions to get Arturo to be on his way to normal speech. I raised my cup of tea and burned the rest of the midnight oil to finish this article.

Resources:
Bickel J, Ruffin A. (1995). Gender-associated differences in matriculating and graduating medical students. Academic Medicine. 70(552).

King CA, Cubic, B. Women psychologists within academic health systems: Mentorship and career advancement. (2005). Journal of Clinical Psychology in Medical Settings. 12(271).

Moy E, Bartman, BA. (1995). Physician race and care of minority and indigent patients. Journal of the American Medical Association. 273 (1515).

Ness RB, Ukoki F, et al. 2000. Analysis of the 1998 AMA Socioeconomic Monitoring System file. Salary equity among male and female internists in Pennsylvania. Annals of Internal Medicine, 133 (11).

Neubert M, Palmer, LD. (2004), The emergence of women in healthcare leadership: Transforming the impact of gender differences. Journal of Men’s Health and Gender. 1(4), 383.

US Department of Health and Human Services, Health Resources and Services Administration. (2008). The Physician Workforce: Projections and research into current issues affecting supply and demand. Washington, DC.

US Department of Health and Human Services publications (www.hhs.gov). US Department of Health and Human Services, Health Resources and Services Administration.

Socioeconomic Monitoring System (SMS) Physician compensation comparison. (1998). Washington, DC. World Health Organization. The World Health Report 2006��Working together for health.

Yedidia MJ, Bickel, J. (2001). “Why aren’t there more women as leaders in academic medicine? The views of clinical chairs.” Academic Medicine, 76 (453).

Resources:
Rajam Ramamurthy, MD served as the 2004 President of BCMS. She is the Rita & William Head Distinguished Professor of Environmental and Developmental Neonatology and the Medical Director, Premature Infant Development PREMIEre Program at The University of Texas Health Science Center in San Antonio.