June
12th 2011
Physicians “opting out:” gender and medical education as a privilege, not an entitlement

Posted under: American history, Gender, jobs, women's history

Karen S. Sibert, MD, a Los Angeles anesthesiologist, raises the alarm about the looming shortage of doctors in the U.S., and notes that this is especially alarming given the trend among younger women doctors to work part-time at a moment when they’ve become more than half of all primary care physicians in the U.S.  (H/t to commenter Susan for this one.)  Sibert writes in the New York Times this morning:

[I]ncreasing numbers of doctors — mostly women — decide to work part time or leave the profession. Since 2005 the part-time physician workforce has expanded by 62 percent, according to recent survey data from the American Medical Group Association, with nearly 4 in 10 female doctors between the ages of 35 and 44 reporting in 2010 that they worked part time.

This may seem like a personal decision, but it has serious consequences for patients and the public.

Medical education is supported by federal and state tax money both at the university level — student tuition doesn’t come close to covering the schools’ costs — and at the teaching hospitals where residents are trained. So if doctors aren’t making full use of their training, taxpayers are losing their investment. With a growing shortage of doctors in America, we can no longer afford to continue training doctors who don’t spend their careers in the full-time practice of medicine.

It isn’t fashionable (and certainly isn’t politically correct) to criticize “work-life balance” or part-time employment options. How can anyone deny people the right to change their minds about a career path and choose to spend more time with their families? I have great respect for stay-at-home parents, and I think it’s fine if journalists or chefs or lawyers choose to work part time or quit their jobs altogether. But it’s different for doctors. Someone needs to take care of the patients.

I think she makes a number of great points, but I wonder why she casts this as purely a problem of female fecklessness?  For example:

Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especiallyto consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve.

I recently spoke with a college student who asked me if anesthesiology is a good field for women. She didn’t want to hear that my days are unpredictable because serious operations can take a long time and emergency surgery often needs to be done at night. What she really wanted to know was if my working life was consistent with her rosy vision of limited work hours and raising children. I doubt that she welcomed my parting advice: If you want to be a doctor, be a doctor.

You can’t have it all. I never took cupcakes to my children’s homerooms or drove carpool, but I read a lot of bedtime stories and made it to soccer games and school plays. I’ve ridden roller coasters with my son, danced at my oldest daughter’s wedding and rocked my first grandson to sleep. Along the way, I’ve worked full days and many nights, and brought a lot of very sick patients through long, difficult operations.

Have we completely given up on the idea that men have a role to play in creating a fairer and more just world?  Or is all revolutionary change up to women alone?

I agree with the thrust of her commentary, and I really like her point about the moral obligation to use one’s medical education in the service of others.  But why do we see “work-life” issues as constructed as something only teh wimminz need to worry about?  Why isn’t anyone asking college men to think about the impact of their career ambitions on any future spouse or children they might like to have?  Maybe more importantly, why isn’t anyone asking men who want to marry doctors to think about the consequences of their spouse’s career on their future possible family lives?  Why aren’t they expected to step up and pick up the slack on the domestic front, the way that “doctors’ wives” are assumed to do?  Medicine is not like just any other job–the hours are often long and inconvenient (especially in primary care). 

An unspoken cause of a lot of these defections is that a large number of the heterosexual women in primary care are marrying male classmates who are aiming to train as specialists in higher paying sub-specialties.  At least, that’s my guess based on the number of women pediatricians I’ve heard of in the past decade who have quit because they’re married to cardiologists or surgeons who need to move to this or that major metro area, and primary care docs are in general more needed outside of major metro areas.  This means that these pediatricians end up in places that tend to be oversaturated with docs, and they’re not free to take jobs in the rural and underserved places in the U.S. that truly need doctors.

Once again, we’re told that “you can’t have it all.”  But which “you” is the author addressing–is this generic advice for all young aspiring physicians, or just for women docs?  (Why is this old cliche always aimed at elite women, when really it’s elite men who’ve been having “it all” all along?  Of course, I forgot:  ambition in men is aggression in women.  Expecting your due is fine in a man, but it’s selfish in a woman.)  In short, I wish that Sibert had encouraged just as much reflection on this among men as she’s urging on young women, because I think the issues she raises about that “real moral obligation to serve” should be considered by all medical students.  The cardiologist or surgeon who expects his pediatrician or family practice wife to trot along behind him to follow his career is at least equally guilty of the cavalier use of public resources as she is. 

What do the rest of you think?  (I should think some primary care types might take umbrage at being lectured by an anesthesiologist!)

56 Comments »

56 Responses to “Physicians “opting out:” gender and medical education as a privilege, not an entitlement”

  1. Jay on 12 Jun 2011 at 11:23 am #

    Um, yeah, umbrage and all that. I worked part-time for 8 years and I was taking care of my patients, thank you very much. I was also doing a ridiculous amount of administrative paperwork required by our fragmented and absurdly constructed health-care system, which reduced the number of hours I could actually *spend* with those patients. A lot of things have changed in medicine since my grandfather’s day; my working part-time was not the biggest difference.

    The men need to step up, and the department chairs and chiefs of service and managing partners of groups need to look at what they’re asking of their colleagues, and what the cost is. Burned-out doctors are bad doctors.

    I’m not sure what to do with the return-on-investment thing. Residents provide plenty of service while they’re being paid, and it’s not just med school tuitions that are subsidized. My husband had an NSF fellowship for his phsyical-science PhD and he is no longer working in physical science, or in academia – is he also reneging on his commitment?

  2. Jonathan Dresner on 12 Jun 2011 at 11:35 am #

    Since when does “service” mean monastic self-sacrifice?

  3. Indyanna on 12 Jun 2011 at 11:48 am #

    “… before they accept (and deny to others)sought after positions…” Wow, whatever the obviously broader or at least different specific contextual connotations Dr. Sibert intended for it, that particular piece of phraseology is *exactly* what generations of aspiring women heard from generations of advisors, mentors, deans, and parents (in my mother’s case), when they even thought about applying to med schools, law schools, grad schools, business schools, and practically everything else except maybe nursing and library schools. Only it wasn’t exactly “accept” and “deny,” or other terms of applicant volition, because the advice generally came paired with the refusal of resources (admission, good letters, familial funding, or whatever) necessary for the project.

    This piece intersects interestingly (and complicatedly) with the recent advice of Sheryl Sandberg to the Barnard graduates, discussed in a post here and summarized again in the NY Times today. If women hold up only half the sky, they can’t solve the whole of the problem of work/life/balance. And why is it “different for doctors” than, say, lawyers? If you were a, say, mesothelioma plaintiff, you might see it differently. This very vocational provinciality somewhat undermines the analysis.

  4. Matt_L on 12 Jun 2011 at 12:08 pm #

    I agree with the comments here. Especially the notion that women are holding up half the sky expressed by Indyanna and Historiann. Indeed. Where are the guys?

    I would like to add that given the amount of time it takes to earn a BA, go to med school, serve the required residencies and then find your way into a practice, is it really a surprise that some docs might decide to chuck it all and leave the profession? Aren’t we talking a decade of stress, a high level of academic performance and serious personal commitment, before you become a full fledged member of the doctor’s guild? (More for some and less for other specializations of course) The system offers plenty of off ramps at every step of the game, so it should not be surprising when people take them.

    I’d also like to say that I am not doing what I started out doing after college. I think its reasonable to expect that some people who started medical school at the age of twenty-one might decide to do something different by the time they hit their mid thirties. Seriously, if everyone else is changing jobs or even careers every five years in this, the best of all possible neo-liberal economies, why wouldn’t medical professionals?

    The good doctor misses some of the structural issues both gender- and economy-wise.

  5. thefrogprincess on 12 Jun 2011 at 12:28 pm #

    I’m of mixed minds about this. As I mentioned over at the Sheryl Sandberg post, I’ve had conversations with men in medical school who were planning to specialize but, even before having a girlfriend or wife, stated that they needed a wife who, if she was a doctor, needed to be in primary care or peds. As I mentioned over there as well, one of these friends married someone who then mysteriously switched from an anesthesiology residency to a peds residency, while he continued on in neurosurgery. So I think these are real issues. Moreover, I think there is a trend going on in women of my age (late 20s) where choosing to stay at home AFTER aggressively pursuing a career like medicine or academia is becoming popular to the point where women are planning to do so at the same time that they pursue these qualifications, often without a boyfriend or husband in the picture. At the end of the day, I do believe it’s on women not to be bowled over by their husband’s career plans, especially if he’s not willing to make comparable sacrifices. True, men should be taking on their share of house and/or parenting work, but under the current cultural climate, I think women have to demand that this happen in their relationships.

    That being said, we can’t blame women for the shortage of primary care physicians. Primary care itself has been devalued, specialization highly prized. I know this isn’t the norm, but there are people in medicine who probably view the prestige and monetary rewards of specializing more highly than the basic mission of medicine, healing. And as long as it’s so expensive to train in medicine in this country, those who otherwise would consider primary care will specialize to get out from under the crippling loans.

    So there are two separate issues here: 1) female physicians opting out, and here I think Sibert is right to point out the obligation to heal that medical students take on; and 2) the abominable shortage of primary care physicians, something that marks the United States as unique among developed nations, if I recall correctly. I personally like the suggestion from another NYTimes editorial a few weeks ago, suggesting that medical school be free but that students pay for specialized training.

    http://www.nytimes.com/2011/05/29/opinion/29bach.html?_r=1

    Not sure how actionable this is, but I like the idea.

  6. wini on 12 Jun 2011 at 12:33 pm #

    What a great example of the way in which attitudes towards mothers working affects all women, whether they choose to have children or be partnered, etc.

    This does help explain what I thought was a localized phenomenon (living in a mid-sized city in the South). All of the female pediatricians in our practice work part-time, the men all have full hours. Okay. But why did my pediatrician suggest that *I* should work less hours? (My husband and I were both at that appointment.) Another professor in my department left the practice for that reason.

  7. Historiann on 12 Jun 2011 at 2:18 pm #

    Jonathan: Since when have you known a physician whose lifestyle suggests “monastic self-sacrifice?” I’ve never met one, or even heard of one, outside of those Medecins Sans Frontiers volunteer-types. Since when is working a solidly upper-middle class job “monastic self-sacrifice?” Seems like a lot of the (male) docs I know have quite the car/house/wife collection (and sometimes all 3), so I doubt there’s a whole lot of poverty, chastity, and/or obedience going around the doctor’s lounge.

    I guess it just blows my mind that someone would seek training as a physician and then decide, “Oopsie! My bad!” You’d think people could figure this out BEFORE four years of medical school and before 3+ years of residency. It seems like an onerous and expensive journey to the self, in any case. What is wrong with the screening process for medical school and residencies these days that they’re accepting so many uncommited (not) future physicians?

    Thefrogprincess breaks it down nicely I think. The shortage of primary care physicians will continue unless and until we decide to increase their pay and/or reform their working conditions. Part-time work as a physician looks a lot like most people’s full-time jobs, from what I understand. What I truly don’t get is the idea that the job of a pediatrician or an ob/gyn is “easier” than that of sub-specialties. The training is shorter than the training for surgery or opthalmology, but there’s just a LOT of call, and a lot of leaving the house in the middle of the night when you’re dealing with obstetrics and kids.

    And, what wini said. Nice formulation: What a great example of the way in which attitudes towards mothers working affects all women, whether they choose to have children or be partnered, etc.

  8. shaz on 12 Jun 2011 at 3:40 pm #

    It strikes me that the “need” to work more-than-fulltime to pay off society’s investment is tied up in the failing and ridiculously overpriced U.S. health insurance — I mean healthcare — system. Having lived in a country with socialized medicine (the horror!), I can think of multiple Doctor friends there who work three-four days a week (including surgeons, anesthesiologists, pain specialists, ER, GP…) and that is considered normal. Quality of life is important to everyone, so people are not expected to give up families to make a good living. Interestingly, I also know far more fathers who take paternity leave and use their days off to care for their children.

  9. Perpetua on 12 Jun 2011 at 4:05 pm #

    In general terms, I think it’s okay to talk about the effect that women opting out has on various professions, individual women, women-as-a-whole (whatever that might mean), and/or feminism. However, I also think those conversations need to be done in a way that makes it clear – as Historiann has done here – that the problems and issues facing working mothers are not their exclusive problems and issues. They are familial problems (in two parent households), *social* problems, and often institutional-structural problems. All this “the women are to blame because they can’t have it all! And they are not professional enough, because the babiez sap their mental skills! And also they are to blame for everything!” in the article is offensive. Many women switch gears from full time to part time because the incredible pressure on their individual families feels like too much for everyone to bear, and in a patriarchal system women are shamed and blamed into being primary caregivers as well as full-time professionals, the ones acculturated to self-sacrifice and self-denial. Kind of like the previous discussion about “choice” feminism – if we’re talking about “choice” it is important to be clear about who is choosing what exactly and what we mean by “choice”. Often “choice” implies autonomy or freedom to make one’s own decisions. But part of living in a patriarchy means some limitations on many women’s autonomy and choice-making abilities. So saying to women, as the author of this piece does, You are responsible for all the problems created by your working or not working, having children or not having children, is a ridiculous and anti-feminist thing to say. I feel like stabbing myself in the eye every time I read the sentence “You can’t have it all.” It’s asinine and anti-feminist, and furthermore it isn’t even true unless “it all” is defined as all your dreams coming true with little fairies sprinkling gold dust on your head. (And for the love of god, would women writing about working mothers please stop invoking the specter of homemade baked goods? Does anybody really care where the cookies come from? Baking cookies from scratch for your kids’ school is NOT the dictionary definition of “having it all”.) The problem is not working mothers. The problem is MEN DON’T HELP. (This is obviously a generalization, but a true enough one.)

    Otherwise, I agree with the larger issue that women opting out is a professional, financial, and social/gender problem. The structural difficulties of my own life are such that I have seriously considering “opting out” many a time (and nothing in this case to do with a man not helping), but at those moments what has kept me going is *pure feminist rage*.

  10. Janice on 12 Jun 2011 at 5:17 pm #

    We don’t exist in a family-friendly society. Or one that’s personal-life friendly. Sibert perpetuates a myth that any historian can punch holes into without even trying – that the mode of working in this profession is natural and simply manageable for privileged men or women who model themselves assiduously on privileged men.

    But how natural is it to ask that our highly trained medical personnel spend so much of their time managing business offices for their practices, dealing with headaches of wildly disparate insurance companies and try to keep on top of all sorts of new medications and treatments often via the propaganda pushed by commercial interests?

    It’s NOT natural, right or even the most efficient use of resources. It’s simply the way that practices have evolved due to a variety of social pressures and interests, isn’t it? And those social pressures and interests aren’t concerned with the physician as parent or child or even, say, painter. Instead, the model is “one size only” and if you don’t fit, you feel squeezed out.

    The same can go for many other jobs and professions. What’s painted as “just the way it has to be” isn’t. But it’s HARD to effect significant change in ingrained social systems, isn’t it? We have to have buy-in from the professionals, themselves, for one matter.

    Historiann, you’ve seen Atul Gawande in the New Yorker talking about abandoning the doctor as cowboy paradigm for the doctor as part of a pit crew? It’s a great insight into what makes for a more effective use of medical resources (especially the people involved!) without simply ratcheting up the expectations. But making a shift like this would be a real challenge. Heck, we professors haven’t done so well at transforming our own workplaces, yet, have we?

  11. Jay on 12 Jun 2011 at 6:14 pm #

    Historiann, you asked why primary care is considered “easier” than specialties. Primary care is generally felt to be more “family-friendly” than the procedural sub-specialties, in large part because women have entered those fields in force and the jobs have shifted in order to accommodate the trends discussed in the original piece. At the same time, the prestige and salaries associated with those fields has declined substantially. In addition, reimbursement is skewed toward procedures; one can make a whole lot more money sticking catheters into people than, say, sitting down and listening to them.

    There’s nothing inherent about surgical or procedural subspecialities that would prevent practitioners from working part-time or at least from having sane and healthy schedules. In some ways, it would be easier to do so in a well-reimbursed field. The problem is that the culture is still the old boy’s club, with a lot of emphasis on being tough and a lot of shit thrown at those who ask for any kind of flexibility. Check out the neurosurgeon who blogs at Mothers In Medicine and who suffered the undying enmity of her residency class for daring to reproduce during residency.

  12. Nicoleandmaggie on 12 Jun 2011 at 6:31 pm #

    ‘I feel like stabbing myself in the eye every time I read the sentence “You can’t have it all.” It’s asinine and anti-feminist, and furthermore it isn’t even true unless “it all” is defined as all your dreams coming true with little fairies sprinkling gold dust on your head. (And for the love of god, would women writing about working mothers please stop invoking the specter of homemade baked goods? Does anybody really care where the cookies come from? Baking cookies from scratch for your kids’ school is NOT the dictionary definition of “having it all”.) ‘

    OMG Perpetua, You are inside my head. We have a mega mega rant on this, but we’ve got it set to post for late July when I’m at a conference (with limited email access) because of the not wanting to stabbity stabb my eye. (Actually it’s more like my heart exploding from anger that I’m trying to avoid.)

    And a big YES on this too: “Atul Gawande in the New Yorker talking about abandoning the doctor as cowboy paradigm for the doctor as part of a pit crew.” There are a LOT of things we can do to get health care costs more manageable, but getting doctors to work longer hours is probably not the smartest of them. I could go on, but an important thing to note is that gender ratios, pay, working conditions, and supply for these fields are not independent of each other. The whole, “women are opting out of these necessary fields” argument isn’t necessarily because they’re women but because the fields don’t pay as well… for example. If they paid more, it would be less desirable to leave work. But why is the pay so comparatively low in these fields… again, all interrelated. (If we really want more GP, then Medicare/Medicaid need to reimburse more. According to David Cutler, insurance companies will follow suit since they’re using the government to enforce prices. Higher prices means more people, men and women, will choose those fields. I’ll stop now…)

  13. mandor on 12 Jun 2011 at 6:32 pm #

    Wait a second, shouldn’t we be encouraging women to go for the big money positions? There’s no money or prestige in primary care!

  14. Rachel on 12 Jun 2011 at 6:41 pm #

    As Jay notes, sociological studies have shown that professions that become saturated with women (think: nursing, teaching, primary care medicine, etc) lose stature/prestige/wages. As certain professions become “feminized” and labeled as the “helping” professions, our world deems them less valuable, thus leading to lower wages (relatively) and less leverage (publically and w/i a family).

    As others have noted, this op-ed dovetails intriguingly with Sandberg’s speech, though the latter seems a little more attuned to the larger picture of women’s lives. I think Sibert’s message is quite reasonable — provided its target audience is men and women (which, alas, it’s not as written). It also suggests that as long as med school + residency is, it might be wiser to encourage students to wait a few years before entering and actually think about what they want their future lives to look like after a little experience living outside the confines of school. Med schools interview; they ought to ask their applicants to think about their future lives and what they want and how they expect to have it.

    Yet Sibert also elevates doctors to an unfair pedestal. Logically her argument that “it’s fine if journalists or chefs or lawyers choose to work part time or quit their jobs altogether. But it’s different for doctors. Someone needs to take care of the patients” sounds logical but is rather spurious. It assumes no other profession has obligations outside the individual practicing it (not to mention to other women who may want careers in those fields).

    But in the end, while I can agree with some of what Sibert says and admire that she has the guts to express unpopular ideas in a very public venue, she failed to take full advantage of her position by refusing to highlight the role of men — as partners (or not), as full parents (or not), as empathetic bosses (or not). And that is the real structural issue that needs to be addressed.

  15. mandor on 12 Jun 2011 at 6:47 pm #

    On a serious note, the concept of full or part time in medicine is not really addressed in the article. And the implication that a part-time doc is somehow neglecting patients. My understanding of the doctor shortage is that no one wants to move to the sticks and practice general medicine. Which given the $$$ med school loans, no wonder.

  16. Historiann on 12 Jun 2011 at 6:47 pm #

    Jay–great points. I’ve always thought that it would be a hell of a lot easier to be a part-time anesthesiologist or opthalmologist, or whatever–in fields where you don’t need to follow patients for years and to put together a comprehensive plan for their care– but I think you’re right about why primary care has gone the way it has. (Also re: Janice’s and Nicoleandmaggie’s comments about cowboy culture in U.S. medicine.)

    I’m sure Nicoleandmaggie is right about the interrelatedness of all of these things: the feminization of primary care, its lower pay/prestige, and the propensity for people in lower pay/prestige fields to go part-time or to drop out.

    I think Mandor is right. Maybe more women should follow the lead of Dr. Sibert, and say to hell with primary care. It’s a lot more difficult to walk away from $300,000/yr. than $120,000 (or less, if part-time).

  17. LadyProf on 12 Jun 2011 at 7:59 pm #

    Friend of mine is a male surgeon with a wife who works part time. He too works part time as far as surgery goes, saving his other daylight hours for lucrative expert witness gigs. Funny how nobody questions his devotion to his work.

    So yeah, it’s backassed to say that pediatrics, with its frequent calls and emergencies, is a family-friendly line. Same with anesthesiology to a lesser extent. What would be family friendly is fancy surgery, especially doing procedures that can be postponed. The surgeon could make a lot of money and still spend time with her kids. But (would you believe?) d00ds don’t like to share.

  18. Feminist Avatar on 13 Jun 2011 at 1:46 am #

    When this same issue came up in the UK (because more than two thirds of med students are now female, and many women doctors choose to work part-time at some point, although it seems mostly only for a short number of years), we did a study. And, it showed that 80% of female med students expected to take a career break at some point, but so did 50% of men. Plus, men cost the NHS more because they are significantly more likely to be sued for malpractice or need retraining (but let’s not talk about that).

    I guess I wonder why it is that we go back to assuming that the male way is the best way, and if you, as a women, can’t fit into the system, then you must change and not the system. Why are fulltime hours the goal? Why aren’t shorter hours better for everyone (less tired doctors, less mistakes)? Why is taking time off/ going part-time to support your family a bad thing? If both genders did this, it wouldn’t be a problem – so why aren’t we pushing for structural change, rather than calling on women to conform? Who said the working week needs to be 40/60/80 hours?

  19. Susan on 13 Jun 2011 at 2:54 am #

    I wrote to Historiann about this as my reactions to the article were complicated, in much the way everyone else has noted. Given that the state and medical profession have together rationed training places the concern for what happens with “our” investment is not trivial. (And as I come from an area with a physician shortage, the shortage of primary care docs is not trivial either.) But Sibert’s failure to address the structural issues, both the structure of the medical system in which doctors work, and the patriarchal world in which families in this country exist. There are sub-issues too, about why it’s somehow more important to be able to do some super specialized procedure than to listen to patients and figure out what’s going on, or why 40 hours is not full time in medicine, or how we measure productivity, but they are part of the two big structural problems.

    That said, Sibert’s comment — “If you want to be a doctor, be a doctor” resonates with me. I understand your interests changing — I have a historian colleague who started out as an internist and realized that she preferred history — but ideally people become doctors in order to help people stay healthy or get well, and choose their specialties according to what intrigues them more than by the hours it may or may not provide.

  20. Anonymous on 13 Jun 2011 at 3:04 am #

    As someone who has taught a gajillion premed students, I have got to question how many would ever consider medicine as a “moral obligation to serve.” Half? 20% Less? Most seem to be motivated by the $$$ and prestige from the beginning.

    They arrive as freshmen with a huge sense of entitlement. Why are we surprised that this carries into med school?

  21. Anonymous on 13 Jun 2011 at 3:11 am #

    And btw, dermatology is the way to go. The big bucks (all those cosmetic procedures!), a growing field (all that skin cancer!), and easy hours. Last I heard, it has become flooded with female students and is now super-competitive.

  22. the15th on 13 Jun 2011 at 4:44 am #

    The AMA has historically limited the supply of doctors, probably based on a model where men work and women stay home. There is no reason that we can’t have more doctors working shorter hours (or even more aggregate hours, considering how many Americans currently lack access to needed care.)

    I’m sure that many nurses work part-time, and there’s supposedly a nursing shortage in some parts of the country (I tend to be skeptical of media-hyped “worker shortages”, but at least the media seem to believe that there’s a nursing shortage). I have never heard arguments like this applied to that profession. If it’s all about serving the public and the obligation to use one’s education, then it makes no sense why this argument wouldn’t also apply to nurses. If, however, it’s really about getting women to stay home altogether and stop bothering everyone with their “politically correct” whining about work-life balance, then it makes perfect sense, because that would imply that men should get their jobs, and everyone knows we can’t have male nurses!

  23. Historiann on 13 Jun 2011 at 5:20 am #

    One of the issues here is whether we see medical education as a private or a public good. One of the consequences of the widespread withdrawl of public support for all higher education (and the consequent rise in student debt) is that students in the main perceive their educations as services that they have purchased and can use however they choose, rather than seeing themselves as needing to pay it forward.

    I thought that Sibert made a good point about how residency training is largely subsidized by public funds, but it’s true that most med students graduate with some major, major debt, even those who attend state university med schools.

    A number of you make great points about re-imagining the working hours of primary care docs. I think that’s something that will work for most basically healthy patients, but I wonder how it would work for chronically ill patients (or their caregivers). Seeing *their* doctor is important for people in crisis situations, and when one is suffering from a chronic or acute illness, they don’t want to feel like they’re being treated by whomever happens to have office hours. They want to see their doctor, someone whom they have had a relationship with built up over months and years.

    I know it may not make sense to organize the working hours of GP’s and pediatricians around the prospect of serving only or mostly chronically ill patients, but isn’t allopathy essentially organized around that model to begin with? (BTW, after this week, I am an ever huger fan of allopathy and aggressive surgeons–something I know makes me unusual among rad fems.)

  24. Anonymous on 13 Jun 2011 at 6:36 am #

    Yes, three cheers for allopathy. (When did we stop calling it medicine?)

    I wonder why the AMA limits the numbers of doctors. It may have more to do with quality control than outmoded ideas about women in the workforce. (Or it could be both.) Many second-rate universities are starting up their own medical schools right now, officially to help with the so-called doctor shortage: “There are students who want to go to medical school but can’t because there is no room for them!” I am sure money is the real reason.

    It is certainly true that there are more premed students that there are spots in med schools, and if more doctors work part-time, it makes sense that we need to train more doctors. In principle. But in my experience, the students who don’t get into med school…not even in the Caribbean? You don’t want them for your doctor.

    And is there a doctor shortage? Are there data on this?

  25. Matt_L on 13 Jun 2011 at 6:47 am #

    ” One of the consequences of the widespread withdrawl of public support for all higher education (and the consequent rise in student debt) is that students in the main perceive their educations as services that they have purchased and can use however they choose, rather than seeing themselves as needing to pay it forward. ”

    This is spot on Historiann: I have an ex-brother in-law who switched from primary care to cardiology. His logic was two fold, sick of talking to patients and maximizing his return on med school.

    “Seeing *their* doctor is important for people in crisis situations, and when one is suffering from a chronic or acute illness, they don’t want to feel like they’re being treated by whomever happens to have office hours. They want to see their doctor, someone whom they have had a relationship with built up over months and years.”

    In some cases I think this is right. In other cases, I don’t think it matters as much especially for chronic illness. For example: One of my parents is chronically ill. Ze has multiple doctors: neurologist, internist, urologist, and most recently an Osteopath. None of these speak with one another or really coordinate care. Over the course of nearly three decades ze has gone through multiple “primary care physicians.” Ze is probably on better terms with the physicians working shifts at the emergency room. I know my family would appreciate it if hir’s care was better coordinated.

    Lets be frank. Another issue in healthcare, an elephant in the room as it were, is professional autonomy. Care organized around teams, with more realistic work schedule and a focus on patient outcomes would undermine the individual autonomy of some doctors, especially specialists. This is bound to raise hackles, especially amongst the men.

    (To be fair I think professional autonomy is also an issue in higher ed. The individual right to teach what you want, how you want, and when you want, is a standard that needs to be discussed.)

  26. Knitting Clio on 13 Jun 2011 at 7:14 am #

    @Anonymous — the number of doctors in the U.S. is constrained in part by the finite number of slots in U.S. medical schools. There are plenty of people who want to become physicians and are well-qualified but unless they have perfect grades and MCAT scores, they can’t get in. This is why there are so many foreign medical graduates staffing urban hospitals and rural medical facilities, where U.S. graduates don’t want to go because they can make more money elsewhere — and they need to make high incomes because the cost of medical school is so high that students need to borrow $100K or more to cover tuition and other expenses. This is on top of the thousands many have already borrowed for their undergraduate degrees. Then there’s the years of indentured servitude known as internship and residency. I took a look at all this 25 years ago and even though I got into medicals school said to hell with it and became a historian.

  27. Anonymous on 13 Jun 2011 at 7:40 am #

    Knitting Clio, where are the data? I teach at a top research university and I see a lot of students with far from perfect grades and far from perfect mcat scores get into med school. The ones who don’t get in anywhere are usually very weak students. I am willing to believe that some good students take themselves out of the running before graduating (women, perhaps?), and I think we should consider the possibility that grades and standardized test scores are not the best indicators for good future doctors. But I do not buy the argument that the crisis is due to not enough spots in med schools.

    As for the finances, yeah, it sucks. But other fields have their own forms of indentured servitude (postdocs, anyone?) and no six figure salary to look forward to (or a job market).

  28. Sarah on 13 Jun 2011 at 9:08 am #

    So let me get this straight. We used to tell women not to work for the good of society, but now we tell women they must work for the good of society, regardless of their own needs? What a bunch of hooey. Sibert’s article Deeply irritated me.

    look, women don’t quit their jobs in a fit of wealth-abetted selfishness. They leave for reasons, and we largely know what those reasons are. Perhaps, instead of berating women for prioritizing work-life balance, we should campaign for policy and attitude changes that would allow parents of any gender to achieve that balance while maintaining their careers. What would help? (1) Make on-site childcare the norm. (2) Make it possible for parents working full-time to have flexible hours–e.g. an anesthesiologist who stays until midnight because a surgery gets complicated could be compensated with a half-day of annual leave, usable when a child gets sick or has a school holiday. (3) Make it possible for parents to work three-quarter, half, or quarter time while their children are young, then ramp back up to full time when they get older. (4) Create a pathway for parents to take a hiatus for child-rearing while being able to rejoin the workforce later. They’d need a way to keep their skills current–maybe require them to volunteer at least X days per month at a free clinic?–but there’s no defensible reason that quitting a job to care for young kids should mean total career death. 

    Women who maintain careers while having families are those who feel capable of doing so. Feeling capable arises from (i) sufficient support at work, (ii) sufficient support at home (iii) sufficient tolerance for stress, and especially for leaving children with hired help.  These factors vary among women and among institutions, and the fact that many women manage to surmount barriers does mean that those barriers are universally surmountable. I feel like this should be obvious.

  29. Historiann on 13 Jun 2011 at 9:26 am #

    Sarah, I agree with much of what you say, but why do you construct this only as a women’s problem, and as a problem for women to solve alone?

    We need to ask ourselves if it’s likely that male-dominated institutions and workplaces are going to offer the kind of revolutionary change you suggest if 1) women drop out of the profession more often than men and thus take themselves out of the running for leadership/decision-making authority, and 2) if the men who stay in the profession feel that the system works for them just fine.

    It seems like more men need to be a lot more inconvenienced in their own search for “work-life balance,” and among heterosexual couples that means that more women need to insist on the importance of their work and to take themselves seriously as professionals, and this will mean refusing to take up the domestic burdens that you list above. Without making it necessary for men to work for change, they won’t.

    Power is never offered up voluntarily–it has to be wrested away from the powerful.

  30. thefrogprincess on 13 Jun 2011 at 9:48 am #

    We need to ask ourselves if it’s likely that male-dominated institutions and workplaces are going to offer the kind of revolutionary change you suggest if 1) women drop out of the profession more often than men and thus take themselves out of the running for leadership/decision-making authority, and 2) if the men who stay in the profession feel that the system works for them just fine.

    I think this is key, which is why I said above that women need to refuse to be bowled over by their husbands’ career plans. Women shouldn’t have to take this up on their own, but the reality is that men benefit from the current state of affairs, in ways even the well-meaning ones don’t realize, and there is simply no incentive for them to change a system that treats them fine and that often rewards them for the same things it penalizes women for–getting married, having children, etc. So it is on us to think very carefully about the messages we send when we do things and give up things for the sake of “our families” that our male partners wouldn’t even dream of giving up.

  31. Nikki on 13 Jun 2011 at 1:55 pm #

    I think the flip side to this is the change in expectations of what it means to be a good parent (mother) over the last 30 years. Tutoring, music lessons, sports, volunteering, play dates etc.–all of this has to be coordinated by someone and kids have to be driven all over to accomplish these goals. Multiply this by several children, add in working-parent unfriendly school schedules, and you can see where (if you believe all of these things are intrinsic to raising successful children)someone might make the choice to work part-time.

  32. Shelley on 13 Jun 2011 at 4:01 pm #

    Sigh. As long as there’s no public option and the insurance companies are driving the whole system, where’s the hope for improvement?

    The elephant in the room is always corporate power.

  33. Linden on 13 Jun 2011 at 4:38 pm #

    “I think the flip side to this is the change in expectations of what it means to be a good parent (mother) over the last 30 years.”

    Who changed those expectations and why, I wonder?

  34. Rachel on 14 Jun 2011 at 1:00 pm #

    It seems like more men need to be a lot more inconvenienced in their own search for “work-life balance,” and among heterosexual couples that means that more women need to insist on the importance of their work and to take themselves seriously as professionals, and this will mean refusing to take up the domestic burdens that you list above. Without making it necessary for men to work for change, they won’t.

    Power is never offered up voluntarily–it has to be wrested away from the powerful.

    Yes. This is what seems to be missing from the “debate” — from Sibert’s article, from the responses to it on Lisa Belkin’s Motherlode blog, from any discussion of women leaving the workforce in numbers far unequal to their partners.

  35. Constantia on 14 Jun 2011 at 2:02 pm #

    I wrote an article on this a bunch of years back…when I was still working as a sociologist…left the field, but I digress. The short of it was that mostly women who worked PT had visible part time work, and yes, in the specialties noted (peds, family medicine). The male docs in higher pay/higher prestige specialties often worked PT *clinical* hours too–just that their lab and/or research or teaching time was not seen by the profession to detract from their “work” time as Docs. Hence the women PT physicians were seen to be less committed to work. Compensated less, carried less authority in most practice groups, less opportunity for advancement etc.

  36. Western Dave on 14 Jun 2011 at 7:31 pm #

    Tangentially related but illustrative example: my wife and I were accidentally left off the kindergarten parent e-mail list and only discovered it existed the last week of school. We were added, or I should say, my wife was added. I wasn’t. And when I saw the list, I went ballistic. There wasn’t a single dad’s name on the list. How can we expect more of men, if we don’t even ask them to show up? Sigh. (And for the lesbian couple, they included the teacher/mom but not the medical researcher mom – way to replicate traditional gender norms folks!).

  37. Nicoleandmaggie on 15 Jun 2011 at 2:59 pm #

    @Western Dave continuing the tangent…
    On our “if ze’s sick” card, it clearly says: On MW, call FATHER first, on T/H call MOTHER first (we’ve been able to stagger our teaching schedules). Yet they ALWAYS call me first.

  38. MDmom on 16 Jun 2011 at 7:52 am #

    My main gripe with Dr. Sibert’s article is where she states, “Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency.”

    At age 21, most of us think we can do it all. When I was getting ready to enter medical school, I assumed I COULD practice full time and have a family. By the time I had my first child in my late thirties, I realized I could not do both without sacrificing too much in terms of physical and especially mental well-being.

    Historiann, you said, “I guess it just blows my mind that someone would seek training as a physician and then decide, “Oopsie! My bad!” You’d think people could figure this out BEFORE four years of medical school and before 3+ years of residency.” You’d think so, but nevertheless, many of us didn’t. There were times I loved what I was doing, but there were times I hated it. I kept hearing people ahead of me say, “It’ll get so much better.” So I think many of us plowed ahead, waiting for the time that it would get better. Many of us were afraid or unwilling to quit by the time we had made it to residency, having invested so much time, sweat, heartache, and money.

  39. Historiann on 16 Jun 2011 at 12:35 pm #

    I hear you, MDMom–but then why wouldn’t you reconsider the other parts of your life? Why didn’t you rethink having children, or having X number of children? Why is not being a medical doctor always the solution to what is (ultimately) a relatively short-term problem?

    I just don’t see very many men deciding that ditching their careers is the best solution to who picks the children up after school. And yet, women make that decision all of the time. Why are children still seen as the woman’s “problem” to solve? Why don’t many fathers sacrifice their careers and their earning potential to stay home with children or to meet the school bus?

    There’s no question but that most physicians in private practice aren’t working nearly as hard as they did through residency. I’ve lived with a pediatrician for 18 years now, from med school through internship and residency and now for 14 years in private practice. (In one job he had, he was on every third night and weekend; now it’s every one in six nights/weekends.) It gets easier the more experience you have, I think–which is to say that it takes more than just gutting out a residency.

    I recognize that these are the same years (late 20s-early 40s) in which people want to have their families. But why is there never a revision to the ideal family form permitted, and the “obvious” solution is that women should quit their jobs, no matter how long they’ve trained or how much they’ve invested?

  40. GMP on 16 Jun 2011 at 1:24 pm #

    But why is there never a revision to the ideal family form permitted, and the “obvious” solution is that women should quit their jobs, no matter how long they’ve trained or how much they’ve invested?

    Because most men don’t want to compromise, they were raised that way, and they know they can get away with it. Because once a couple have kids, most women are not going to leave on account of child pick-up after school or household chores.
    I can totally imagine that many competitive, ambitious women have serious arguments with their competitive, ambitious husbands about who does what regarding childcare and household work and who gets to pull overtime and whatnot… And I am not at all surprised that if someone’s career has to take a hit, if someone’s got to give in, it’s always the women. If you feel your kids and your home are falling by the wayside and the husband won’t budge, what kind of a stick do you actually have to make him care and do more? For many women, it’s just easier to pick up the slack because there is only so much arguing about home/family/chores that one can take on a daily basis before giving up and doing it yourself…

  41. Historiann on 16 Jun 2011 at 4:34 pm #

    I know, GMP–what you say makes a lot of sense.

    This is why it’s important not to marry douchey men, IMHO. (Or women for that matter. I don’t mean to be so heterocentric.) Don’t put yourself in a position where you’re the only person who has to give something up.

  42. Nicoleandmaggie on 16 Jun 2011 at 7:17 pm #

    Re: douchey men…

    One of my friends said when her parents were married her father did not do a lick of housework, and it was a point of contention with them. Somehow with his second, much younger, wife, he does at least half the housework if not more. My friend says wife #2 just doesn’t put up with him being lazy, but who knows why the change. But change can occur. I wouldn’t marry someone thinking that they’ll change after the wedding, but I also wouldn’t give up hope either. As for the stick, I would hope a stick wouldn’t be needed with a loving couple, just communication and problem solving, which marriage counseling could help.

  43. NW Luna on 16 Jun 2011 at 8:52 pm #

    OMG! Shortage of primary-care “doctors!” Well, how about moving some of those specialists, or “partialists,” and PCPs call them, out of their silos and into the whole-person-healthcare field.

    Author ignores the large numbers of nurse practitioners and physician assistants who are educated and trained to do 90%-95% or more of what the average family practice physician does. And with equal or even improve health and safety outcomes. Except that I had to pay for my graduate NP education all by myself, without any help from taxpayer dollars that physicians get.

    BTW, lots of people in any profession would really rather work part-time in this crazy world. Maybe we should look at why that is, before railing about it.

    ….now back to 1 hr of paperwork for every 1 hour with patients. Is it any wonder I work part-time?

  44. NW Luna on 16 Jun 2011 at 8:53 pm #

    That should have been ‘”partialists,” as PCPs call them.’

    Really too much insurance paperwork today….

  45. Historiann on 17 Jun 2011 at 4:16 am #

    I feel for you if you have to deal with the CF that is the U.S. “health” “insurance” “system.” What a colossal waste of time and talent that is, all in the name of profit$!

    But–really: who wouldn’t want to work part-time and enjoy the status and the money of a full-time job? To be a professional is, in my mind, to be a professional, which means the experience and the chops of someone who works full-time at a professional job. Physicians who work part-time see half (or fewer) the number of interesting, rare diseases and conditions, and are only half as competent at diagnosing them in the future. Professors who work only part-time are only half as experienced as their full-time counterparts at teaching, administrative experience, and research and writing. Attorneys who work only half-time have only half the experience, etc.

  46. Nicoleandmaggie on 17 Jun 2011 at 5:07 am #

    @Historiann: if your worry is that doctors aren’t getting enough hours to become competent at diagnosing… a much simpler solution would be to completely separate the paperwork function from the diagnostic function. You would gain more hours from that than from forcing everybody to work full-time. In fact, if the NPR stories are right, that is what many part-time female GP and Pedi actually do– they work in 40 hour a week multi-doctor practices, often overseen by an HMO that deals with all of the paperwork for them (which is streamlined because true HMOs generally take primarily their own insurance). They also get paid less per hour than a regular practice.

    As Wandering Scientist points out on her post on this article, there’s also a sweet point where efficiency goes down, somewhere between 45 and 60 hours/week. One of my colleagues prefers to get his medical care in India because doctors there see many times more patients for a shorter amount of time, making snap diagnoses, but in the US there’s a general belief, right or wrong, among patients that having a doctor able to take the time and listen to you is better. There is some evidence (a recent article from last year) that more experienced doctors run fewer tests (and thus are less expensive), but on average they come out about the same in terms of diagnosis, if I’m remembering correctly.

    And, if experience is what you’re worried about, that argues you should only see older doctors. While I never intend to go to the hospital in July again, I would feel uncomfortable making that decision. I’m also not sure how much depth a GP needs outside of being able to refer to a specialist once he or she is unable to diagnose. Even if the specialist is the wrong one, at that point the specialist may be able to make the correction. If we didn’t have such a (some argue) oversupply of specialists vis-a-vis primary care physicians then perhaps experience would be more important.

    And how long is this less-experience going to be compared to other doctors? I’m guessing during the child-bearing years. Then I’m betting that as doctors get older, the male doctors ramp down themselves (more golf) and the female doctors who had downshifted ramp up. What is the experience-outcome profile for doctors… when does it start to flatten out? Again, it’s been shown that new residents cause lots of deaths every July, but by the end of their first year that has flattened out.

  47. Historiann on 17 Jun 2011 at 5:28 am #

    I suppose it’s all a matter of personal comfort, but if I ever get an abnormal pap smear or a hinky mammogram, I’m going to feel more confident about the judgment of the more experienced, harder-working person.

    Why do you think the experience curve of new residents is pretty steep? They’re in the hospital 60-80 hours a week, that’s why. They take overnight call in the hospital. There are things that hard work and experience can teach that no amount of reflection ever can.

  48. That's Grantastic! on 17 Jun 2011 at 10:12 am #

    Unions frequently base seniority for PT employees based on number of hours worked.

    I don’t know why being a “professional” would exempt somebody from fair-minded and fairly logical ideas about effort –> experience –> expertise.

  49. That's Grantastic! on 17 Jun 2011 at 10:24 am #

    Though I suppose opting out to work PT does leave one more time for buying yogurt to eat in a gray hoodie, perhaps the only real economic engine this country has left.

    http://current.com/shows/infomania/88941392_sarah-haskins-in-target-women-yogurt-edition.htm

  50. Nicoleandmaggie on 17 Jun 2011 at 12:36 pm #

    @Historiann– how steep the experience profile is for different specialties is an empirical question. Babies don’t stay babies forever, and often happen after a residency. If women go part-time for a few years, how is that a big deal in the grand scheme of things? That’s like the argument to not lengthen tenure clocks for academic women who have babies.

    And there’s TONS of research showing that sleep-deprived medical personnel make mistakes. If they’re working too many hours, that is just as much a problem as less experience. There’s a sweet-spot for hours/week worked, and that probably not at 80 hours/week. That’s why there’s recent legislation on not allowing residents to work too many hours/week. Again, where that sweet spot is is an empirical question and no doubt differs dramatically depending on what the doctor is actually doing with his or her time. (Cloud’s post suggests somewhere between 45 and 60.) Again, paperwork has zero value added to diagnostics and is what most doctors spend a large chunk of their time doing. And it’s something that many of these women in large group practices working part time do not spend their time doing… the majority of their time is face time seeing patients.

    Paperwork is also why a childless doctor I know decided to drop out of medical practice entirely (for shame!). If your main concern is lack of doctor-patient time causing lack of experience, that is where you are going to get first-order gains in terms of professional satisfaction, increases in patient care, and increases in face time. You’ll probably even be able to drop reimbursement costs because most doctors did not go to medical school in order to fill out insurance forms.

    And actually, the best doctors I have had have not been the most experienced. They’ve been younger doctors who actually read up on recent research in their areas. The doctor who tried to force my son’s foreskin was very experienced. The one who actually knew why that was bad had her first baby (a daughter) about two weeks after she delivered mine. The OB/GYN who had no idea what to do with my infertility problems, highly experienced, the RE who knew what she was talking about including all the most recent research on metformin’s safety during pregnancy, in her 30s.

    One of the known problems with experience and doctors (known in both my research field area and my husband’s very different research field area) is that doctors tend to do what they were trained to do at their hospital of residency. That’s one of the reasons that so much of the country is on flat-of-the curve medicine — some parts of the country do not keep up with new technologies so they end up using more expensive technology that is worse for the patient. This is especially true of heart attacks (there’s a long series of papers on this topic out of the Dartmouth Atlas project). Experience is not everything.

  51. That's Grantastic! on 17 Jun 2011 at 12:59 pm #

    Nicoleandmaggie, you’re conflating hours of experience with years in practice, when the entire point is that they are not the same.

    Sure, doctors who are up on modern technology are better than those who aren’t. Fine, recent med school grads have advantages over doctors who don’t resolutely stay on top of advances, in that respect.

    The question is that *within each cohort* who do you prefer, those who work more or those who work less?

    Recent grad who has 1 year post-residency at 20 hrs/week, 40 hrs/week, 60 hrs/week, or 80 hrs/week? That’s the question.

    You say that because babies don’t remain babies forever, this is a short-term decision women are making. Of course that’s true for some. But the “short-term” (how many years is short-term?) aspect of this decision is certainly not true for MANY women who opt out, including those who originally intend for the arrangement to be short-term but find out later that opting back in isn’t as simple as they assumed.

    I’m all for making it simple. But I think it’s a joke to pretend that it IS already, or to assume that there’s no substantive difference between working a full time paid job and…NOT. The mommy track is the mommy track.

  52. That's Grantastic! on 17 Jun 2011 at 1:01 pm #

    In other news, by combining this topic & the Barnard speech, I think this guy is totally ripping off Historiann’s blog!

    http://onpoint.wbur.org/2011/06/16/should-doctors-work-more

  53. These… are the Links of our lives. « Grumpy rumblings of the untenured on 18 Jun 2011 at 12:08 am #

    [...] love.  In the mean time, pop over there and see what she’s written.  Start with this one on female physicians opting out.  Related:  Wandering scientist comments on the same article, as does Dr. Isis.  This last [...]

  54. Co history 1858 on 20 Jun 2011 at 8:58 pm #

    I’m still scratching my head over this one. Do NO male doctors choose to be part-time when they have young fsmilies? is this because their partners give them a choice? Having never been part time for one second, I’m just envious of people who do have that choice!

  55. Jonathan Moy on 26 Sep 2011 at 4:59 pm #

    I am a medical doctor who has left clinical medicine.

    Just because someone completes a medical degree does not mean that they are endebted to anyone to continue in the field. Many factors influence people to study medicine, and factors change over peoples lives they give priority over career! Career is not everything. Family and relationships have been shown to be more important than career in most studies.

    Their is no debt to society for having a medical degree anymore than a lawyer must practice law, or a political scientist must be a politian.

  56. shelley on 29 Nov 2012 at 7:07 pm #

    I couldn’t have said it better myself. “you go girl, dr. sibert!”

    I’ve been complaining for years that our society has been misleading women about the fairy tale of being able to have a “power career” (yeah, we’re doctors, not secretaries, teachers, or nurses), be a great wife, and a great mother. it just doesn’t work that way with doctors. some aspect will invariably suffer.

    blah, blah, blah, the part-time doctors are part of a team or deserve a “balanced” life. in my practice, the part-timers take the same amount of call as us “full-timers” lest they be seen as slackers.

    sorry, but when it comes to medicine, women need to PULL UP THEIR BIG GIRL PANTS AND JUST BE DOCTORS.

    S

Trackback URI | Comments RSS

Leave a Reply