Deferred Personal Life Decisions of Women Physicians

Introduction

As the number of practicing women physicians continues to increase each year, female attitudes regarding careers in medicine have become a rising topic of interest. ^{1 –4} This is especially true as issues regarding equal pay and paid family leave time have become major areas of cultural focus. ^{5 –7} In the United States in 2014, ∼33% of active physicians were female, and in other areas of the world, women are starting to outnumber men in medical schools. ^4,8,9 This trend shows that the medical community at large is in the midst of a slow demographic shift with future implications on the American medical community.

It is generally accepted that being a physician requires a certain amount of personal sacrifice. This is particularly so among the women physician community. Many sources suggest that compared with other workers, physicians are more likely to be dissatisfied with work-life balance and that there is an association with the female gender. ^{10 –12} In addition, a survey of women physicians conducted by Tracy et al. shows that for 91% of the respondents attaining a satisfactory work-life balance was a significant concern. ¹³ Given the traditional role of women in the family unit and professional workplace, our aim was to assess if and what types of personal compromises women physicians make in pursuit of career success. For example, in the western world, working women tend to delay childbearing, leading to potential complications due to advanced maternal age and consequent health impact on the mothers and their children. ¹⁴ Through this examination we hope to better understand what types of commitments and sacrifices contribute to the social context of the medical culture surrounding women physicians and help to inform future research.

Despite large numbers of women within academic medicine and leadership in the United States, the work environment continues to show modest (if any) improvement. Larger numbers of women are present in nontenured and nonresearch tracks that are considered less competitive. ¹⁵ According to the 2014 Women in Medicine and Science Survey done by the American Association of Medical Colleges, “Women remain underrepresented at key career stages—in particular among senior faculty ranks, department chairs, and medical school deans.” ¹⁶ Given this information, we questioned whether women who had high research output or served on committees during their clinical careers had to choose between their personal and work lives.

We expect that women in the medical field defer major life decisions due to their career. Much like what has been observed of women in the science, technology, engineering, and mathematical fields (STEM), we anticipate that women more than men would put off or defer important milestone decisions, such as getting married or having children in pursuit of their career. ^{17 –22} Anecdotally, based on personal observations from physician stories on social media groups (such as Physician Moms Group) and women physicians' professional society listservs and meetings, deferment of personal life decisions appears to be widespread. Within social media and women physicians closed groups, there are numerous posts of fears articulated by junior faculty and trainees about the consequences of pregnancy or rescheduling work days to attend events valued by the women physicians. Rich et al. have shown that “within residency training, particularly, women with children were particularly affected, suggesting this group would benefit the greatest from changes to improve the work-life balance of trainees.” ²³ This is largely due to the medical community's expectations (employers, program directors of residency programs, mentors, and department chairs) and the traditional male-dominated professional workforce.

Overall, we hope this study will help evaluate and describe specific factors that can affect the social context of the medical culture driven by women physicians, particularly personal decision deferments, as well as potentially expose any associations that may exist.

Methods

We sought to examine the work-life experiences and personal decision deferment of women physicians. This study was performed with approval of our Institutional Review Board.

The survey was designed after the authors identified common themes as a result of active engagement on social media sites (Facebook™, Twitter™, Linked-In™ groups); personal discussions with colleagues, mentoring sessions, and literature review (Supplementary Data S1; Supplementary Data are available online at www.liebertpub.com/jwh). The questions were developed and refined based on feedback from colleagues. An electronic survey was created and distributed via an email link to the website, Survey Monkey™. The survey link was distributed to women physician faculty and staff of local area health systems through various women physicians' organizations and social media platforms as both an email as well as social media postings. This email and posts included information about the survey as well as the risks and benefits of participating. Completing the survey was an indication of the respondent's willingness to participate in the study. Because of the resources leveraged to distribute this link, we are unable to quantify the exact number of surveys that were distributed. Responses were maintained as anonymous with no identifying factors collected. A total of 900 survey responses were collected. Ninety-nine surveys were removed for not answering the primary endpoint question leaving a total of 801 surveys that included the final analysis.

The primary endpoint assessed whether or not a personal decision had been deferred in pursuit of a medical career. Secondary endpoints include: type of decisions deferred, number of children, choosing a medical career again, choosing specialty again, reasons a physician would or would not choose medicine again, and any unexpected personal sacrifices. Demographic data were also collected, such as age, relationship status, year of medical school graduation, specialty, average hours worked per week, number of research publications, and number and types of committees served. Workload questions were aimed at assessing clinical research as well as administrative functions, including average hours worked per week, number of research publications, as well as number and types of committees served.

Deferred versus nondeferred groups were evaluated using chi-square tests or Pearson correlation tests for all categorical data. For each continuous variable, outliers exceeding three standard deviations (1%) were removed. Continuous variables were summarized using the mean and standard deviation within each nondeferred and deferred group. Differences between nondeferred and deferred groups were examined using two tailed t-tests or nonparametric tests as appropriate. All statistical analyses were performed using JMP 11 from SAS corporation, using two-sided tests with p-values less than 0.05 considered significant.

Qualitative data were gathered from free-response sections through which survey respondents were able to convey personal experience. For these free-response questions, respondents were prompted to provide a free-response comment based on their answer choice. If a respondent provided a free-response comment when not prompted, these answers were not included in the final analysis. These sections allowed for the opportunity to provide examples of the types of decisions that women deferred as well as reasons why they would or would not choose a medical career again. These responses were manually collected, grouped, and coded based on similar themes. If a participant cited multiple reasons or examples, each example was counted as a response for its respective category. Comments were only collected for items that the respondent endorsed.

Results

Survey respondent characteristics were compared between deferred and nondeferred groups (Table 1). There were 513 women in the deferred group and 287 women in the nondeferred group. There were no significant differences with regard to age (p = 0.1229), marital status (p = 0.8527), career specialty (p = 0.0523), medical school graduation year (p = 0.1007), or average hours worked per week (p = 0.1967) between the two groups.

Sixty-four percent of respondents reported deferring personal decisions (Table 2). Of these, 86% reported the deferment of having children and 28% reported the deferment of marriage (Table 2). Decision deferment was correlated with having less children on average with women in the nondeferment group averaging 2.06 children, whereas those in the deferment group averaged 1.7 children (p < 0.0001; 95% confidence interval [CI] nondeferred 1.96–2.16; 95% CI deferred 1.62–1.77) (Table 2). Women physicians who deferred personal decisions had lower rates of career satisfaction; conversely, those who did not defer personal decisions had higher rates of career satisfaction. Seventy-one percent of women who endorsed a decision deferment would choose a career in medicine again compared with 85% of women in the nondeferment group (p < 0.0001, Table 2). Respondents who stated that they would choose medicine again cited reasons such as career satisfaction, positive patient interactions, and intellectual stimulation. Those who would not choose medicine again reported reasons such as poor work-life balance, decreasing job satisfaction, and insurance/administrative burden (Table 3). Finally, it was noted that physicians who had deferred major personal decisions also reported that they had made unexpected personal sacrifices in comparison to physicians in the nondeferred group (46% vs. 31%; p < 0.0001).

We assessed if physicians would choose their same specialty again, and there was no significant difference between the physicians in the deferred and nondeferred groups. Physicians in both groups would select their specialty again (80% vs. 83%, p < 0.272). Finally, there was no difference between groups with regard to the number of research publications or number and types of committees served (p < 0.0642, p < 0.4058, p < 0.9537, respectively).

To further examine the data, we reviewed and categorized survey comments submitted by the respondents. With regard to postponing marriage and childbearing, one physician responded, “My first marriage was at [age] 39 and my first child at [age] 40. Too stressed to focus on marriage before that time.” Another wrote, “[Deferred] having a second child. Never got to it. Big regret in my life.”

Survey participants also provided reasons as to why they would or would not choose a career in medicine again. A poor work-life balance was cited by 44% of women in the deferred group and 53% of women in the nondeferred group, with one physician stating, “I feel torn from myself as a person and a mother.” In addition, administrative and bureaucratic challenges were reported by 36% of women in the deferred group and 28% of those in the nondeferred group. It was felt that “[The] government and insurance don't let us practice medicine.” Finally, responses such as “the field is no longer worth the effort,” support that low career satisfaction is another important reason why 29% of women in the deferred group and 15% of those women in the nondeferred group would not choose medicine again as a career.

There were also several positive responses captured, which show that many women physicians are still motivated and driven to practice medicine despite the challenges. Out of those participants who would choose medicine again, career satisfaction was the most highly cited reason noted by 85% of those who deferred and 86% of those who did not defer. “I truly love what I do and can't imagine doing anything else,” wrote one physician. Another stated, “The work is rewarding. It's rare to find a job where you can make such an impact on another person.”

Discussion

The results of this survey have significant implications on the future of the workforce in medicine. Overall, our analysis revealed that a majority of women physicians postpone important life decisions in pursuit of their medical career. It was surprising that there were no differences between the two groups with respect to age, relationship status, specialty, or average hours worked per week. We expected there to be more deferred decisions among physicians who were older and trained before work-hour restrictions, as well as among physicians who belong to surgical specialties and those who worked more hours per week. Although it is unclear as to why these factors are not correlative, it proposes that there are other dynamics impacting these results that affect all physicians equally such as administrative burden, work-life balance difficulties, opportunities for career advancement, and issues regarding equal pay for women and men, among others.

In addition, the reported deferred decisions were often choices that impacted important life milestones such as getting married or starting a family. According to the 2015 Medscape Physician Lifestyle Report, spending time with family was the top-rated pastime reported by physicians. ²⁴ However, the results of our study suggest that there is now a growing population of women physicians who are waiting to start a family because of the demands of their medical career, and in fact, these women also have less children on average. This finding is also consistent with data relating to women in the STEM fields, with one study reporting nearly 40% of women in these fields also delay childbearing. ¹⁵ This may have important ramifications as well as a potential negative impact on individual performance, satisfaction, and retention of women physicians in practice.

This study also indicates there is a negative imbalance in the risk–benefit ratio of becoming a physician as 24% of all respondents indicated they question their career choice. Nearly one third of physicians in the deferred group stated that they would not choose medicine again as a career. A variety of reasons were cited for this decision, including decreased career satisfaction, poor work-life balance, debt, decreasing compensation, and increasing administrative and bureaucratic burden. The current atmosphere in the medical field suggests that many of these points such as administrative and bureaucratic burden and decreasing compensation are going to only continue to devalue the work that physicians conduct and further negatively impact career satisfaction.

While data are convincing, the heartfelt responses submitted by the physicians helped to exemplify that there is a true disconnect between personal values and the current system in which medicine is practiced. In addition, there is evidence that women are more negatively affected by the way work interferes with family life. ^10,25

Finally, we feel that one of the most important and surprising results of this survey was the finding that women who did not defer major personal decisions were more likely to indicate that they would choose medicine as a career again. We feel that this is a factor of considerable significance that needs to be considered by women physicians in making personal and professional decisions as it directly correlated with career fulfillment and satisfaction. Giving equal emphasis on personal and professional decisions may have a major impact on preventing burnout and promoting satisfaction with career choice.

Our survey has several limitations. One of the major limitations of our study was the fact that it was an exploratory survey designed to identify themes that were emerging in social media and discussion boards. There is also the inability to truly assess response rate which could lead to concerns about the generalizability of our data and difficulty eliminating bias. However, we feel that this study provides significant contributions to social science research in the medical field that may have a substantial impact on programs designed to engage and retain the workforce. Furthermore, this study helps to define an area of research that can be more rigorously studied moving forward. That is, exploring further, the career satisfaction levels of those physicians who have deferred personal decisions in pursuit of their careers.

To summarize, a majority of the survey respondents reported deferring personal decisions, however, among the group that did not defer their decisions there was a higher rate of career satisfaction. Further longitudinal research is needed to confirm the findings of our survey; however, mentors, support groups, and employers must consider the results of our survey in their employee retention strategies. As working women physicians continue to bear the majority of the domestic burdens while juggling their careers, increased support at work is one way to improve job satisfaction and help women to achieve better work-life balance. Creating mechanisms for increased schedule flexibility, expansion of child-care services, paid family leave, and programming for career development are just a few ways that employers can begin to address these issues.

Conclusions

The number of practicing women physicians continues to increase each year and a dramatic demographic shift is occurring within the medical field. Interestingly, despite this change in workforce many of the domestic tasks and responsibilities continue to fall on these working women. ²⁶ Because of this, the work-life balance of women physicians has become an issue of increasing importance. It has been shown that women physicians are deeply affected by issues regarding work-life balance, and we believe that, overall, the results of this survey have significant implications on the future of the workforce.

While our female predecessors have worked hard in conquering the blatant bias that women once faced in this field, there is still room to grow. Lack of support and deferred personal decisions have a potential negative impact on individual performance and retention. Female providers should have career-support measures available to help tackle the unique challenges they face as a woman in medicine. In addition, employers must consider the economic impact and potential workforce shortages that may develop if these issues are not addressed.