A Daughter's a Daughter for All of Her Life

Approximately 25,000 faculty members of U.S. medical schools are women >50 years of age. ¹ This number is rapidly increasing as the cohorts of women who entered medical school in the 1980s and 1990s progress in their careers. Although there has been significant focus on family issues facing women early in their careers, surprisingly little is known about work/life integration and other issues for women physicians in middle age and older. Women's caretaking responsibilities are generally assumed to be predominantly focused on the needs of young children, allowing older female faculty members to prioritize professional and other interests. Unfortunately, the reality for many professional women is a “second wave” of caretaking in middle age and later. This is not exclusively a women's issue; many men also undertake caretaking roles, and many more are impacted, directly or indirectly, even if a woman is the primary caretaker.

Regardless of her professional responsibilities, a daughter is often regarded as the most appropriate family member to care for elderly relatives. The saying “a son's a son till he takes a wife, a daughter's a daughter for all of her life” still reflects the experience of many women. In some cultures, a wife may be expected to care for her husband's parents as they age. With smaller nuclear families, a professional couple may find themselves responsible for several elderly relatives or family members with chronic or disabling health conditions. This new phase of caretaking is quite different from raising children. It requires mastering an entirely new set of information; addressing multiple unfamiliar issues; navigating the health care system from the patient perspective; and negotiating new relationships, responsibilities, and boundaries with family members. Similar to childrearing, caring for an older adult or an adult with a chronic health condition can be physically and emotionally draining. For women physicians, such caretaking has been associated with significantly increased rates of mood or anxiety disorders and burnout. ² Caretaking responsibilities pervade all areas of life. As one colleague stated, “At social events we used to chat about our kids' activities, schools, and trying to get them into a good college. Now the conversations are about home help, assisted living, and wondering if we will have to consider nursing homes for our parents.”

For senior female faculty members, the impact of late caregiving may be mitigated to some extent by knowledge of the medical system, practice in managing complex personal and professional lives, and access to financial resources. Nevertheless, finding the time required is challenging. Institutional policies and practices to support family life remain focused, almost exclusively, on reproductive and early childhood issues. For the older caregiver, options for flexible work hours or working from home may be limited. Time to attend to caretaking demands can often be leveraged only through use of vacation, unpaid leave, or deducted from sick leave through the Family and Medical Leave Act. ³ We know of colleagues whose sick leave was totally depleted by the demands of managing the terminal illness of parents. For those supporting loved ones through a chronic condition, especially dementia, the demands can be enormous. ⁴

For many older women, caretaking is not restricted to elderly relatives. “Baby boomers” increasingly find themselves responsible for grandchildren, ailing partners, or dependent adult children. A recent report estimated that almost half of middle-aged Americans are “sandwiched” between providing for the needs of parents aged ≥65 years while also caring for children or providing for a dependent adult child ≥18 years—and that this situation is getting worse. ⁵ Obviously, the assumption that women faculty members can anticipate a “golden” period to focus on their careers once their children are older is seriously flawed.

Business has begun to pay serious attention to caretaking issues and the intensifying demands on the sandwich generation to provide financial, caregiving, and emotional support to a range of dependents. A recent report from the Harvard Business School defines “the care economy” as covering a spectrum of care, from childcare to eldercare, and affecting employees of all ages and levels of seniority. ⁵ The report paints a stark picture of companies incurring millions of dollars of overt and hidden costs due to turnover, loss of institutional knowledge, absenteeism, and reduced productivity by employees who are also caretakers. The greatest impact was on the most senior members of the organization. Middle-aged and more senior individuals were most likely to report loss of productivity by the intrusion of caretaking responsibilities. An astonishing 61% of senior leaders reported leaving a position due to conflicts of caregiving compared with 23% of other employees. ⁵ According to the report's authors, the central issue is poor alignment of institutional culture and benefits with the priorities and actual needs of employees. The authors identify the first step in creating a “caring company” as clarifying the type and extent of caretaking undertaken by employees. They recommend regular surveys or “care censuses” to more precisely identify caretaking needs and guide the implementation of innovative policies and individualized benefits to support all employees. It must be emphasized that this is not a zero sum game in which policies and benefits for young colleagues are threatened by calls for more support of older workers. The central issue is that family responsibilities are lifelong, and the appropriate organizational support must be adaptable to individual needs that change over time. Unfortunately, this approach appears to be still largely conceptual and has not yet been widely implemented.

For medical schools, the damage to professional performance, team function, and workplace morale inflicted by unsupported caretaking responsibilities of senior faculty members may be even more significant than the substantial financial loss highlighted by the business literature. Caretaking pressures and distractions are likely to impact the quality of health services. They are also central to the most recent of the “quadruple aims” of the Institute for Healthcare Improvement, that is, improving the work life of health care clinicians and staff. ⁶ The importance of individualized approaches to family responsibilities has recently been recognized by the Federation of State Medical Boards in a position paper on physician burnout. ⁷ Although mid-career and senior female faculty may be leading beneficiaries of expanding support of caretaking to cover all dependents, faculty members of all ages and genders would also benefit—and institutions are likely to see significant return on investment.

Women faculty members are likely to face other issues in mid and late career, including persistent discrimination, harassment, and denial of opportunities based on age and/or gender, in addition to the effects of persistent salary inequity. ^8,9 These issues may be even more significant for women who need to take time away from professional responsibilities to care for family members. Medical schools cannot postpone addressing issues that impair the professional vitality, resilience, and productivity of the ever-larger numbers of female faculty members who are entering middle age and older age groups. A basic first step is to ask women at all stages of their careers about caretaking responsibilities that are interfering with work demands and vice versa. Women should also be asked for recommendations on how to address these challenges so that institutions can develop strategies that genuinely provide meaningful and sustained support of women throughout their professional lives. Embracing the culture, policies, and practices of a “caring institution” to reduce lifelong caretaker burden seems a good place to start to meet the challenges faced by women and could place medicine at the forefront of most industries.