Expert forum: Why are women physicians less engaged than men?

  | August 2, 2017

Physician engagement affects an organization's performance and culture — and the quality of care it delivers. And while engagement levels are strikingly low among all physicians, they're even lower among women than men.

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athenahealth's 2016 Physician Engagement and Leadership Index found that 84 percent of women physicians — compared to 78 percent of men — are not fully engaged with their work and are unlikely to stay at their current organization.

Why the disparity?

athenaInsight assembled a panel of women physician leaders, all balancing work with complex lives, to discuss the survey results and their implications at a time when women are entering medicine at greater rates than men.

Our panelists spoke openly about persistent gender stereotypes, the dearth of female mentors, and work that must be done to bring careers in medicine and women's lives into alignment.

Here are edited excerpts from their conversations; add yours to the comment section below, or tweet us your thoughts @athena_Insight.

On lack of engagement:

Manisha Sharma, M.D., family physician, director of primary care and community health for CareMore, director at Doctors for America; balances 16-hour workdays with full days off with her 11-month-old baby.

Sharma: You'll find women are the medical directors of clinics or in on-the-ground leadership roles but not really as the folks up at the big table. Having a voice with leadership and being a part of the solution — that's what engagement means to me. I think the difference with women is that having a family, when that does happen, becomes more of a priority. So, then they shift to a get-in, get-out mindset.

Vineet Arora, M.D., assistant dean and associate professor of medicine at the University of Chicago, author of a JAMA editorial about unequal pay for women physicians; balances full-time work and parenting of her 2-year-old with her equally as busy physician husband.

Arora: Physicians don't want to be in an organization where they're not living up to their skills of practice. They want to feel challenged, but they want to feel challenged in a way they can grow to meet the challenge. You need a vision for upward growth. But how does that translate for women?

Deborah Shlian, M.D., MBA, family physician, healthcare management consultant and recruiter; author of "Lessons Learned: Stories from Women in Medical Management." When she entered medical school at University of Maryland School of Medicine, there were eight women in her class. Today, 60 percent of the students there are women.

Shlian: People coming out of medical school have different expectations from my generation. A lot are willing to take jobs to have schedules so that they can have a life. So, while they're at work from 8 to 5, they are very engaged. More women that I talk to really go into medicine for the pure love of medicine as opposed to just making a living.

Mary Ellen Benzik, M.D., chief medical officer at QuadMed; previously chief medical officer of Trinity Health; got her start launching community health partnerships through a clinic in Battle Creek, Michigan.

Benzik: More of the women I know in leadership move that way because there's something they wanted to right. They felt this is something where I could make a difference. The more traditional male leadership is about power and hierarchy. Women will end up in leadership based on their mission.

On burnout:

Angela Nicholas, M.D., vice president medical affairs, Einstein Medical Center Montgomery, and chief medical information officer, Einstein Healthcare Network. Caregiver for her husband, who is in treatment for stage 4 cancer: 

Nicholas: Engagement is about burnout. If you're not feeling good about the work that you're doing, then you become less engaged.

Arora: When you think of a woman physician, you think somebody who's going to be calm, caring, and always empathetic. That expectation leads to burnout among women physicians, because they're striving for perfection that doesn't exist.

Nicholas: When [physicians] get overwhelmed, we don't ask for help. We don't know how to ask for help. We just keep doing what we're doing until one day you just snap and get a new job because you can't take it anymore. But all you've done is perpetuate the cycle, not solve the problem.

Shlian: Medicine has changed since I started. My father was a primary care doctor, and so well respected in the community. We don't trust physicians the way we used to. So there's that sense of not being appreciated. And that's very wearing. [Burnout] among doctors is a real emergency. I think that's true for men and women.

On gender stereotypes:

Sharma: Women who in their residencies take a break and say, "I had a baby," or "I started a family." I'm lucky to have worked with men who are more progressive and don't look at that as a red flag. But I have also been at organizations where older generations see that break as a sign of weakness. They think it means that the job won't be primary, and it's still very necessary to fight that.

Arora: We haven't yet adjusted medical practice to acknowledge the social norms that men and women have outside and inside the workplace. In the healthcare space, you have to advocate for your patient effectively, and that means you've got to be aggressive and present your case. Over and over again, I've seen that women have a harder time with that.

Shlian: I think we have been brought up, as women — we're sort of taught to behave a certain way. It doesn't mean we have to emulate the guys in the bad ways, but certainly to be a little bit more confident, there's nothing wrong with that.

Benzik: Women are less worried about the title. They're less worried about the corner office and more concerned with how close they are to the teams that need to get the job done. The trappings that traditionally mark leadership don't matter, so we don't seek them. But that may set us back in terms of our progression, because others may see us as not as driven if we don't compete. The perception is that she isn't as strong of a leader.

On balancing work and home:

Arora: Turnover is the Achilles' heel of any organization. And women turn over a lot, [especially] hospitalists. If you cannot make [that job] work for a 30- to 40-year-old woman who's raising kids, you cannot make it work for anyone. It's not sustainable, because the only people that can do that job are basically single men.

Sharma: I have turned down jobs because it would take me away from my kid. I don't want my kid to think that I'm a nice lady that holds him at night. I want him to actually feel like I'm involved in his life, but it's still hard. The hustle is different for men and women in medicine. And we aren't naturally on a leadership path.

Nicholas: When I got married, I took on more responsibilities at work [as I became a vice president]. And then, I got divorced. This job had responsibilities that he just wasn't willing to buy into. But I was a doctor way before I was a wife. And that's a really hard thing to change. I transitioned into midlife, got married again, and my husband was diagnosed three years later with cancer. So that takes me into a different kind of role, because now I'm a caregiver in a pretty stressful situation.

On mentors:

Nicholas: I've been very lucky to have [mentors] in my entire career. And I've been able to offer that same thing to my employees as well. When I became a new vice president, I worked for the CEO of the hospital. When I didn't understand something or needed some help, I would go over to his office, and we'd pull out the spreadsheets and sit down and he'd spend that time with me.

Sharma: Someone once asked me who my mentors were in my career [as a physician leader]. And I realized in that moment that they were all white men. I couldn't think of one woman I know in a leadership position I aspire to. It's not that women don't want to mentor. But our pulls and pushes and priorities are different as we get older.

Arora: You would think women leaders would be very supportive of the women coming up, but in fact, my experience has been that sometimes the women leaders that are at the top are the most critical of the junior women that are coming up. And it's because they were held to such a high standard, it's a Catch-22. Their ride made it easier for me to come, but they resent the fact that my ride is easier.

Shlian: The American Medical Women's Association has a big program to mentor women to demand that they have opportunities to move ahead.... Women need to push, they need to really make demands about their expectations.

Benzik: The challenge is, if we're still thinking of a mentor as someone who is going to leverage us into a career change, there are still more males than females who can do that. I'm surprised that I've had less structured mentorship relationships with women than I think I should have [as CMO]. But women ask for it in less of a structured way. And when women ask for it, it's more around the challenges of the work-life balance versus trying to climb the corporate ladder.

On speaking up:

Nicholas: I'm pretty upfront with what I need. And maybe that's part of [why I've made it to the c-suite]. When I need help, I'm not afraid to ask for it. I think that's something that's hard for a lot of people to do.

Arora: The No. 1 fear that I hear from women: “I don't want to sound dumb." And at medical Grand Rounds, the people that are perceived as leaders raise their hands; 9 times out of 10, it's a man, and that has nothing to do with having a kid. This is a gender norm that starts very, very early.

Sharma: In a hospital or academic setting, they want you to be opinionated but not too opinionated. Women with opinions can easily become "someone you can't work with." My male mentors taught me to get to this place where I could say, "Are you punishing me because I have an opinion that was different from yours?" ... When I meet young women who want to be doctors, I ask them are you "mission over paycheck" or "paycheck over mission"? If you're paycheck over mission, that means your No. 1 enemy is going to be yourself, and you have to keep your mouth shut. But if you're mission over paycheck — then you're unapologetic about what you want to do to change the world.

Chelsea Rice and Gale Pryor are staff writers for athenaInsight.

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Thank you for the interview and the great write up. I would like to make the following correction to my profile: My husband (also an academic physician) and I both travel for work and balance our work with co-parenting our 2-year old daughter!

Name: 
Vineet Arora
Email: 
test@test.com
What is the definition of "engaged" that was used for this article? It is very difficult to read this without a specific definition of the this word.
Name: 
Kathleen Rheaume MD
Email: 
karheaume01@gmail.com
Hi Kathleen, Thanks so much for commenting! We asked physicians to characterize their level of engagement by responding to three statements: 1. My organization inspires me to go above and beyond what is required. 2. I am very likely to be working for my current organization three years from now. 3. I would recommend my organization to a friend or relative to receive care. Respondents answered on a scale of 1-6, with a 6 being “strongly agree” and a 1 being “strongly disagree”. To be considered engaged, a respondent had to answer a 6 for at least two of the questions and no less than a 5 for all three questions. Read more at this overview here: https://www.athenahealth.com/insight/strong-physician-leaders-key-tackling-change/
Name: 
Chelsea Rice
Email: 
crice@athenahealth.com
As a male residency program director in orthopaedic surgery I appreciate the comments made in this interview and published in this forum. 10-15% of all orthopaedic resident applicants are women who at times are challenged by a male-dominated profession. Diversity raises not only challenges but opportunities that give every field of medicine improved societal engagement. Early exposure to musculoskeletal medicine allows female medical students the interest needed to pursue the field. Orthopaedic surgeons work more hours than most physicians and while the reasons are not clear, my experience is this is a major challenge if you desire orthopaedic surgery and family. A better definition of work/life balance may help set expectations of a rewarding and challenging career.
Name: 
Kevin Gill
Email: 
kevin.gill@utsouthwestern.edu

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Expert forum: Why are women physicians less engaged than men?