May 8, 2017
JAMA Intern Med. Published online May 8, 2017. doi:10.1001/jamainternmed.2017.1243
Afew days before we were invited to write this Mother’s Day article, both of us—mother (M.A.) and daughter (L.G.)—walked arm in arm in one of the many marches in January 2017 to underscore women’s rights in the face of the new Trump administration. The sense of intergenerational connection was palpable. Thousands of daughters—millennials and members of generation X—fell in step with their baby-boomer mothers, many of whom had started marching for women’s causes back in the 1960s.
In medicine, that warm intergenerational connection has been present for many years—but for men, not women. We know of many father-son pairs who have made their mark in medicine, but mother-daughter pairs are relatively new (and sometimes hidden, since mother and daughter often have different surnames). Being such a pair, we have reminisced at length about our lives in medicine. Because they straddled the entry of large numbers of women into the profession, our experiences differed from each other far more than would be likely for a father and son.
We entered medical school exactly 30 years apart (both in Boston). In 1963, M.A. was one of only 8 women in a medical school class of 75 (an unusually high percentage then). When L.G. entered medical school in 1993, there were approximately equal numbers of men and women. We thus directly experienced the enormous changes that occurred as women progressed from being a small and often unwelcome presence in medical school to, as of today, being about half,1 and from being a tiny percentage of practicing physicians to a third.2
When M.A. entered medical school, physicians, almost all of whom were men, were threatened by the entrance of women into the profession, in part because the “feminization” of a profession usually meant a decline in status and income (and still does). Many of the men in M.A.’s class were openly hostile to the women, accusing them of irresponsibly taking up a place that should rightfully be filled by a man. Professors addressed the class as “gentlemen,” as though willing the women to disappear. For residency, women were shunted toward certain specialties, such as pediatrics and psychiatry, and away from others, like surgery (not coincidentally, the higher-paid fields). It was eminently clear that many professional opportunities were, in practice, closed to women. No accommodations were made for pregnancy or motherhood, despite the fact that medical training coincides exactly with women’s prime reproductive years (and day care was rare). When M.A. became pregnant in her second year of residency, she was not invited back for a third year.
The offset for M.A. was the opportunity to care for patients in a way not possible for L.G. The relationship between resident and patient was closer in the 1960s because care was provided almost exclusively by 1 resident, rather than teams, and patients stayed in the hospital much longer (about 8 days on average).3 This afforded the time to witness the entire course of illness, from presentation to full recovery. Although residents, then as now, spent long hours in the hospital, the pace was more leisurely. There were many fewer diagnostic tests in those days, so ascertaining the diagnosis by history and physical examination—the interesting detective work—was more a focus, and residents came to know their patients well, even if they could do less for them. Sometimes patients would initially be worried by having a woman physician, assuming she would be less competent, but that concern almost always quickly dissipated.
When L.G. was in medical school and residency (1993-2001), she felt no discrimination whatsoever from the men in her class or from male faculty. With perhaps the exception of the very top of organizational hierarchies, she had the impression that every opportunity was open to her. Men and women physicians shared a strong camaraderie. This was the “era of high throughput”4 and before the institution of work-hour limitations. Hospitals were making concerted efforts to increase market share, and for those that were successful, the number of admissions was increasing, while the length of stay was dropping. Patients had to be very sick to be admitted to the hospital. So the intensity and acuity of workload was high, the pace frantic, and the hours often more than 100 per week.5 Since patients were discharged so rapidly and their care was shared among many services and physicians, it was hard to develop the kind of close physician-patient relationships that M.A. remembers. In contrast to M.A., who found refuge from the skepticism of her peers in her relationships with patients, the primary joy in work for L.G. lay in the relationships among fellow trainees. Their unwritten code was always to go the extra mile to help one another, and their shared experience seemed to trivialize any differences, including gender.
We each observed that women nurses sometimes responded to women physicians, at least on first contact, with less respect and more resistance than to their male counterparts. It was interesting to us to see this phenomenon confirmed by the survey of Adesoye et al6 in this issue of JAMA Internal Medicine, in which 38.8% of physician mothers reported discrimination from nursing or support staff.6 (This was more than any other type of discrimination investigated, with the second most common type—not being included in administrative decisions—reported by 27%.) Although in our experiences the initial distrust from some women nurses generally reverses quickly, it can be tiring and inefficient to have to work through it, and it flies in the face of what one might think would be a natural alliance. It is beyond the scope of this article to consider the causes, and they have likely changed over time, but clearly, relationships with nurses and support staff are among the important professional challenges for women physicians. Perhaps we should pay attention not only to the glass ceiling, but also to our colleagues at the bedside.
Women physicians have come a long way, but we are not there yet. The glass ceiling is still largely intact; in 2014 only 15% of department chairs in academic medicine were women.1 Climbing to the top is probably slowed by the demands of motherhood and the reactions to it. In the survey by Adesoye et al6—in which two-thirds of physician mothers reported discrimination on the basis of gender—35.8% believed the discrimination they felt had to do with conditions specific to motherhood, such as pregnancy, maternity leave, or breastfeeding. These women felt that reasonable accommodations should be made for the special circumstances of women, and they are right. When fully half of young physicians are women of childbearing age, it is absurd not to structure our facilities and schedules to better support motherhood—as M.A. pointed out in an editorial in 1981, 36 years ago.7Decisions about clinical staffing levels (including residency program size) should anticipate the need to schedule around reasonable maternity leave, reduced call schedules in late pregnancy, and part-time schedules for new mothers (and, more and more often, fathers). If the demands of pregnancy and motherhood are built into the system, there is no reason for colleagues to feel burdened or resentful because they are taking up slack. Health care organizations should also provide breastfeeding and pumping facilities and affiliated day care centers.
Perhaps the most important difference for us is that L.G. had a woman role model and mentor—her own mother, while M.A.’s mother was a housewife who shared the prevailing belief at the time that medical school made no sense for women. Her professional mentors were by necessity men with very different life experiences, who often had to overcome their own preconceptions about women’s place in the world. In contrast, M.A. has encouraged L.G. professionally throughout her life. We spend long hours talking about patients and editing each other’s professional writing; the personal and professional relationships enrich each other. Although not every woman physician has the benefit of a mentor so close to home, most are now able to find role models and mentors who are women, and senior women physicians should actively embrace this role. It is clear that L.G.’s relatively easy path in medicine was made possible because of the efforts of M.A.’s generation, and M.A., in turn, built on the struggles of the generation before her. The question now is whether we can hold the doors open—and open a few more—for our daughters in future generations.
It’s what mothers do for their daughters.
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Corresponding Author: Lara Goitein, MD, Christus St Vincent Regional Medical Center, 455 St Michael’s Drive, Santa Fe, NM 87505 (firstname.lastname@example.org).
Published Online: May 8, 2017. doi:10.1001/jamainternmed.2017.1243
Conflict of Interest Disclosures: None reported.
AAMC Group on Women in Medicine and Science. The state of women in academic medicine: the pipeline and pathways to leadership, 2013-2014. Association of American Medical Colleges website. https://www.aamc.org/members/gwims/statistics/#tables. Accessed March 10, 2017.
AAMC 2016 Physician Specialty Data Report. Association of American Medical Colleges website. https://www.aamc.org/data/workforce/reports/457712/2016-specialty-databook.html. Accessed March 10, 2017.
Ludmerer KM. Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. New York, NY: Oxford University Press; 2015.
Goitein L. Training young doctors: the current crisis. http://www.nybooks.com/articles/2015/06/04/training-young-doctors-current-crisis/. Accessed April 3, 2017.
Adesoye T, Mangurian C, Choo EK, et al. Perceived discrimination experienced by physician mothers and desired workplace changes: a cross-sectional survey [published online May 8, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.1394