The Changing Face of Medicine WOMEN DOCTORS AND THE EVOLUTION OF HEALTH CARE IN AMERICA Ann K. Boulis Jerry A. Jacobs ILR Press an imprint of Cornell University Press ITHACAANDLONDON This book u to our da Sophia and I an Copyright © 2008 by Cornell University Elizabe All rights reserved. Except for brief quotations in a review, this book, Madeleir, or parts thereof, must not be reproduced in any form without permission in writing from the publisher. For information, address Cornell University Press, Sage House, 512 East State Street, Ithaca, New York 14850. First published 2008 by Cornell University Press Printed in the United States of America Library of Congress Cataloging-in-Publication Data Boulis, Ann K., 1968- The changing face of medicine : women doctors and the evolution of health care in America /Ann K. Boulis, Jerry A. Jacobs, p. cm. — (The culture and politics of health care work) Includes bibliographical references and index. ISBN 978-0-8014-4446-3 (cloth: alk. paper) 1. Women physicians—United States. 2. Medical care—United States. I. Jacobs, Jerry A., 1955-. II. Title. HI. Series. R692.B6752008 610.82—dc22 2008019828 Cornell University Press strives to use environmentally responsible suppliers and materials to the fullest extent possible in the publishing of its books. Such materials include vegetable-based, low-VOC inks and acid-free papers that are recycled, totally chlorine-free, or partly composed of nonwood fibers. For further information, visit our u*m website at www.cornellpress.cornell.edu. Cloth printing 10 9 8 7 6 5 4 3 2 1 This book is dedicated to our daughters, Sophia and Renie Harris and Elizabeth and Madeleine Jacobs s in a review, this book, ly form without information, address it State Street, Ithaca, lata ars and the evolution A. Jacobs, i care work) cal care—United ;ries. 2008019828 nmentally responsible ossible in the publishing i-based, low-VOC inks Property <& chlorine-free, or partly >rmation, visit our m m si it mm w ^CataB& UstwarsiJy Contents Acknowledgments ix 1 Introduction 1 2 Feminization of an Evolving Profession 15 3 Applying for Change 41 4 The Gendered Map of Contemporary Medicine 65 5 Gender, Sorting, and Tracking 86 6 Work, Family, Marriage, and Generational Change 113 7 Women Physicians Caring for Patients 132 8 Medicine as a Family-Friendly Profession? 153 9 Conclusion: A Prognosis for Gender and Medical Care 187 Appendix 213 Notes 229 Bibliography 235 Index 261 Acknowledgments I his project has had a long gestation, and consequently we have accu- mulated many debts along the way. The research presented here has been funded by research grants from the Josiah H. Macy Foundation and the Robert Wood Johnson Foundation, and a National Academy of Education Post-Doctoral Fellowship for Ann Boulis funded by the Lyle M. Spencer Foundation. We are grateful to Dr. June Osborn, president of the Macy Foundation, and Dr. Cathy DeAngelis, editor, of the Journal of the American Medical As- sociation, who played a central role in organizing the Macy Foundation Conference in 2006 where the issues addressed in this book were discussed (Hager 2007). At Cornell University Press, Fran Benson has been very en- couraging since the first outline of this project was put together some years ago. Sioban Nelson read several drafts of the manuscript and offered very thoughtful and detailed advice. We wish to acknowledge the valuable research assistance provided by Arielle Kuperberg, Terry Labov, Daniella Main, and Kristin Turney. Ruth Schwartz Cowan, Jason Schnittker, and Chloe Bird organized seminars and professional panels that gave us the opportunity to present some of our findings. Charles Bosk met with us shortly after the inception of this project and has provided collegial advice as we brought this study to fruition. We acknowledge the Association of American Medical Colleges (AAMC) for sharing its data on entering and graduating students. The conclusions presented here are our own and do not reflect those of the AAMC. Similarly, we thank Linda Sax and William S. Korn at the UCLA Higher Education X ACKNOWLEDGMENTS Research Institute for generously providing tabulations of their unique data on American college freshmen. We have benefited from lengthy discussions with Dr. Stephanie Abbuhl and Dr. Judith Long regarding many issues examined here, especially about the role of women in academic medicine. Special thanks to Gus Harris and to Renee and Matt Boulis for their support throughout this project. ACKNOWLEDGMENTS iing tabulations of their unique data :ussions with Dr. Stephanie Abbuhl •ues examined here, especially about le. Special thanks to Gus Harris and >ort throughout this project. The Changing Face of Medicine 1 Introduction Betty Friedan was very proud of her daughter the doctor. Friedan's 1963 book The Feminine Mystique helped to spark the second wave of the wom- en's movement during the 1960s, and Friedan went on to help establish the National Organization for Women. Her daughter, Emily, entered Harvard Medical School in 1978, just as the number of young women in medical school classes began its rapid ascent. Encouraging one's daughter to pursue a career in medicine is no longer an unusual idea restricted to feminist leaders who happen to be Jewish. In fact, Americans are now more likely to report that they feel comfortable recom- mending a career in medicine for a young woman than for a young man. The Gallup Organization has polled Americans on this subject periodically since the Second World War (see Figure 1.1). In 1950 more than one quarter of those sampled reported that they would recommend a career in medicine for a young man, but only 2 percent would do so for a young woman (Saad 2005).1 The question was not asked again about young women until 1985. By this time the number of respondents who volunteered medicine as a career for young men had declined to fewer than 10 percent, but the level of support for young women physicians had grown to nearly the same level. Since 1998 the proportion who would recommend a career in medicine to a young woman has exceeded that for young men. A career in medicine is now the top recommendation for young women, surpassing the most prominent alternatives—nursing, teaching, computers, and business—by a wide margin. Moreover, the overall level of endorse- ment for careers in medicine has rebounded from its lows during the 1980s. We think Betty, who passed away in 2006, would be pleased to know of this trend. THE CHANGING FACE OF MEDICINE INTRODUCTION questions: (1) How can the feminize best be explained? (2) How and wr ences of male and female physicians physicians changing as the need to b salient? and (4) What effect has the fe daily practice of medicine and on th< Has the entry of women into the p: status of medicine? In other words, ing point in the status of the medica led to a further deterioration in the ; women themselves as well as their come full and equal members of the toized in a small set of low-paying, their white coats, have women begu T 1 r 1953 1967 practiced? Finally, are women bring 1950 1973 1985 1998 2001 2005 ing to the science of medicine, or do Figure 1.1. Trends in Advice to Young Men and Women. Source: Gallup Organization, the same procedures make the same Saad 2005. care in essentially interchangeable w the medical profession and its social For Friedan, the women's movement was principally about opening up Our study follows women (and me avenues of opportunity for daughters which had previously been reserved We chart the pathways that men and A for sons. Whereas feminist politics in recent years have centered on debates By comparing these processes for dif about abortion, contraception, and gay marriage and parenting, it may be a period of rapid change, we are ablt useful to remember that expanding new career possibilities for young women tered this most prominent of professi was central to the original agenda. From this vantage point, the burgeon- Are gender differences in mediciri ing numbers of women entering the medical profession surely constitutes dividual women, or do gendered in a success story. Female physicians are not simply a symbol of women's The bulk of research to date highligh accomplishments; they also constitute a significant fraction of the highest- derplays the effects of institutional. earning women in the United States. In 2000 they represented nearly one in tracing changes over time, we are b( ten women who earned more than $100,000.2 of choices and constraints that worm Since the 1970s, women have made significant progress in the U.S. medi- When patients come into a family cal profession. Most notably, between 1970 and 2005 women's share of seats an emergency room or specialist's oi in medical schools increased from 11 percent to 48.9 percent (AAMC 2006). woman or a man? Will the nature of During the same period, women's numerical representation among prac- physicians be consistently more col ticing physicians increased nearly ninefold, from 25,000 in 1970 to 225,000 to psychosocial issues? Will diagnos in 2002. In this book we examine whether women's entry into medicine tions be the same regardless of the represents a success for feminism or if the story is more complex than the differences that pertain across the b term "success" might suggest. We first document why and how women's stricted to a limited set of ambiguo representation among physicians in the United States has grown so dra- physicians and patients? matically since 1970. We then assess the place that women currently oc- And what will happen to the str cupy in the medical profession and examine how they came to occupy this physicians are as numerous as men'i place. And finally, we consider the impact of this demographic transforma- physicians change the focus of medi tion on the provision of health care services. Specifically, we address four style of organized medicine? Will th INTRODUCTION 3 questions: (1) How can the feminization of medicine in the United States best be explained? (2) How and why do the career locations and experi- ences of male and female physicians differ? (3) How are the family lives of physicians changing as the need to balance work and family becomes more salient? and (4) What effect has the feminization of U.S. medicine had on the daily practice of medicine and on the medical profession? Has the entry of women into the profession resulted from a decline in the status of medicine? In other words, does women's entry represent a turn- ing point in the status of the medical profession? Has the entry of women led to a further deterioration in the status of the profession, impacting the women themselves as well as their male counterparts? Have women be- come full and equal members of the profession, or have they become ghet- toized in a small set of low-paying, low-status specialties? Once they don their white coats, have women begun to change the way medicine is being practiced? Finally, are women bringing a heritage of nurturance and car- ing to the science of medicine, or do male and female physicians trained in the same procedures make the same diagnoses and deliver the same expert care in essentially interchangeable ways? Will women change the nature of the medical profession and its social position? Our study follows women (and men) as they enter the medical profession. We chart the pathways that men and women traverse as they become doctors. By comparing these processes for different generations of physicians during a period of rapid change, we are able to better understand how women en- tered this most prominent of professions and, once there, where they land. Are gender differences in medicine the result of the choices made by in- dividual women, or do gendered institutions also play an important role? The bulk of research to date highlights the role of individual choice and un- derplays the effects of institutional arrangements and social pressures. By tracing changes over time, we are better positioned to assess the evolution of choices and constraints that women have faced. When patients come into a family practice setting, or find themselves in an emergency room or specialist's office, does it matter if the physician is a woman or a man? Will the nature of the encounter be different? Will female physicians be consistently more collegial, more caring, and more attuned to psychosocial issues? Will diagnoses, referrals, procedures, and prescrip- tions be the same regardless of the physician's gender? Are there gender differences that pertain across the board, or are differences in practice re- stricted to a limited set of ambiguous conditions or to distinct parings of physicians and patients? And what will happen to the structure of the profession when women physicians are as numerous as men? Will the increasing number of women physicians change the focus of medical research or influence the leadership style of organized medicine? Will this dramatic demographic change cause 4 THE CHANGING FACE OF MEDICINE INTRODUCTION all physicians, regardless of gender, to employ a more collaborative ap- thesis predicts that women will be proach with other health care providers? Will the presence of women lead with their patients and less intere; to the creation of more family-friendly supports within the profession? counterparts. Advocates of the diffe In endeavoring to answer these questions, we draw on a wide array of tendency for female physicians to sj data sources. Since most sources of data have both strengths and weak- ner 2003; Ross 2003; Fang et al. 2004 nesses, our approach is to cast a wide net in order to gather as much infor- to know and care for their patients r. mation as possible on the evolution of gender and medicine. Our analysis of medical conditions. They also belies the processes of recruitment into the profession takes advantage of multiple medical students which leads to thi longitudinal data sources, including a series of national surveys of college underprivileged patients (Crandall < students' career plans which span the 1970s, 1980s, and 1990s and data from The second perspective, which w the Association of American Medical Colleges (AAMC) surveys of prospec- nation thesis, suggests that specif tive and matriculating medical students before and after graduating from acteristics and the behaviors of otl medical school. In order to understand the career experiences of physicians, workforce are responsible for man' we analyzed data from 1996 and 2004 on physicians' attitudes and practices female physicians. One of the most < from the Community Tracking Study, a nationally representative longitu- perspective is the "structural differ dinal sample of doctors. Our examination of changes in the family lives of holds that differences between me physicians draws on data from the 1980,1990, and 2000 U.S. censuses. differences in status and power in th We supplement these rich and varied quantitative sources with dozens of medical context it suggests that ob& in-depth interviews with female physicians at all stages of the career cycle. status stem from women's weaker c We also posted questions on-line at the MomMD and the Student Doctor Advocates of the structural discrin Network Web sites, and we monitored scores of postings that followed. for women to spend more time wit Both sites include frequent discussions of gender issues in medicine. These who believe that women are inherei data sources are described in more detail in the Appendix. tain that the propensity for womei time with patients results from th« patients and the tendency for wome Perspectives on Gender and Medicine fact, research shows that a large por We draw on three main perspectives on gender and work to inform our an- mary care physicians stems from thi swers to the four questions delineated earlier. The first perspective, which women patients who often need t we refer to as personal choice, suggests that gender differences in the work- and Bertakis 2003). In a similar ligh force stem primarily from differences in the choices that men and women physicians are more likely to be en make as they pursue education and paid employment. In other words, gen- parts, and physicians in such setti der differences in the status of male and female physicians reflect prefer- visit (Kikano et al. 1998). Finally, thi ences and values that women bring with them into the medical profession offers an explanation of why wome (Hinze et al. 1997; Grant et al. 1990). More specifically, this viewpoint as- provide charity care even though sti serts that women physicians choose to work fewer hours than men and cal students, women are more amer gravitate toward primary care roles because they give higher priority to (Cunningham et al. 1999; Crandall « the care of their families. physicians who work as employees The personal choice perspective also emphasizes the relationship be- for free; consequently, women's cor tween personal values and gender differences in career choice. The crux of typically in hospital settings, accoui this perspective is best articulated by Carol Gilligan in her book In a Differ- A closely related phenomenon inv ent Voice (1982). Gilligan holds that women are generally less competitive iors of physicians' colleagues and p. and status conscious and more sensitive, caring, and concerned about oth- encounter more harassment and 1< ers' feelings than are men. In the context of medicine, the "different voice" gender-linked behaviors might also INTRODUCTION 5 thesis predicts that women will be more interested in close relationships with their patients and less interested in high earnings than their male counterparts. Advocates of the different voice perspective suggest that the tendency for female physicians to spend more time with patients (Dorsch- ner 2003; Ross 2003; Fang et al. 2004) stems primarily from women's desire to know and care for their patients rather than simply treating their specific medical conditions. They also believe that it is the caring nature of women medical students which leads to their disproportionate interest in serving underprivileged patients (Crandall et al. 1993). The second perspective, which we refer to as the institutional discrimi- nation thesis, suggests that specific industry and organizational char- acteristics and the behaviors of other key groups in the health services workforce are responsible for many of the disparities between male and female physicians. One of the most common theories in the discrimination perspective is the "structural difference" view (Kanter 1977). This theory holds that differences between men and women workers reflect gender differences in status and power in the organization or the profession. In the medical context it suggests that observed gender differences in practice or status stem from women's weaker organizational or professional position. Advocates of the structural discrimination perspective see the tendency for women to spend more time with patients very differently from those who believe that women are inherently more caring. These analysts main- tain that the propensity for women physicians to spend relatively more time with patients results from the greater needs of women physicians' patients and the tendency for women physicians to work as employees. In fact, research shows that a large portion of the time differential among pri- mary care physicians stems from the fact that women physicians see more women patients who often need time-consuming pelvic exams (Franks and Bertakis 2003). In a similar light, researchers have shown that women physicians are more likely to be employees than are their male counter- parts, and physicians in such settings spend more time in each patient visit (Kikano et al. 1998). Finally, the structural discrimination perspective offers an explanation of why women physicians are actually less likely to provide charity care even though studies suggest that as graduating medi- cal students, women are more amenable than men to providing such care (Cunningham et al. 1999; Crandall et al. 1993). The evidence suggests that physicians who work as employees spend less time offering their services for free; consequently, women's concentration in positions as employees, typically in hospital settings, accounts for their lower rate of charity care. A closely related phenomenon involves the social expectations or behav- iors of physicians' colleagues and patients. At one extreme, women might encounter more harassment and less mentoring support. At the other, gender-linked behaviors might also be more subtle but the effects no less 6 THE CHANGING FACE OF MEDICINE INTRODUCTION important. For example, assumptions regarding patients' preferences might We challenge the assumptions of cause men to assign breast surgeries to their female colleagues in a gen- path to developing a new underste eral surgery practice (Cassell 1998; McMurray et al. 2000). In a similar light, medicine. Our thesis is that the mei the expectation that women are good communicators might cause patients fies broader changes in women's r< with emotional problems to seek them out, and this process of sorting may Women's status has changed as a r explain why female physicians see more patients with complex social prob- cifically the women's movement); s lems (McMurray et al. 2000). tion, work, and family life; and the The third perspective that motivates our analysis focuses on social change. society. One of the more prominent theories maintains that increases in the repre- Women's entry into medicine refi sentation of women in an occupation are related to declines in the status of labor force and the professions as w the field. The underlying idea here is that women constitute a surplus labor occurring in the U.S. health care sysl force, and that they enter professions only when more desirable workers— profession in the context of the evoli; namely, men—are no longer interested. society. Women's achievements in m< The dramatic influx of women into medicine and other occupations has. of complete equality in a number o prompted social scientists to investigate demographic changes in the labor women in the broader labor market, force (Reskin and Roos 1990; Strober 1984; Cohn 1985). This research exam- manding in terms of training, workir ines changes in the status of women workers that accompany their entry and thus the dilemmas of balancing into an occupation such as medicine. In particular, Reskin and Roos (1990) are especially salient among physicia suggest that women's entry into male-dominated occupations tends to nizational landscape of medicine haj occur in a similar fashion regardless of the specific profession. A shortage of the rise of managed care and other p male employees prompts employers to recruit women. The shortage of men care. These forces have limited the t is typically due to a decline in the status of the occupation. In some cases the medical profession in their own ii the impetus for the initial departure of men from an occupation is a tech- influence of women physicians on tl nological shift that lowers skill levels and earnings in the field. Reskin and grow as they make inroads through Roos also find that, in general, women's entry into male-dominated fields professional leadership. does not result in true integration. Rather, women cluster in the least desir- Relative to other occupational and able niches of male-dominated occupations—niches with lower pay, fewer icine ranks high in terms of financi required skills, less autonomy, and limited promotion opportunities. Thus women's successes in the fielc Another aspect of social change involves generational shifts among women to a sharp decline in the desirability physicians. From this perspective, the first groups of women to enter medi- as medicine remains at the top of tru cine in the late 1960s and 1970s represented "pioneers" who blazed uncharted same time, medicine is a highly strat: paths in a male-dominated terrain. Consequently, these "trailblazers" faced f ession, and the inequality within the different expectations and challenges than did the "settlers"—those women women face in pursuing complete e who followed in their footsteps. The first small, elite group had few role of increasing inequality among phys models, and were committed to proving that women could succeed. They remain in specialty areas, ownershij also felt so privileged to enter the profession that they tolerated unequal sentation, and leadership positions. I treatment. Empowered by their growing numbers and increasing attention of the medical career, in some specia to women's professional issues in the broader labor force, many among the to positions of leadership. But worn generation of women physicians who entered medicine during the 1990s institutional arrangements which an and beyond seek a fulfilling family life along with the satisfactions of en- sistance and sexist attitudes of some gaging professional work. At the same time, it may be that work expecta- generation or so have entered a pro tions are shifting for male physicians as well, as they are increasingly likely winner with a stay-at-home spouse. ] to find themselves in dual-career families. professional commitments, with fev INTRODUCTION 7 We challenge the assumptions of many of these perspectives along the path to developing a new understanding of women's representation in medicine. Our thesis is that the medical profession reflects and exempli- fies broader changes in women's roles in American culture and society. Women's status has changed as a result of political developments (spe- cifically the women's movement); social and cultural changes in educa- tion, work, and family life; and the economic forces buffeting American society. Women's entry into medicine reflects broader accomplishments in the labor force and the professions as well as the unique institutional changes occurring in the U.S. health care system. Our research situates the medical profession in the context of the evolution of women's position in American society. Women's achievements in medicine, however, continue to fall short of complete equality in a number of important areas, as is the case with women in the broader labor market. Careers in medicine are especially de- manding in terms of training, working time, and professional commitment, and thus the dilemmas of balancing and integrating work and family life are especially salient among physicians. The economic, technical, and orga- nizational landscape of medicine has rapidly evolved since the 1970s with the rise of managed care and other pressures to rein in the costs of medical care. These forces have limited the extent to which women could remake the medical profession in their own image. Nevertheless, we expect that the influence of women physicians on the medical landscape will continue to grow as they make inroads throughout the profession and in positions of professional leadership. Relative to other occupational and professional choices for women, med- icine ranks high in terms of financial rewards and personal satisfaction. Thus women's successes in the field of medicine are not principally due to a sharp decline in the desirability of careers in the medical profession, as medicine remains at the top of the occupational status hierarchy. At the same time, medicine is a highly stratified and internally differentiated pro- fession, and the inequality within the profession compounds the difficulties women face in pursuing complete equality. Indeed, there are indications of increasing inequality among physicians. Marked disparities by gender remain in specialty areas, ownership and employee status, faculty repre- sentation, and leadership positions. Discrimination persists in some stages of the medical career, in some specialties, and in terms of women's access to positions of leadership. But women also face the challenges posed by institutional arrangements which are at least as salient as the lingering re- sistance and sexist attitudes of some male physicians. Women over the last generation or so have entered a profession designed for the male bread- winner with a stay-at-home spouse. Intense time demands and continuing professional commitments, with few opportunities to leave and reenter, 8 THE CHANGING FACE OF MEDICINE INTRODUCTION dominate the lives of physicians during their twenties and well into their America. Does the experience of it thirties, spanning most of the childbearing years. Very few women physi- optimistic view? An alternative vie cians have stay-at-home husbands who provide the kind of support that entrenched in our institutions and c stay-at-home wives provided an earlier generation of men. of household labor continues to cor The evidence we have compiled is largely inconsistent with the notion of 2003). The trade-offs between work a "post-pioneer" pattern of female physicians' career choices. We find that demanding professions, such as lai women doctors are not dropping out of the labor force, nor are they more degree of professional devotion (Biz likely to marry and have children today than did previous generations. Our study builds on the fine histc Moreover, the gender gap in work habits and earnings is quickly closing for Walsh (1977), Morantz-Sanchez (196 childless male and female physicians. We also show that women physicians sented here focuses on the period si are more similar to other women today in terms of marriage and mother- portant studies of Bowman and colli hood than was the case a generation ago. Women physicians face enduring (1984) examined the experiences of tl challenges in combining work which are similar in kind, though perhaps the transformation of the profession, more extensive in nature, than those faced by other employed women. of perspective, we are in a position The values that women bring with them to medicine differ from those of in medicine is changing. their male counterparts. Careers in medicine offer not only financial rewards but also the personal satisfaction of helping others in their times of great- Women's Entry into Medicine est need. Thus medicine has become a more socially attractive professional option for scientifically oriented women than other technical fields such as Since the 1970s the face of studer engineering. Although evidence indicates that women medical students are changed markedly, with women rat more altruistic in their professional goals than are their male classmates, this ing medical students. While womer particular gender gap is not as sizable as one might assume but amounts to studies have directly confronted the only a few percentage points, and changes in the intentions of male and is occurring. The next two chapters female physicians over time dwarf differences between the two genders. explain this trend. Is women's entry Moreover, the values and preferences of entering medical students are not of the medical profession, or are the sufficient to explain subsequent behavior. Ultimately, the structure of the examine several interrelated aspects environment in which physicians work and the expectations of peers and ings, autonomy, and prestige, as wel patients influence physician behaviors as much as or more than the abstract Medical Association. We consider sp ideals that physicians hold during and immediately after their training. changes in government reimburserr Women physicians do interact with their patients in subtly different ways concerns over malpractice insurance than their male peers, but gender differences in diagnosis and treatment tion to the interest levels in the proft are not extensive. Differences in practice patterns are most evident in areas review the 1970s, the 1980s, and the involving patients' personal privacy and sexually sensitive conditions. As the same factors play the same roles i far as the structure of the profession is concerned, women are just beginning to the status of the profession is the c to have an impact on the profession and the way medicine in practiced, and In chapter 3 we set the feminizatio: more change is likely as their representation continues to grow. changing gender roles in society at la This book is a case study of one profession that plays a key role in the degree of preparation for career the health care sector, which now represents about one seventh of the women's education, the rates at wh U.S. economy. It examines the most dramatic demographic change in this ence courses in high school, and th< sector in the last century. But the issues we raise are likely to be of inter- college with degrees in biology. est more broadly for what they say about the changing roles of women in We find that women have entered contemporary society. Women's entry into medicine is taken as dramatic flight of men but rather because mar evidence that the barriers to opportunity for women are rapidly falling in timing of women's entry, as well as th INTRODUCTION 9 America. Does the experience of female physicians to date bear out this optimistic view? An alternative view is that gender roles remain deeply entrenched in our institutions and culture. Specifically, the gender division of household labor continues to constrain the choices of all women (Moen 2003). The trade-offs between work and family may be clearest in the most demanding professions, such as law and medicine, which require a high degree of professional devotion (Blair-Loy 2003). Our study builds on the fine histories of women in medicine written by Walsh (1977), Morantz-Sanchez (1985), and More (1999). The analysis pre- sented here focuses on the period since 1970, thus complementing the im- portant studies of Bowman and colleagues (2002) and Bickel (2000). Lorber (1984) examined the experiences of the generation of women who pioneered the transformation of the profession. With the benefit of additional decades of perspective, we are in a position to examine whether the role of gender in medicine is changing. Women's Entry into Medicine Since the 1970s the face of students at American medical schools has changed markedly, with women rapidly approaching 50 percent of enter- ing medical students. While women's arrival has been widely noted, few studies have directly confronted the question of how and why this change is occurring. The next two chapters of the book are devoted to trying to explain this trend. Is women's entry a reflection of the plummeting status of the medical profession, or are the reasons more varied and complex? We examine several interrelated aspects of professional status, including earn- ings, autonomy, and prestige, as well as the political clout of the American Medical Association. We consider specific historical developments, such as changes in government reimbursement policies and the ebb and flow of concerns over malpractice insurance premiums. We pay considerable atten- tion to the interest levels in the profession exhibited by young men. As we review the 1970s, the 1980s, and the 1990s in detail, we do not assume that the same factors play the same roles in each decade. The series of challenges to the status of the profession is the central concern of chapter 2. In chapter 3 we set the feminization of medicine in the broader context of changing gender roles in society at large. We examine factors that influence the degree of preparation for careers in medicine, including the extent of women's education, the rates at which young women take math and sci- ence courses in high school, and the number of women graduating from college with degrees in biology. We find that women have entered medicine not so much because of the flight of men but rather because many barriers to access have eroded. The timing of women's entry, as well as the ups and downs of men's applications INTRODUCTION THE CHANGING FACE OF MEDICINE 10 women and men bring into the pro: to medical school, does not map onto the timing of challenges to the author- ties? What role do experiences duri ity, status, and earnings of the profession. In many ways, women's entry career choices? We also examine can into medicine is in line with the broader patterns of women's growing share we seek to resolve an apparent pan of the labor market, leadership, and power as a whole. Women earn an in- pursuing academic careers but end i creasing proportion of college degrees, and they have pursued historically ment of the profession. We seek to pu male-dominated academic tracks in increasing numbers, and these changes periences play in this process. The ei are beginning to influence our society. Women's entry into the medical pro- provides a new context for women's fession reflects and exemplifies these trends. Women continue to occupy a disai Changes in women's roles are not confined to the United States, nor is in the broader professional labor mai the feminization of medicine a uniquely American phenomenon. Our re- gering discrimination in the workpl view of the trends in physician employment patterns in developed coun- nizational arrangements that fail to z tries shows an increased representation of women in all of the thirty-five labor force dominated by members o countries examined. Indeed in many of these countries women's share of son 2004). Those who suggest that g< the profession exceeds that in the United States. In conjunction with this stem from the tendency for women analysis, we discuss the role that foreign-born physicians have played in the less procedure-focused specialties ha feminization of medicine in the United States. Much of our story, however, social forces such as male chauvinist is uniquely American. The organization and financing of health care differs cumscribe the opportunities of worn sharply from that in many other countries, and the evolution of medicine in explanation simply ignores how soci< the United States has followed a distinctive trajectory (Riska 2001). In short, ture of medical education and medic the evolution of gender and medicine sketched in this book is inextricably In chapter 6 we examine motherhc linked to the distinctively American features of our medical system. Further plore the contrast between the pionei research will be required to detail fully which elements of our story reso- cians able to combine work and fan nate in other countries. as women in the general population counterparts? Are women physiciar Careers in Medicine spend time with their children? We the growing length of workweeks fc Next we turn to women's careers in the profession. There are many aspects and find little evidence of an increase of the opportunity structure to examine. Traditional indices include earn- amine the nature of physicians' fami ings, specialties, and access to leadership positions. We are also interested has been improving in the families in a number of nontraditional measures of career success, such as the ability Finally, we examine changing patterr to combine work and family. To the extent possible, we address these ques- are physicians. The evidence suggesl tions historically, examining how the various gender gaps have evolved as ments in education and training, mar women's representation in the medical profession has increased. far from equal. We start in chapter 4 by describing the gendered landscape of the medical profession. We examine the distribution of women by specialty, employee and ownership status, involvement with research, faculty appointments, Gender Differences in Practice Patte and leadership positions. We map the connection between these positions Having explored how women enter in the profession onto earnings disparities among physicians. physicians, we turn to the question < Chapter 5 turns to a more detailed consideration of gender and medical Does it matter in terms of treatment i specialties. We explore the historical basis of specialty practice in order to that women constitute a major and gi understand better how the connection between specialties and gender came cal workforce, it is essential that we to take its current form. We also examine the process of sorting into spe- differences in practice patterns exist. cialties that occurs during medical school. Do the values and preferences INTRODUCTION 11 women and men bring into the profession explain their choice of special- ties? What role do experiences during medical school play in subsequent career choices? We also examine careers in academic medicine. In this area we seek to resolve an apparent paradox: women express more interest in pursuing academic careers but end up being underrepresented in this seg- ment of the profession. We seek to pin down the role that medical school ex- periences play in this process. The emergence of the clinical educator track provides a new context for women's entry into academic medicine. Women continue to occupy a disadvantaged place both in medicine and in the broader professional labor market. This disadvantage stems from lin- gering discrimination in the workplace, and from the persistence of orga- nizational arrangements that fail to accommodate the needs of parents in a labor force dominated by members of dual-career families (Jacobs and Ger- son 2004). Those who suggest that gender differences in physicians' status stem from the tendency for women to choose "controllable" lifestyles and less procedure-focused specialties have not adequately acknowledged how social forces such as male chauvinistic faculty, colleagues, and patients cir- cumscribe the opportunities of women and men physicians. The "choice" explanation simply ignores how social factors have contributed to the struc- ture of medical education and medical work. In chapter 6 we examine motherhood and marriage. Here we further ex- plore the contrast between the pioneers and the settlers. Are women physi- cians able to combine work and family? Do they marry at the same rates as women in the general population and to the same degree as their male counterparts? Are women physicians "opting out" of careers in order to spend time with their children? We report surprising evidence regarding the growing length of workweeks for both men and women in medicine, and find little evidence of an increase in part-time employment. We then ex- amine the nature of physicians' families. We find that the status of women has been improving in the families of both male and female physicians. Finally, we examine changing patterns of marriages in which both partners are physicians. The evidence suggests that, despite broadly similar invest- ments in education and training, marriages between two physicians remain far from equal. Gender Differences in Practice Patterns Having explored how women entered medicine and their experiences as physicians, we turn to the question of the consequences for medical care. Does it matter in terms of treatment if physicians are men or women? Now that women constitute a major and growing portion of the American medi- cal workforce, it is essential that we ascertain whether significant gender differences in practice patterns exist. Identifying the existence and etiology 12 THE CHANGING FACE OF MEDICINE INTRODUCTION of such differences will help to ensure that all patients of the U.S. health collegial approach to the doctor-pati care system receive the highest-quality care possible and will also help to chosocial issues more than their ma provide the most equitable work environment for health care providers re- communication, however, highlights gardless of gender. Although much research has been done on gender dif- as well. Thus researchers on doctor-p ferences in practice, the research is not complete. that physicians of both genders can ii The standard view of the relationship between gender and the provision We present an analysis of vignettes of medical services is that the sex of a physician does not affect the pro- (CTS) physician survey, which incluc vision of care to patients. Because physicians are carefully screened and model patients with presentations des rigorously trained, patients can count on physicians to diagnose, treat, and treatment plans. The results reveal a g refer patients as medically indicated regardless of whether they wear pants dirions even after differences in pract or skirts under their medical garb. Although they note that there are some With respect to the daily practice sex differences, some researchers, such as Mattila-Lindy and colleagues men and women outweigh the diffe (1998), conclude that socialization into the medical profession makes physi- respect to time spent with patients a cians' practices more alike and diminishes gender differences. While there with respect to diagnoses or even tre is no reason to suspect that either male or female physicians provide sys- cian and patient can be of greater si tematically inadequate care, a variety of perspectives suggest that gender daily sexual, privacy. differences in practice styles may exist. One possibility, in keeping with the Chapter 8 examines the question w "different voice" perspective, is that women provide more nurturing care friendly profession. We find that m; because they are more interested in the satisfaction of their patients. hours as ever. We examine the histori Another possibility, motivated by the discrimination perspective, is that workweeks and find that despite thi; gender differences in practice stem from the lower status accorded to interest in working less. Given the j women in terms of their social roles and organizational positions. For ex- hours or part-time work, we explor ample, the reluctance of nurses to support female physicians might force fe- tunities and consider the barriers tha male doctors to perform a higher portion of routine procedures themselves advantage of these choices. We conch (Gjerberg and Kj0lsred 2001; Wear and Knight-McNulty 2004; Zelek and physicians handle the demands of f Philips 2003).3 professional commitments. Similarly, it could be that the gender stereotypes of patients contribute to In the final chapter of the book wi gender differences in practice (Street 2002). The social change perspective dence, and discuss the prospects, for J would focus on changes across generations of women physicians and the in the coming years. Will women em extent to which the growing representation of women is changing the prac- Will they help to foster a more carir tice of medicine. tern, or will physicians increasingly In addition to these perspectives, we examine a fourth possibility: that sistants and other medical care practi gender differences are most likely to emerge in the treatment of specific for women's leadership in medicine sex-linked diseases, especially, though not exclusively, those involving per- research on women's health. sonal privacy (Bouchard and Renaud 1997; Britt et al. 1996; Ivins and Kent 1993; Fang et al. 2004; Lurie et al. 1997). For example, a female patient might In this book we examine how wo be more reluctant to raise an issue of vaginal itching with a male physician, faring in the rapidly evolving medic while a male patient might feel less comfortable raising potential concerns integrate and balance work and fan- about a prostate condition with a female doctor. At the same time, physi- day-to-day basis, and how they are c cians might be uncomfortable in exploring certain conditions or performing the United States. These large themes certain procedures with patients of the opposite sex (Lurie et al. 1998). the answers to each of these question In chapter 7 we assess these issues and find evidence that women phy- Although individual choices play i sicians on average do approach patients differently, employing a more en's place in medicine, they cannot INTRODUCTION 13 collegial approach to the doctor-patient relationship and prioritizing psy- chosocial issues more than their male colleagues. Research on physician communication, however, highlights similarities between men and women as well. Thus researchers on doctor-patient interactions frequently suggest that physicians of both genders can improve their communication skills. We present an analysis of vignettes from the Community Tracking Study (CTS) physician survey, which includes physicians' reactions to a series of model patients with presentations designed to suggest multiple appropriate treatment plans. The results reveal a gender effect for sexually sensitive con- ditions even after differences in practice environment are acknowledged. With respect to the daily practice of medicine, the similarities between men and women outweigh the differences. Gender matters far more with respect to time spent with patients and communication styles than it does with respect to diagnoses or even treatment regimes. The gender of physi- cian and patient can be of greater significance in areas of personal, espe- cially sexual, privacy. Chapter 8 examines the question whether medicine is becoming a family- friendly profession. We find that many physicians are working as many hours as ever. We examine the historical roots of the medical culture of long workweeks and find that despite this culture, many physicians express an interest in working less. Given the prevalence of this interest in reduced hours or part-time work, we explore the availability of part-time oppor- tunities and consider the barriers that inhibit more physicians from taking advantage of these choices. We conclude this discussion by examining how physicians handle the demands of family life in the context of extensive professional commitments. In the final chapter of the book we take stock of the argument and evi- dence, and discuss the prospects, for further gender integration of medicine in the coming years. Will women emerge as a new majority of physicians? Will they help to foster a more caring, patient-centered medical care sys- tem, or will physicians increasingly leave primary care to physicians' as- sistants and other medical care practitioners? We also discuss the prospects for women's leadership in medicine and the impact women have had on research on women's health. In this book we examine how women entered medicine, how they are faring in the rapidly evolving medical system, how they are managing to integrate and balance work and family, how they practice medicine on a day-to-day basis, and how they are changing the system of medical care in the United States. These large themes are interconnected in many ways, and the answers to each of these questions echo throughout the other analyses. Although individual choices play a significant role in determining wom- en's place in medicine, they cannot explain the origins and implications 14 THE CHANGING FACE OF MEDICINE of this profound demographic change. In contrast to much of the avail- able literature, we repeatedly find that the entry of women into medicine, their place in the profession, and their influence on medical practice stem from broad changes occurring throughout American society, from lingering traditional attitudes and arrangements and from independent structural changes in the profession. Feminization of c The medical profession has been undergoing many fundamental changes in recent decades. In some ways the pace of change regarding gender roles has been slower than other developments, and slower in the United Evolving Profess States than has been the case in a number of other countries. As women increasingly become a critical mass in the profession, especially in some specialty areas, they are increasingly poised to make a profound differ- ence in how the medical profession operates. Thus the biggest changes with respect to gender and medicine may lie ahead. Uver the past several decades healti tists have debated the status and pres there is nearly universal agreement th leged place in our society during the policymakers and social researchers b in the earnings, autonomy, control, an States (McKinlay 1977; Haug 1973). A sky is about to fall on modern medic until recently they have been matche maintain that political and economic ] challenge the dominant position of m« 1991; Freidson 1994). Regardless of tl as a profession, however, it is clear the physician have changed dramatical!) today, physicians at all levels of the pr ity to set prices for their services and also increasingly likely to face expec and resource use from both the govei son and Lee 1996; Kelly and Toepp 1 likely to face a demanding and critica As suggested previously, social res (Ross 2003; Levinson and Lurie 2004 plication of women's growing preser monly voiced concern is that increas the profession will inevitably lead to 2 Feminization of an Evolving Profession l iver the past several decades health policy researchers and social scien- tists have debated the status and prestige of the medical profession. While there is nearly universal agreement that medicine enjoyed a uniquely privi- leged place in our society during the 1950s and 1960s, in the 1970s some policymakers and social researchers began to observe and forecast declines in the earnings, autonomy, control, and prestige of physicians in the United States (McKinlay 1977; Haug 1973). Although the voices predicting that the sky is about to fall on modern medicine have grown in number over time, until recently they have been matched by more optimistic observers who maintain that political and economic pressures have done relatively little to challenge the dominant position of medicine in American society (Mechanic 1991; Freidson 1994). Regardless of the debate over the status of medicine as a profession, however, it is clear that the work experiences of the average physician have changed dramatically since the early 1970s. Most notably, today, physicians at all levels of the profession have significantly less capac- ity to set prices for their services and to determine their earnings. They are also increasingly likely to face expectations regarding treatment patterns and resource use from both the government and private insurers (Culbert- son and Lee 1996; Kelly and Toepp 1994), and they are significantly more likely to face a demanding and critical patient population (Mechanic 2003). As suggested previously, social researchers (Riska 2001) and physicians (Ross 2003; Levinson and Lurie 2004; Hall 2004) have questioned the im- plication of women's growing presence in the medical profession. A com- monly voiced concern is that increases in the representation of women in the profession will inevitably lead to declines in the status, autonomy, and 16 THE CHANGING FACE OF MEDICINE FEMINIZATION OF AN EVOLVING PROFESSION earnings of all physicians. This concern is based on the assumption that We begin our discussion with a mo: there is an inverse relationship between the status of the medical profes- proaches to the feminization of occuj sional and women's representation in it. For example, Riska (2001) points vided into three sections, each of whic out that women's representation in medicine was relatively high in the So- thirty-year period in which women's viet Union, although the status of the profession was quite low compared nounced. In each section we ask three with that in Western countries. In contrast, over the course of the late nine- opments altered the structure of medi teenth and most of the twentieth centuries, medicine in the United States of these changes for the status of the 1 had a relatively privileged status, while women practitioners were scarce. these transformations affect women's Riska places the Scandinavian case in an intermediate position, with more how the interest of young men and wc women doctors but lower status for physicians than in the United States. American medicine has evolved. The i While much has been said about both the alleged decline in dominance pertaining to applications to medical; of the medical profession and the increasing representation of women in lie esteem for the medical profession medicine, few efforts have been made to assess the relationship between declines in the status of medicine we: these two trends systematically. In this chapter we begin this assessment by own synthesis of trends in the status c comparing reforms in the structure of medicine and gender differences in a number of previous studies in this interest in the medical profession in the United States over time. We suggest (1989), and Freidson (2001), among otl that although the interest and presence of women in the medical profession has grown dramatically since the 1970s, there is little reason to believe that The Feminization of Occupations women's entry into medicine was prompted by declines in the status and autonomy of the profession. Instead, our account is a multifaceted one that The dramatic influx of women into i emphasizes different contributing events and processes occurring during prompted social scientists to investigc each of the last three decades. regation and integration (Reskin and The increasing representation of women among medical students during This research examines changes in tl the 1970s resulted from the confluence of three largely independent trends: their entry into an occupation such as the removal of barriers to women's entry into medical education, the sharp Reskin and Roos (1990) present t expansion in the capacity of medical schools, and the end of the military women's entry into male-dominated draft for young men. While challenges to the status of the profession had in which women made significant i already begun during this decade, the authority and daily practice patterns dominated by men. Eleven of these < of physicians remained resilient. Queues, Gender Queues. The commor The 1980s are the period that most closely fits the "male flight" explana- that a shortage of male employees pi tion, as male applications to medical school fell substantially. But even at The shortage of men is typically due this point there are many discrepancies. Physicians' incomes grew briskly cupation. In some cases the impetus : during the decade, and the managed care phenomenon had not yet made an occupation is a technological shift significant inroads. Also, the "male flight" argument does not predict and in the field. For example, the advent ( cannot explain the limited growth in female applications during this era, es- typesetting from a highly skilled mai pecially in light of the dramatic rise in the numbers of female college gradu- skill-intensive keyboarding occupati ates and biology majors. decline in union strength, which cor The events of the 1990s clearly depart from the "male flight" thesis. Dur- predominantly male to a predomin; ing this decade both male and female applications to medical schools rose rently employed men left, but more ir sharply, even though some of the most serious challenges to professional avoided this field. autonomy and authority were experienced during this time. Women's rep- In this account the status of the field resentation over the 1990s grew despite sharp increases in the number of incumbents leave, and few new male men interested in pursuing medical careers. quent recruitment of women simply c THE CHANGING FACE OF MEDICINE FEMINIZATION OF AN EVOLVING PROFESSION 17 ;rn is based on the assumption that We begin our discussion with a more detailed review of sociological ap- ;en the status of the medical profes- proaches to the feminization of occupations. The historical analysis is di- it. For example, Riska (2001) points vided into three sections, each of which focuses on a different decade of the sdicine was relatively high in the So- thirty-year period in which women's entry into medicine was most pro- profession was quite low compared nounced. In each section we ask three distinct questions: (1) Which devel- .xast, over the course of the late nine- opments altered the structure of medicine? (2) What were the implications :uries, medicine in the United States of these changes for the status of the medical profession? and (3) How did ile women practitioners were scarce. these transformations affect women's entry into the profession? We track an intermediate position, with more how the interest of young men and women in medical careers has varied as nysicians than in the United States. American medicine has evolved. The analysis in this chapter draws on data )th the alleged decline in dominance pertaining to applications to medical schools, physician incomes, and pub- :reasing representation of women in lic esteem for the medical profession in order to pinpoint the times when e to assess the relationship between declines in the status of medicine were most pronounced. We present our ; chapter we begin this assessment by own synthesis of trends in the status of the medical profession, drawing on f medicine and gender differences in a number of previous studies in this area, including Starr (1982), Stevens e United States over time. We suggest (1989), and Freidson (2001), among others. e of women in the medical profession )s, there is little reason to believe that The Feminization of Occupations >mpted by declines in the status and )ur account is a multifaceted one that The dramatic influx of women into medicine and other occupations has ents and processes occurring during prompted social scientists to investigate the processes of occupational seg- regation and integration (Reskin and Roos 1990; Strober 1984; Cohn 1985). >men among medical students during This research examines changes in the status of women that accompany ; of three largely independent trends: their entry into an occupation such as medicine. try into medical education, the sharp Reskin and Roos (1990) present the most comprehensive analysis of schools, and the end of the military women's entry into male-dominated fields. They examine fourteen cases ?s to the status of the profession had in which women made significant inroads into occupations previously authority and daily practice patterns dominated by men. Eleven of these cases are presented in their book Job Queues, Gender Queues. The commonality that Reskin and Roos posit is closely fits the "male flight" explana- that a shortage of male employees prompts employers to recruit women. school fell substantially. But even at The shortage of men is typically due to a decline in the status of the oc- es. Physicians' incomes grew briskly cupation. In some cases the impetus for the initial departure of men from care phenomenon had not yet made an occupation is a technological shift that lowers skill levels and earnings ight" argument does not predict and in the field. For example, the advent of computer technology transformed anale applications during this era, es- typesetting from a highly skilled manual field to a much cleaner but less the numbers of female college gradu- skill-intensive keyboarding occupation. Accompanying this shift was a decline in union strength, which contributed to the rapid switch from a irt from the "male flight" thesis. Dur- predominantly male to a predominantly female occupation. Some cur- : applications to medical schools rose rently employed men left, but more important, young men seeking careers )st serious challenges to professional avoided this field. ?nced during this time. Women's rep- In this account the status of the field declines first. In response, some male ute sharp increases in the number of incumbents leave, and few new male recruits are to be found. The subse- ireers. quent recruitment of women simply confirms and crystallizes the debased 18 THE CHANGING FACE OF MEDICINE FEMINIZATION OF AN EVOLVING PROFESSION status of the occupation. Feminization of a field is thus seen as the result of 40,000 a decline in status rather than its initial cause.1 This theory holds that employers generally prefer men, and allow women 35,000 Males—**^/'\ in only when there is a shortage of available men. Faced with such a short- 30,000 age, employers (or, in the case of the professions, professional gatekeepers) must seek alternative streams of personnel, and thus actively begin to 25,000 recruit women. The very presence of growing numbers of women itself, •'**/ however, signals an imminent decline in the status of the profession. This 20,000 further deters men from entering the field, thus hastening the day when an #*"**"*' occupation previously staffed by men becomes a feminine preserve (En- 15,000 Females ^ ^ gland et al. 2007). In short, the typical sequence of events is that there is an 10,000 initial decline in the status of a field, precipitated by some external event, such as a challenge to the authority of the profession, which leads employ- 5,000 / ers or gatekeepers to recruit women, which in turn further contributes to the decline in status of the field. 0 "i—i—i—i—i—i—i—i—i—i—i—i—I—I—i—i—i—i—r The implication of this perspective is that women's advances into the 1961 1966 1971 1976 1 professions represent less than meets the eye. While optimists cite the prev- Figure 2.1. Medical School Application; alence of women in fields previously dominated by men, Reskin and Roos maintain that such advances rarely represent true equality or full integra- tion. Moreover, they suggest that occupations are unlikely to maintain a bal- Trends in the number of newly mi anced gender profile over any significant period of time. Rather the fields at the male flight thesis. Figure 2.2 tr are likely to undergo a gender reversal, starting as male fields, then passing and women. Increases are evident f( through a brief transition period before becoming female fields. Feminiza- mid-1980s. Thus the entry of women tion thus involves a tipping point process just like residential segregation, coincided with a notable increase in in which the racial composition of neighborhoods can rapidly switch from decade. Since the 1980s the number o predominantly white to predominantly black. This approach has been ap- because the overall number of new r plied to such instances of occupational feminization as teaching in the nine- just over 15,000 per year, and becau; teenth century (Preston 1995) and banking, as in the case of bank tellers ing share of these new graduates. E\ during the 1950s (Strober and Arnold 1987) and bank branch managers dur- male physicians continued to exceec ing the 1970s (Bird 1990), although Wright and Jacobs (1994) suggest that In other words the number of male t the case of computer programmers during the 1980s is not fully consistent spite women's impressive gains. This with this approach. which displays the number of practk Does this perspective illuminate the influx of women into medicine? As number of male physicians more thai we have seen, the level of interest that men express in a field is a key ele- creasing from 300,000 to nearly 650,0( r ment of this theory. Consequently, the number of male and female appli- sicians rose from 25,401 to 235,627. cants to medical schools is of central interest.2 male flight thesis is that men did not Figure 2.1 presents trends in male and female applications to U.S. medical in the number of women physicians c schools between 1961 and 2004. The number of men who applied to medi- increase in the number of male physi< cal schools did in fact decline from 1975 through 1990. Male applications After 1985, however, women's gro rebounded sharply during the 1990s, however, a period when women's ap- minted domestic MDs was matched b plications also showed their sharpest increases. The pattern of applications given the fixed number of seats in med thus suggests that a somewhat more complex discussion of women's entry In fact, between 1985 and 2003 annuc into the profession may be in order. by 2,004 individuals while annual ]