“Oh, ugh, a particularly noxious salvo in the mommy wars,” was my reaction yesterday when I read this op-ed titled “Don’t Quit This Day Job” in The New York Times.
Written by Dr. Karen S. Sibert, a Los Angeles anesthesiologist and mother of four who has always worked full-time, it argues that women physicians have an obligation to work full-time. If they work part-time or take time off, Dr. Sibert argues, they’re contributing to the national shortage of doctors, and the resources that went into training them have been partly wasted. “We can no longer afford to continue training doctors who don’t spend their careers in the full-time practice of medicine,” she writes.
Let me confess that I’m deeply biased in favor of part-time work for parents who want it, and my reaction was visceral: “Great. Instead of pushing for more of the workplace flexibility that so many families so desperately need, she wants less.” But I’m no expert, and I thought I should consult with those who are. So below are seven points on why the op-ed is off-base from some who know the data: Tracey Hyams, director of the Women’s Health Policy and Advocacy Program at Brigham and Women’s Hospital; Dr. Paula Johnson, executive director of the Connors Center for Women’s Health and Gender Biology at the Brigham; and Lotte Bailyn, professor of management at MIT's Sloan School of Management.
Readers, what do you think? Please comment below; nytimes.com does not seem to have enabled comments on the op-ed piece, so here's your chance!
Quality of care trumps productivity
Dr. Sibert makes the argument that women physicians don’t have the same productivity as men because they work fewer hours. In fact, women physicians spend more time with their patients than male physicians regardless of work schedule. And at least one study refutes her productivity argument, finding that part-time productivity among primary care providers is greater than that of full-time practitioners. Further, focusing on productivity neglects the essential metric of quality of care. Some research shows that part-time physicians are associated with higher quality performance than physicians working longer hours. (See references below.)
It’s not part-timers, its access
Dr. Sibert argues that the lack of access to physicians leads to more emergency room visits, more preventable hospitalizations and more patients dying of treatable conditions, particularly for low-income Americans. Lack of access can’t be blamed on women physicians in part-time practice, however. Low-income residents are less likely to have health insurance coverage, which affects access to care throughout the lifespan. In addition, physicians have few incentives to practice in medically underserved areas – reimbursement rates are low, and patients need intensive social support and intervention to live healthy lives. Even if women doctors all worked full-time, the problems of chronically underserved populations would not be solved. Medical schools need to do more to recruit students who are likely to work in underserved areas after graduation.
[module align="right" width="half" type="pull-quote"]If women are not given the choice about how to structure their lives, they may reject medicine as a career choice altogether.[/module]
Doctors aren’t needed to provide all medical care
It is true that when critical medical decisions need to be made, patients want a “fully qualified doctor” leading the team. But much of medicine involves routine and preventive care and doesn’t require critical decision-making. Many aspects of care can be provided by nurses, physicians’ assistants and other ancillary providers – most of whom are likely to be women as well. Physicians and other clinicians should work at the top of their training in conjunction with a team that addresses all the social determinants of health. For example, nutrition counseling and chronic disease management may be recommended by a physician but can be provided by other members of the care team. In fact, our delivery system is already moving in this direction – away from solo practices and towards large, integrated provider organizations.
It’s also about policy
As the author notes, policy decisions have contributed to the shortage of physicians in this country. For example, Congress did not expand residency slots as part of the 2010 health reform law. From 1983-2004, medical schools voluntarily chose to keep enrollment flat after Congress voted to withdraw federal funding of medical education. Since then, medical school enrollment has increased, but not enough to keep pace with population growth and the overall needs of an aging and increasingly sicker population. These decisions are unrelated to what has been called the “feminization of medicine.”
What about the other part-timers, in research and administration?
In academic medical centers, most physicians are part-time clinicians regardless of gender; other activities include administration, research, and teaching. Should we hold them to a different standard as well? Dr. Sibert’s piece misunderstands the medical profession, where most people are “part-time” because they divide their time between clinical work and other essential roles in health care delivery.
The reality is that in our society, women are burdened disproportionately with caregiving responsibilities across the lifespan, from childcare to eldercare. Unless there’s gender equity at home and in society, we can’t expect that women will not want and need to work part-time at some point during their lives.
You think you have a shortage now...
Women are much more likely than men to populate the lower-paying ranks of primary care, family medicine, pediatrics, and internal medicine. Regardless of whether women physicians choose to spend part of their careers working part-time, they are filling essential medical roles that U.S.-trained male medical graduates are less likely to assume. If women are not given the choice about how to structure their lives, they may reject medicine as a career choice altogether.
Special thanks to Katie Sullivan and Laura Cohen for research assistance. References:
i Fairchild DG, McLoughin KS, Gharib S, et al. Productivity, quality, and patients satisfaction. JGIM 2001 16:663-667.
ii Parkerton PH, Wagner EH, Smith DG et al, Effect of Part-time Practice on Patient Outcomes, J Gen Intern Med. 2003 Sep;18(9):717-24