Women face challenges, opportunities as roles change in endocrinology
Endocrinology, like most subspecialties of internal medicine, remains primarily a male-predominant field. According to a 2014 analysis from the Center for Workforce Studies, approximately 62% of adult endocrinologists in the United States are men, reflecting a larger trend across the specialties in general — 67% men.
New data, however, suggest those numbers are about to shift dramatically. According to 2013 data from the Electronic Residency Application Service, 72% of fellows entering endocrinology were women, whereas the number of male applicants decreased more than 40% during a 4-year period.
“If this trend continues, over the next several decades, endocrinology will become a female-predominant specialty,” Elaine Pelley, MD, of the division of endocrinology, diabetes and metabolism at University of Wisconsin School of Medicine and Public Health, and colleagues wrote in a January 2016 study published in The Journal of Clinical Endocrinology & Metabolism. The analysis, which assessed gender trends in endocrinology, noted that the gender shift is occurring in the setting of a projected endocrinology workforce shortage. The deficit of adult endocrinologists — currently estimated at 1,500 — is predicted to nearly double to 2,700 by 2025.
“With trends suggesting this workforce will be predominantly female, understanding challenges and strengths characteristic of female physicians will be key to the success of the specialty as a whole,” Pelley and colleagues wrote.
“I’m a program director, and in the past few years, we haven’t had a male fellow at Loyola,” Pauline M. Camacho, MD, FACE, professor of medicine and director of the Osteoporosis and Metabolic Bone Disease Center at Loyola University Medical Center, president of the American Association of Clinical Endocrinologists and an Endocrine Today Editorial Board member, said in an interview. “Endocrinology is definitely currently a women’s field, and it will probably stay that way for many years.”
That shift, according to experts, offers both opportunities and challenges.
“Women face unique challenges in endocrinology and in medicine in general,” Karen Klahr Miller, MD, professor of medicine at Harvard Medical School, faculty member in the neuroendocrine unit of Massachusetts General Hospital and the president of the advocacy group Women in Endocrinology, told Endocrine Today. “Women tend to be paid less than their male counterparts for doing the same work despite having the same needs men do in terms of needing to support their families. In addition, even in this generation, women are still more likely than men to have the primary responsibility for children, for their elderly parents and for the household. And, this is occurring as all of us in medicine are experiencing a tremendous increase in our administrative burden.”
In addition, a female-predominant field may have less of a voice since women are underrepresented in academic leadership, Pelley said in an interview.
“If it continues to be true that the majority of leaders are male, and there are fewer and fewer male endocrinologists, it stands to reason that there will be fewer and fewer endocrinologists in leadership roles,” Pelley told Endocrine Today. “Therefore, we as a specialty may be facing more challenges and simultaneously have a lesser ability to advocate for ourselves because we will be less represented in leadership.”
Tipping the balance
Pelley and colleagues noted that gender differences in specialty plans have been identified from the start of medical school. Female internal medicine residents, for example, were more likely to rank time for family, interest in long-term patient relationships and desire to provide a needed service as important considerations in a subspecialty choice; male residents were more likely to consider compensation.
Those desires continue to hold true as women move forward in their careers, Camacho said.
“Women are wives and mothers, and the roles we try to juggle can be a challenge for a lot of people,” Camacho said. “For me to have grown in AACE and risen in the leadership, I required a lot of support. I had a full-time nanny and a supportive husband. Everything had to be in place to make things work. It is quite a challenge to maintain an academic practice, run a major organization, which includes attending board meetings, out-of-town travel, conference calls, and at the same time manage the household.”
But the “conventional wisdom” that endocrinology is attracting women because of family-friendly hours or more patient-centered care does not tell the full story, Pelley said.
“If we were still attracting the same number of men, but suddenly women were flocking to endocrine and making it more competitive, this new gender ratio would be much less concerning,” Pelley said. “However, the reality is that men are choosing other specialties. That means that our applicant pool is becoming smaller and less competitive. That can’t be good, for any reason.”
Career advancement and leadership
In an August 2015 symposium sponsored jointly by the Endocrine Society and the Endocrine Society of Australia, researchers cited inequality in career advancement in both research and clinical practice as a key issue facing the next generation of endocrinologists. A summary of the symposium attributed the imbalance in part to a lack of adequate mentorship, as well as gender discrimination and bias in career advancement.
“Awards predominantly go to men, and leadership positions are primarily held by men, whether in academia, medicine or pharmaceutical companies,” Miller said. “There are many reasons for this. Some of it is that there are many successful men who are already in the pipeline, but it’s naive to think that is all that is going on.”
The trend, Miller said, is a pattern observed across medicine and science and in the larger society, where women rise to positions of power in fewer relative numbers than men.
Research also points to women purposefully opting out of positions that may advance a career, according to Andrea Dunaif, MD, of the Northwestern University Feinberg School of Medicine and a past president of the Endocrine Society. Although such decisions are made for many reasons, Dunaif said, other factors, including a perceived lack of support or even a hostile work environment, may come into play.
“There are a couple of things going on,” Dunaif told Endocrine Today. “There are data that women opt out. One thing often not reported is that there is still a gap in the tenure track with women vs. men. You look at the assistant professor level, and it is pretty level [between genders], but then, suddenly, women disappear at the associate professor level. So, the pipeline is full early on, and there is something happening.”
Women in Endocrinology, Miller said, is working to make changes with a multi-pronged approach, including providing merit-based awards, forums for mentorship and networking, and nominating women for leadership positions within the Endocrine Society, she said.
To support career development among women, the AACE Women’s Task Force is also preparing to launch a women’s leadership program that will engage women endocrinologists across the country, Camacho said.
“We have a project that is brewing where we will engage women in different cities and build a network,” Camacho said. “We want to share experiences and give tips and have speakers to talk about work–life balance and leadership skills. That, hopefully, will be a good start for endocrine.
“There’s less of a tendency for women to network,” she said. “So, we want this to be a program that pulls people out of their comfort zone.”
Recent surveys point to a substantial gender pay gap among full-time physicians, in general, and among endocrinologists, in particular. In her research, Pelley and colleagues cited an annual gender wage gap among full-time endocrinologists ranging between $38,000 and $66,000, depending on endocrine practice type (not controlled for hours worked).
The gender wage gap is compounded by a specialty pay gap. According to the 2012 Endocrinologist Survey, the mean income for private practice, university faculty and hospital-based adult endocrinologists was $217,297, $196,154 and $189,063, respectively. Median incomes for more procedure-based specialties, such as noninvasive cardiology and gastroenterology, were $431,740 and $463,955, respectively.
“There are several wage gaps,” Miller said. “One is the wage gap between women and men. Another is the wage gap between the endocrinology specialty and other subspecialties. Finally, there are diminishing wages for the work that endocrinologists and scientists are doing as the financial structure of medicine changes, and as academic institutions are increasingly strapped for funds.
“I do think there is a potential opportunity here,” Miller said. “If population health management pushes payment for medical services toward a capitation model, some of this gap between procedure-based specialties and nonprocedure-based specialties, like endocrinology, may be narrowed. We need to advocate for those types of changes.”
In a workforce study of adult endocrinologists conducted in 2014 and published in The Journal of Clinical Endocrinology & Metabolism, Robert A. Vigersky, MD, medical director for Medtronic Diabetes and a past president of the Endocrine Society, and colleagues cited both age and gender differences in the mean number of weekly hours and visits per year in direct patient care (exclusive of teaching, administration and continuing education responsibilities).
Male adult endocrinologists work 42 hours each week, provide 3,434 visits per year and attain peak productivity from age 41 to 45 years, the researchers wrote; female adult endocrinologists work 39 hours per week, provide 2,482 visits per year and reach their peak of productivity from age 46 to 50 years.
“For a lot of women in endocrinology — and this is based both on my experience as a division chief here at Northwestern and at Brigham and Women’s Hospital — there is a desire for work–life balance. Endocrinology is one of the easier specialties in which to achieve this balance. As a result, many women are working less than full time” Dunaif said. “I think that makes women feel that they’re in not as strong of a negotiating position when it comes to salary. They’re already asking for non-full-time work. That’s a very important factor.
“Women don’t negotiate for salary in the same way that men do,” Dunaif said. “They tend not to ask for more [pay], and they accept what they’re offered. I have a Building Interdisciplinary Careers in Women’s Health career development grant from NIH. One of the things that we offer is seminars on negotiation skills. Women learn they should be asking for more.”
Dunaif called the problem an “eminently correctable issue.” Women, she said, should receive professional development support early in their careers with didactic training in negotiation and presentation skills, grant writing and the requirements for academic advancement. Any institution receiving federal funding should be held to a pay equity standard.
“I understand it’s a lot of money to bring the women up to where they should be paid, and there is resistance to spending that money,” Dunaif said. “But, I just don’t think gender pay inquality should be tolerated in an organization that receives state or federal funds.”
Anne L. Peters, MD, director of the University of Southern California Clinical Diabetes Program and professor at the Keck School of Medicine of USC, echoed the need to empower women to ask for what they need.
“No one ever taught me in medical school how to negotiate for a job,” Peters told Endocrine Today. “I wish I had known that I have more of a voice than I thought I had. Even at my age, I think I make less than my male counterparts, but part of it is I never asked for more.”
Research suggests that gender also plays a role in the physician–patient relationship. In an April 2004 study published in the Annual Review of Public Health, Debra L. Roter, DrPH, of the department of health policy and management at Johns Hopkins Bloomberg School of Public Health, and Judith A. Hall, PhD, professor at Northeastern University College of Science, considered two meta-analyses on the effects of physician gender on communication in the clinical practice setting. Medical visits with women physicians were, on average, 2 minutes (10%) longer than those of male physicians. During visits, researchers found that female physicians engaged in more patient-centered communication.
In addition, the researchers found that the patients of female physicians spoke more, disclosed more biomedical and psychosocial information, and made more positive statements to their physicians vs. patients of male physicians.
However, what may appear to be a strength can be a disadvantage, Pelley said.
“Studies show that patients perceive patient-centeredness more positively when it is demonstrated by a male physician. It appears that patient-centeredness is so expected in female physicians that it essentially goes unnoticed,” she said. “When patients see a female physician who is patient-centered, that’s fine. If they see a male physician who is equally patient-centered, that physician was fantastic. He outperformed their expectations.”
With patient satisfaction increasingly becoming a metric that could affect compensation, the issue can contribute to the wage gap, Pelley said.
“Female and male physicians are put on the same scale in terms of patient satisfaction,” she said. “But if you come in the room and there is a higher expectation [for you than for] your male counterpart, that is intrinsically disadvantaging the female physician.”
Mentoring and support
As more women move into the endocrine field, building relationships with mentors established in their careers can help them navigate the challenges they may face, Peters said.
“The notion of mentoring can’t be stressed enough,” she said. “The reason I have been successful is because I have always had good mentors who looked out for me. All of my mentors were men because that is who was there, and that was great.”
Today, Peters said, she actively works with young women starting out in the specialty and enjoys sharing her experiences and challenges.
“What makes me happiest in life right now is to mentor these young women and let them know that it is OK to make this choice or that choice, and validate them,” she said. “If a woman comes to me at a meeting and is [age] 35 [years] and full of ideas, I don’t care where she is from, I’m going to help her. We who have been through this want to help them. Women need to seek mentors out. There isn’t one way, but they can find their way.”
“Filling the pipeline” with many women at the trainee and young faculty level does not ensure things will change, according to Pelley, nor does simply linking women with female mentors.
“It has been shown that while professional women utilize mentors, those mentors are on average less powerful than the mentors of male peers,” Pelley said.
She said “high-potential” female faculty members should be matched with senior faculty members who can serve as strong advocates for career advancement, not just as advisors. Endocrine division chiefs should also advocate for gender salary equity in academic medicine.
“We can pretend this isn’t happening and wait and see what the outcome is, or we can recognize that more and more women are pursuing careers in medicine, and we in endocrinology could be the trailblazers in terms of finding a way to start overcoming these issues,” Pelley said. “We can be the model that other specialties will follow.” – by Regina Schaffer
- Association of American Medical Colleges. 2014 Physician Specialty Data Book. Available at: https://www.aamc.org/data/workforce/reports/439208/specialtydataandreports.html. Accessed Dec. 14, 2016.
- Pelley E, et al. J Clin Endocrinol Metab. 2016;doi:10.1210/jc.2015-3436.
- Roter DL, Hall JA. Annu Rev Public Health. 2004;doi:10.1146/annurev.publhealth.25.101802.123134.
- Santen RJ, et al. J Clin Endocrinol Metab. 2016;doi:10.1210/jc.2016-3016.
- Vigersky RA, et al. J Clin Endocrinol Metab. 2014;doi:10.1210/jc.2014-2257.
- For more information:
- Pauline Camacho, MD, FACE, can be reached at Loyola University Medical Center, 2160 South First Ave., Maywood, IL 60153; email: firstname.lastname@example.org.
- Andrea Dunaif, MD, can be reached at Northwestern University Feinberg School of Medicine, 303 E. Chicago Ave., Chicago, IL 60611; email: email@example.com.
- Karen Klahr Miller, MD, can be reached at Massachusetts General Hospital, Neuroendocrine Unit, Bul-457, 55 Fruit St., Boston, MA 02114; email: firstname.lastname@example.org.
- Elaine Pelley, MD, can be reached at the Division of Endocrinology, Diabetes and Metabolism at the University of Wisconsin School of Medicine and Public Health, 4170 Medical Foundation Centennial Building, 1685 Highland Ave., Madison, WI 53705; email; email@example.com.
- Anne Peters, MD, can be reached at the USC Clinical Diabetes Program, 150 N. Robertson Blvd., Suite #210, Beverly Hills, CA 90211-2142; email: firstname.lastname@example.org.
Disclosures: Camacho, Dunaif, Miller, Pelley and Peters report no relevant financial disclosures.
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