As shown by the articles by Morgan, Brotherton et al., Schaller, and Albers in this issue, women have a long history in medicine and in pediatrics and have made significant contributions to both fields. Proportionately, more women than men enter pediatric practice, general pediatrics, and primary care, and their types of employment are similar to those of men in pediatric practice. There are also substantial numbers of women in academic pediatrics, at least in entry-level positions. However, for both practice-based and academic-based pediatricians, there are some differences in the situations of women and men.
Although women tend to work fewer hours per week than men, this difference is not substantively meaningful for the practice of pediatrics. However, women in academia distribute their time differently, spending more time in patient care and teaching and less in research. Women pediatricians in both practice and academia are more likely to be found in general pediatrics or patient-oriented subspecialties, whereas men pediatricians are more likely to enter high-technology subspecialties, such as pediatric cardiology. In practice, women pediatricians spend more time per patient than do men pediatricians. There are fewer women in leadership positions in both academia and the practice of pediatrics. And, nationally, women in practice and in academia work for lower salaries than do men, even when corrections are made for the variables that influence salary, such as rank, hours worked, age, and region.
No one can predict the future. The following are some cautious and empirically supportable speculations about the future of women in pediatrics, their needs, their particular problems, and their possible future contributions.
There is evidence that the number of women entering medical schools has stabilized at approximately 43% of entering classes, and that the number of women entering pediatrics continues to rise slowly (see the article by Schaller). The changing face of health care with increasing emphasis on primary care should increase the attraction of pediatrics as a specialty for both men and women. How should pediatrics respond to the differential practice of and academic pressures on men and women to demonstrate the value of and maintain the stature of pediatrics?
It is not clear why women make the choices that they are now making about their careers. Why do women not aspire to higher administrative positions, such as department chairs and deanships? Does this reflect an aversion to the nature of the jobs? Or, is it the result of perceived poor prospects in attaining these positions based on the absence of women role models? Why do women write fewer papers and obtain fewer research grants than men? Is this a conscious choice or a function of conditions in the environment of academic pediatrics? Why do relatively fewer women enter high-technology specialties, such as pediatric cardiology? There are currently no answers to these questions. Whether career advancement for women is based on outdated hierarchic structures, outmoded productivity targets, biased work distribution, or more subtle influences, there is a need to address the equities for women in pediatrics.
One possible improvement could target the description and the content of women's jobs, especially early in their careers. The study of the Association of Medical School Pediatric Department Chairs, Inc. (AMSPDC)1 has shown that in academic pediatrics, women at lower ranks are spending more time in patient care and teaching than are men faculty, and that such apportionments of academic duties correlate with lack of academic success (as measured by numbers of publications and research grants) and also with rank and salary. Changing the job descriptions for young women in these early career stages might hasten the academic development and advancement of women.
It is disconcerting that there is such a dearth of women in leadership roles in medicine in general, as demonstrated by Bickel et al.2 as well as by data from the Association of American Medical Colleges Faculty Roster System; in pediatrics; in the senior positions of the provider organizations that are vastly important in setting the rules for the future of health care; and, indeed, in the overall worlds of various professions and businesses. Preparing women for leadership roles should be one of our top priorities, particularly in a profession such as pediatrics, which includes and will continue to include a significant number of women professionals.
Finally, the issues of salary equity are glaring. The clear salary inequities in academic pediatrics (see the article by Schaller) and in the practice of pediatrics cannot be corrected by considering possible variables such as types of work, subspecialty training, or hours worked per week. We must continue to insist on equal pay for equal work for all pediatricians, whether they be women or men.
NEEDS FOR FAMILY LIFE
Women have long borne the primary responsibility for caring for children and families, and childbearing is an event that happens during the young adult years of women, which are also the years of training and early careers. The AMSPDC study1 and an earlier survey of women scientists3 have shown no correlation between academic success and family status. No such studies exist for women in the practice of pediatrics, but we know that many women are successfully combining families and pediatric practice. It is actually surprising that the number of hours worked per week is so similar for women and men pediatricians, given the perception that women tend to pursue more part-time employment.
Unfortunately, the United States is not known for its humane policies toward women and children. Three months of unpaid maternity (or paternity) leave are now mandated by our federal government. Data from the AMSPEXD study indicate that many women in academic pediatrics actually have taken less than 3 months of maternity leave (see the article by Schaller). Many other countries of the world, such as those of the European Union and Israel, have much more family-friendly policies; maternity leave may be as long as 1 year with full pay. Some countries also make provisions for child care when parents return to the workforce; no such formal policy exists in the United States, and working parents are left to make their own arrangements.
Traditionally, we have looked down on part-time work in academic pediatrics, although perhaps less so in the practice of pediatrics. Few programs have yet been devised for sharing jobs on a part-time basis, or for shared residency arrangements. Rigid rules in academic pediatrics for obtaining tenure within a finite time period during early career years still exist in many institutions, and may serve as an impediment to academic advancement for women who establish their families during these years. Finally, the AMSPDC study tells us that accommodating twocareer families is more problematic for women than for men. There is some evidence, however, that such attitudes may be changing. A recent study found that men are now more frequently changing their job situations to benefit their own family lives; interestingly, the major accommodation is a decrease in hours worked per week.4
The need for all professionals to have decent family lives with adequate time for personal development and for meaningful relationships with spouses and children requires serious attention. Although no recent data exist, old data show an alarming rate of divorce among physicians, and this is higher for women than for men.5 In the AMSPDC study, we observed alarmingly low levels of morale and quality of life among both men and women pediatricians.1 Of all specialists, we in pediatrics should be particularly attuned to the importance of sound and rewarding family lives for the development and nurturing of healthy children. It would seem central to the professional agenda of pediatrics to address the quality of family life for pediatricians, their families, and their children. We should be innovative leaders in identifying ways to not only facilitate career advancement for both women and men, but also help pediatricians treat themselves and their families more humanely. A beleaguered and demoralized workforce cannot deliver a high-quality product. If we do not alter the work environment to reflect the personal needs of professionals, we are likely to lose some of our best and brightest colleagues.
Unfortunately, biases against women remain widespread in society. Although a recent effort on the part of a department of medicine to address the needs of women faculty resulted in a number of strides during a 5-year period, one of the strides not made was a significant change in women's perception that they were disadvantaged as compared with their male counterparts.6 The AMSPDC study also pointed out a number of feelings on the part of women in academic pediatrics that, although not correlated with academic success, did correlate with basic job comfort.1 The matter of feeling comfortable in the workplace is still a problem for women in medicine and many other fields. This issue has been called "the comfort syndrome," and was recently highlighted in die Harvard Business Review in a case study entitled "Will She Fit In?"7 This study points out that not only do women not always feel comfortable in the workplace, but that the workplace does not always feel comfortable with women. Such perceptions interfere with both the hiring and the promotion of women, and may result in women being passed over because "we're just not comfortable with her" or "we're not sure it's a good fit."
Women are still not accepted as readily in leadership roles as are men. One classic study showed that, given scripted leadership roles that said the same things, women leaders received more negative responses (scowls and frowns instead of smiles and nods) than did men. And women received poorer evaluations for their performances.8 Women who aspire to leadership roles continue to face the entrenched barriers of gender discrimination that may be difficult to surmount without major and determined efforts, efforts that may themselves exact a toll.
And, finally, issues of sexual harassment still continue in the workplace, including in the halls of medicine. A recent survey of women residents in a leading residency program showed that a significant percentage of them felt that they had been sexually harassed during their training.9 In the AMSPlDC study, 53% of women faculty felt that gender discrimination had delayed their careers.1 Although there were no direct inquiries about sexual harassment in this study, vigilant awareness of and attention to this problem should be maintained to ensure that the medical workplace is a safe and productive environment for both women and men.
CHANGES IN THE PROFESSION OF MEDICINE
The rise of women in medicine and in pediatrics has caused some to worry that our profession will suffer a denigration of status. Those who share this sentiment point to the decline in the status of medicine in Russia coincident with the rise in the number of women physicians. Working conditions deteriorated, salaries fell, and the number of clinical scientists declined. This same forecast of doom was brought up for academic pediatrics a few years ago when fears were expressed that increasing numbers of women in academic pediatrics would "weaken the scientific underpinnings of our profession."10 Such arguments, although unwarranted, should not be ignored, because they reflect the kind of inherent prejudice among colleagues that can impede the progress of not only individuals or groups of individuals, but also our profession generally. Nor should we allow such "twotiered" medicine to occur. We must continue to work to make pediatrics a field that will attract the best and brightest young professionals of both sexes and a field that maintains excellence in patient care, teaching, and research.
Indeed, the whole profession of medicine is undergoing rapid changes - some desirable, some not. The economic constraints in health care delivery, the rise of managed care, and the shifting attention to market forces have radically changed the microenvironment of the individual professional. Visits are shorter, practice volume has increased, and even the specific content of test-ordering and doctor-patient communication has been limited. These changes have potentially serious consequences for pediatrics.
The historic predominance of specialty medicine is also changing. Internal medicine is now emphasizing primary care as a career track. Current efforts to coordinate care place the generalist at die center of patient management. Pediatrics has traditionally trained fewer subspecialists (approximately 20% of the workforce) than internal medicine. Indeed, pediatrics in many ways has anticipated some of the changes other disciplines are now implementing. We must now work together to capitalize on this strength for the future of our profession.11,12
FUTURE CONTRIBUTIONS OF WOMEN
Women have made, and will continue to make, important contributions to knowledge and skills as well as to patient care in pediatrics. Women physicians spend more time with their patients than do men physicians, and are considered more empathetk and more inclusive of patients in treatment decisions.13 It has been shown that male patients receive better interpersonal care from women than from men physicians.13,14 It has also been shown that child patients communicate better with women than with men pediatricians.15,16 Perhaps gender differences in the use of and interaction with health care providers may be learned in childhood. The strengths of women in empathy and in communicating with patients are important for pediatrics, not only in the care of children, but also in the formation of their future attitudes to health care.
It is not yet clear what the professional roles of women will be in their later years, but, due to greater longevity, it could be argued that women will ultimately be disproportionately represented in the senior workforce. The increased presence of older and seasoned women pediatricians in the health care workforce will change the demographics of our profession. How this might affect policy and medical care remains to be seen.
There are, and there will continue to be, significant numbers of women in the field of pediatrics. Women's role in humanizing working conditions benefits both genders, for personal achievement and, ultimately, for improved patient care. All pediatricians have a clear and challenging responsibility to make sure that the health of all children is featured in the clinical and health care policy agenda. We must continue to forward the needs of children and families as the stresses on them and on us mount.
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