Pediatric Annals

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pediatric annals 

Women in Pediatric Practice: Trends and Implications

Sarah E Brotherton, PhD; Holly J Mulvey, MA

Abstract

One of the most noteworthy trends in the physician workforce is the increasing number of women in medicine. According to data collected by the American Medical Association, between 1970 and 1996 the number of women in medicine increased more than fivefold. During this time, the specialty of pediatrics was on the leading edge of this increase. Pediatrics has consistently attracted a greater proportion of women than any other specialty. In 1996, 45% of all pediatricians in practice were women (24,271) compared with 25% of the total number of physicians in internal medicine and 21% of all physicians. Of tangential interest is the fact that only seven specialties, including pediatrics and internal medicine, have together consistently attracted more than 60% of the total female physician population. The other five are family practice, psychiatry, anesthesiology, obstetrics/gynecology, and pathology.1

The rising number of women in medicine has led to a growing interest in the effect of women on the physician workforce and to studies of the differences between male and female pediatricians. A study released in July 1995 by the Council on Graduate Medical Education (COGME) identified that the increasing number of female physicians will have an ongoing influence on all levels of medical education, research, and practice.2 In this article, we look particularly at the differences between male and female pediatricians in practice.

As described below, most of the data that are used in this article are from the American Academy of Pediatrics (AAP) Periodic Survey 21. A gender-based analysis is presented on the following aspects of pediatric practice: employment characteristics, including hours spent in practice per week, practice type, and location; practice characteristics, including patient visits per week and average length of visit; and productivity, including full-time versus part-time practice. Many of the findings mirror those of female physicians, overall.

Table

The data from this AAP Periodic Survey demonstrate that women are less likely than their male counterparts to practice a pediatric subspecialty. This is a probable result of the ongoing pressure for professional women to balance career and family, as demonstrated by our finding that subspecialty pediatricians work more hours than do general pediatricians. Both the 1995 COGME report2 and the more recent "Pediatric Workforce Statement" from the AAP Committee on Pediatric Workforce3 have noted the effect that lifestyle considerations (including dualcareer marriages and child rearing) have on employment decisions. Although such considerations affect both men and women, they are more significant for women in pediatrics. To a limited extent, the decision not to subspecialize may be attributed to the younger age of female pediatricians, who could have been influenced by the recent increased emphasis on and efforts to promote careers in primary care medicine, although there are suggestions that there are fewer practice differences between younger male and female pediatricians than among older pediatricians.4 The tendency for women in pediatrics not to subspecialize may become a factor in future subspecialty workforce considerations.

According to data collected by the American Board of Pediatrics, from 1997 to 1998 approximately 42% of pediatric subspecialty fellows were international medical graduates (IMGs), although they made up only 25% of general pediatrics residents.5 Immigration policy, particularly as it pertains to IMGs, is in a state of flux; however, a number of important policy-making groups have called for a reduction in the number of IMGs, a reduction in the ability to provide extensions of a visa for additional training or service, or both. If the number of IMGs who are eligible to enter pediatric subspecialty education is reduced and if the growing number of women in the specialty continue not to subspecialize, this will have implications…

One of the most noteworthy trends in the physician workforce is the increasing number of women in medicine. According to data collected by the American Medical Association, between 1970 and 1996 the number of women in medicine increased more than fivefold. During this time, the specialty of pediatrics was on the leading edge of this increase. Pediatrics has consistently attracted a greater proportion of women than any other specialty. In 1996, 45% of all pediatricians in practice were women (24,271) compared with 25% of the total number of physicians in internal medicine and 21% of all physicians. Of tangential interest is the fact that only seven specialties, including pediatrics and internal medicine, have together consistently attracted more than 60% of the total female physician population. The other five are family practice, psychiatry, anesthesiology, obstetrics/gynecology, and pathology.1

The rising number of women in medicine has led to a growing interest in the effect of women on the physician workforce and to studies of the differences between male and female pediatricians. A study released in July 1995 by the Council on Graduate Medical Education (COGME) identified that the increasing number of female physicians will have an ongoing influence on all levels of medical education, research, and practice.2 In this article, we look particularly at the differences between male and female pediatricians in practice.

As described below, most of the data that are used in this article are from the American Academy of Pediatrics (AAP) Periodic Survey 21. A gender-based analysis is presented on the following aspects of pediatric practice: employment characteristics, including hours spent in practice per week, practice type, and location; practice characteristics, including patient visits per week and average length of visit; and productivity, including full-time versus part-time practice. Many of the findings mirror those of female physicians, overall.

Table

TABLE 1Primary Specialty Area (> 50% of Time) of Male and Female Pediatricians

TABLE 1

Primary Specialty Area (> 50% of Time) of Male and Female Pediatricians

METHODS

This article presents practice characteristics of pediatricians from a number of Periodic Surveys administered by the AAP. Periodic Surveys of the membership are conducted 4 times annually on current topics of importance to pediatrics. Each survey uses a unique random sample of 1,600 active U.S. members of the AAP; those selected to participate are not selected again for approximately 4 years. Unless otherwise specified, the results presented in this article come from Periodic Survey 21, which was conducted in 1993; the response rate was 70.9%.

We chose to analyze the practice characteristics of pediatricians who had completed their residency or fellowship training (n = 1,145). Of these pediatricians, 35.7% were female, and 81.6% were white and non-Hispanic, 9.2% were Asian or Pacific Islander, 4.3% were Hispanic, 1.9% were African American, and 3.0% were from another racial or ethnic group. The average age for female respondents at the time of the survey was 40; for male pediatricians it was 47. These demographic characteristics were typical of respondents to other Periodic Surveys. Unless otherwise indicated, studies were based on all responding pediatricians irrespective of whether they considered themselves full-time or part-time.

RESULTS

Employment Characteristics

We have segmented the respondents into two gross categories, using the percent of time each pediatrician spends in general pediatrics. For the purpose of these analyses, pediatricians who spend more than 50% of their time in general pediatrics are considered general pediatricians; all others are considered subspecialty pediatricians. Women are more likely than men to be general pediatricians (61.4% vs 55.4%, P < .001). Because of the number of statistical tests performed in these analyses, all statistical differences reported are atP<.01.

There are gender differences within the different pediatric subspecialty areas as well (Table 1). Pediatric subspecialists were divided into the different subspecialty areas using the same percent of time (ie, greater than 50%). Female subspecialty pediatricians are significantly more likely to be in adolescent medicine and emergency medicine, and less likely to be in cardiology and infectious diseases.

Pediatricians were asked about the number of hours in a typical week they spend in various activities. Figure 1 presents the breakdown of activities by gender and by specialty area. Altogether, male pediatricians work more hours per week than do female pediatricians (57.0 vs 48.0, P < .001), and subspecialty pediatricians work more hours than do general pediatricians (55.3 vs 52.7, P < .01). Female general pediatricians work 45.7 hours, male general pediatricians work 57.0 hours, female subspecialty pediatricians work 51.8 hours, and male subspecialty pediatricians work 57.0 hours a week. Male pediatricians work more hours in direct patient care than do female pediatricians (42.4 vs 35.2, P < .001 ), but there are no other differences in the number of hours spent in professional activities by gender. Primarily, general pediatricians spend more hours per week in direct patient care than do subspecialty pediatricians; conversely, subspecialty pediatricians spend more time in administrative, teaching, and research activities.

The employment settings of pediatricians vary by specialty area, not by gender (Table 2). Female general pediatricians are equally as likely to be found in the various employment settings as are male general pediatricians; the same is true for pediatric subspecialists. General pediatricians are more likely to be found in solo or group practice settings, whereas subspecialists are more likely to work in medical schools or hospitals.

Given that male pediatricians work more hours per week and are typically older than female pediatricians, it is not unexpected that they earn higher incomes than female pediatricians (Table 3). One in five female general pediatricians earned less than $49,000 in 1992, compared with less than 2% of male general pediatricians. More than half of male pediatric subspecialists earned more than $125,000 in 1992, compared with one in five female subspecialists. We repeated this analysis using only pediatricians older than age 40 (not shown), resulting in a similar distribution of income and similar statistical differences between the genders. So even at a more established career point, female pediatricians earn significantly less than male pediatricians. Significantly, more male pediatricians derive income from being a sole proprietor or a partner in the ownership of a practice than do female pediatricians (P < .001; Fig. 2). Women are much more likely to be salaried employees, doubly so in the case of general pediatricians (P < .001). Women are also less likely to be a partner-shareholder in a salaried position (P < .005). Considering there were no significant gender differences in practice settings (Table 2), it is interesting that the income arrangements vary so substantially, especially for general pediatricians.

Figure 1. Average number of hours per week by specialty area and gender.

Figure 1. Average number of hours per week by specialty area and gender.

Table

TABLE 2Average Percentage of Time in Employment Settings, by Specialty Area and Gender

TABLE 2

Average Percentage of Time in Employment Settings, by Specialty Area and Gender

Table

TABLE 3Income by Specialty Area and Gender

TABLE 3

Income by Specialty Area and Gender

Patient Visits

Those pediatricians who provide ambulatory care were asked several questions about their patients (60.9% of pediatric subspecialists and 97.5% of general pediatricians provide ambulatory care to patients). The average number of patient visits per week in either the office or other ambulatory care settings was 134-7 for male general pediatricians and 107.6 for female general pediatricians (not a significant difference at the .01 level). Pediatric subspecialists of either gender saw roughly 54 patients per week. Table 4 presents the age distribution, as well as the racial or ethnic distribution, of these patients. General pediatricians are significantly more likely to see patients in the two younger age groups, whereas pediatric subspecialists are significantly more likely to see patients in all of the age groups older than 6 to 8 years. There are no differences in the age distribution of patients by gender. The majority of patients seen by pediatricians are white and non-Hispanic; however, female pediatricians have significantly fewer white, non-Hispanic patients than their male counterparts. The difference between the specialty areas in the percentage of patients who are African American approaches statistical significance (P = .01).

Figure 2. Percent of income from different arrangements by specialty area and gender.

Figure 2. Percent of income from different arrangements by specialty area and gender.

Table

TABLE 4Age and Race or Ethnicity Distributions of Patients, by Specialty Area and Gender

TABLE 4

Age and Race or Ethnicity Distributions of Patients, by Specialty Area and Gender

Pediatricians who provide primary care were asked how many minutes they personally spend with a child and parent during a preventive care visit (30.2% of pediatric subspecialists and 96.9% of general pediatricians report providing primary care). AU pediatricians reported spending approximately 17 minutes with the patient and the parent for children aged birth to 2 years, 3 to 5 years, and 6 to 1 1 years. Pediatric subspecialists reported spending more time with patients aged 12 to 17 and with patients older than the age of 18 (roughly 23 vs 19 minutes, P < .005). Female pediatricians, general or subspecialty, spent more time with these two age groups compared with their male colleagues (roughly 22 vs 19 minutes, P < .005).

Productivity

Pediatricians were asked to indicate whether they work full-time or in some other arrangement. As can be seen in Table 5, most pediatricians worked fulltime. However, female general pediatricians were significantly more likely to work part-time. As discussed above, the average numbers of hours worked for the four groups (men and women, generalists and specialists) ranged from 46 to 57 per week. Hours worked during a typical week were examined for the pediatricians who indicated they worked part-time. Part-time pediatricians worked 32.3 hours per week, and the average number of hours per week did not differ by specialty area or gender. Overall, pediatric subspecialists said their primary reasons for working fewer than 35 hours per week are personal preference and "other." However, 30% of female pediatric subspecialists indicated that child care responsibility was their primary reason. For general pediatricians, the primary reason was child care responsibility, reported by 66.7% of the women and by one male pediatrician.

Table

TABLE 5Employment Status, by Specialty Area and Gender

TABLE 5

Employment Status, by Specialty Area and Gender

We further examined hours worked by combining data from 12 different Periodic Surveys that were fielded between 1992 and 1998 (numbers 20, 22, 23, 25, 26, 27, 29, 30, 31, 33, 34, and 35). We used a more stringent definition of a general pediatrician for these analyses, restricting the category to those who spend 75% or more of their time in general pediatrics (n = 8,505), of whom 44-4% are female. In contrast, 35% of the 4,154 subspecialty pediatricians are female. We used 40 hours in direct patient care per week as a standard for a full-time equivalent (FTE) pediatrician (as used by the U.S. Health Resources and Services Administration) and compared male and female general and subspecialty pediatricians' hours in different practice settings (the entire range of hours was included, te, those obviously working part-time were not excluded). The average FTE values are presented in Table 6. We can see that, male or female, the typical general pediatrician in a typical practice setting is an FTE pediatrician, working at least 40 hours per week in direct patient care. The competing demands in other work settings present difficulties for working as an FTE for most pediatricians.

DISCUSSION

Considerable data have been collected pertaining to women in medicine and women in pediatrics. Many of these findings demonstrate ongoing trends. Some of these trends may be explained by age or gender (or an interaction of the two), but others, particularly those trends pertaining to productivity, require further study. The major differences between male and female pediatricians in this study are in the areas of hours worked and income. A trend that has equally important implications for future pediatric workforce discussions is that of the decision to train and practice as a pediatric generalist or a pediatric subspecialist.

Table

TABLE 6Average FTE Values (40 Hours per Week in Direct Patient Care) for Pediatricians in Different Practice Settings

TABLE 6

Average FTE Values (40 Hours per Week in Direct Patient Care) for Pediatricians in Different Practice Settings

The data from this AAP Periodic Survey demonstrate that women are less likely than their male counterparts to practice a pediatric subspecialty. This is a probable result of the ongoing pressure for professional women to balance career and family, as demonstrated by our finding that subspecialty pediatricians work more hours than do general pediatricians. Both the 1995 COGME report2 and the more recent "Pediatric Workforce Statement" from the AAP Committee on Pediatric Workforce3 have noted the effect that lifestyle considerations (including dualcareer marriages and child rearing) have on employment decisions. Although such considerations affect both men and women, they are more significant for women in pediatrics. To a limited extent, the decision not to subspecialize may be attributed to the younger age of female pediatricians, who could have been influenced by the recent increased emphasis on and efforts to promote careers in primary care medicine, although there are suggestions that there are fewer practice differences between younger male and female pediatricians than among older pediatricians.4 The tendency for women in pediatrics not to subspecialize may become a factor in future subspecialty workforce considerations.

According to data collected by the American Board of Pediatrics, from 1997 to 1998 approximately 42% of pediatric subspecialty fellows were international medical graduates (IMGs), although they made up only 25% of general pediatrics residents.5 Immigration policy, particularly as it pertains to IMGs, is in a state of flux; however, a number of important policy-making groups have called for a reduction in the number of IMGs, a reduction in the ability to provide extensions of a visa for additional training or service, or both. If the number of IMGs who are eligible to enter pediatric subspecialty education is reduced and if the growing number of women in the specialty continue not to subspecialize, this will have implications for the future of pediatric subspecialties.

Of the many gender differences in all professions, the one that often receives the most attention is that of income. Periodic Survey data demonstrate that female pediatricians make less money than their male counterparts; differences in hours worked and age are likely important related factors. The fact that more women in pediatrics are salaried employees and less likely to be practice partners also leads to a difference in income.

Although these are tangible reasons, one must at least mention the often intangible factors. Some female pediatricians believe that gender discrimination, sexual harassment, or both are factors that limit the career, promotion, and/or income potential of women in medicine. Another prevalent belief is that established, male physician networks often limit upward career mobility.6·7 Whether the increasing number of women in pediatric practice will erode these intangible factors remains to be seen. Proactively, several steps could be taken to rectify the situation, such as fostering networking opportunities for female pediatricians; educating all pediatricians on the value of mentoring and how to be an effective mentor; and taking a hard look at whether there are still barriers to organizational leadership advancement and, if so, how these can be addressed.

Two other important factors in any study of gender comparisons of the physician workforce are the differences in the number of patients seen and the number of hours worked. Here the data reveal that male pediatricians do indeed work more hours than female pediatricians, although in the case of general pediatricians in typical practice settings, males and females are equally likely to be FTE pediatricians. A discussion of these related trends encompasses a considerable number of issues, some of which are supported by additional data and others that are speculative or anecdotal. The issue of hours worked has sometimes had a negative inference. Some have countered that, overall, female physicians spend more time per patient and possibly facilitate better physician-patient communication.2 Indeed, we found that female pediatricians spend more time with older patients than do male pediatricians.

It has also been postulated that the difference in hours worked is not so much a function of gender as it is of age. Indeed, for some time survey data have revealed that young physicians place a high priority on what has been termed "lifestyle considerations." Unpublished data from the AAP Department of Research lend credence to this supposition. Two annual surveys queried 1996-1997 and 1997-1998 PL-3 pediatric residents regarding their practice choices on completion of residency education. Respondents to both surveys listed "spouse/family considerations" as the most important factor when selecting a job. Both groups also ranked "job security" and "geographic location" as important. Approximately 60% of the respondents to the PL-3 surveys were women; however, men were equally as likely to give "spouses/family considerations" a high ranking.

Flexibility of work schedules, whether in education, academia, or practice, has long been cited as imperative to a workforce that has a predominance of young women. In addition to this concrete step, there have been increasing demands for a change in the prevailing attitude that hours worked is the gold standard by which the productivity of a physician is measured. Currently, many female physicians and pediatricians who require fewer or more flexible hours to attend to children or family responsibilities maintain that they bear the burden of negative perceptions (eg, they are less serious about their careers than others) and career delays.2,6 Whether any measure of success in ameliorating these perceptions has been achieved in recent years depends on one's perspective. Some have postulated that as the number of women in pediatric practice increases, these circumstances will cease to be of issue.4 Others point to the current business climate of the health care delivery system wherein corporate decisions, and not the demographics of the physician employees or contractors or possibly even characteristics of the patients themselves, determine hours worked, number of patients seen per week, and amount of time spent with each patient.8

CONCLUSION

Although pediatrics is commonly viewed as supportive of women physicians, hence the high number of female pediatricians, there is still undoubtedly much that remains to be done to create an environment that many female pediatricians believe will be both equitable and flexible. Periodic Survey 21 provides important data on several key issues, many of which are, in fact, ongoing trends. The reasons, implications, and rationale behind these data and trends require constant and unbiased review. Any of these gender differences, whether in subspecialty practice, hours worked per week, or others, cannot be viewed negatively or positively for one gender versus the other. Admittedly, gender comparisons are important measures of achievement (or lack thereof) for women in pediatrics. Still, it must be acknowledged that in this shifting health care delivery environment, there is no one gold standard related to productivity or other factors that must apply to all pediatricians in practice.

Many women have become leaders in the specialty of pediatrics. Still more have served as role models and mentors, and organizations have made strides to address issues of particular interest to female pediatricians. These efforts are to be applauded, and ongoing vigilance and efforts are required to ensure that the specialty meets the needs of all its practitioners.

REFERENCES

1. Randolph L Physician Characteristics and Distribution m Ae U.S. Department of Physician Data Services. Chicago, IL; American Medical Association, Department of Physician Data Services. Division of Survey and Data Resources; 1998.

2. Council on Graduate Medical Education. Ftfth Report: Women 9 Medicine. Rockville, MD: Department of Health and Human Services; Public Health Service, Health Resources and Services Administration; 1995.

3. American Academy of Pediatrics. Pediatric workforce statement. Pediatrics. 1998;102:418-427.

4. Brotherton SE, Tang SS, O'Connor KG. Trend* in practice characteristics: analyses of 19 Periodic Surveys (1987-1992) of Fellows of the American Academy of Pediatrics. Pediatrics. 1997;100:8-18.

5. American Board of Pediatrics. Collected Workforce Information. April 4-5, 1998. Chapel HiU, NC

6. Asch-Goodkin J. Women in pediatrics. Contemporary Pediatrics. 1994;1 1:54-67.

7. American Academy of Pediatrics. Prevention of sexual harassment in the workplace. In: Policy Reference Giade. Elk Grove Village. IL: American Academy of Pediatrics; 1997:796-797.

8. Rodwin MC. Conflicts in managed care. NEnJJ Med. 1995;332:604-607.

TABLE 1

Primary Specialty Area (> 50% of Time) of Male and Female Pediatricians

TABLE 2

Average Percentage of Time in Employment Settings, by Specialty Area and Gender

TABLE 3

Income by Specialty Area and Gender

TABLE 4

Age and Race or Ethnicity Distributions of Patients, by Specialty Area and Gender

TABLE 5

Employment Status, by Specialty Area and Gender

TABLE 6

Average FTE Values (40 Hours per Week in Direct Patient Care) for Pediatricians in Different Practice Settings

10.3928/0090-4481-19990301-11

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