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March 2015 (Volume 93)
Catherine D. DeAngelis
Women have always made a significant contribution to the health of the American public, in both nursing and medicine. But it is only over the past several decades that more and more women have become physicians, thus entering a medical profession that for many years had been primarily a man’s world.
Every medical student knows, or should know, that Elizabeth Blackwell became the first woman physician in the United States, after graduating from Geneva Medical College in 1849. She also was the first woman to be listed in the United Kingdom’s medical register. Interestingly, her sister, Emily, was the third woman to graduate from a US medical school.
To put this in perspective, Elizabeth Blackwell graduated 84 years after the University of Pennsylvania School of Medicine, the first medical school in the United States, was established in 1765. The University of Pennsylvania, however, admitted only male students to its medical school, as was the case for most American medical schools in all of the 18th, and most of the 19th, century. In 1850, 85 years after the founding of Penn’s medical school, the Women’s Medical College of Pennsylvania was founded as the first medical school exclusively for women.
Women physicians fared only slightly better with the American Medical Association, which was established in 1847 but did not accept its first woman member until 1876. It took 113 more years for Nancy Dickey to become the first woman board member in 1989.
This tendency for women to be accepted as members but not as leaders in medicine has continued to the present day. According to the American Association of Medical Colleges (AAMC), in 1905 only 4% of medical school graduates were women; by 1965, this had increased only slightly, to 8%; in 1985, the number was 31%; and since 2003, about 48% of graduates of US medical schools have been women.1 So it essentially has been only for the past decade that women and men have been graduating from medical school at about the same rate.
In contrast, according to the AAMC, while women comprised 35% of the faculty in the 141 US medical schools in 2012, only 13 were deans, and women accounted for 21% of division and section chiefs, 19% of professors, 31% of associate professors, and 42% of assistant professors. The goal, of course, is that these iniquities will lessen as more women assume senior professorial and leadership positions.
It is also important to note that the specialty fields chosen by women, as compared with men, are quite different. According to the AAMC, 30.4% of all actively practicing physicians in the United States in 2010 (the latest data available) were women. However, 48% of pediatricians, 47% of obstetricians/gynecologists, 34% of general internists, and 32% of family physicians were women. Clearly, these specialties had a higher proportion of practicing women physicians than all other medical fields in 2012. In contrast, only 6% of urologists and 4% of orthopedic surgeons were women, representing the specialties least frequently chosen by women.2
These career choices made by women physicians have substantial financial consequences. The current median annual salary for a pediatrician is about $177,000; for an obstetrician/gynecologist, about $256,000; for a urologist, about $338,000; and for an orthopedist, roughly $432,000 (www.salary.com). The specialty choices made by women contribute, at least to some degree, to the generally 20% to 30% smaller salaries for female than for male physicians. Another reason for this disparity is the relative disproportion of women in leadership positions, which also command higher salaries. In any case, men simply are not choosing the primary care (ie, lower-paying) specialties at the same rate that women are.
So what effect do these specialty choices made by women have on the health of the population? It is hardly a secret that there is a substantial need for primary care physicians in this country. Considering the aging population and the expansion of health insurance coverage because of the passage of the Affordable Care Act of 2010, we will need 35,000 to 50,000 more primary care physicians over the next decade. Who will fill this need? If you have been reading this column carefully, you already know the answer. Since 1996, according to the AAMC, there has been a 40% increase in women choosing primary care specialties versus a 16% decrease for men.1
Looking to the future, women comprise 81% of obstetrics/gynecology residents and fellows, the highest percentage for any field, and 72% of pediatric residents and fellows, the second highest percentage. But only 13% of urologists and 9% of orthopedic residents and fellows are women.1 So the trend of more women in the primary care fields should continue in the near future.
Pediatrics is a primary care specialty and the only one in which the number of generalists versus specialists is balanced. And even though obstetrics/gynecology is not a primary care specialty per se, the majority of women will need the care of an obstetrician/gynecologist at some point in their life, usually for routine gynecological care.
I recently learned from my obstetrician/gynecologist colleagues that many of their patients refuse to allow male medical students or residents to care for them or even allow them in the room to observe the care provided by a woman physician. This bodes ill for men interested in that specialty and has great implications for the future of women’s health. I found this decision by women patients to be a very interesting twist, especially considering how few women are urologists, and yet female patients do not appear reluctant to be seen by male urologists or male medical students in those situations.
Some argue that because women physicians work fewer hours than men and take off months or years for child bearing and caring, their contributions to patient care is diminished. But it is also important to note that men have more significant health problems in later life, when they tend to be at the peak of their earning capacity, and live, on average, 2 to 3 fewer years than women. So might this total practice effort even out over a lifetime? In any case, until the unlikely event in which men are able to bear children, true equality will never be accomplished. We can aim only for equity.
In addition, it can be argued that women in general are naturally more nurturing than men. Surely a nurturing personality is what patients seek in a physician, but how important is that for physicians caring for patients? I know of no good study that has answered that question. It’s time for someone to do it. Will women physicians work as hard and for as many hours over their lifetime as men do? This question, too, needs to be studied and can be answered only over the next few decades, as we now have a better balance of the sexes in medicine and as many men are now contributing more to the care of their children.
Whatever the answers to these questions turn out to be, it is clear that while women were late in being allowed into the medical profession of medicine, most have chosen the primary care specialties and thus are contributing disproportionately more to the primary care medical needs of Americans, not to mention the population’s overall health. More to the point, Americans should be grateful that women physicians have made these choices.
Author(s): Catherine D. DeAngelis
Read on JSTOR
Volume 93, Issue 1 (pages 28–31)
Published in 2015
Catherine D. DeAngelis is Johns Hopkins University Distinguished Service Professor Emerita and professor emerita at the Johns Hopkins University Schools of Medicine (Pediatrics) and Public Health (Health Policy and Management), and editor-in-chief emerita of JAMA, where she served as the first woman editor-in-chief from 2000 to 2011. She received her MD from the University of Pittsburgh’s School of Medicine, her MPH from the Harvard Graduate School of Public Health, and her pediatric specialty training at the Johns Hopkins Hospital. She has authored or edited 12 books on pediatrics, medical education, and patient care and professionalism and has published over 250 peer-reviewed articles, chapters, and editorials. Her recent publications have focused on professionalism and integrity in medicine, conflict of interest in medicine, women in medicine, and medical education. DeAngelis is a member of the Institute of Medicine and a fellow of the American Association for the Advancement of Science and the Royal College of Physicians (United Kingdom). She currently serves on the advisory board of the US Government Accountability Office, is a member of the board of Physicians for Human Rights, and serves on the board of trustees of the University of Pittsburgh.
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