Characteristics of Women Internists

Erica Frank, MD, MPH; Tricia Kunovich-Frieze, MD; Giselle Corbie-Smith, MD

Medscape General Medicine. 2002;4(1) 

In This Article

Discussion

There have been no previous large studies of ways in which women internists differ from or are similar to other women physicians, and the authors know of none that examine ways in which women generalist and subspecialist interns differ. In general, women general internists resemble other women primary care physicians more than they do subspecialized women internists; the authors found interesting differences between groups regarding a number of dimensions.

Prior studies have found that women internists are younger and more recent graduates from medical school than are men internists,[10,11] a pattern that is true for most specialties.[12] The authors found further, however, that women internists were even younger than other women physicians, a reflection of the especially dramatic increases in numbers of women choosing internal medicine as their specialty.

The authors found that women general internists were more likely to have children and to be the primary caretaker of those children. Generalists may reject additional training (and the frequent accompaniment of inflexible and rigorous schedules) because they wish to start their families earlier or have larger families; alternatively, subspecialists may delay family obligations to allow further training.

Internists' personal health behaviors of are of interest because previous studies have shown that physicians in general,[13] and internists in particular,[14] with better health habits are more likely to counsel patients. In addition, internists with better health habits may have less anxiety, less job stress, less conflict, and greater life satisfaction than those with poor habits.[15]

There have only been a few prior investigations of internists' health habits, and they have primarily included men. A large national study[14] (N = 1349, 7% women), and a smaller study[15] conducted at a western urban teaching hospital (N = 211, 91% men) both found that only 4% of internists smoked daily, similar numbers to the authors' findings (3.4% current smokers). Daily alcohol use was reported by 11%[14] and 9%,[15] versus the authors' finding of 3%; the national study[14] reported that fewer women (30%) than men (40%, P < .05) drank daily or several times per week. Women internists were also found to be more likely than were men internists to always or almost always wear their seat belts (79% vs 70%, P < .05); these rates are similar to those in the women internist population (84%). The authors found that internists generally had personal health habits that were as good as those of other physicians' excellent habits.[5]

A few studies have delineated ways in which male and female internists' training- and practice-related characteristics differ. Women internists are more likely than are men to train in the most prestigious residency programs and to practice general internal medicine, but are less likely to be board certified.[16] Among academic internists, women were more likely to have completed a primary care residency and were less likely to have been chief resident.[10] Once in practice, female academic physicians worked somewhat fewer hours per week (55 vs 58), but spent a greater percentage of time in patient care and less in research or administration.[10] They also perceived less support for all work activities (patient care, education, research, and administrative work). Some have found that academic women physicians have fewer grants submitted, fewer grants funded, a lower grant funding rate, fewer recent and fewer total publications, lower academic ranking, and lower salaries.[10] Others[17] have found, however, after adjusting for variables such as age, Alpha Omega Alpha honor society membership, race, training, and rank, there were no significant gender-based differences in work hours per week; time in patient care, teaching, research, or administration; access to research help; grants submitted, funded, or funding rates; number of current or total publications; abstracts submitted or accepted; frequency of being a reviewer or editorial board member; having tenure; career satisfaction' or likelihood of leaving academic medicine. Higher achieved academic rank and compensation for men internists, however, did persist, even after adjustment for the abovementioned variables, as well as adjustment for other variables such as work hours per week, number of grants, and number of first-authored publications.

The authors are not the first to report compromised career satisfaction among internists. A 1990 study[18] of 1290 internists (% of women not reported) found that 69% view their practices, on balance, as satisfying. However, while > 80% of internists were satisfied with their relationships with patients, professional challenges, and opportunities to interact with colleagues, only 39% would repeat their decision to enter internal medicine (21% would choose another medical specialty, 19% would select a nonmedical career, and the other 21% were undecided). Barriers to satisfaction include insufficient time for nonmedical interests, low personal control over one's practice, and relatively low income (with only one half of all generalists satisfied with income, vs two thirds of specialists). Despite the dissatisfaction with income, 30% would give up income if they were assured less administrative duties and less interference in decision-making.

Internists reported less career satisfaction than did other women physicians. Subspecialized women internists, despite similar numbers of call nights and perceived work control, were more likely than other women specialists to feel they worked too much, perhaps due to having heavier nonclinical workloads. Women general internists were also more likely than other primary care women physicians to report severe work stress and were more likely than other women internists and other primary care women physicians to change their specialty if they were to relive their careers.

The authors found that work control was the most potent and consistent predictor of internists' career satisfaction. This is true for all women physicians, with those always/almost always being in control of their work environment having 11.3 times the career satisfaction of those sometimes, rarely, or never in control of their work environment.[6] Internists may be acutely aware of such control issues as real and potential losses of clinical autonomy and income, undesired administrative responsibilities, and threatened suits that characterize the changing healthcare environment. Some HMOs are reverting to higher degrees of clinical autonomy for physicians; this may boost satisfaction.[19]

The authors also found that prior harassment severity significantly predicted career satisfaction among subspecialists. The authors had found in previous work that both gender-based and sexual harassment significantly (P < .01) predicted career satisfaction and desire to again become a physician.[20] As with work control, this finding is susceptible to change by receptive institutions. Finally, the authors also found that those who had some night call but were on less than 3 times/week reported the most career satisfaction. It is difficult to know whether this is a function of optimization of call or a marker for some other condition such as control of the work environment.

Previous counseling studies[14] have found that more women than men internists counsel on smoking, that general internists are more likely than subspecialized internists to counsel all patients at risk on smoking, alcohol, and exercise,[14] and that some subspecialized internists may be especially avid counselors on relevant disease-related habits.[21] Physicians[13] in general, and internists in particular[21] who practice healthy related personal practices have previously been found to be more likely to discuss related health practices with their patients.

Other investigators have also demonstrated[22] that subspecialized internists exhibited more compliance with recommended health promotion and disease prevention practices than did other subspecialists. However, they found that these high levels of compliance were specific to those practices that directly related to their subspecialty, presumably where they had received the most training, and did not carry over into other health promotion and disease prevention practices. What are also concerning in the authors' results and supported by other work[18,22] are the areas where self-supported counseling/screening rates by general internists are low compared with those of other primary care physicians or inadequate given the practice population's needs. While generalists counseled more frequently on flu vaccines, they were less likely to perform yearly clinical breast examinations or to counsel regarding HRT than were general or family physicians. Although most of the women general internists believed that these activities were important and felt confident in their ability, relatively few felt they had received extensive related training, suggesting some potential directions for internal medicine training programs.

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