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For mid-career oncologist Tanya Wildes, MD, the pandemic was the last straw. In late September, she tweeted: "I have done the academically unfathomable: I am resigning my faculty position without another job lined up."
She wasn't burned out, she insisted. She loved her patients and her research. But she was also "100% confident" in her decision and "also 100% sad. This did not have to happen," she lamented, asking not to disclose her workplace for fear of retribution.
Dr Tanya Wildes and family
Being a woman in medicine "is a hard life to start with," Wildes told Medscape Medical News. "We all have that tenuous balance going on and the pandemic made everything just a little bit harder."
She describes her pre-pandemic work-life balance as a "Jenga tower, with everything only just in place." But she realized that the balance had tipped, when after a difficult clinic she felt emotionally wrung-out. Her 11-year-old son had asked her to help him fly his model airplane. "I told him, 'Honey, I can't do it because if it crashes or gets stuck in a tree…you're going to be devastated and I have nothing left for you.' "
This was a eureka moment, as "I realized, this is not who I want to be," she says, holding back tears. "Seventy years from now my son is going to tell his grandchildren about the pandemic and I don't want his memory of his mom to be that she couldn't be there for him because she was too spent."
When Wildes shared her story on Twitter, other women oncologists and physicians responded that they too have felt they're under increased pressure this year, with the extra stress of the pandemic leading others to quit as well.
The trend of doctors leaving medicine has been noticeable. A July survey from the Physicians Foundation found that roughly 16,000 medical practices had already closed during the pandemic, with another 8000 predicted to close within the next year.
"Similar patterns" were evident in another analysis by the Larry A. Green Center and the Primary Care Collaborative, as reported by The New York Times. In that survey, nearly one fifth of primary care clinicians said "someone in their practice plans to retire early or has already retired because of COVID-19," and 15% say "someone has left or plans to leave the practice." About half said their mental exhaustion was at an all-time high, the survey found.
"COVID-19 is a burden, and that added burden has tipped people over the edge of many things," acknowledges Monica Bertagnolli, MD, chief of the Division of Surgical Oncology at Brigham and Women's Hospital in Boston and former president of the American Society of Clinical Oncology (ASCO).
"It has illustrated that we do have a lot of people who are working kind of on the edge of not being able to handle everything," she says.
While many in medicine are struggling, the pandemic seems to be pushing more women to leave, highlighting longtime gender disparities and increased caregiving burdens. And their absence may be felt for years to come.
Firm numbers are hard to come by, says Julie Silver, MD, associate professor, associate chair, and director of cancer rehabilitation in the Department of Physical Medicine and Rehabilitation at Harvard Medical School and an expert in gender equity in medicine. But she sees some troubling trends.
"There are many indications that women are leaving medicine in disproportionately high numbers," Silver told Medscape Medical News. "A lack of fair pay and promotion opportunities that were present before COVID-19 are now combined with a host of pandemic-related challenges."
A survey of 1809 women conducted in mid-April with the Physician Moms Facebook Group and accepted for online publication by the American Journal of Psychiatry found that 41% scored over the cutoff points for moderate or severe anxiety, with 46% meeting these criteria among frontline workers.
"It's really important for society to recognize the extraordinary impact this pandemic is having on physician mothers, as there will be profound ripple effects on the ability of this key segment of the healthcare workforce to serve others if we do not address this problem urgently," co-senior author Reshma Jagsi, MD, DPhil, a radiation oncologist at the University of Michigan, told Medscape Medical News.
Women weighed in on Twitter, in response to Silver's tweet to #WomenInMedicine: "If you are thinking of leaving #medicine & need a reason to stay: we value you & need you"
In reply, Emmy Betz, MD, MPH, associate professor of emergency medicine at the University of Colorado School of Medicine, said via Twitter, "I've had lots of conversations with women considering leaving medicine."
"I have thought about leaving many times. I love what I do, but medicine can be an unkind world at times," responded Valerie Fitzhugh MD, associate professor and pathologist at Rutgers New Jersey Medical School.
"Too late. Left at the end of July and it was the best decision ever," wrote Michelle Gordon, DO, who was previously a board-certified general surgeon at Northern Westchester Surgical Associates in Putnam Valley, New York.
Prepandemic Disparities Accentuated
The pandemic "has merely accentuated — or made more apparent — some of the longstanding issues and struggles of women in oncology, women in medicine, women in academia," says Sarah Holstein, MD, PhD, another mid-career oncologist and associate professor at the University of Nebraska Medical Center.
"There are disparities in first-author/last-author publications, disparities in being asked to give speaking engagements, disparities in leadership," Holstein told Medscape Medical News. "And then when you put on top of that the various surges with the pandemic where you are being asked to do clinical responsibilities you don't normally do, perhaps some things you haven't done since your training 10 or 20 years ago."
This is backed up with data: There is already a "robust" body of prepandemic literature demonstrating pay gaps for female physicians and scientists, notes Silver, who founded the Her Time Is Now campaign for gender equity in medicine and runs a women's leadership course at Harvard.
In addition, female physicians are more likely to be involved in "nonpromotable" work, group projects and educator roles that are often underappreciated and undercompensated, she says.
Writing recently in a blog post for the BMJ, Silver and her colleagues predict that as a result of the pandemic, female physicians will "face disadvantages from unconscious bias in decisions about whose pay should be cut, whose operating schedules should take priority when resources are limited, and whose contributions merit retention...The ground that women lose now will likely have a profound effect for many years to come, perhaps putting them at a disadvantage for the rest of their careers."
There is already evidence of reduced publishing by female scientists during the pandemic, something that "could undermine the careers of an entire generation of women scholars," notes Caitlyn Collins, PhD, an assistant professor of sociology at Washington University in St. Louis.
"Science needs to address the culture of overwork," Collins told Medscape Medical News. "Parents and other caregivers deserve support. The stress and 'overwhelm' they feel is not inevitable. A more fair, just, and humane approach to combining work and family is possible — what we need is the political will to pass better policies and a massive shift in our cultural understandings about how work should fit into family life, not the other way around."
Lack of support for "vulnerable scientists," particularly "junior scientists who are parents, women or minorities" could lead to "severe attrition in cancer research in the coming years," warned Cullen Taniguchi, MD, PhD, a radiation oncologist and associate professor at the University of Texas MD Anderson Cancer Center, and colleagues, in a recent recent letter to the journal Cancer Cell.
"The biggest worries of attrition will come from young faculty who started just before or after the pandemic," adds Taniguichi in an email. "The first year in an academic setting is incredibly challenging but also important for establishing research efforts and building networks of colleagues to collaborate with. While completely necessary, the restrictions put in place during the pandemic made doing these things even more difficult."
Another Stressor: Caregiving at Home
Another reason female physicians may be marginalized during the pandemic is because they are more often the primary caregivers at home.
"Anyone who is a caregiver, be it to kids, parents, or spouses, can relate to the challenges brought [on] by the pandemic," says Ishwaria Subbiah, MD, a palliative care physician and medical oncologist at MD Anderson.
"Most of us work toward meeting our responsibilities by engaging a network of support, whether it's home care workers, center-based or at-home childcare, schools, or activities outside of school. The pandemic led to a level of disruption that brought most (if not all) of those responsibilities onto the caregivers themselves," she told Medscape Medical News.
As the mother of an adult son with severe epilepsy, Bertagnolli has certainly experienced the challenges of parenting during the pandemic. "Our son is now 24 but he is handicapped, and lives with us. The care issues we have to deal with as professionals have been enormously magnified by COVID," she says.
But she cautions against making gender distinctions when it comes to caregiving. "Has it fallen on the women? Well, this kind of stuff generally falls on the women, but I am certain it has fallen on an awful lot of men as well, because I think the world is changing that way, so it's fallen on all of us."
There is no question that female oncologists are bearing the brunt, both at work and at home, contends Taniguchi. "Absolutely. I have seen this first-hand," he told Medscape Medical News.
"If it was difficult for women, underrepresented minorities, and junior faculty to find a voice in the room prepandemic. I think it can be harder in the times of virtual meetings when it is difficult to engage audiences," he says.
Holstein says she is lucky to be well-supported at her institution, with both a female chief of hematology/oncology and a female chair of internal medicine, but still, she worries about the long-term consequences of the pandemic on the gender landscape of medicine.
"If you're having to put aside research projects because you have extra responsibilities — again because women just tend to have a lot of other things going on — that might not be a big deal for 3 months, 6 months, but this is going to be a year or 2 years before 'normal' comes back," she says. "One to two years of underpublishing or not getting the grants could be career killers for women in academic oncology."
Cancer COVID-19 Combo
As Wildes completed her final weeks of seeing cancer patients, she received an outpouring of support which she says convinced her of the shared experience of all doctors, and especially female doctors, during the pandemic. But even more specifically, she feels that she has tapped into the unique burden shouldered by oncologists during this time.
"It's intimidating being an oncologist; we are literally giving people poison for a living. Then throw into it a pandemic where early in March we had so little data. I was helping my patients make decisions about their cancer care based on a case-series of four patients in China. The burden of those conversations is something I never want to have to live through again," she says.
"Oncology is a particularly intense subspecialty within medicine," agrees Subbiah. "The people we care for have received a life-altering and potentially life-limiting diagnosis. Coupled with that, the COVID-19 pandemic has brought an unprecedented cloud of uncertainty…Whether the patients can see it overtly or not, oncologists carry the weight of this worry with them for not just one but all of their patients."
Wildes says she plans to return to academic medicine and clinical care "in time," but for now, the gap that she and others like her leave is troubling to those who have stayed on.
"We need these women in medicine," says Holstein. "We have data suggesting that women take more time with their patients than men, that patient outcomes are better if they have a female physician. But also for the generations coming up, we need the mid-career and senior women to be in place to mentor and guide and make sure we continue to increase women in leadership."
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Cite this: Are More Women Physicians Leaving Medicine as Pandemic Surges? - Medscape - Nov 30, 2020.