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Gender gap in choosing primary care continues to widen

As more men choose specialties, the implications for care run deep

From the October ACP Observer, copyright © 2007 by the American College of Physicians.

By Jessica Berthold

Sarah Simpson, FACP, runs a Seattle primary care clinic where eight of the 10 providers are women. Sometimes, said Dr. Simpson, she feels like the Marines.

"In my practice, we're just looking for a few good men," she quipped.

Dr. Simpson's is hardly an isolated case. A recent study shows that the much-reported decline in primary care doctors in the U.S. can largely be attributed to an increase in the number of men choosing specialties over primary care. Meanwhile, women continue to pick primary care at about the same historical rate, according to the June 2007 report by the Center for Studying Health System Change (HSC), a nonprofit policy research group (www.hschange.com).

Between 1996-97 and 2004-05, the number of male primary care doctors dropped from 39.3 per 100,000 people to 33, while female primary care doctors increased to 17 per 100,000 from 12.1, the report found. That's a 16% decrease in the supply of male primary care doctors relative to the U.S. population, compared with a 40% increase in female primary care doctors. At the same time, the portion of specialists within the overall physician population rose to 38% from 32%.

For now, women—who comprise 27% of practicing physicians—are helping to stem the decline in primary care physicians. Yet it remains to be seen whether this trend will continue, experts said. Not only have primary care salaries declined compared with specialty and surgery medicine in the last decade, women made 22% less, on average, than men for the same jobs in 2003, even after controlling for factors like hours worked, board certification and practice ownership. Eventually, women may decide to go the way of their male counterparts into higher-paying positions, said Ann O'Malley, MD, co-author of the report.

"If these trends continue, we may see fewer women as well as men going into primary care," Dr. O'Malley said. "It definitely has implications for the adequacy of the primary care workforce and whether it can meet the needs of the population."

Patient-centered temperaments

Experts are understandably hesitant to make generalizations about why women might prefer primary care more than men. They are especially leery of pointing to stereotypes about differences in temperament.

Yet research supports the idea that there may be gender differences in attitudes that, in turn, drive medical career choices. A June 2002 article in Medical Education found female gender was strongly associated (P<0.001) with patient-centered attitudes. And an October 1999 article in the International Journal of Psychiatry in Medicine found female medical students were more patient-centered, a trait that was associated with interest in primary care practice.

"Women tend to value the patient-physician communication aspect of primary care pretty highly, and others have found in their research that some of the relationship issues that make primary care an attractive career choice just appeal to women," Dr. O'Malley said.

Of course, practical considerations come into play when choosing a career, too. Given that a man is still more likely to be the primary wage earner in a family than a woman, it makes sense that men would gravitate toward higher-paying positions like specialties, several experts said.

In some cases, it's a simple case of doing the math, if you are a man whose wife doesn't work and you have a family and medical school debt, then becoming a sub-specialist may make it easier to pay the bills," said Christine Laine, FACP, senior deputy editor of Annals of Internal Medicine. "Many female physicians are in dual-working families, and might not be the primary breadwinner."

The average net income of a primary care doctor in 2003 was $146,405, compared with $235,820 for specialists, according to a 2006 report by the HSC. After adjustment for inflation, primary care doctors' incomes declined 10% between 1995 and 2003, while that of specialists kept pace with inflation, the June 2007 report said.

Biology drives career choice as well. Most women are at least in their late 20s when they finish residency training, and may need to balance another three years of fellowship training with trying to start a family, Dr. Laine said.

"It's difficult to start a family when you are in training, and there isn't a lot of flexibility in these programs," Dr. Laine said. "In many training programs, if someone has to go on leave for six weeks it creates a huge burden for their colleagues."

Natalie Doyle, ACP Member, a solo primary care internist in Wilson, N.C., knows firsthand how difficult it is to blend motherhood with fellowships.

"I was in fellow practice for two of my three pregnancies, and it was tough, because I pretty much had to work those long hours and weekends. Plus, patients get upset if you take time off," said Dr. Doyle. "Now that I have three small children, I can't imagine going back to do a fellowship."

Seeking mentors

Another factor in women's career decisions, Dr. Doyle added, is that they lack role models in many of the specialties in their training years. During her residency rotations at Wright State University in Dayton, Ohio, she said, there was only one female gastroenterologist out of eight, and there were no female cardiologists.

"I think both men and women go where they are welcomed," agreed Sharon Meyers, FACP, a primary care internist in Eugene, Ore. "Back when I was a resident, women were just not as welcomed in the surgical fields."

The current lack of positive role models may partially explain why fewer men are choosing general internal medicine after residency, said Steven Weinberger, FACP, senior vice president for medical education and publishing at ACP.

"Residents have been seeing role models who have become somewhat disillusioned by the practice of general internal medicine. In general, people who are dissatisfied end up being more vocal than those who are happy," Dr. Weinberger said. "In fact, though, there is a lot of satisfaction among primary care physicians as far as having a positive impact on society and their patients."

In addition, residents are mostly trained at academic medical centers, which tend to be oriented toward inpatient, subspecialty medicine. This sends a tacit message that acute, subspecialty care is the better place to practice, Dr. Weinberger said, when in reality most internists are office-based. For example, 43% of respondents to ACP's 2006 Member Survey reported working in a private ambulatory care office, compared with 19% in academic medical centers and 17% in private community hospitals.

"We really don't have it right in the training model we use," said Dr. Weinberger. "We should be switching our training process to reflect where the majority of care is actually given."

Flexible lifestyles

Some see primary care as more appealing to mothers because of the potential for more flexible hours. Virginia Collier, FACP, noted that primary care doctors who work with hospitalists or use a "shared hours" model often have more predictable, curtailed schedules.

"Two people in a full practice can share patients, which would allow part-time work for each. And a primary care doctor can work with a hospitalist so the latter will admit patients on weekends and after-hours," Dr. Collier said. "Also, a person with a primary care degree can go into health care policy, consulting or public health, where the job hours are more defined."

Nonetheless, several internists countered, it's easier for some outpatient-based specialties to schedule regular part-time hours than it is for many primary care doctors.

"Anyone can set up a primary care practice to have predictable hours, but when you are on call, or a patient crumples, your life is turned upside down," said Dr. Doyle.

At least one study has found that the desire for controllable hours isn't gender-based. A Sept. 2005 article in Academic Medicine found graduating male and female medical students expressed similar rates of declining interest in specialties with "uncontrollable" lifestyles—and that women were actually slightly more likely to choose an uncontrollable lifestyle specialty.

Fallout factors

An increase in women in primary care may yield benefits in terms of quality of care, as women often have a better sense of what it's like to be a patient in the health care system, said Dr. Laine.

"Usually, it is the woman's role in the family to organize health care for her kids, herself, her husband and her parents," said Dr. Laine. "Women might realize more why it's important to write prescriptions that don't need to be refilled every week, or why it's just as important to let people know when test results are normal as when they are abnormal."

As well, the finding that women remain interested in primary care is positive in light of the fact that more and more women are becoming doctors, said Edward Salsberg, director of the Center for Workforce Studies at the Association of American Medical Colleges.

“In 2006-07, women comprise 44% of all residents in training,” said Mr. Salsberg. “Their growing representation in medicine will help primary care.”

On the other hand, there may be negative consequences to the surge of women in primary care. Since female doctors already get paid less than male doctors, their increase in numbers in primary care may drag the average paycheck downward, Dr. Laine noted. That, in turn, might cause the status of the profession to decline—both things that will continue to make primary care a less attractive career option.

Women also tend to work fewer hours—46.9 per week, compared with 53.6 for men in 2004-05, according to the HSC report.

"The increase in female primary care physicians cannot make up, on a one-to-one basis, for the departure of men from the field," the authors wrote.

Having a choice of primary care doctors is also important for patients, Dr. Doyle noted. "Some people want to see a man; others prefer a woman. I don't think it's good to have any more of one over the other, from a patient perspective," she said.

Remedies

Fatter paychecks would be the single most effective way to draw both men and women into primary care, experts and general internists agreed. While Medicare did increase payments for evaluation and management services in its 2007 update of physician fee schedules, the gains for primary care doctors are thought to be small, and still don't cover services like coordinating care and educating patients, the HSC report said.

"Reimbursement needs to better reflect the work that primary care doctors do. Cognitive services are under-reimbursed compared to the more procedural services that specialists do," said Dr. O'Malley. "We don't just need to attract more men to the field; we need to attract more of everyone."

Other developed countries don't have the same problems drawing primary care doctors as the U.S., because their pay tends to be more in line with that of specialists, noted David Blumenthal, ACP Member, director of the Institute for Health Policy at Massachusetts General Hospital/Partners HealthCare System and an expert on physician supply.

"The differential in payments is much higher here than elsewhere," Dr. Blumenthal said.

The U.S. marketplace does seem to be waking up to the shortage of primary care doctors—which, in turn, may elevate incomes, Mr. Salsberg said. He pointed to the recently released 2007 Review of Physician Recruiting Incentives by Merritt, Hawkins & Associates, which found that searches conducted for general internists rose by 120% from 2003 to 2007.

"There seem to be more signs in the last six to 12 months that the marketplace is having a harder time recruiting primary care doctors, and that may have an impact on the wages employers are willing to pay," Mr. Salsberg said.

As well, Dr. Blumenthal noted, even the Democratic presidential candidates are talking about the primary care shortage.

"I think it will lead to some change to the reimbursement system eventually, though it is probably going to take a while," Dr. Blumenthal said.

Primary care doctors tend to suffer from a lack of prestige which, if corrected, might draw more men to the field as well, said Dr. Weinberger.

"During training, people are almost indoctrinated to think that subspecialties require more skill," Dr. Weinberger said. "And some subspecialists look down on primary care physicians as being unable to handle complicated problems, when the converse is often true because the general internist needs to have a broader scope of knowledge."

Attitudes are, admittedly, difficult to fix, he added. But medical schools can take it upon themselves to identify primary care champions who are willing to "raise the flag" about the positive elements of primary care. Training programs also bear responsibility for assuring that residents get connected with positive primary care role models, he said.

"If the subspecialists are saying that what they do is the peak of internal medicine, there need to be an equal number of general internists saying the same thing," Dr. Weinberger said.

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