Every doctor needs a wife: An old adage worth reexamining

Half of medical school graduates are women, but female doctors experience significant professional tensions. Low numbers of women in leadership roles, high burnout and attrition, and continued harassment suggest a culture that undermines the contributions of women. This manuscript explores research from sociology, business and medicine through a personal lens. Understanding the way gender influences the complex state of women in medicine suggests changes are needed in the architecture of the modern medical workforce. Individuals, mentors and organizations can make changes that would improve the way that the working environment cultivates a diverse workforce to reach its full potential.

tension in the careers of female doctors [5]. Women are more likely to leave academic medicine than men before becoming associate professors [6]. In 2014, women represented 38% of full-time medical school faculty, 21% of full professors, 15% of department chairs, and 16% of deans [7].
Why has the prominence of women physicians lagged behind? The phenomenon is seen in other fields. Women earn half of professional degrees and occupy managerial roles, but few reach the upper echelons of leadership [8]. Across industries, qualified women leaving the workforce is causing a 'brain drain' [9]. Sociologists give three explanations for this: women opt out of opportunities based on different values; women spend time on non-work priorities; and women face discriminatory barriers at work [10]. Each of these factors plays a role.
Gender stereotypes describe certain characteristics as masculine: aggressiveness, decisiveness, independence, and confidence. Other characteristics are seen as feminine: kindness, cooperation, concern for others [11]. Role congruity theory suggests that stereotypes prescribe norms-the 'should' and 'should nots'-of how individuals behave [12]. Women may not aspire to roles that conflict with socially constructed values. A woman whose behaviour violates stereotype norms may be penalized in terms of social approval and performance evaluations [11,13]. The result is fewer women come forward and those that do have a harder time.

The influence of gender on professional aspirations and achievements
So what happens, then, when the doctor is a wife? I always wanted to be a doctor, but I remember the discrete moments of panic when I realized I would earn my medical degree before I married; when I learned about age-related declines in fertility. I feared that my professional choices would stand in the way of the life I had envisioned with a husband and children. My mother has a PhD, and worked full-time as a single mother after my parents divorced. I didn't see the professional trade-offs she faced, although she tells me they were there. What I saw was a mother who showed up to my field hockey games and stayed home when I was out of school sick. I did not think that I would have to choose between my professional aspirations and my hopes for a family.
An exclusive focus on work is neither the goal nor the reality for professional women. Globally, successful women describe paths that account for both career and family [14]. Balancing these goals leads to trade-offs: women are more likely than men to take time off, work part-time or choose roles with fewer responsibilities-and lower salaries [9-11, 15, 16]. Female physicians spend more time doing domestic work, and are more likely to interrupt work or reduce their hours when they have children [17][18][19]. This pattern reflects society's expectations as well as women's own values. One study concluded, 'for successful women in academic medicine, satisfaction is balance.' [20] At the end of residency, I remember weighing the subspecialty fellowship I had wanted to pursue against the plans I was making in my home life. I was getting married. I was turning 30 I count myself lucky. Research shows that academic productivity for female faculty is adversely affected by childrearing [6]. If women take opportunities to work part-time, reduce hours, share a job or stop a tenure clock, they get less satisfying work and may be perceived less worthy for promotion [10,21]. Flexibility policies intended to alleviate work-home conflict are associated with stigma of low professional commitment [6,7,9]. Women physicians around the world earn less than men [10,20,22,23]. This gap widens with age, spreading dramatically in the 40-44 year age range [9,13]. As an obstetrician, this timing seems chilling: at the same time careers accelerate, professional women may face consequences to fertility. Work-home tensions are cited as a barrier to women's involvement in leadership roles, and a contributor to high levels of burnout and depression seen in women physicians [8,24,25].
Despite recognizing inhospitable practices, discriminations, and trade-offs, female physicians report satisfaction with their professional lives [10]. It is a paradox that so many women who remain engaged in their work report satisfaction while studies show high rates of burnout among female doctors. High rates of attrition from women leaving the medical workforce suggest that many do not feel similarly satisfied with the balance between work and family roles [24,25].

The influence of gender on professional aspirations, expectations and evaluations
Unlike women of earlier generations who were conscious of their trade-offs in breaking with gender roles, I grew up assuming all paths were open. I'm not alone here. Young, white women may not recognize discrimination unless it is grossly obvious [12]. But in retrospect, the role of gender is clearer. From a very early age, I planned to be an orthopaedist. But as I worked in orthopaedic research labs and sports medicine clinics, I noticed two gendered roles available for women. I could retreat from my feminine side and assume a steely, aggressive pose. Or, I could giggle and tolerate being treated like a little girl. I didn't think that gender had anything to do with it, per se. I just started to feel like I did not belong. In obstetrics and gynaecology, I saw strong, smart, capable women surgeons who were warm to their patients and colleagues. The job fit with the vision I had for myself as a doctor and a woman. I'm not the only one feeling this way; most of our residency applicants are women. But even in obstetrics and gynaecology, only 20% of department chairs are women [26] Gender plays a subtle role in modern medicine. Reports of frank harassment and obstruction are no longer the norm. But, it is naïve to pretend that these do not exist [16,27]. A 2018 study of women physicians and their physician daughters revealed rampant, unchanged discrimination [13]. In interviews with women surgeons, each denied the role of gender in their own experience, but reported that discrimination was pervasive in their field [15]. Many medical students experience harassment [28]. Female doctors' contributions may be undermined [4,29]. It is not surprising that female physician leaders feel like cultural outsiders [8,13].
Differences in both academic and clinical priorities for women influence their career trajectories. Valuing the broad impact of service, teaching and personal balance, women have fewer grants and publications than male peers [19,20,25]. It is rare for academic centres to consider the role that these other activities play in academic productivity [6]. No one doubts that there is value in this work: that value is just challenging to account for in measuring productivity. In clinical practice, women take more time with patients, display superior communication skills and practice more in line with guidelines. They also have lower productivity in terms of terms of hours worked and number of patients seen [16,30]. A New York Times article asked 'Should You Choose a Female Doctor?' citing better outcomes for cardiac patients, surgical patients and Medicare recipients cared for by women physicians [16,[30][31][32]. These differences in outcomes are small, but these findings cast an important light on the question of 'productivity.' How could we better capture patient outcomes and satisfaction when measuring the quality of their physicians? In academic medicine, faculty must be 'individually successful contributors to their institution and society; committed professionals who work tirelessly for their patients, students, and the public; and role models of emotional, social and physical health. These expectations compete and no one achieves all of them all of the time' [19]. Faculty achieving this standard have personal support to 'devote the full force of their talents to these pursuits' [19]. The culture favours the support that a traditional housewife might provide. Both young men and women question this narrow definition of success, favouring more flexibility and engagement in non-work roles [10,19].

Organizational policies, practices and culture
Women represent half the medical workforce but are underrepresented in leadership roles [5]. Salary inequities exist between men and women doctors [5]. Flexibility policies (job-sharing, part-time work, stopping a tenure clock are rare and using them is associated with stigma) [26,41]. Traditional metrics of productivity (clinical dollars, research grants) may underestimate women's contributions (service, teaching, committees, mentoring, collaborative research) [11]. Women physicians approach their work differently, taking more time with patients and adhering to guidelines more. Some studies show improved patient outcomes for patients of women doctors [31,33]. Work centric culture and unrealistic expectations on the part of colleagues may play a role in high rates of attrition among women physicians [10,34]. Gender bias may result in discrimination, hostility and underestimating work done by women [11,25,29].

Work-home conflict
For women in academic medicine, 'satisfaction is balance' [20]. Real and perceived trade-offs exist for women between work and non-work life, parental and work roles, and delaying a family for the sake of not falling behind professionally [10]. Women physicians spend more time than their male peers doing domestic work [10]. Women more likely to work part-time or take time off for life events. There may not be an 'on-ramp' for doctors who take an 'off-ramp' [9]. Both men and women increasingly question narrow definitions of professional success, favouring more flexibility and engagement in non-work roles [10,19].

Role models and community
More women enter academic medicine than men, but leave in disproportionate numbers before achieving the rank of associate professor [6]. Women balance goals at home and work and often have separate identities within these different spheres [34]. Women physicians report feeling isolated, invisible and marginalized [34]. Women leaders may cope with these challenges by self-silencing and creating micro-environments which do not lead to broader culture change [34]. Women leaders may be penalized in terms of social approval for professional competence when their behaviour violates gender expectations [11,13]. There is a lack of role models and sponsors [9,25]. Women of colour report being in a 'double bind' as outsiders [38].

The importance of mentors to consider personal and professional goals
In my own life, I see gains as well as losses in the trade-offs between work and home. My husband and daughters have a sweet private bedtime ritual when I am on call. When my kids are sick, our nanny cares for them as I am not the household manager my grandmother was. But I make the muffins when it is time for special snack at school. A mentor gave me treasured advice to think hard about when I need to be home, and when I don't. Did I really need to give my kids a bath? Or was it enough for me to dive right into bedtime reading at the end of a long day?
Role models who represent both a desirable career path and a desirable lifestyle are hard to find [25]. Strategies used by successful female physicians to navigate traditionally male roles can be isolating. Women silence themselves to gain acceptance or create 'dual selves' for different roles, and in doing so lose power to influence professional culture together [25,33]. Individual women feel discouraged by role strain and concerns about their own competence [10,34]. The ones who succeed continue to feel isolated within traditions that favour men [20,33].
Mentors offer the potential to improve satisfaction by helping a mentee clarify values and navigate institutional barriers [20]. Sponsorship (publicly endorsing a mentee or offering an opportunity) may be more effective in promoting professional advancement than relational mentorship that focuses on professional style. Networking through professional societies may provide valuable, impartial supports [19]. Studies show that shared values between mentor and mentee are more important than shared gender [16]. Advice to female students to assume an assertive, masculine style is short-sighted [35]. In considering professional choices, one size does not fit all, and mentees should be challenged to question their sense that they do not 'fit' a particular role, as this may be the influence of stereotypes [19]. Given how important balancing activities in both personal and professional spheres seems to be for success, both work and home should be considered in mentoring. Mentees may need encouragement to navigate institutional barriers, or to consider whether stigma is preventing a mentee from taking advan- 2. Mentors should engage in both relational mentorship (coaching, advice) but also in concrete sponsorship (promoting mentee and identifying opportunities for advancement). 3. Help mentee to clarify values and goals in both personal and professional spheres. Encourage reflection on personal style and conflicts between approaches needed for success in these different arenas. 4. Discuss time management and look for ways to help balance work and life activities. 5. Challenge barriers that may reflect the mentee's perception that they do not 'fit' a particular role. This may be the influence of stereotypes. 6. Look for professional development opportunities that exist through professional societies, especially those involving group work and networking with mentors [19,41]. 7. Identify institutional obstacles and discuss how these can be strategically navigated. 8. Encourage use of flexibility policies when they exist. Explore perceptions of stigma around making use of these options. 9. Coach women through career setbacks. Successfully navigating these leads to empowerment, resiliency and acceptance [20]. 10. 'Push out' professional development opportunities to promising women rather than assuming these women will identify their own potential or suggest themselves for these roles unless they are overqualified.
tage of existing flexibility policies. Mentors of female faculty will want to consider the complex landscape (Tab. 1) and encourage their mentee to reflect on their own goals (Tab. 2). The most engaging and productive career is the one that fits best with that individual's overall life.

Looking ahead
The other day, one of my most talented junior colleagues shared with me her concerns about her career. She was applying for a competitive position, and worried that she would be disqualified as a serious candidate because she had taken a short detour on a less demanding path during a critical time in her family. I encouraged her that she had gained valuable experience, and the short delay was insignificant in the timeline of her career. I could not guarantee that others would see her competence and potential the same way I did. But I did encourage her to pursue her path to leadership, knowing that she-and the diversity of experience she brings to the table-will bring us one step further in the right direction.
Women make excellent doctors and leaders [31]. Across the globe, studies show that women leaders add value [8]. The number of female professionals is increasing, with disproportionate growth coming from underrepresented groups [9]. Minority women are in a 'double bind', and may be better equipped to identify the subtle biases operating in academic health centres [19,33,36]. Without diversity in leadership, the factors obstructing the progress of many gifted physicians will persist.
Statistics about disparities in rank, pay and representation do not tell the story of why doctors who do not fit traditional archetypes struggle over the arc of their careers [12]. Both practical adjustments and a cultural shift are needed to capture an individual's contribution beyond traditional metrics [10,19,37]. Investing in flexibility policies, faculty development and mentoring will help cultivate a diverse workforce [9,10].
There is an economic argument for investing in physician resilience, based on poor performance by burned out physicians [38,39]. Addressing work-home conflict, exhaustion, and dissatisfaction will benefit both men and women. Professional dissatisfaction is increasing in younger male faculty [6,40]. The work of academic medicine is inherently demanding. But there is no reason to hold fast to a system that fails to capture the full potential of its workforce.

Call to arms
Does every doctor need a wife? No. But, she needs a village. She needs a revolution, and she needs a path to reach her full potential personally and professionally. Only by challenging the unexamined expectations for success will healthcare evolve to meet the needs of its doctors-and their patients.