Women found more likely to burn out from practice stress

General internist Barbara Horner-Ibler, MD, PhD, finds keeping to her schedule difficult, even though she sees only the minimum number of patients her practice requires -- eight per half-day.

"This week I had one male patient in my schedule in the middle of my afternoon," she said. "I was running late, as usual, and my thought when I saw his name was, 'Oh good, a man. He'll want to get back to the office. I can catch up.' "

When she walked in and asked him how he was doing, the patient's eyes welled with tears. He'd just lost his job.

"So much for my one quick visit," Dr. Horner-Ibler said. "Needless to say, I did not catch up."

The practices of female primary care physicians are different from those of their male counterparts, according to data collected by Dr. Horner-Ibler.

Typically, women doctors find that their patient panels are highly complex and predominantly female -- often because these patients seek out female physicians. Like Dr. Horner-Ibler, physicians may find it difficult to stay on schedule as they deal with these time-intensive patients. They are also twice as likely to report high levels of stress and feeling burned out as their male counterparts.

As women inch closer to being half of the physician work force, their impact on the medical profession will grow. This makes it paramount that women become involved at the highest levels in their organizations to make practicing medicine a better fit for women, say Dr. Horner-Ibler and fellow researchers.

Dr. Horner-Ibler, who is also an assistant professor at the University of Wisconsin Medical School in Madison, presented her most recent research results at an Assn. of American Medical Colleges conference last month. Her work is part of a larger project called "Minimizing Error, Maximizing Outcomes" or MEMO, a three-year study on whether physician satisfaction means higher quality care with fewer errors.

The study surveys 420 primary care physicians in Illinois, New York and Wisconsin and their office administrators as well as 2,500 of their patients. The MEMO study is intended to build on the "Physician Work Life Study" published in the June 2000 Journal of General Internal Medicine.

Not enough time

What this research has found is that female physicians tend to have more Medicare, Medicaid and uninsured patients than male physicians. They wish they had more time per patient and feel more at odds with the values of the organizations in which they work than men.

"As a woman physician, I know I spend much more time with patients than my male colleagues," Dr. Horner-Ibler said. "I spend probably double the amount of time in phone calls to patients that my male colleagues spend in a week. What surprised me [in this research] was the fact that nothing in my experience is unique. Women everywhere in every system are experiencing these stressors. ... The data we have thus far clearly show that the essence of the job is different for women because of how patients sort themselves out."

To deal with this, practices need to devise a compensation plan that reflects the different patient panels women physicians treat, she said.

"Someone has to see these more difficult patients, and who better than women? But practices need to understand that seeing these patients requires more time and energy and that more time needs to be allotted to women physicians [to treat these patients]," Dr. Horner-Ibler said.

In the National Football League, this is called revenue sharing, which allows teams in smaller markets to survive, increasing the appeal of the entire sport.

"Revenue sharing in practices, where men are seeing more patients and women are seeing more difficult patients, should be implemented, so that all physicians and all patients find themselves more satisfied, less stressed and healthier," she said.

Finding solutions

While Dr. Horner-Ibler has yet to find a practice that accommodates female physicians by expanding appointment times or instituting a revenue-sharing compensation package, Mark Linzer, MD, chief of general internal medicine at the University of Wisconsin in Madison and principal investigator for MEMO, is optimistic that it's only a matter of time before such changes are implemented.

"These problems are solvable," he said. "I think many places would be willing to change if there were clearer data. What is the adjustment factor one would give for women doctors? What's the correct panel size? We need to get templates out there that are based on good evidence, and I think we're close to being able to show that with the MEMO study."

In the meantime, women are finding their own solutions. Anecdotal reports say some women are leaving primary care to return to fellowships in procedural fields where they can earn more and have more manageable schedules. Work-force watchers say a growing number are working part time, and some say women are retiring earlier than men.

What will it take to make the profession more woman-friendly? Molly Carnes, MD, a geriatrics professor and director of the Center for Women's Health Research at the University of Wisconsin, said it is critical for women to rise within the profession to have their needs valued.

"You can't leave the societal roles that women and men have played in our culture at the doorstep when you come to work, and they work against women when they move into a traditionally male field that's built to meet a man's lifestyle and career trajectory," Dr. Carnes said.

When Bernadine Healy, MD, became the first woman director of the NIH, the agency launched the Women's Health Initiative, significantly changing how health care for women is approached. Female physicians can duplicate such gains if they move up in the medical hierarchy, Dr. Carnes said.

"If you make a system good for the most vulnerable population, you make it better for everyone," she said. "If we change the system of medical practice to make it better for women, it will be better for men, for everyone."

Carol Berkowitz, MD, executive vice chair of pediatrics at Harbor-UCLA Medical Center, president of the American Academy of Pediatrics and a member of the American Medical Association's Women Physicians Congress governing council, said the way to reshape the profession to accommodate women is an ongoing discussion.

Women want family-friendly workplaces from medical school through the early years of practice. They want more part-time employment options and the opportunity to leave their career and return to it, depending on the other demands in their lives, such as family obligations.

"Women tend to be coalition builders, bridging differences in a positive, constructive way," she said. "Our next step is to figure out how to overcome the challenges, like burnout, discouragement and feeling unappreciated."