Part time women in medicine: are they pulling their weight?

A number of years ago I was seeing a female executive for a physical exam.  As I chatted with the sixty-something female CEO she remarked: “women sell themselves short,” attributing the lack of women in top management positions to their tendency to opt for less ambitious “mommy tract” positions.  While I had certainly heard these words before, that day they hit closer to home.  At the time I was in year nine of employment at the Emory Clinic and feeling professional success in my job, which included a leadership position within my practice. I was the senior woman in my group, the university-based general medicine practice of Emory, and a busy and well-liked internist.  Though at the time I had been recipient of various departmental awards, I was still an assistant professor—a detail that was, in fact, a chip on my shoulder.  However, no woman in my practice had ever been promoted to associate professor.

When my first child was born in 1999 I had opted for “part-time” status, 75 percent of full-time, gradually increasing my work load after my second child turned four to 90 percent of full time.  My husband is an interventional cardiologist and our work-life balance had been tough. Thankfully, I had a wonderful nanny who helped out at home.

Now, working full time in a medical practice that I started, I reflected on those years again after reading a recent editorial in the New York Times on part time women in medicine. The piece, Don't Quit this Day Job, authored by Karen Sibert, an anesthesiologist, argued that federal funding for residency training was wasted on women who increasingly opt for part-time positions. In fact over 50% of female physicians report seeing patients fewer than 40 hours per week (most commonly 30 to 40 hours per week), compared to men, who more commonly report spending 41 to 50 hours per week on patient care. When I posted Dr. Sibert’s editorial on Facebook it was met with a flurry of impassioned negative responses by many of my female physician colleagues, who have opted for the flexibility of part-time primarily in order to accommodate their domestic roles as primary caregivers of young children.

 In my experience women working “part-time” in medicine and earning “part-time” incomes often add professional work into their unpaid time—seeing extra patients, taking equivalent call despite a part-time salary, and in the academic setting, taking on unpaid teaching, or educational administrative positions.  In fact, I recognize that it was my part-time status that enabled me to participate in these types of activities and actually helped my reputation in my division, allowing me to pursue professional interests that I would not have had time for otherwise.

In the past several decades women have made significant gains toward equal status in medicine. According to statistics from the Association of American Medical Colleges, in the year that I graduated from high school, 1986, 31% of medical school graduates were women.  In 1994, when I graduated from medical school, 39% of graduates were women, and in 2010 48% of medical school graduates were women.  However, as in other fields, women still lag far behind men in terms of their representation in leadership positions.  In terms of income, significant gaps also remain.  In the past these income disparities have been attributed to differences in work hours and a tendency for female physicians to enter primary care fields.  However, a provocative recent study published in Health Affairs found that an average gap of $16,819 in salary between newly trained female and male physicians could not be explained by controlling for these factors.

Why should we care about having female physicians? Studies have suggested some differences between male and female physicians. 
Findings include:

• Women may spend more time with their patients.
• Women have different communication styles—they are perceived as more empathic and sensitive.
• Women tend to employ more participatory decision-making styles, which are correlated with higher patient satisfaction.
• Women tend to emphasize preventive services more.
• Women are more likely to discuss lifestyle and social concerns.

Of course these observed differences are highly variable depending on the  individual physicians in question. Interestingly, male gynecologists have been rated as more empathic and sensitive than male physicians in other fields.  Nonetheless, there is strong female preference for female gynecologists. The interaction between gender and patient preference is complex. One interesting study looked at 10,000 patients in an HMO setting and found that male patients of female physicians were the most satisfied customers, compared with female patients of these same female physicians, who were the least satisfied group.  Patients have different expectations about communication between male and female physicians and this may impact their satisfaction with care.

Going back to the female CEO, I too have been let down at times by what I have perceived as a relative lack of career ambition in some female physicians.  Thinking about it, however, I’ve been equally let down by male physicians with what I viewed as misguided professional goals. If women can best manage their careers in medicine as part-time then so be it.  Society will benefit, perhaps we will learn something from one another, and women in medicine are already paying the price.

ACP Leadership Day 2011

Last month I attended the American College of Physician’s Leadership Day at the Capitol. The American College of Physicians is a national organization of internists--physicians who specialize in the prevention, detection and treatment of illnesses in adults. ACP is the largest medical-specialty organization and second-largest physician group in the United States after the AMA.

ACP Leadership Day brings together primary care physician advocates from all over the country to discuss national health policy and to lobby for key health regulation. I went as a representative of the Georgia Chapter along with six other physicians from our state, including our Chapter Governor, Jacqueline Fincher, MD, MACP, a medical resident and a medical student from Emory University School of Medicine and Executive Director of the Georgia Chapter, Mary Daniel.  The event included a learning session in which we reviewed the ACP’s priorities.  We heard from ACP president Virginia Hood and Bob Doherty, SVP, Governmental Affairs & Public Policy for ACP. Dr. Doherty also summarizes the day in his blog ACP Advocate.

Nancy Nielsen, MACP, Senior Advisor, Center for Medicare & Medicaid Innovation spoke, appealing to physicians to provide feedback to the Center on the recently proposed rule for Accountable Care Organizations, which has been criticized for its complexity and for being out of reach for smaller medical practices.  We also heard from a bipartisan congressional panel that discussed the ACP priority issues in the context of current legislative considerations. As one might imagine, much of this year’s discussion focused on the national budget crisis and lack of available funds for key Accountable Care Act programs.  Later in the evening, after a keynote address by Alex Castellanos, Political Strategist and Analyst at CNN, Max Baucus was awarded the Joseph F. Boyle Award for Distinguished Public Service. 

The ACP supports the following legislative action:

•  Fix the Sustainable Growth Rate:  The "SGR" is the formula used to determine physician payment by Medicare. The formula is linked to the GDP. However, with advances in technology and the aging population, health expense has outpaced inflation leading to a series of short term fixes to avoid drastic cuts in physician payment.  The "fixes" continuously threaten to expire. The next expiration date is January 1^st, 2012 when physician payment will be cut by 29.5% unless action is taken.  As reported recently in Modern Medicine: 

"Wiping out Medicare’s accumulated debt would cost almost $300 billion, according to the Congressional Budget Office, and maintaining it with 0% updates until the end of the decade would cost more than $275 billion. With the current focus on reducing the deficit, neither of those options looks appealing."

• Fund programs that support expansion of the primary care workforce:   the National Health Service Corps, Section 747 Training in Primary Care Medicine and the National Health Care Workforce Commission.   

• Strengthen access to primary care, improve quality and lower cost by funding: 
• The Medicare Primary Care Incentive Program, which preserves primary care incentive payment through 2015, while enacting further reforms to strengthen primary care (Medical Homes and Accountable Care Organizations).
• The Medicaid Comparability Program (ties Medicaid payment rates to Medicare rates--currently they are significantly lower).
• The Center for Medicare and Medicaid Innovation.  The new Center needs adequate resources to accelerate broad pilot testing of new health care delivery models to improve access, quality and value)
• The Patient Centered Outcomes Research Institute, which researches the clinical effectiveness of different treatments to better inform patients and physicians in decision-making.

• Improve Health Reform by supporting:
• Empowering States to Innovate (allows states to opt out of ACA requirements three years early if they enact a program with equivalent coverage, i.e. Vermont).
• Patient’s Freedom to Choose Act, which repeals a provision of the ACA that requires that physicians provide written authorization for over the counter drugs reimbursed by a flexible spending account or a health savings account.
• State pilots to test health courts (would have medical liability cases heard by expert judges rather than lay juries).

On Thursday the Georgia Chapter broke out into small groups to speak with our legislators about these priorities.  Among others, our chapter met personally with Senator Saxby Chambliss and Representative Tom Price.  I was struck by various things I learned while at Leadership Day.  As I spoke with a local physician who is employed by the Piedmont Physician’s Group in Atlanta I learned that this large multispecialty group is no longer accepting new Medicare patients who are enrolled in Medicare Advantage programs, and that many Piedmont physicians are also closed to new traditional Medicare patients. This speaks to the significant access issue that patients of the future will have unless Medicare is able to successfully reform, while still guaranteeing stable reimbursement for physicians. 

In Washington there was significant discussion about Medicare innovation and the proposed new models of care delivery—Medical Homes and Accountable Care Organizations.  Whether or not participation in such models will be feasible for small independent physician practices remains to be seen—and many are fearful.  At present most physicians cannot get health insurance funding for being “Medical Home” certified.  Locally, in Atlanta, several hospital-based groups are experimenting with Medical Home Pilots:   Wellstar participates in a Medical Home pilot with Humana, Piedmont Physicians Group participates in a Medical Home pilot with Cigna, and Emory will soon launch a Medical Home pilot with Aetna. However, none of these pilots involve more than a single payer.

While I sensed bipartisan support for fixing the SGR, there was significantly less agreement about how to best reduce Medicare cost while improving quality of care and access.  

CMS’ Administrator Don Berwick recently stated in the Health Affairs blog that health care transformation

"won’t yield to a massive top-down national project...Successful redesign of health care is a community by community task. That’s technically correct and it’s also morally correct, because in the end each local community – and only each local community – actually has the knowledge and the skills to define what is locally right"

This being said, Dr. Berwick will need to work to succeed in convincing many that implementing these ACA programs can make a positive difference on a community level in improving health care. To help reach consensus from both sides of the aisle, ACP Leadership Day was a good opportunity for practicing internists from around the country to tell their local stories, illustrating how federal policy impacts day to day practice on a micro-level. I hope that some of our messages were heard.

Osteoporosis: What about Men?

Treating reduced bone density in women is a big business—from its detection with bone density screening (DXA), to its treatment with medications, such as the blockbuster bisphosphonates, to the medical care that the condition generates through referrals to specialists.  It seems curious to me that men have been neglected as the objects of this frenzy.  

It’s estimated that the lifetime risk of an osteoporotic fracture in women is 1 in 2, and in men that it’s 1 in 5. With our aging population, hip, femoral and vertebral fractures are a significant source of morbidity and mortality in the elderly.  I’ve written about treating bone loss in women: “Osteopenia: to treat or not to treat.”  A study published last year in the Annals of Internal Medicine demonstrated that although hip fractures are more common in women, they lead to higher mortality in men. In general, the onset of osteoporosis is ten year delayed in men compared with women.

Recently a middle-aged man consulted with me about osteoporosis.  Several years prior a gastroenterologist had been worried about my patient’s chronic use of omeprazole, a proton pump inhibitor. Proton pump inhibitors reduce acid secretion in the stomach. Their use has been linked to reduced absorption of calcium and possibly to an increased risk of osteoporotic fractures, though this is still controversial.  A bone density test was ordered and my patient’s bone density was found to be low, in fact, in the “osteoporosis” range (T score <-2.5).  My patient was sent to an endocrinologist and was determined to have no secondary risk factors for osteoporosis.  However, my patient was prescribed alendronate.  With no clear end in sight for treatment with this medication, he asked me whether I felt it was necessary to continue.

The fact is little is known about treating men’s bones--that is, the ones in their skeletons.  

A few trials have looked at DXA screening in men and found that T-scores, the measurement used to define bone loss (a “T-score” is the standard deviations from the mean for peak bone density), are as predictive of fracture risk in men as they are in women. However, the data is very limited. Bisphosphonate use has not been widely studied in male patients, particularly not in younger men with idiopathic osteoporosis.  A couple of trials have looked at alendronate use in men with secondary risk factors and found it to have efficacy in preventing fractures.  Best practice guidelines for treating osteoporosis in men were published in April 2011 by Gielen in BEST PRACTICE & RESEARCHCLINICAL ENDOCRINOLOGY & METABOLISM , which states:

 “With the ageing of the population, male osteoporosis is an increasingly important health problem:  from age 50 onward, one in three osteoporotic fractures occurs in men and fracture-related morbidity and mortality is higher than in women. In men with low BMD, 50% have an underlying cause, most often glucocorticoid excess, hypogonadism or alcohol abuse.  DXA is recommended in all men from 70 years of age on and in men age 50–70 with a prior fragility fracture or clinical risk factors.  Treatment decisions should be based on assessments of absolute fracture risk and not on  BMD alone.  Supplementation of calcium and vitamin D is essential in ageing men to prevent age-related secondary hyperparathyroidism.  Bisphosphonates and PTH seem to be as effective in men as in women and should be given to men with DXA-documented osteoporosis, a prior fragility fracture or high absolute fracture risk as assessed by FRAX.  Testosterone replacement can only be recommended in older men with osteoporosis who have symptoms of hypogonadism as well as total testosterone values below 250 ng/dL(9 nmol/l).”

Experts acknowledge that while bone mineral density testing may be useful, it is just one piece of the equation when it comes to assessing a person’s fracture risk. Clinical risk calculators take into account clinical risk factors and project a person’s ten year risk of suffering an osteoporotic fracture. The most widely known risk calculator is called FRAX,  a tool developed by the World Health Organization.  Clinical factors that contribute to fracture risk include age, body mass index, tobacco use, glucocorticoid use, alcohol use (>3 drinks per day), parental history of hip fracture, “secondary” causes of osteoporosis (low testosterone, hyperparathyroidism, hyperthyroidism and certain drugs),  and the presence of rheumatoid arthritis.

In their recently released Guidelines on the Treatment of Osteoporosis the USPSTF concludes that there is insufficient evidence to support screening men for osteoporosis. 

The case of my patient is a good example of how the well-intentioned use of testing may lead to information that we just don’t have good answers for yet.  In the absence of firm data, the question becomes, does one opt to treat with medication, for how long, and with what sort of monitoring? And if not, then what should one suggest?  Frankly, I find the relative lack of data about male osteoporosis surprising.