Gender Differences in the Practice Characteristics and Career Satisfaction of Psychiatrists in Ontario
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《精神病学术期刊》
ABSTRACT
OBJECTIVE: The authors explored practice characteristics, activities, and career satisfaction of male and female psychiatrists. METHOD: A questionnaire was mailed to all practicing psychiatrists in Ontario, Canada, to which 52% responded. RESULTS: More women specialized in child, women’s mental health and geriatrics than did men, while men specialized more in forensics and psychosomatics. Women saw fewer patients for pharmacotherapy than did men. Women spent more time in session with their patients than did the men. Women were less involved in research, less likely to hold pharmaceutical funding, and less likely to have published within the last 5 years than men. Women described their careers as less successful than men but felt less regret in choosing psychiatry as a career. CONCLUSIONS: Men and women practicing psychiatry in Canada show similar differences to that reported in the U.S., although women report more satisfaction with their careers than men in Canada, a finding not reported in the U.S.
In the past decade there has been an increase in the number of Canadian women pursuing medicine as a career (1, 2, 3). In 1968, only 11% of the medical degrees conferred by Canadian universities were to women. Since then, there has been a steady increase in this percentage, such that more women (53%) than men received medical degrees in 1999 (4). There has also been a steady increase in women choosing psychiatry as a medical specialty. In the U.S., 14% of the practicing psychiatrists in 1982 were women, compared to 25% in 1996 (5). Although there are no comparable data readily available in Canada, recent data from the Canadian Medical Association (4) reveals that 34% of physicians practicing psychiatry as a specialty were women in the year 2002. Thus, it is probably safe to assume that in Canada, as in the U.S., women are playing an increasingly greater role in the delivery of psychiatric services.
In Canada, despite the increase of women choosing psychiatry as a medical career, there is an absence of studies exploring potential differences between male and female psychiatrists with respect to practice characteristics and satisfaction with their careers. Surveys of career pattern and practice characteristics in the U.S., however, indicate that female psychiatrists, compared with their male counterparts, work fewer hours, treat less patients, are more likely to work part-time, and spend more time in public and private clinics and in outpatient facilities (6, 7, 8). In the U.S., female psychiatrists also have lower mean annual incomes even after controlling for a variety of work related variables that could spuriously inflate this income difference (7). Men are more likely to see patients diagnosed with anxiety and somatoform disorders, alcohol and drug abuse and organic diseases; in contrast, women are more likely to see patients with adjustment disorders, childhood and development disorders and eating disorders.
With respect to academics and research, there are a number of differences between male and female psychiatrists. In an 11-year follow-up study, male and female psychiatrists were equally likely to have retained their academic appointment, but female psychiatrists were less likely to have advanced to associate professor or full professor (9). Other studies have indicated that women spend more time teaching than men (10), although one study reported that female psychiatrists (in Canada) receive poorer evaluation for supervisory activities than men, which was thought to be related to sex bias (11). Women are less likely than men to have research training, become principal investigators on peer-reviewed grants, or be currently involved in research and have fewer peer-reviewed grants (10,12).
Noticeably absent from these studies of male and female psychiatrists in the U.S. is information regarding potential differences in career satisfaction and gender-related factors related to such differences. For example, balancing career with family and personal life, the apparent lack of equal financial compensation, and lesser academic achievement and recognition may contribute to dissatisfaction female psychiatrists experience with their careers, yet none of these have been examined extensively in either Canada or the U.S. In an earlier study, conducted in the U.S., published nearly 20 years ago, Kashtan & Dickey (13) questioned a sample of male and female psychiatrists about balancing the demands of both career and family. Whereas both men and women reported that their careers were "too demanding," more women (83%) than men (63%) reported experiencing career/family conflict.
The goal of this study was to examine differences between male and female psychiatrists currently practicing in Canada (Ontario) with respect to a number of factors related to personal demographic information and clinical practice characteristics, specialty training, and academic activities, including research and training. A further aim was to assess for gender differences in career satisfaction. As this study is the first of its kind in Canada, it is exploratory in nature, and no specific hypotheses were proposed.
METHOD
Participants
This study is part of a larger program of research examining the lives and careers of psychiatrists. To this end, questionnaires were mailed to 1,547 Ontario psychiatrists in the spring of 1999. These psychiatrists represented the entire population of psychiatrists as listed in the Directory of the Ontario Medical Association. The questionnaires were accompanied by a cover letter explaining the nature of the study and the anonymous form of responding. Those who did not respond to the initial mailing received a follow-up mailing four months later. Of the 1,547 potential respondents, 803 (52%) completed and returned their questionnaire in response to these two mailings. Of those who responded, 251 were women (31%) and there were 552 men (69%). This demonstrates a relatively low response rate, particularly among the women, potentially introducing a degree of bias in the results.
Procedure and Questionnaire Design
The questionnaire was a 12-page bound booklet entitled "Survey Study of Professional and Practice Characteristics of Psychiatrists" and was composed of a total 79 questions. The booklet was divided into five sections: Personal and Professional Characteristics, Clinical Practice Characteristics, Patient Treatment Characteristics, Professional Activities (subdivided into university teaching, research, continuing education and community involvement) and Personal and Professional Satisfaction. The questions in the first four sections were primarily categorical and dichotomous. The questions in the final section addressing personal and professional career satisfaction were scaled on a continuous, 5-point Likert scale, with question-specific anchors. Responses endorsed at the lower regions of the scale were representative of a general absence or disagreement with the statement, whereas responses at the upper regions of the scale were representative of a general presence or agreement. This questionnaire was used in an earlier study (14) and has received approval for use by the Research Ethics Board of the University of Toronto and the Center for Addiction and Mental Health.
Statistical Analysis
Summary statistics, including percentages, measures of central tendency and range of scores were used to describe the data. Statistical inference testing was performed using chi square analyses for the categorical variables and analysis of variance (ANOVA) were used for the continuous variables. Effect sizes (Cohen’s d and partial eta2) were used to supplement group mean differences. For Cohen’s d, values of 0.10 are indicative of a small effect, 0.25 as a medium effect and 0.40 as a large effect. For partial eta2, values of .01 refer to a small effect size, .06 as a medium effect size, and .14 as a large effect size. Only the significant results are reported in the text.
RESULTS
As the number of women entering medicine and psychiatry has increased steadily over the years, we first examined the distribution of age separately for men and women to determine whether a potential cohort effect was operating in the data. Overall, the mean age of the men was significantly larger that for the women (t=5.77, df=794, p<0.001; d=0.41), although both men and women can be characterized as "middle-aged." Other measures of central tendency indicated that the women (median=45 years; mode=44 years) were younger than the men (median=50 years; mode=52 years). Given these differences, we assessed the distribution of age across nine 5-year age categories similar to that employed by Dial et al. (1994). A chi-square analysis indicated that the men and women were not equally distributed across these age ranges (2=43.5, df=8, p<0.001. Examination of the contingency cross tabulation table revealed that there was a proportionately greater number of men than women included in all age groups greater than 45 years, revealing a possible confound of age with sex. We therefore created "cohorts" of "younger" (i.e., 45 years) and "older" (i.e., 46 years) psychiatrists to control for this effect. Within these two age groups there were no differences found in the age at the time of the survey between the men and women, effectively demonstrating the elimination of an age cohort effect. However, there were significant age differences between the "younger" and "older" cohorts in both the men (mean age=40.0 [SD=3.9] versus 56.3 years [SD=7.8]; t=87.61, df=547, p<0.001) and women (mean age=39.1 [SD=4.3] versus 55.3 years [SD=7.8]; t=46.78, df=247, p<0.001). All subsequent ANOVAs, therefore, employed a 2 (men/women) by 2 (older/younger) design; simple effects for interpretation of significant interactions were tested using univariate Fs (p<0.01, Bonferroni corrected).
Personal Demographic and Professional Training Characteristics
Differences in age distributions for the men and women are reflected in the modal year for which men and women graduated from medical school (1982 versus 1973, respectively) and mode year for which they completed residency training in psychiatry (1984/1996 versus 1978, respectively). For the whole sample, there were no significant main or interaction effects for the age of graduation from medical school. There was, however, a significant interaction for the age) men and women completed residency training in psychiatry (F=10.90, df=1, 771, p<0.001; eta2= 0.01), such that among the older cohort of psychiatrists, men were significantly younger than women when they completed their training, F=44.84, df=1, 771, p<0.001; eta2=0.06; however, among the younger cohort of men and women, this age difference was not significant.
Overall, there were more men than women in the sample who were currently married or co-habitating (2=24.39, df=3, p<0.001) and there was a greater proportion of women who reported that they were never married, or had been separated or divorced (2=17.71, df=2, p<0.001). When compared to the men, however, this difference was manifest only for the older cohort of psychiatrists, and not the younger cohort (2=17.71, df=2, p<0.001). There was a significant interaction for the number of children (F=0.573, df=1, 770, p<0.05; eta2=0.01), in the overall comparison women had fewer children than men (F=30.8, df=1, 770, p<0.001; eta2); however, this difference was only statistically significant among the older cohort when comparing men and women.
Subspecialty Practice and Theoretical Orientation
There were no significant gender differences in whether men or women had a subspecialty or not, and this was demonstrated for both the younger and the older cohort of psychiatrists. However, there were significant differences in the types of subspecialties. Proportionately more women than men had a subspecialty in child (2=17.73, df=1, p<0.001), geriatrics (2=5.19, df=1, p<0.05), and women’s mental health (2=24.78, df=1, p<0.001). This gender difference in subspecialty is revealed for the child and women’s mental health subspecialties for both the younger women (2=8.17, df=1, p<0.01 and 2=16.54, df=1, p<0.001, respectively) and the older women (2=11.28, df=1, p<0.001 and 2=12.11, df=1, p<0.001). On the other hand, proportionately more men than women had subspecialties in forensic (2=15.86, df=1, p<0.001) and psychosomatics (2=4.86, df=1, p<0.05). A greater proportion of both younger men (2=4.32, df=1, p<0.05) and older men (2=10.07, df=1, p<0.01) indicated forensics as a subspecialty choice when compared to younger and older women. However, the apparent difference between men and women in choosing psychosomatics as a subspecialty did not reveal itself when the younger and older cohorts of men and women were compared. Gender differences in the proportion of men and women indicating schizophrenia as a subspecialty between men and women was evident for the younger cohort, with the greater proportion residing with the males, (7.3% for women vs. 16.3% for men; 2=8.07, df=1, p<0.05).
With respect to theoretical orientation, there were no significant differences between men and women among the younger and older cohorts across four broad categories: psychoanalytic/psychodynamic, cognitive/behavioural, biological, eclectic categories.
Men were more likely than women to have hospital admitting privileges (2=8.23, df=1, p<0.01. This sex difference emerged for both younger (2=4.38, df=1, p<0.05) and older cohorts (2=4.92, df=1, p<0.05). There were no significant gender differences with respect to population of practice area for the men and women in the overall sample, and within the two age groupings.
With regard to the clinical practice activities for men and women, on average, men reported working a greater number of hours per week than women (F=24.66, df=1, 757, p<0.01; eta2=0.03). The younger cohort of psychiatrists saw fewer patients per week (F=13.39, df=1, 739, p<0.01; eta2=0.02) and had less sessions per week (F=16.25, df=1, 674, p<0.01; eta2=0.02) than the older cohort. In addition, a significant gender by age interaction effect was found for number of minutes spent in each psychotherapy session (F=4.71, df=1, 727, p<0.05; eta2=0.01) such that among the older cohort of psychiatrists, women spent a greater amount of time in psychotherapy than the men (F=15.61, df=1, 728, p<0.001; eta2=0.02); this difference that was not found among the younger cohort. With respect to pharmacotherapy/medication treatment, there was a significant main effect for gender where men reported seeing more patients for pharmacotherapy/medication treatment than women (F=10.98, df=1, 702, p<0.01; eta2=0.02). Women spent more time with their patients than men when they did see them for pharmacotherapy/medication treatment (F=21.23, df=1, 624, p<0.01; eta2=0.03). In addition, women spent more of their time in individual work with children and adolescents than did men (F=3.89, df=1, 322, p=0.05; eta2=0.01) and family therapy (F=8.65, df=1, 360, p<0.01; eta2=0.02) when compared to the men. No other significant main or interaction effects were found for percentage of practice time spent in individual adult, couple/marital, or group settings.
Clinical Practice Activities
Main effects for the diagnostic characteristics of patients seen by men and women were found, with women seeing a larger proportion of patients with anxiety disorders, other than PTSD and panic disorder (F=4.72, df=1, 301, p<0.05; eta2=0.02) and patients with comorbid axis I disorders (F=5.06, df=1, 714, p<0.05; eta2=0.03) than the men. Men reported seeing a larger proportion of patients than the women with comorbid substance abuse disorders (F=3.75, df=1, 750, p=0.05; eta2=0.01). Significant main effects for age revealed that the younger cohort of psychiatrists saw more patients with panic disorder (F=4.73, df=1, 156, p<0.05; eta2=0.03) and other anxiety disorders aside from PTSD (F=7.99, df=1, 301, p<0.01; eta2=0.03) as well as pain/somatoform disorders (F=3.88, df=1, 83, p=0.05; eta2=0.05) than the older cohort. The younger cohort also reported seeing more patients than the older cohort with comorbid substance abuse disorders (F=8.03, df=1, 750, p<0.01; eta2=0.01) and axis I disorders (F=4.33, df=1, 714, p<0.05; eta2=0.01.
There was a significant gender by age interaction for those psychiatrists who see patients with depressive disorders (F=5.10, df=1, 596, p<0.05; eta2= 0.01). The younger cohort of women saw significantly more patients with these disorders than the young men (F=11.35, df=1, 596, p<0.001; eta2=0.02); however, this difference did not emerge in the older cohort of psychiatrists. In addition, there was a significant gender by age interaction effect for those who saw schizophrenic patients (F=9.08, df=1, 219, p<0.01; eta2=0.04), such that the younger cohort of male psychiatrists saw more schizophrenia patients than the younger cohort of females (F=5.56, df=1, 219, p<0.05; eta2=0.03); however, among the older population this trend was reversed and the older women reported seeing more schizophrenia patients than the older men, although this difference was not significant. There was also a significant gender by age interaction effect for those who saw patients with a co-occuring medical diagnosis (F=14.09, df=1, 743, p<0.01; eta2=0.02). The younger men saw a greater percentage of patients with these disorders than the younger women (F=32.80, df=1, 743, p<0.001; eta2=0.04); however, among the older cohort the female psychiatrists, on average, saw more patients with a co-occurring medical diagnosis than the older men.
No significant differences were found for those who saw patients with PTSD, personality disorders or comorbid axis II disorders.
Teaching and Research Activities
A greater proportion of men when compared to women in the older cohort reported active involvement in research (2=6.35, df=1, p<0.01). There were no differences between the men and women in the younger cohort of psychiatrists. In addition, men were more likely to have published in a scholarly journal (2=12.78, df=1, p<0.001), and this effect was evident across both the younger (2=4.46, df=1, p<0.05) and older (2=12.06, df=1, p<0.001) cohorts. Men were also more likely than women to have held pharmaceutical funding (2=6.102, df=1, p< 0.05), evident in both the older (2=4.624, df=1, p<0.05) and the younger cohorts (2=5.00, df=1, p<0.05).
There were no significant differences in the percentage of men or women in the overall sample or within the two age cohorts who taught in the university on a regular basis. Nor was there were any significant differences between men and women in their attendance at hospital rounds or in presenting at hospital rounds, within the two cohorts. For the overall sample, a similar proportion of men and women indicated that they had been active in research in the past 5 years and there were no significant differences in the proportion of men and women for the overall group and for the two age groups with respect to their presenting at scholarly conferences and holding peer-reviewed funding.
Significant main effects emerged for age when considering the reported work and income distributions over particular practice activities, whereby the younger psychiatrists reported spending a greater percentage of their work time on research (F=1.43, df=1, 333, p<0.05; eta2=0.02), and less in clinical practice (F=4.78, df=1, 763, p<0.05; eta2=0.01) when compared to the older cohort. The younger cohort also reported that a greater percentage of their income was derived from research than the older cohort (F=6.19, df=1, 125, p<0.01; eta2=0.05). There was also a main effect for age where the older cohort reported a greater percentage of their income was generated from other professional activities when compared to the younger cohort (F=4.22, df=1, 222, p<0.05; eta2=0.02). There was a significant interaction with respect to the time devoted to professional development (F=4.77, df=1, 563, p<0.05; eta2= 0.01), such that the men overall reported spending less time than the women engaged in professional development, however, this difference was only significant for the older cohort (F=12.56, df=1, 563, p<0.001; eta2=0.02.
No significant differences were found for percentage of work time spent in university teaching, administration, or in other professional activities. Moreover, no differences were found for percent of income generated by clinical practice, university teaching or administration.
Professional and Personal Satisfaction
The men rated their careers as more successful than did the women in terms of financial compensation (F=9.34, df=1, 786, p<0.01; eta2=0.01), peer recognition (F=8.28, df=1, 787, p<0.01; eta2=0.01), and academic recognition (F=8.11, df=1, 774, p<0.01; eta2=0.01). The men also reported feeling more satisfied treating patients with pharmacotherapy than did the women (F=5.79, df=1, 782, p<0.05; eta2=0.01). The women, however, felt a greater sense of satisfaction than the men with regards to participating in research (F=5.83, df=1, 754, p<0.05; eta2=0.01) and from their sense of involvement in the community (F=3.90, df=1, 767, p<0.05; eta2=0.01). In addition, there was also a difference with respect to reported satisfaction with administrative responsibilities, whereby the women reported greater satisfaction than the men (F=4.00, df=1, 35, p=0.05; eta2=0.10). Significant main effects for age emerged when considering perceptions of satisfaction with respect to appreciation from patients (F=6.50, df=1, 783, p<0.01; eta2=0.01), the psychiatrists’ feeling of their own professional career (F=14.28, df=1, 785, p<0.01; eta2=0.02), and from psychotherapy (F=4.89, df=1, 784, p<0.05; eta2=0.01), where the younger psychiatrists reported feeling less satisfied from these areas than their older counterparts. On the other hand, the younger cohort placed greater priority on collegial interaction than did the older cohort (F=5.89, df=1, 158, p<0.05; eta2=0.04).
The only significant gender-by-age interaction to emerge from analyses of satisfaction with career was with the priority given to pharmacotherapy (F=5.47, df=1, 574, p<0.01; eta2=0.01), such that among the younger cohort of psychiatrists, the women placed greater priority on pharmacotherapy than the men (F=5.82, df=1, 574, p<0.05; eta2=0.01); however, among the older cohort, the men placed a greater priority on this same type of treatment than did the women. No significant differences for perceptions of success were found when considering community recognition, consultations, university teaching, collegial interaction and administration. In addition, there were no differences reported on the priority given to consultations, psychotherapy, teaching, supervision, or research.
The female psychiatrists indicated that given the choice, they were more likely than the men to choose psychiatry as a specialty (F=6.62, df=1, 780, p=0.01; eta2=0.01) and had less regret than the men about choosing psychiatry as a career (F=13.16, df=1, 788, p<0.01; eta2=0.02). Men reported feeling a greater degree of emotional burden (F=4.64, df=1, 773, p<0.05; eta2=0.01) when compared to the female psychiatrists. A significant main effect of age also emerged for degree of emotional burden, such that the younger cohort reported feeling a greater degree of burden than the older cohort (F=19.20, df=1, 773, p<0.01; eta2=0.02). Other significant main effects for age were found with respect to the extent to which psychiatrists felt other medical and nonmedical mental health professionals specialists respected psychiatry (F=9.79, df=1, 780, p<0.01; eta2=0.01) (F=4.50, df=1, 778, p<0.05; eta2=0.01), where the younger cohort felt less respect from these professionals than the older cohort. Significant interaction effects were found for the sense of availability of professional contact (F=4.12, df=1, 736, p<0.05) where the older cohort of women felt this more than the older cohort of men, however, the younger cohort of men reported a greater availability of professional contact than the women. In addition, there was an interaction for the ability to devote time to their professional career (F=7.95, df=1, 776, p<0.01; eta2=0.01), where women felt they were less able than the men overall to devote time to their career (F=15.81, df=1, 776, p<0.001; eta2=0.02); however this difference was significant only among the younger cohort of psychiatrists.
With regards to the ratings of professional and personal satisfaction among the psychiatrists, the women indicated that they had struggled more to achieve a good balance between their professional and personal lives than the men (F=6.22, df=1, 785, p<0.01; eta2=0.01). Significant main effects for age revealed that the younger psychiatrists also struggled more than the older psychiatrists to achieve a balance between their personal and professional lives (F=15.94, df=1, 784, p<0.01; eta2=0.02), and that both nonprofessional and professional commitments impinged on their professional life (F=11.98, df=1, 784, p<0.01; eta2=0.02) (F=46.57, df=1, 784, p<0.01; eta2=0.06), more so than the older cohort. The younger cohort were also less likely to report that their work offered some intrinsic value when compared to the older cohort (F=5.89, df=1, 789, p<0.05; eta2=0.01). In addition, there was a significant interaction effect for the extent to which major personal life changes prompted psychiatrists to alter their professional career (F=5.60, df=1, 779, p<0.05; eta2=0.01), whereby the younger cohort of female psychiatrists expressed this significantly more than any of the other groups (F=9.35, df=1, 779, p<0.01; eta2=0.01).
DISCUSSION
On many dimensions, the men and women in this study were very similar—they worked long hours and involved themselves in a wide range of professional activities, including consultation, care and administration, as well as teaching and research. Both groups worked hard, were committed to clinical care and although they experienced the burden of their work, felt they had available supportive relationships. With respect to theoretical orientation, there were no significant differences between men and women across four broad categories: psychoanalytic/psychodynamic, cognitive/behavioral, biological, and eclectic. At the same time, there were significant differences between the genders and age groups that have a bearing on the delivery of psychiatric care and on the understanding of issues faced by practicing psychiatrists.
The survey data indicated that females were likely to work slightly fewer hours per week. This is in keeping with other literature on physician behavior (7, 13, 15). Whereas women were likely to work slightly fewer hours, psychiatrists of both genders indicated a wish to work less hard. Nearly three-quarters (73%) of the sample reported that they would prefer to work less. This latter figure is of particular interest as it may suggest a high degree of overwork and possible excessive fatigue for this sample, which is consistent with reports from other sources. Recent research, for example, has emphasized the importance of work-related exhaustion in medicine in general, and the relation between exhaustion and fulfillment at work (16). Deary et al. (17) reported that psychiatrists displayed greater emotional exhaustion as a result of work than a comparison group of physicians in other specialties, despite having fewer clinical work demands. Psychiatrists have been reported to experience more work-related exhaustion than mental health nurses, probably related to the nature of the work load itself, which in the Thomsen et al. (16) study accounted for a large degree of the variance in exhaustion. High levels of emotional exhaustion were reported by male psychiatrists in comparison to other physicians in Finland (18). Male psychiatrists ranked second out of 11 physician groups, and female psychiatrists ranked fifth, in "burnout." Similarly, in our study, men reported feeling significantly more emotionally burdened than the women across both age cohorts in accordance with results from some earlier research (19, 20). This is especially interesting in light of the additional roles women traditionally carry outside of work.
Whereas there were no gender differences in the numbers of psychotherapy patients seen per week, (in both the younger and older age cohorts) men saw more people for pharmacotherapy. Women saw patients for longer periods; in the case of pharmacotherapy, this was true for both age cohorts and for psychotherapy, for the older cohort of women only. There were no differences in whether people had developed a subspecialty; but there were differences in the type: proportionately more women than men had a subspecialty in child, geriatric, and women’s mental health and spent their time in individual work with children and adolescents and in family therapy. On the other hand, proportionately more men had subspecialties in forensics and psychosomatics, and for the younger men, in schizophrenia. Women more commonly saw patients with anxiety disorders and co-morbid axis I disorders, and amongst the younger cohort, depression; men saw patients with co-morbid substance abuse disorders and with the younger group, co-occurring medical illnesses more frequently. Men, both in the younger and older categories, were more likely to have hospital privileges. With respect to teaching and research, no significant differences were found except that men in both age groups were more likely to have published in a scholarly journal and to have held pharmaceutical funding than women.
One striking finding of this survey related to how physicians assessed their success and satisfaction with their careers. Overall, across a number of dimensions the men rated their careers as more successful; this was true when rated in terms of financial compensation, peer recognition, and academic recognition. On the other hand, women had less regret about choosing psychiatry as a career. For the group as a whole, regrets in choosing psychiatry were uncommon (about 9%). While women accounted for 31% of the respondents to the questionnaire, they were only 13% of the high-regret group. Women indicated that they if they were able to choose again, they would choose psychiatry as a specialty, than did the men. One explanation for the discrepancy across these ratings is that whereas both men and women are able to rate themselves objectively on more objective or tangible indicators, such as financial compensation, men’s ratings on more global levels of success, unmoored from objective markers, may rate themselves as less successful. This may be attributable to a self-critical style that is more characteristic of men than women (21). These differences are all the more striking since women (not surprisingly, especially the younger group) reported that their careers had been more highly affected by their personal lives than did men. The women, independent of age, also indicated that they had struggled more to achieve a good balance between their professional and personal lives, and also endorsed to a larger extent that major personal life change prompted them to alter their professional career.
Interestingly, however, the men from both the young and old cohorts reported feeling significantly more emotionally burdened than the women. One explanation for this finding might be that the men tended to work longer hours and saw more emotionally difficult patients. In addition, feelings of burden may be influenced by perceptions of social support. While the results of the survey did not reveal any significant differences with regards to perceptions of support, perhaps the nature of support received or interpreted by men is not as effective as that received by women. This view is consistent with socialization experiences between men and women in general, with women emphasizing empathy and nurturance. This support might increase the women’s threshold of tolerance. Further research exploring this issue is warranted.
Age also had some bearing on the feelings of success and satisfaction with career—for both genders. For example, both the older cohort of men and women reported increased satisfaction with psychotherapy and they reported less of a burden from their patients than did the younger cohort of men and women. Similarly, as the psychiatrists aged, they were less likely to hold a university appointment or to do research, hold funding for research or to teach or present at hospital rounds. This change may have decreased overall job demands thereby increasing satisfaction.
Of importance, the gender related findings on a number of the parameters varied according to age. For example, the younger women spent less time in each psychotherapy session, in a fashion similar to the men of the study. They also spent less time reading the professional literature than did the older women. While there was a decrease in research involvement in both men and women, the older cohort of women was involved significantly less in research than the older men or the younger women.
Younger women in comparison to the older women group had less of a satisfying balance between professional and personal lives, and a greater struggle for such balance. They felt a greater emotional burden from their patients (but younger male psychiatrists experienced the greatest degree of burden). They also felt less respect from other medical specialists and nonmedical colleagues. They described that their personal lives affected their professional careers more and they had greater regrets in selecting psychiatry as a career. Perhaps this can be explained by the personal burdens that may be more salient for a young cohort of women such as child rearing, and personal and societal demands. Alternatively, it seems that despite the fact the younger psychiatrists are following the professional course of men more, they are still burdened by gendered responsibilities that expect them to maintain their domestic roles. Combining this urge to strive for professionalism with the maintained need to fulfill female expectations will result in increased difficulties in balancing these opposing roles.
What is striking, however, is that in spite of these changes, the two age cohorts of women did not differ in their perceptions of personal success on any parameter—both were lower than the two groups of men respondents. Most interestingly, the younger women were more like both the older and younger men, in that they displayed higher levels of regret in selecting psychiatry as a career. The younger women, like the younger men, were less likely to endorse the choice of psychiatry as a career if they were starting again.
Why these gender differences occurred in terms of success, satisfaction and regret is not entirely clear. The specific work demands on psychiatrists vary. Often the work is very isolating. It is difficult to be the recipient of the emotional needs of many ill and needy patients—this was indicated by one–quarter of the Ontario sample. The nature of practice often forces psychiatrists to face fears of one’s own vulnerabilities. Patient suicide can be an important occupational hazard, which causes disruption in psychiatrists’ professional and personal lives (22). The risk of over-involvement with patients may be great in psychiatry, possibly because of the nature of the illnesses being treated and the methods of treatment. Over-involvement has been linked to greater staff "burnout" (23). It is possible that aspects of these demands are experienced differently by men and women, although contrastingly, the response to the question of degree of emotional burden was higher in men in this survey (and especially high in the young cohort of men). Perhaps women’s emphasis on the relational aspects of their work may provide increased satisfaction as compared to the men, in spite of the burdens of practice and less objective external success. Women have often been socialized to place the wishes and needs of others in primary focus, rather than focusing on their own (24). Men and women may also define success differently with men emphasizing external markers more than do the women.
Other explanations for these findings are also possible. It may be that men and women enter a medical career with different expectations, which may be especially true for the older women in this cohort. The older cohort of psychiatrists had entered medicine at a time when it was less common for women and they may have not expected as much in terms of recognition and financial compensation as compared to the men. Younger women appear to have more of the expectations, and behaviors of their men colleagues, but don’t see themselves attaining the same levels of success. Alternatively, it may be understood simply by the fact that as individuals mature through middle age, personal satisfaction and happiness tend to increase (25).
Occupational stress and job satisfaction vary considerably among physicians. Often this is dependent on the external world: respect for physicians, compensation, administrative burdens, overcrowded emergency rooms, the relationship of the physician to the multi-disciplinary team, and to society, all play a role. Edwards et al. (26) have recently noted that dissatisfaction among physicians is a world–wide phenomenon, and they feel the cause is a breakdown in the implicit contract between doctors and society. The individual orientation that doctors were trained for does not fit with the demands of current health care systems. In a recent (late 2001) survey of more than 2,300 Ontario physicians (27) almost 41% reported being either "dissatisfied" or "very dissatisfied" with current medical practice. Almost half (46%) reported that they find their current medical practice to be "very" or "extremely stressful." An earlier study of Canadian physicians found that both men and women had high levels of both stress and job satisfaction, with the genders appearing to have overall similar levels on both (28). For both men and women in this study, dissatisfaction with various aspects of practice was predictive of stress. Many were the same for both groups and involved practice characteristics and poor relationships with colleagues.
With regards to psychiatrists in comparison to other women physicians, Frank et al. (6) surveyed a large U.S. cohort. This group of psychiatrists were likely to work less hours, and more likely to be solo practitioners compared to other female physicians. There were no differences in perceived work amount, work stress, or career satisfaction. Interestingly, about 15% of both the female psychiatrists and physicians described little career satisfaction.
The gender differences in the current study in satisfaction, recognition and regret occurred independently of the social supports available to each of the gender groups. Fortunately, 93% reported having professional colleagues to share their concerns. Of those 93%, the majority (81%) rated their professional contacts as readily available and of excellent quality. At the same time, a significant minority reported feeling professionally isolated; 5% felt extremely isolated and another 13% moderately isolated. Outside of their professional worlds, the vast majority of the psychiatrists in this sample (86%) felt they had significant others with which to share their concerns. Again, as with their professional collegial support, those with these nonprofessional/personal supports rated the availability (78%) and their quality (91%) as very high.
Overwhelmingly, the psychiatrists in the survey felt they would choose psychiatry as a career again, with only 5% reporting that they would be extremely hesitant, and another 6.3% reporting that they would be moderately hesitant. As a whole, the sample believed strongly in the intrinsic value of psychiatry, with only about 2% expressing extreme or moderate concerns about the intrinsic value of their work. In a related study, we reported that psychiatrists’ belief in the intrinsic value of their work is a key predictor in determining whether they have regrets about choosing their specialty (29). Only 7% believed that their expectations for a career in psychiatry had not been met. A recent study of psychiatrists in Texas found that almost one-quarter were considering leaving the field (30), and 70% of respondents in a survey of Manhattan private practitioners indicated that they would not recommend a career in private practice (31). Sturm (32) described data from the Community Tracking Study physician survey. It involved over 600 psychiatrists in comparison with over 4,000 other medical and surgical specialists and over 7,000 primary care doctors. Over 21% of psychiatrists reported being very or somewhat dissatisfied with their careers, a higher figure than for other physicians, due to an age cohort effect. By contrast, the Ontario psychiatrists have far less regret in the selection of their careers, possibly due to the effects of the health care environment and reimbursement issues in the United States.
Clearly, psychiatrists value the opportunity to assist in relieving human pain and suffering, to connect with people, and nurture healing and growth. Nevertheless, there are problems experienced in psychiatric practice. While many of these problems are partially related to the personality and vulnerability to illness that individuals bring to any type of work, others are related to the stresses of practice, some of which are unique to providing psychiatric care. Understanding these issues is one of the best investments we can make in assuring that psychiatrists are available, prepared, and supported in carrying out this very important work.
Results from this study suggest that discussion regarding physicians’ balancing their professional and personal lives is probably not adequately addressed in psychiatric residency training. Perhaps assigning staff psychiatrists as mentors who can discuss openly the difficulties associated with such balancing would serve to enhance overall career satisfaction levels. In addition, intensive focus groups of potential residents might center on clarifying reasons for choosing psychiatry as a specialty prior to the potential resident making a choice. These focus groups might also benefit from using the types of data obtained in this study that ultimately proved to be predictive of career satisfaction.
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OBJECTIVE: The authors explored practice characteristics, activities, and career satisfaction of male and female psychiatrists. METHOD: A questionnaire was mailed to all practicing psychiatrists in Ontario, Canada, to which 52% responded. RESULTS: More women specialized in child, women’s mental health and geriatrics than did men, while men specialized more in forensics and psychosomatics. Women saw fewer patients for pharmacotherapy than did men. Women spent more time in session with their patients than did the men. Women were less involved in research, less likely to hold pharmaceutical funding, and less likely to have published within the last 5 years than men. Women described their careers as less successful than men but felt less regret in choosing psychiatry as a career. CONCLUSIONS: Men and women practicing psychiatry in Canada show similar differences to that reported in the U.S., although women report more satisfaction with their careers than men in Canada, a finding not reported in the U.S.
In the past decade there has been an increase in the number of Canadian women pursuing medicine as a career (1, 2, 3). In 1968, only 11% of the medical degrees conferred by Canadian universities were to women. Since then, there has been a steady increase in this percentage, such that more women (53%) than men received medical degrees in 1999 (4). There has also been a steady increase in women choosing psychiatry as a medical specialty. In the U.S., 14% of the practicing psychiatrists in 1982 were women, compared to 25% in 1996 (5). Although there are no comparable data readily available in Canada, recent data from the Canadian Medical Association (4) reveals that 34% of physicians practicing psychiatry as a specialty were women in the year 2002. Thus, it is probably safe to assume that in Canada, as in the U.S., women are playing an increasingly greater role in the delivery of psychiatric services.
In Canada, despite the increase of women choosing psychiatry as a medical career, there is an absence of studies exploring potential differences between male and female psychiatrists with respect to practice characteristics and satisfaction with their careers. Surveys of career pattern and practice characteristics in the U.S., however, indicate that female psychiatrists, compared with their male counterparts, work fewer hours, treat less patients, are more likely to work part-time, and spend more time in public and private clinics and in outpatient facilities (6, 7, 8). In the U.S., female psychiatrists also have lower mean annual incomes even after controlling for a variety of work related variables that could spuriously inflate this income difference (7). Men are more likely to see patients diagnosed with anxiety and somatoform disorders, alcohol and drug abuse and organic diseases; in contrast, women are more likely to see patients with adjustment disorders, childhood and development disorders and eating disorders.
With respect to academics and research, there are a number of differences between male and female psychiatrists. In an 11-year follow-up study, male and female psychiatrists were equally likely to have retained their academic appointment, but female psychiatrists were less likely to have advanced to associate professor or full professor (9). Other studies have indicated that women spend more time teaching than men (10), although one study reported that female psychiatrists (in Canada) receive poorer evaluation for supervisory activities than men, which was thought to be related to sex bias (11). Women are less likely than men to have research training, become principal investigators on peer-reviewed grants, or be currently involved in research and have fewer peer-reviewed grants (10,12).
Noticeably absent from these studies of male and female psychiatrists in the U.S. is information regarding potential differences in career satisfaction and gender-related factors related to such differences. For example, balancing career with family and personal life, the apparent lack of equal financial compensation, and lesser academic achievement and recognition may contribute to dissatisfaction female psychiatrists experience with their careers, yet none of these have been examined extensively in either Canada or the U.S. In an earlier study, conducted in the U.S., published nearly 20 years ago, Kashtan & Dickey (13) questioned a sample of male and female psychiatrists about balancing the demands of both career and family. Whereas both men and women reported that their careers were "too demanding," more women (83%) than men (63%) reported experiencing career/family conflict.
The goal of this study was to examine differences between male and female psychiatrists currently practicing in Canada (Ontario) with respect to a number of factors related to personal demographic information and clinical practice characteristics, specialty training, and academic activities, including research and training. A further aim was to assess for gender differences in career satisfaction. As this study is the first of its kind in Canada, it is exploratory in nature, and no specific hypotheses were proposed.
METHOD
Participants
This study is part of a larger program of research examining the lives and careers of psychiatrists. To this end, questionnaires were mailed to 1,547 Ontario psychiatrists in the spring of 1999. These psychiatrists represented the entire population of psychiatrists as listed in the Directory of the Ontario Medical Association. The questionnaires were accompanied by a cover letter explaining the nature of the study and the anonymous form of responding. Those who did not respond to the initial mailing received a follow-up mailing four months later. Of the 1,547 potential respondents, 803 (52%) completed and returned their questionnaire in response to these two mailings. Of those who responded, 251 were women (31%) and there were 552 men (69%). This demonstrates a relatively low response rate, particularly among the women, potentially introducing a degree of bias in the results.
Procedure and Questionnaire Design
The questionnaire was a 12-page bound booklet entitled "Survey Study of Professional and Practice Characteristics of Psychiatrists" and was composed of a total 79 questions. The booklet was divided into five sections: Personal and Professional Characteristics, Clinical Practice Characteristics, Patient Treatment Characteristics, Professional Activities (subdivided into university teaching, research, continuing education and community involvement) and Personal and Professional Satisfaction. The questions in the first four sections were primarily categorical and dichotomous. The questions in the final section addressing personal and professional career satisfaction were scaled on a continuous, 5-point Likert scale, with question-specific anchors. Responses endorsed at the lower regions of the scale were representative of a general absence or disagreement with the statement, whereas responses at the upper regions of the scale were representative of a general presence or agreement. This questionnaire was used in an earlier study (14) and has received approval for use by the Research Ethics Board of the University of Toronto and the Center for Addiction and Mental Health.
Statistical Analysis
Summary statistics, including percentages, measures of central tendency and range of scores were used to describe the data. Statistical inference testing was performed using chi square analyses for the categorical variables and analysis of variance (ANOVA) were used for the continuous variables. Effect sizes (Cohen’s d and partial eta2) were used to supplement group mean differences. For Cohen’s d, values of 0.10 are indicative of a small effect, 0.25 as a medium effect and 0.40 as a large effect. For partial eta2, values of .01 refer to a small effect size, .06 as a medium effect size, and .14 as a large effect size. Only the significant results are reported in the text.
RESULTS
As the number of women entering medicine and psychiatry has increased steadily over the years, we first examined the distribution of age separately for men and women to determine whether a potential cohort effect was operating in the data. Overall, the mean age of the men was significantly larger that for the women (t=5.77, df=794, p<0.001; d=0.41), although both men and women can be characterized as "middle-aged." Other measures of central tendency indicated that the women (median=45 years; mode=44 years) were younger than the men (median=50 years; mode=52 years). Given these differences, we assessed the distribution of age across nine 5-year age categories similar to that employed by Dial et al. (1994). A chi-square analysis indicated that the men and women were not equally distributed across these age ranges (2=43.5, df=8, p<0.001. Examination of the contingency cross tabulation table revealed that there was a proportionately greater number of men than women included in all age groups greater than 45 years, revealing a possible confound of age with sex. We therefore created "cohorts" of "younger" (i.e., 45 years) and "older" (i.e., 46 years) psychiatrists to control for this effect. Within these two age groups there were no differences found in the age at the time of the survey between the men and women, effectively demonstrating the elimination of an age cohort effect. However, there were significant age differences between the "younger" and "older" cohorts in both the men (mean age=40.0 [SD=3.9] versus 56.3 years [SD=7.8]; t=87.61, df=547, p<0.001) and women (mean age=39.1 [SD=4.3] versus 55.3 years [SD=7.8]; t=46.78, df=247, p<0.001). All subsequent ANOVAs, therefore, employed a 2 (men/women) by 2 (older/younger) design; simple effects for interpretation of significant interactions were tested using univariate Fs (p<0.01, Bonferroni corrected).
Personal Demographic and Professional Training Characteristics
Differences in age distributions for the men and women are reflected in the modal year for which men and women graduated from medical school (1982 versus 1973, respectively) and mode year for which they completed residency training in psychiatry (1984/1996 versus 1978, respectively). For the whole sample, there were no significant main or interaction effects for the age of graduation from medical school. There was, however, a significant interaction for the age) men and women completed residency training in psychiatry (F=10.90, df=1, 771, p<0.001; eta2= 0.01), such that among the older cohort of psychiatrists, men were significantly younger than women when they completed their training, F=44.84, df=1, 771, p<0.001; eta2=0.06; however, among the younger cohort of men and women, this age difference was not significant.
Overall, there were more men than women in the sample who were currently married or co-habitating (2=24.39, df=3, p<0.001) and there was a greater proportion of women who reported that they were never married, or had been separated or divorced (2=17.71, df=2, p<0.001). When compared to the men, however, this difference was manifest only for the older cohort of psychiatrists, and not the younger cohort (2=17.71, df=2, p<0.001). There was a significant interaction for the number of children (F=0.573, df=1, 770, p<0.05; eta2=0.01), in the overall comparison women had fewer children than men (F=30.8, df=1, 770, p<0.001; eta2); however, this difference was only statistically significant among the older cohort when comparing men and women.
Subspecialty Practice and Theoretical Orientation
There were no significant gender differences in whether men or women had a subspecialty or not, and this was demonstrated for both the younger and the older cohort of psychiatrists. However, there were significant differences in the types of subspecialties. Proportionately more women than men had a subspecialty in child (2=17.73, df=1, p<0.001), geriatrics (2=5.19, df=1, p<0.05), and women’s mental health (2=24.78, df=1, p<0.001). This gender difference in subspecialty is revealed for the child and women’s mental health subspecialties for both the younger women (2=8.17, df=1, p<0.01 and 2=16.54, df=1, p<0.001, respectively) and the older women (2=11.28, df=1, p<0.001 and 2=12.11, df=1, p<0.001). On the other hand, proportionately more men than women had subspecialties in forensic (2=15.86, df=1, p<0.001) and psychosomatics (2=4.86, df=1, p<0.05). A greater proportion of both younger men (2=4.32, df=1, p<0.05) and older men (2=10.07, df=1, p<0.01) indicated forensics as a subspecialty choice when compared to younger and older women. However, the apparent difference between men and women in choosing psychosomatics as a subspecialty did not reveal itself when the younger and older cohorts of men and women were compared. Gender differences in the proportion of men and women indicating schizophrenia as a subspecialty between men and women was evident for the younger cohort, with the greater proportion residing with the males, (7.3% for women vs. 16.3% for men; 2=8.07, df=1, p<0.05).
With respect to theoretical orientation, there were no significant differences between men and women among the younger and older cohorts across four broad categories: psychoanalytic/psychodynamic, cognitive/behavioural, biological, eclectic categories.
Men were more likely than women to have hospital admitting privileges (2=8.23, df=1, p<0.01. This sex difference emerged for both younger (2=4.38, df=1, p<0.05) and older cohorts (2=4.92, df=1, p<0.05). There were no significant gender differences with respect to population of practice area for the men and women in the overall sample, and within the two age groupings.
With regard to the clinical practice activities for men and women, on average, men reported working a greater number of hours per week than women (F=24.66, df=1, 757, p<0.01; eta2=0.03). The younger cohort of psychiatrists saw fewer patients per week (F=13.39, df=1, 739, p<0.01; eta2=0.02) and had less sessions per week (F=16.25, df=1, 674, p<0.01; eta2=0.02) than the older cohort. In addition, a significant gender by age interaction effect was found for number of minutes spent in each psychotherapy session (F=4.71, df=1, 727, p<0.05; eta2=0.01) such that among the older cohort of psychiatrists, women spent a greater amount of time in psychotherapy than the men (F=15.61, df=1, 728, p<0.001; eta2=0.02); this difference that was not found among the younger cohort. With respect to pharmacotherapy/medication treatment, there was a significant main effect for gender where men reported seeing more patients for pharmacotherapy/medication treatment than women (F=10.98, df=1, 702, p<0.01; eta2=0.02). Women spent more time with their patients than men when they did see them for pharmacotherapy/medication treatment (F=21.23, df=1, 624, p<0.01; eta2=0.03). In addition, women spent more of their time in individual work with children and adolescents than did men (F=3.89, df=1, 322, p=0.05; eta2=0.01) and family therapy (F=8.65, df=1, 360, p<0.01; eta2=0.02) when compared to the men. No other significant main or interaction effects were found for percentage of practice time spent in individual adult, couple/marital, or group settings.
Clinical Practice Activities
Main effects for the diagnostic characteristics of patients seen by men and women were found, with women seeing a larger proportion of patients with anxiety disorders, other than PTSD and panic disorder (F=4.72, df=1, 301, p<0.05; eta2=0.02) and patients with comorbid axis I disorders (F=5.06, df=1, 714, p<0.05; eta2=0.03) than the men. Men reported seeing a larger proportion of patients than the women with comorbid substance abuse disorders (F=3.75, df=1, 750, p=0.05; eta2=0.01). Significant main effects for age revealed that the younger cohort of psychiatrists saw more patients with panic disorder (F=4.73, df=1, 156, p<0.05; eta2=0.03) and other anxiety disorders aside from PTSD (F=7.99, df=1, 301, p<0.01; eta2=0.03) as well as pain/somatoform disorders (F=3.88, df=1, 83, p=0.05; eta2=0.05) than the older cohort. The younger cohort also reported seeing more patients than the older cohort with comorbid substance abuse disorders (F=8.03, df=1, 750, p<0.01; eta2=0.01) and axis I disorders (F=4.33, df=1, 714, p<0.05; eta2=0.01.
There was a significant gender by age interaction for those psychiatrists who see patients with depressive disorders (F=5.10, df=1, 596, p<0.05; eta2= 0.01). The younger cohort of women saw significantly more patients with these disorders than the young men (F=11.35, df=1, 596, p<0.001; eta2=0.02); however, this difference did not emerge in the older cohort of psychiatrists. In addition, there was a significant gender by age interaction effect for those who saw schizophrenic patients (F=9.08, df=1, 219, p<0.01; eta2=0.04), such that the younger cohort of male psychiatrists saw more schizophrenia patients than the younger cohort of females (F=5.56, df=1, 219, p<0.05; eta2=0.03); however, among the older population this trend was reversed and the older women reported seeing more schizophrenia patients than the older men, although this difference was not significant. There was also a significant gender by age interaction effect for those who saw patients with a co-occuring medical diagnosis (F=14.09, df=1, 743, p<0.01; eta2=0.02). The younger men saw a greater percentage of patients with these disorders than the younger women (F=32.80, df=1, 743, p<0.001; eta2=0.04); however, among the older cohort the female psychiatrists, on average, saw more patients with a co-occurring medical diagnosis than the older men.
No significant differences were found for those who saw patients with PTSD, personality disorders or comorbid axis II disorders.
Teaching and Research Activities
A greater proportion of men when compared to women in the older cohort reported active involvement in research (2=6.35, df=1, p<0.01). There were no differences between the men and women in the younger cohort of psychiatrists. In addition, men were more likely to have published in a scholarly journal (2=12.78, df=1, p<0.001), and this effect was evident across both the younger (2=4.46, df=1, p<0.05) and older (2=12.06, df=1, p<0.001) cohorts. Men were also more likely than women to have held pharmaceutical funding (2=6.102, df=1, p< 0.05), evident in both the older (2=4.624, df=1, p<0.05) and the younger cohorts (2=5.00, df=1, p<0.05).
There were no significant differences in the percentage of men or women in the overall sample or within the two age cohorts who taught in the university on a regular basis. Nor was there were any significant differences between men and women in their attendance at hospital rounds or in presenting at hospital rounds, within the two cohorts. For the overall sample, a similar proportion of men and women indicated that they had been active in research in the past 5 years and there were no significant differences in the proportion of men and women for the overall group and for the two age groups with respect to their presenting at scholarly conferences and holding peer-reviewed funding.
Significant main effects emerged for age when considering the reported work and income distributions over particular practice activities, whereby the younger psychiatrists reported spending a greater percentage of their work time on research (F=1.43, df=1, 333, p<0.05; eta2=0.02), and less in clinical practice (F=4.78, df=1, 763, p<0.05; eta2=0.01) when compared to the older cohort. The younger cohort also reported that a greater percentage of their income was derived from research than the older cohort (F=6.19, df=1, 125, p<0.01; eta2=0.05). There was also a main effect for age where the older cohort reported a greater percentage of their income was generated from other professional activities when compared to the younger cohort (F=4.22, df=1, 222, p<0.05; eta2=0.02). There was a significant interaction with respect to the time devoted to professional development (F=4.77, df=1, 563, p<0.05; eta2= 0.01), such that the men overall reported spending less time than the women engaged in professional development, however, this difference was only significant for the older cohort (F=12.56, df=1, 563, p<0.001; eta2=0.02.
No significant differences were found for percentage of work time spent in university teaching, administration, or in other professional activities. Moreover, no differences were found for percent of income generated by clinical practice, university teaching or administration.
Professional and Personal Satisfaction
The men rated their careers as more successful than did the women in terms of financial compensation (F=9.34, df=1, 786, p<0.01; eta2=0.01), peer recognition (F=8.28, df=1, 787, p<0.01; eta2=0.01), and academic recognition (F=8.11, df=1, 774, p<0.01; eta2=0.01). The men also reported feeling more satisfied treating patients with pharmacotherapy than did the women (F=5.79, df=1, 782, p<0.05; eta2=0.01). The women, however, felt a greater sense of satisfaction than the men with regards to participating in research (F=5.83, df=1, 754, p<0.05; eta2=0.01) and from their sense of involvement in the community (F=3.90, df=1, 767, p<0.05; eta2=0.01). In addition, there was also a difference with respect to reported satisfaction with administrative responsibilities, whereby the women reported greater satisfaction than the men (F=4.00, df=1, 35, p=0.05; eta2=0.10). Significant main effects for age emerged when considering perceptions of satisfaction with respect to appreciation from patients (F=6.50, df=1, 783, p<0.01; eta2=0.01), the psychiatrists’ feeling of their own professional career (F=14.28, df=1, 785, p<0.01; eta2=0.02), and from psychotherapy (F=4.89, df=1, 784, p<0.05; eta2=0.01), where the younger psychiatrists reported feeling less satisfied from these areas than their older counterparts. On the other hand, the younger cohort placed greater priority on collegial interaction than did the older cohort (F=5.89, df=1, 158, p<0.05; eta2=0.04).
The only significant gender-by-age interaction to emerge from analyses of satisfaction with career was with the priority given to pharmacotherapy (F=5.47, df=1, 574, p<0.01; eta2=0.01), such that among the younger cohort of psychiatrists, the women placed greater priority on pharmacotherapy than the men (F=5.82, df=1, 574, p<0.05; eta2=0.01); however, among the older cohort, the men placed a greater priority on this same type of treatment than did the women. No significant differences for perceptions of success were found when considering community recognition, consultations, university teaching, collegial interaction and administration. In addition, there were no differences reported on the priority given to consultations, psychotherapy, teaching, supervision, or research.
The female psychiatrists indicated that given the choice, they were more likely than the men to choose psychiatry as a specialty (F=6.62, df=1, 780, p=0.01; eta2=0.01) and had less regret than the men about choosing psychiatry as a career (F=13.16, df=1, 788, p<0.01; eta2=0.02). Men reported feeling a greater degree of emotional burden (F=4.64, df=1, 773, p<0.05; eta2=0.01) when compared to the female psychiatrists. A significant main effect of age also emerged for degree of emotional burden, such that the younger cohort reported feeling a greater degree of burden than the older cohort (F=19.20, df=1, 773, p<0.01; eta2=0.02). Other significant main effects for age were found with respect to the extent to which psychiatrists felt other medical and nonmedical mental health professionals specialists respected psychiatry (F=9.79, df=1, 780, p<0.01; eta2=0.01) (F=4.50, df=1, 778, p<0.05; eta2=0.01), where the younger cohort felt less respect from these professionals than the older cohort. Significant interaction effects were found for the sense of availability of professional contact (F=4.12, df=1, 736, p<0.05) where the older cohort of women felt this more than the older cohort of men, however, the younger cohort of men reported a greater availability of professional contact than the women. In addition, there was an interaction for the ability to devote time to their professional career (F=7.95, df=1, 776, p<0.01; eta2=0.01), where women felt they were less able than the men overall to devote time to their career (F=15.81, df=1, 776, p<0.001; eta2=0.02); however this difference was significant only among the younger cohort of psychiatrists.
With regards to the ratings of professional and personal satisfaction among the psychiatrists, the women indicated that they had struggled more to achieve a good balance between their professional and personal lives than the men (F=6.22, df=1, 785, p<0.01; eta2=0.01). Significant main effects for age revealed that the younger psychiatrists also struggled more than the older psychiatrists to achieve a balance between their personal and professional lives (F=15.94, df=1, 784, p<0.01; eta2=0.02), and that both nonprofessional and professional commitments impinged on their professional life (F=11.98, df=1, 784, p<0.01; eta2=0.02) (F=46.57, df=1, 784, p<0.01; eta2=0.06), more so than the older cohort. The younger cohort were also less likely to report that their work offered some intrinsic value when compared to the older cohort (F=5.89, df=1, 789, p<0.05; eta2=0.01). In addition, there was a significant interaction effect for the extent to which major personal life changes prompted psychiatrists to alter their professional career (F=5.60, df=1, 779, p<0.05; eta2=0.01), whereby the younger cohort of female psychiatrists expressed this significantly more than any of the other groups (F=9.35, df=1, 779, p<0.01; eta2=0.01).
DISCUSSION
On many dimensions, the men and women in this study were very similar—they worked long hours and involved themselves in a wide range of professional activities, including consultation, care and administration, as well as teaching and research. Both groups worked hard, were committed to clinical care and although they experienced the burden of their work, felt they had available supportive relationships. With respect to theoretical orientation, there were no significant differences between men and women across four broad categories: psychoanalytic/psychodynamic, cognitive/behavioral, biological, and eclectic. At the same time, there were significant differences between the genders and age groups that have a bearing on the delivery of psychiatric care and on the understanding of issues faced by practicing psychiatrists.
The survey data indicated that females were likely to work slightly fewer hours per week. This is in keeping with other literature on physician behavior (7, 13, 15). Whereas women were likely to work slightly fewer hours, psychiatrists of both genders indicated a wish to work less hard. Nearly three-quarters (73%) of the sample reported that they would prefer to work less. This latter figure is of particular interest as it may suggest a high degree of overwork and possible excessive fatigue for this sample, which is consistent with reports from other sources. Recent research, for example, has emphasized the importance of work-related exhaustion in medicine in general, and the relation between exhaustion and fulfillment at work (16). Deary et al. (17) reported that psychiatrists displayed greater emotional exhaustion as a result of work than a comparison group of physicians in other specialties, despite having fewer clinical work demands. Psychiatrists have been reported to experience more work-related exhaustion than mental health nurses, probably related to the nature of the work load itself, which in the Thomsen et al. (16) study accounted for a large degree of the variance in exhaustion. High levels of emotional exhaustion were reported by male psychiatrists in comparison to other physicians in Finland (18). Male psychiatrists ranked second out of 11 physician groups, and female psychiatrists ranked fifth, in "burnout." Similarly, in our study, men reported feeling significantly more emotionally burdened than the women across both age cohorts in accordance with results from some earlier research (19, 20). This is especially interesting in light of the additional roles women traditionally carry outside of work.
Whereas there were no gender differences in the numbers of psychotherapy patients seen per week, (in both the younger and older age cohorts) men saw more people for pharmacotherapy. Women saw patients for longer periods; in the case of pharmacotherapy, this was true for both age cohorts and for psychotherapy, for the older cohort of women only. There were no differences in whether people had developed a subspecialty; but there were differences in the type: proportionately more women than men had a subspecialty in child, geriatric, and women’s mental health and spent their time in individual work with children and adolescents and in family therapy. On the other hand, proportionately more men had subspecialties in forensics and psychosomatics, and for the younger men, in schizophrenia. Women more commonly saw patients with anxiety disorders and co-morbid axis I disorders, and amongst the younger cohort, depression; men saw patients with co-morbid substance abuse disorders and with the younger group, co-occurring medical illnesses more frequently. Men, both in the younger and older categories, were more likely to have hospital privileges. With respect to teaching and research, no significant differences were found except that men in both age groups were more likely to have published in a scholarly journal and to have held pharmaceutical funding than women.
One striking finding of this survey related to how physicians assessed their success and satisfaction with their careers. Overall, across a number of dimensions the men rated their careers as more successful; this was true when rated in terms of financial compensation, peer recognition, and academic recognition. On the other hand, women had less regret about choosing psychiatry as a career. For the group as a whole, regrets in choosing psychiatry were uncommon (about 9%). While women accounted for 31% of the respondents to the questionnaire, they were only 13% of the high-regret group. Women indicated that they if they were able to choose again, they would choose psychiatry as a specialty, than did the men. One explanation for the discrepancy across these ratings is that whereas both men and women are able to rate themselves objectively on more objective or tangible indicators, such as financial compensation, men’s ratings on more global levels of success, unmoored from objective markers, may rate themselves as less successful. This may be attributable to a self-critical style that is more characteristic of men than women (21). These differences are all the more striking since women (not surprisingly, especially the younger group) reported that their careers had been more highly affected by their personal lives than did men. The women, independent of age, also indicated that they had struggled more to achieve a good balance between their professional and personal lives, and also endorsed to a larger extent that major personal life change prompted them to alter their professional career.
Interestingly, however, the men from both the young and old cohorts reported feeling significantly more emotionally burdened than the women. One explanation for this finding might be that the men tended to work longer hours and saw more emotionally difficult patients. In addition, feelings of burden may be influenced by perceptions of social support. While the results of the survey did not reveal any significant differences with regards to perceptions of support, perhaps the nature of support received or interpreted by men is not as effective as that received by women. This view is consistent with socialization experiences between men and women in general, with women emphasizing empathy and nurturance. This support might increase the women’s threshold of tolerance. Further research exploring this issue is warranted.
Age also had some bearing on the feelings of success and satisfaction with career—for both genders. For example, both the older cohort of men and women reported increased satisfaction with psychotherapy and they reported less of a burden from their patients than did the younger cohort of men and women. Similarly, as the psychiatrists aged, they were less likely to hold a university appointment or to do research, hold funding for research or to teach or present at hospital rounds. This change may have decreased overall job demands thereby increasing satisfaction.
Of importance, the gender related findings on a number of the parameters varied according to age. For example, the younger women spent less time in each psychotherapy session, in a fashion similar to the men of the study. They also spent less time reading the professional literature than did the older women. While there was a decrease in research involvement in both men and women, the older cohort of women was involved significantly less in research than the older men or the younger women.
Younger women in comparison to the older women group had less of a satisfying balance between professional and personal lives, and a greater struggle for such balance. They felt a greater emotional burden from their patients (but younger male psychiatrists experienced the greatest degree of burden). They also felt less respect from other medical specialists and nonmedical colleagues. They described that their personal lives affected their professional careers more and they had greater regrets in selecting psychiatry as a career. Perhaps this can be explained by the personal burdens that may be more salient for a young cohort of women such as child rearing, and personal and societal demands. Alternatively, it seems that despite the fact the younger psychiatrists are following the professional course of men more, they are still burdened by gendered responsibilities that expect them to maintain their domestic roles. Combining this urge to strive for professionalism with the maintained need to fulfill female expectations will result in increased difficulties in balancing these opposing roles.
What is striking, however, is that in spite of these changes, the two age cohorts of women did not differ in their perceptions of personal success on any parameter—both were lower than the two groups of men respondents. Most interestingly, the younger women were more like both the older and younger men, in that they displayed higher levels of regret in selecting psychiatry as a career. The younger women, like the younger men, were less likely to endorse the choice of psychiatry as a career if they were starting again.
Why these gender differences occurred in terms of success, satisfaction and regret is not entirely clear. The specific work demands on psychiatrists vary. Often the work is very isolating. It is difficult to be the recipient of the emotional needs of many ill and needy patients—this was indicated by one–quarter of the Ontario sample. The nature of practice often forces psychiatrists to face fears of one’s own vulnerabilities. Patient suicide can be an important occupational hazard, which causes disruption in psychiatrists’ professional and personal lives (22). The risk of over-involvement with patients may be great in psychiatry, possibly because of the nature of the illnesses being treated and the methods of treatment. Over-involvement has been linked to greater staff "burnout" (23). It is possible that aspects of these demands are experienced differently by men and women, although contrastingly, the response to the question of degree of emotional burden was higher in men in this survey (and especially high in the young cohort of men). Perhaps women’s emphasis on the relational aspects of their work may provide increased satisfaction as compared to the men, in spite of the burdens of practice and less objective external success. Women have often been socialized to place the wishes and needs of others in primary focus, rather than focusing on their own (24). Men and women may also define success differently with men emphasizing external markers more than do the women.
Other explanations for these findings are also possible. It may be that men and women enter a medical career with different expectations, which may be especially true for the older women in this cohort. The older cohort of psychiatrists had entered medicine at a time when it was less common for women and they may have not expected as much in terms of recognition and financial compensation as compared to the men. Younger women appear to have more of the expectations, and behaviors of their men colleagues, but don’t see themselves attaining the same levels of success. Alternatively, it may be understood simply by the fact that as individuals mature through middle age, personal satisfaction and happiness tend to increase (25).
Occupational stress and job satisfaction vary considerably among physicians. Often this is dependent on the external world: respect for physicians, compensation, administrative burdens, overcrowded emergency rooms, the relationship of the physician to the multi-disciplinary team, and to society, all play a role. Edwards et al. (26) have recently noted that dissatisfaction among physicians is a world–wide phenomenon, and they feel the cause is a breakdown in the implicit contract between doctors and society. The individual orientation that doctors were trained for does not fit with the demands of current health care systems. In a recent (late 2001) survey of more than 2,300 Ontario physicians (27) almost 41% reported being either "dissatisfied" or "very dissatisfied" with current medical practice. Almost half (46%) reported that they find their current medical practice to be "very" or "extremely stressful." An earlier study of Canadian physicians found that both men and women had high levels of both stress and job satisfaction, with the genders appearing to have overall similar levels on both (28). For both men and women in this study, dissatisfaction with various aspects of practice was predictive of stress. Many were the same for both groups and involved practice characteristics and poor relationships with colleagues.
With regards to psychiatrists in comparison to other women physicians, Frank et al. (6) surveyed a large U.S. cohort. This group of psychiatrists were likely to work less hours, and more likely to be solo practitioners compared to other female physicians. There were no differences in perceived work amount, work stress, or career satisfaction. Interestingly, about 15% of both the female psychiatrists and physicians described little career satisfaction.
The gender differences in the current study in satisfaction, recognition and regret occurred independently of the social supports available to each of the gender groups. Fortunately, 93% reported having professional colleagues to share their concerns. Of those 93%, the majority (81%) rated their professional contacts as readily available and of excellent quality. At the same time, a significant minority reported feeling professionally isolated; 5% felt extremely isolated and another 13% moderately isolated. Outside of their professional worlds, the vast majority of the psychiatrists in this sample (86%) felt they had significant others with which to share their concerns. Again, as with their professional collegial support, those with these nonprofessional/personal supports rated the availability (78%) and their quality (91%) as very high.
Overwhelmingly, the psychiatrists in the survey felt they would choose psychiatry as a career again, with only 5% reporting that they would be extremely hesitant, and another 6.3% reporting that they would be moderately hesitant. As a whole, the sample believed strongly in the intrinsic value of psychiatry, with only about 2% expressing extreme or moderate concerns about the intrinsic value of their work. In a related study, we reported that psychiatrists’ belief in the intrinsic value of their work is a key predictor in determining whether they have regrets about choosing their specialty (29). Only 7% believed that their expectations for a career in psychiatry had not been met. A recent study of psychiatrists in Texas found that almost one-quarter were considering leaving the field (30), and 70% of respondents in a survey of Manhattan private practitioners indicated that they would not recommend a career in private practice (31). Sturm (32) described data from the Community Tracking Study physician survey. It involved over 600 psychiatrists in comparison with over 4,000 other medical and surgical specialists and over 7,000 primary care doctors. Over 21% of psychiatrists reported being very or somewhat dissatisfied with their careers, a higher figure than for other physicians, due to an age cohort effect. By contrast, the Ontario psychiatrists have far less regret in the selection of their careers, possibly due to the effects of the health care environment and reimbursement issues in the United States.
Clearly, psychiatrists value the opportunity to assist in relieving human pain and suffering, to connect with people, and nurture healing and growth. Nevertheless, there are problems experienced in psychiatric practice. While many of these problems are partially related to the personality and vulnerability to illness that individuals bring to any type of work, others are related to the stresses of practice, some of which are unique to providing psychiatric care. Understanding these issues is one of the best investments we can make in assuring that psychiatrists are available, prepared, and supported in carrying out this very important work.
Results from this study suggest that discussion regarding physicians’ balancing their professional and personal lives is probably not adequately addressed in psychiatric residency training. Perhaps assigning staff psychiatrists as mentors who can discuss openly the difficulties associated with such balancing would serve to enhance overall career satisfaction levels. In addition, intensive focus groups of potential residents might center on clarifying reasons for choosing psychiatry as a specialty prior to the potential resident making a choice. These focus groups might also benefit from using the types of data obtained in this study that ultimately proved to be predictive of career satisfaction.
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