Women and Academic Psychiatry
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《精神病学术期刊》
This special issue of Academic Psychiatry provides an excellent and varied series of articles that celebrate the richness of women in psychiatry and highlight many of the challenges facing female psychiatrists in academia. The articles include surveys of female psychiatrists’ activities (1–3), reviews of the issues facing women in medicine and psychiatry during training and throughout their careers (4–7), and descriptions of the personal journeys of three academic psychiatrists with different backgrounds (8–10). Since women now constitute approximately 46% of U.S. medical students and more than 50% of psychiatry residents, a better understanding of the issues and career paths of women in medicine and psychiatry is vital for those responsible for training physicians and structuring academic and medical care systems if we are to realize the full potential of women in our field.
Psychiatry, pediatrics, and, more recently, obstetrics/gynecology have been the specialties most frequently chosen by female physicians due to the patient populations these specialties serve and the skill sets they require. In addition, many women choose psychiatry because it can be better time-defined than most other specialties and less intrusive to the rest of the practitioner’s life, therefore making its practice more compatible with parenting and other family roles. Although not overly-abundant, psychiatry has visible female leaders and role models, with several women having served as presidents of major psychiatric organizations and female psychiatrists holding prominent practice roles in the community.
Today, female psychiatrists are more likely to enter academic careers than they were in the past but less likely than men to remain in academia or rise to the highest ranks. As a result, female psychiatrist role models at the highest academic ranks are sparse, and most Chairs and departmental leaders are still men. Many senior female psychiatrist role models are master clinicians and therapists, often serving as part-time or clinical faculty rather than full-time academics. Some suggest that this is a cohort effect that will change as more women enter our field and that women will eventually rise to academic and organizational leadership roles proportionate with their numbers.
However, I believe that this prediction is unlikely, as women have a harder path than men in medicine and psychiatry because of both societal and professional cultural expectations. Our society continues to expect women to be primarily responsible for child and family care giving and the maintenance of the home, an issue, noted in one of the articles (9), that is even more significant in certain subcultures and for some international medical graduates. With the increasing number of dual career families, one member, usually the man, is expected to work full-time and earn the majority of the family income, while the other, usually the woman, is expected to decelerate her career and if necessary work only part-time in order to allow for time to take care of the children and the home. The training and junior faculty years coincide biologically with the usual time for child bearing and child rearing, resulting in female physicians with children being unable, and often unwilling, to devote full-time to a career that conflicts with their concurrent family responsibilities. This puts them out of step with the usual academic expectation that junior faculty are to devote full-time attention to their careers and establish a track record of productivity if they wish to be successful.
In addition, postresidency research training, in either a formal fellowship or as a member of an ongoing research group, is often required for a physician to learn skills necessary to become an independent investigator, and full-time attention is essential in order to obtain grant funding to undertake one’s own research. With these restrictions, women who are part-time psychiatrists are less likely to undertake careers in research or to publish as prolifically as their male peers. With publications the "coin of the realm" in most academic systems, a limited publication record keeps women from achieving the higher academic ranks. Since some Chairs want their investigators to teach, one report (1) found that female faculty members teach fewer core courses to medical students and residents, making it less likely that the latter are exposed to successful female faculty during their training.
So, it should be no surprise that women usually have lower written productivity than men, advance more slowly in academics, and often do not achieve tenure within the usual timeframe, all of which may lead to discouragement as their male peers advance. This often stimulates female psychiatrists to focus on clinical roles, especially outpatient practice which can be substantially time-bound, allowing them to more reliably control their professional work time to be in line with their family responsibilities. Women who remain in academic positions on a part-time basis usually cannot be as available as their full-time male peers to take on the additional commitments expected of good academic citizens (i.e., committee work, late meetings, and the other hassles of academic life). Outpatient practice, often done privately, is also attractive to female psychiatrists who have large debts but limited time to devote to their professional work. In order to earn maximum dollars within a limited amount of time, female psychiatrists often leave less financially rewarding academic positions for private practice. Women who remain in academic and other organizational jobs part-time also realize that no matter what is stated as their official part-time "percentage," they will have to put in additional time in order to attend critical organizational meetings and communicate about and "hand-off" clinical responsibilities to those covering them. Women who are part-time academic psychiatrists also find it harder to strive for and accept leadership positions, especially those that add extra hours to their workday without extra dollars in their paycheck, because of their time commitments to home and family. This therefore pushes most committee work and leadership possibilities onto the men in the department who at times are resentful of women being spared these "extra burdens" (although the men are often less cognizant of the extra networking opportunities such departmental work affords them).
As a department Chair I personally cherish the women faculty members who have added so much to my department’s success, but they also have raised special challenges for me. Although in my 14 years as Chair I have hired more junior women faculty than men, most of whom started out full-time, almost all now have become part-time due to their family roles. Many have excellent leadership potential and several rose to major leadership roles in the department; however when their family responsibilities increased, they have had to pull back from the large time commitment required by their leadership roles. I feel limited in the amount I can call on my part-time faculty members for departmental, hospital, and medical school committees and projects because I respect their need to confine their professional work to specific hours. I’ve had to be clear with part-time faculty that a half-time job will require somewhat more than half-time to adequately keep up with what’s going on in the department, come to vital meetings, and make critical clinical hand-offs to those who cover when they are not working. I’ve similarly had to discuss with my full-time faculty, now mostly men, that they will be asked to pick up disproportionately more of the committee meetings, organizational work and call responsibilities. I have reluctantly watched some of my most talented women faculty members go into private practice in order to maximize income within the limited time they can devote to their professional careers, and I’ve worked with them to find ways they can retain respected, part-time academic roles in the department. I’ve also helped them continue moving toward academic promotion on a longer timeline rather than giving up and conveyed that I value their difficult balancing act in combining academic and family roles.
The articles in this issue highlight how everyone in medicine, especially those in academia, will have to change to accommodate the reality of the increasing number of women in our profession. Although there are many wonder(ous) women in psychiatry, there are neither superwomen nor supermen. No one can do everything well, and everyone needs help to achieve a balanced professional and personal lives. Female and male physicians need support systems both at home and in the workplace to succeed in concurrent professional, personal, and family roles, and medicine has to fully recognize and accommodate this reality, just as it is working to accept the 80-hour work week rule for residents. Despite the grumbling about the latter, training systems are reluctantly accommodating and finding new ways of structuring and operating care and training systems to meet this rule’s requirements.
Organized medicine will have to find new ways to help female physicians succeed because it cannot afford to lose one-half of its workforce. Similarly, academic psychiatry cannot afford to have some of its best and brightest stop focusing on the pressing problems of our field and leave academia for private practice. To achieve these goals, a number of structural changes in academic systems will be required.
We have to change academic systems to provide more ways that women (and men) can productively work part-time, with better job sharing and covering arrangements, and better methods for sharing academic responsibility and credit. Such part-time positions must be visibly valued, and academic leaders must celebrate the "total productivity" of women faculty members at the hospital and in the home.
We must create clearer ways to accommodate pregnancy and family responsibilities for our women trainees and faculty members. This will require rethinking the structure of our programs and care processes and funding the redundant workforce necessary to continue clinical and academic missions without inappropriately adding the tasks of absent women faculty onto their peers.
We have to change promotion timelines and some of the basic academic expectations of faculty. This will include extending the time to "up or out" tenure decisions (in those systems which still have tenure) to reflect the actual percentage of time and effort women are able to devote to their professional careers rather than the absolute time since they joined the faculty, and in non-tenure systems we must find ways to value the slower trajectory of academic productivity associated with part-time work as an honored, albeit chronologically longer, path toward professional excellence and advancement. Equally important, we must re-engineer our systems so that women can re-enter the academic mainstream in midlife, after their childrearing responsibilities have diminished. At present it is very hard for anyone who has left the straight and narrow academic path to find a meaningful way to re-enter academia, a problematic roadblock that we must resolve. This may require providing supplemental clinical and research training opportunities to allow midlife psychiatrists to re-enter full-time practice and/or restart productive academic careers for the remaining 20–30 years of their professional lives.
We have to provide more supports for women in the medical workplace. These include abundant childcare opportunities within the work environment and effective mentoring by both women and men about the multitude of honorable and rewarding professional pathways in psychiatry. For example, my institution, Brigham and Women’s Hospital in Boston, has instituted an Office of Women’s Careers (headed by Dr. Carol Nadelson, the first woman APA President) to advise and support women physicians in their academic careers.
Both women and men require better mentoring about ways to establish a healthy balance of priorities in their professional and personal lives. Female psychiatrists need mentors to help them find a successful professional path that is in harmony with their personal and family responsibilities. Although male physicians clearly have an easier path professionally, as a therapist who treats physicians I can attest that the unexamined "straight and narrow," full-speed ahead academic career often can lead to an unsatisfying balance between work and family life.
The increasing number of women in psychiatry has greatly enriched our patients, our science and our profession. This change in our field’s workforce should challenge us to rethink the structure of medical systems in general, and academic ones in particular; this is a challenge we can ill afford to ignore.
REFERENCES
Garfinkel PE, Bagby RM, Schuller DR, et al: Gender differences in the practice characteristics and career satisfaction of psychiatrists in Ontario. Acad Psychiatry 28:310–320
Hirshbein LD, Fitzgerald K, Riba M. Women and teaching in academic psychiatry. Acad Psychiatry 2004; 28:292–298
Olarte SW. Women psychiatrists: personal and professional choices—a survey. Acad Psychiatry 2004; 28:321–324
Bickel J. Women in academic psychiatry. Acad Psychiatry 2004; 28:285–291
Bogan AM, Safer DL. Women in psychiatric training. Acad Psychiatry 2004; 28:305–309
Hirshbein LD. History of women in psychiatry. Acad Psychiatry 2004; 28:337–343
Verlander GA. Female physicians: Balancing career and family. Acad Psychiatry 2004; 28:331–336
Goodwin JM. Autumn: Thoughts on commencing a fourth decade in academic psychiatry. Acad Psychiatry 2004; 28:325–330
Juthani NV. Challenges faced by international women professionals. Academic Psychiatry 2004; 28:347–350
Weerasekera P. Swimming upstream: Reflections of a career educator. Acad Psychiatry 2004; 28:344–346(Jonathan F. Borus, M.D.)
Psychiatry, pediatrics, and, more recently, obstetrics/gynecology have been the specialties most frequently chosen by female physicians due to the patient populations these specialties serve and the skill sets they require. In addition, many women choose psychiatry because it can be better time-defined than most other specialties and less intrusive to the rest of the practitioner’s life, therefore making its practice more compatible with parenting and other family roles. Although not overly-abundant, psychiatry has visible female leaders and role models, with several women having served as presidents of major psychiatric organizations and female psychiatrists holding prominent practice roles in the community.
Today, female psychiatrists are more likely to enter academic careers than they were in the past but less likely than men to remain in academia or rise to the highest ranks. As a result, female psychiatrist role models at the highest academic ranks are sparse, and most Chairs and departmental leaders are still men. Many senior female psychiatrist role models are master clinicians and therapists, often serving as part-time or clinical faculty rather than full-time academics. Some suggest that this is a cohort effect that will change as more women enter our field and that women will eventually rise to academic and organizational leadership roles proportionate with their numbers.
However, I believe that this prediction is unlikely, as women have a harder path than men in medicine and psychiatry because of both societal and professional cultural expectations. Our society continues to expect women to be primarily responsible for child and family care giving and the maintenance of the home, an issue, noted in one of the articles (9), that is even more significant in certain subcultures and for some international medical graduates. With the increasing number of dual career families, one member, usually the man, is expected to work full-time and earn the majority of the family income, while the other, usually the woman, is expected to decelerate her career and if necessary work only part-time in order to allow for time to take care of the children and the home. The training and junior faculty years coincide biologically with the usual time for child bearing and child rearing, resulting in female physicians with children being unable, and often unwilling, to devote full-time to a career that conflicts with their concurrent family responsibilities. This puts them out of step with the usual academic expectation that junior faculty are to devote full-time attention to their careers and establish a track record of productivity if they wish to be successful.
In addition, postresidency research training, in either a formal fellowship or as a member of an ongoing research group, is often required for a physician to learn skills necessary to become an independent investigator, and full-time attention is essential in order to obtain grant funding to undertake one’s own research. With these restrictions, women who are part-time psychiatrists are less likely to undertake careers in research or to publish as prolifically as their male peers. With publications the "coin of the realm" in most academic systems, a limited publication record keeps women from achieving the higher academic ranks. Since some Chairs want their investigators to teach, one report (1) found that female faculty members teach fewer core courses to medical students and residents, making it less likely that the latter are exposed to successful female faculty during their training.
So, it should be no surprise that women usually have lower written productivity than men, advance more slowly in academics, and often do not achieve tenure within the usual timeframe, all of which may lead to discouragement as their male peers advance. This often stimulates female psychiatrists to focus on clinical roles, especially outpatient practice which can be substantially time-bound, allowing them to more reliably control their professional work time to be in line with their family responsibilities. Women who remain in academic positions on a part-time basis usually cannot be as available as their full-time male peers to take on the additional commitments expected of good academic citizens (i.e., committee work, late meetings, and the other hassles of academic life). Outpatient practice, often done privately, is also attractive to female psychiatrists who have large debts but limited time to devote to their professional work. In order to earn maximum dollars within a limited amount of time, female psychiatrists often leave less financially rewarding academic positions for private practice. Women who remain in academic and other organizational jobs part-time also realize that no matter what is stated as their official part-time "percentage," they will have to put in additional time in order to attend critical organizational meetings and communicate about and "hand-off" clinical responsibilities to those covering them. Women who are part-time academic psychiatrists also find it harder to strive for and accept leadership positions, especially those that add extra hours to their workday without extra dollars in their paycheck, because of their time commitments to home and family. This therefore pushes most committee work and leadership possibilities onto the men in the department who at times are resentful of women being spared these "extra burdens" (although the men are often less cognizant of the extra networking opportunities such departmental work affords them).
As a department Chair I personally cherish the women faculty members who have added so much to my department’s success, but they also have raised special challenges for me. Although in my 14 years as Chair I have hired more junior women faculty than men, most of whom started out full-time, almost all now have become part-time due to their family roles. Many have excellent leadership potential and several rose to major leadership roles in the department; however when their family responsibilities increased, they have had to pull back from the large time commitment required by their leadership roles. I feel limited in the amount I can call on my part-time faculty members for departmental, hospital, and medical school committees and projects because I respect their need to confine their professional work to specific hours. I’ve had to be clear with part-time faculty that a half-time job will require somewhat more than half-time to adequately keep up with what’s going on in the department, come to vital meetings, and make critical clinical hand-offs to those who cover when they are not working. I’ve similarly had to discuss with my full-time faculty, now mostly men, that they will be asked to pick up disproportionately more of the committee meetings, organizational work and call responsibilities. I have reluctantly watched some of my most talented women faculty members go into private practice in order to maximize income within the limited time they can devote to their professional careers, and I’ve worked with them to find ways they can retain respected, part-time academic roles in the department. I’ve also helped them continue moving toward academic promotion on a longer timeline rather than giving up and conveyed that I value their difficult balancing act in combining academic and family roles.
The articles in this issue highlight how everyone in medicine, especially those in academia, will have to change to accommodate the reality of the increasing number of women in our profession. Although there are many wonder(ous) women in psychiatry, there are neither superwomen nor supermen. No one can do everything well, and everyone needs help to achieve a balanced professional and personal lives. Female and male physicians need support systems both at home and in the workplace to succeed in concurrent professional, personal, and family roles, and medicine has to fully recognize and accommodate this reality, just as it is working to accept the 80-hour work week rule for residents. Despite the grumbling about the latter, training systems are reluctantly accommodating and finding new ways of structuring and operating care and training systems to meet this rule’s requirements.
Organized medicine will have to find new ways to help female physicians succeed because it cannot afford to lose one-half of its workforce. Similarly, academic psychiatry cannot afford to have some of its best and brightest stop focusing on the pressing problems of our field and leave academia for private practice. To achieve these goals, a number of structural changes in academic systems will be required.
We have to change academic systems to provide more ways that women (and men) can productively work part-time, with better job sharing and covering arrangements, and better methods for sharing academic responsibility and credit. Such part-time positions must be visibly valued, and academic leaders must celebrate the "total productivity" of women faculty members at the hospital and in the home.
We must create clearer ways to accommodate pregnancy and family responsibilities for our women trainees and faculty members. This will require rethinking the structure of our programs and care processes and funding the redundant workforce necessary to continue clinical and academic missions without inappropriately adding the tasks of absent women faculty onto their peers.
We have to change promotion timelines and some of the basic academic expectations of faculty. This will include extending the time to "up or out" tenure decisions (in those systems which still have tenure) to reflect the actual percentage of time and effort women are able to devote to their professional careers rather than the absolute time since they joined the faculty, and in non-tenure systems we must find ways to value the slower trajectory of academic productivity associated with part-time work as an honored, albeit chronologically longer, path toward professional excellence and advancement. Equally important, we must re-engineer our systems so that women can re-enter the academic mainstream in midlife, after their childrearing responsibilities have diminished. At present it is very hard for anyone who has left the straight and narrow academic path to find a meaningful way to re-enter academia, a problematic roadblock that we must resolve. This may require providing supplemental clinical and research training opportunities to allow midlife psychiatrists to re-enter full-time practice and/or restart productive academic careers for the remaining 20–30 years of their professional lives.
We have to provide more supports for women in the medical workplace. These include abundant childcare opportunities within the work environment and effective mentoring by both women and men about the multitude of honorable and rewarding professional pathways in psychiatry. For example, my institution, Brigham and Women’s Hospital in Boston, has instituted an Office of Women’s Careers (headed by Dr. Carol Nadelson, the first woman APA President) to advise and support women physicians in their academic careers.
Both women and men require better mentoring about ways to establish a healthy balance of priorities in their professional and personal lives. Female psychiatrists need mentors to help them find a successful professional path that is in harmony with their personal and family responsibilities. Although male physicians clearly have an easier path professionally, as a therapist who treats physicians I can attest that the unexamined "straight and narrow," full-speed ahead academic career often can lead to an unsatisfying balance between work and family life.
The increasing number of women in psychiatry has greatly enriched our patients, our science and our profession. This change in our field’s workforce should challenge us to rethink the structure of medical systems in general, and academic ones in particular; this is a challenge we can ill afford to ignore.
REFERENCES
Garfinkel PE, Bagby RM, Schuller DR, et al: Gender differences in the practice characteristics and career satisfaction of psychiatrists in Ontario. Acad Psychiatry 28:310–320
Hirshbein LD, Fitzgerald K, Riba M. Women and teaching in academic psychiatry. Acad Psychiatry 2004; 28:292–298
Olarte SW. Women psychiatrists: personal and professional choices—a survey. Acad Psychiatry 2004; 28:321–324
Bickel J. Women in academic psychiatry. Acad Psychiatry 2004; 28:285–291
Bogan AM, Safer DL. Women in psychiatric training. Acad Psychiatry 2004; 28:305–309
Hirshbein LD. History of women in psychiatry. Acad Psychiatry 2004; 28:337–343
Verlander GA. Female physicians: Balancing career and family. Acad Psychiatry 2004; 28:331–336
Goodwin JM. Autumn: Thoughts on commencing a fourth decade in academic psychiatry. Acad Psychiatry 2004; 28:325–330
Juthani NV. Challenges faced by international women professionals. Academic Psychiatry 2004; 28:347–350
Weerasekera P. Swimming upstream: Reflections of a career educator. Acad Psychiatry 2004; 28:344–346(Jonathan F. Borus, M.D.)