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“If we want to alleviate the fatigue and frustration women physicians are experiencing, we can always start by solving two old problems: (1) All doctors need fewer bureaucratic tasks forced upon them, and (2) women physicians must be able to work in environments free of harassment and discrimination.
There’s yet another solution that must come from outside the workplace. The spouses and partners of women physicians must confront any gender inequalities that may exist within their relationship.
It would be impossible for anyone to work eight extra hours each week at home — on top of a busy work schedule — without experiencing greater exhaustion, cynicism, and feelings of detachment (a.k.a. burnout).
We know from the data that occupational burnout harms personal relationships. If not addressed, it will continue to add stress to doctors’ home lives. But physicians must also recognize that gender inequality at home strongly contributes to burnout in the workplace. It, too, must be addressed.”
Robert Pearl is a plastic surgeon and author of Uncaring: How the Culture of Medicine Kills Doctors and Patients. He can be reached on Twitter @RobertPearlMD.
He shares his story and discusses his KevinMD article, “Gender inequality is making burnout worse.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.
Today we welcome back on the show Robert Pearl. He is a professor of surgery at Stanford University as well as a professor of business. His latest book is Uncaring: How the Culture of Medicine Kills Doctors and Patients, and all proceeds from that book go to Doctors Without Borders. His latest KevinMD article is titled “Gender inequality is making burnout worse.” Robert, welcome back to the show.
Robert Pearl: Thank you, Kevin. It’s a pleasure to be here.
Kevin Pho: So for those who haven’t listened to our first few episodes together, I highly recommend that, and listening to Robert’s story. But I want to jump straight into his latest article, like I said, titled “Gender inequality is making burnout worse.” Now, for those of you who get a chance to read that article, just walk my audience through it and share the story of why you decided to write it.
Robert Pearl: Burnout, as all of your listeners know, is a major problem for physicians and for nurses. With my comments, I focus on physicians because it’s what I know most about. And there is no question, when you ask doctors the reasons why they are burned out, they point to three factors. They don’t make enough money, which means they have to see too many patients per day and rush them along. They have way too many bureaucratic tasks. In fact, that’s the number one source of dissatisfaction: having to get authorization for things that they know are indicated, fill out extensive claims forms, and do the other tasks they’re forced to do. And the computers literally come between themselves and their patients.
All of these are real problems, but I find it interesting. I always look at the Medscape burnout survey, and I look at the variation by specialty. I’m always looking for the inconsistencies, where these systemic problems don’t fully explain the data that’s there. And the most recent study was fascinating to me. The specialties that were the most burned out were the ones affected by COVID-19. Looking at ER and critical care doctors, that was predictable. But the third most burned-out specialty was OB/GYN, and pediatrics was not too far behind it.
I found this interesting. I asked myself, “Why should these specialties be so burned out in a COVID era?” I mean, after all, they didn’t take care of a lot of very sick COVID patients, because it’s not within their specialties. They were able to be relatively safe across the pandemic. Their bureaucratic tasks didn’t increase any more than any other specialty’s. Their computer problems didn’t get much worse. Something else had to be going on.
When we looked at these two specialties, of course, what’s different about them is they have a huge percentage of women compared to men. In fact, they are the two highest of all of the different specialties: OB/GYN at about 85 percent, pediatrics at around 72 to 74 percent. And I realized that much of what was going on was actually not happening in the medical office. It was going on in the physician’s home, because there was a lot of other data in the literature about how women are working eight to 10 more hours, particularly during the pandemic, taking care of children and doing tasks around the house.
It’s easy to understand how you’d feel totally overwhelmed if, in addition to a full-time job, in addition to your regular responsibilities, you all of a sudden had another eight to 10 hours of work. And I pointed that out because I think that is something that we can work on at the same time that we’re addressing the systemic issues and some of the cultural ones that, as you say, I talk about in the book Uncaring.
Kevin Pho: So tell me how something like this could be addressed, because this is something that I’ve obviously read about in New York Times op-eds: how, today, in this day and age, women in general have more of the tasks at home. What kind of approaches do you have to solve an issue like this?
Robert Pearl: I believe that the first step in addressing any problem is to recognize it. And it’s not that people don’t know that, in general, women have more responsibilities in the home than men. But here we’re talking about doctors. We’re talking about, let’s say, often two professionals who have the same job. Now, why would one of them, simply based upon whether they have two X chromosomes or an X and a Y, have eight to 10 hours more responsibility? And I think it needs to be talked about.
We speak a lot about how burnout in the workplace impacts people’s personal lives: It gets in the way of relationships, diminishes sexual pleasure, and leads to anger and unhappiness, making every situation worse. But we haven’t talked about the reverse. How does what goes on in the home significantly take away from satisfaction and fulfillment in the workplace? And until we acknowledge that it exists, nothing is going to happen.
And then, I think, as in any relationship, you have to have a conversation about it. Once it’s acknowledged, you may decide that what you really want to do is invest some money in getting more help and assistance with some of these tasks. That’s a reasonable solution. You might decide consciously that one or the other partner, whether the man or the woman, and I’m speaking now of a heterosexual relationship; obviously, in other relationships, you don’t have the same sexual differentiation. But in that situation, one of them decides they want to take on this responsibility. Now it’s not a problem; it’s a choice.
And then, of course, you have the situation that is all too common, which is that it’s just assumed. This is why I’m such an investigator of the role that culture plays, because it’s like gravity. You don’t see it. It’s so powerful, it affects us in all ways, but it often goes unnoticed. And that’s where I think a conversation has to happen between the couples. The last thing you’d want is the government interfering, or a regulatory body. This should be within the relationship.
And again, this is why I think it’s so important to have this conversation in the context of physicians. These are highly educated, very smart, skilled individuals, and they should be able to have these types of conversations. Although, don’t minimize it. These will be very difficult conversations, because there’s a winner and a loser, as the change might happen or the change doesn’t occur.
Kevin Pho: So is the path forward as straightforward as you say in terms of the next steps? Is it simply a more equitable distribution of the home responsibilities? In your opinion, would that be a major solution to the physician burnout crisis?
Robert Pearl: Well, I can say that in my relationship, yes. I think equitability is what we want, and that’s what I feel does exist. But in other relationships, it won’t be the same. There’s not one size that can possibly fit all. But if one partner in the relationship is suffering as badly as it seems to be, and I’ll point out that the burnout rate among women is 56 percent and among men 41, a gap of 15, we need to talk about why that happens, because I believe that the three factors we mentioned earlier aren’t any worse for women than men. There are no more bureaucratic tasks. Yes, there may be some lower income that needs to be addressed, but that’s a discriminatory issue inside the profession. And the computer systems are the same.
I think that we need to recognize this and decide what we want to do about it. If this is a choice that people make, we have to live with and accept that choice. But it’s not a choice that people want to make. We should start to change it. And every couple, every individual, is going to have to decide that, in my opinion, for themselves. I mean, I don’t know how you feel in your relationship, as to whether you feel the tasks are divided equally, whether something needs to change, or whether you’ve even talked about that. But I think if we keep it hidden, it’s just going to make burnout become that much worse.
Kevin Pho: One thing that you mentioned was the pay disparity between men and women physicians, and that’s been well documented and well studied. Do you think that’s a contributing factor to that 15 increased frequency of burnout in women physicians?
Robert Pearl: I think the pay differentiation has to have an impact, but I think it is more psychological than it is economic. What I mean by that is that our brains are wired, the amygdala is wired, to respond to unfairness. And when you’re sitting in a situation that is unfair, where you’re not being paid as well for the jobs that you do, even though you do a job that is equal to or, even more often, better than other doctors, then yes, that’s going to wear away at you every single day. So there’s no question in my mind that this pay differentiation is a factor.
The data doesn’t seem to indicate that women are having to see more patients as a consequence of that, or at least they don’t see more patients, so that factor of having to rush patients more isn’t there. And again, I put this into a cultural context, and the cultural context is how our bodies and our brains respond to things that are unfair. And when you start putting on top of that, laying on top of that, the harassment issues, and you layer on top of that the discrimination issues, and you layer on top of that the people who are discouraging, particularly in medical school and residency, the only surprise is that the gap is not bigger than 15, given all the factors that are contributing to it. And I think that probably speaks well to the resiliency that women often have, I’d say, compared to men.
Kevin Pho: Talk about the specific impacts COVID has had in illustrating and highlighting this imbalance when it comes to home responsibilities. You know, I know you talk to a lot of physicians. You talk to a lot of women physicians, of course. Tell us some of the stories that you hear that really illustrate that point about the home responsibility imbalance that you’re talking about.
Robert Pearl: If you look at the imbalance in specialties like OB/GYN and pediatrics, what you see is that it has been created very much over the past, I’ll say, two decades. If you look at the past two decades, you’re looking at people who are now in their 30s and 40s. These are the prime years for having and raising children.
So let’s take a family where you have two physicians working, and they have two kids, one of whom is a third or fourth grader, and one of whom is in middle school. Every morning, they get up, they race around, they cart the kids around, and they finally head into the office or the hospital, wherever they’re going for the particular day of medical practice. They’re tired, but their kids are taken care of. Now they’re going to focus on the job at hand: preventing, curing, addressing patient problems, the things that physicians do in their day-to-day work.
Now, all of a sudden, the school is closed. And now the school is closed, but there’s no one around to help take care of the kids, because all of the gatherings have now been stopped, particularly during the first, I’ll say, year, year and a half of the COVID pandemic. Well, who’s going to take care of them? They can’t be left home alone. You don’t have any relatives; maybe you grew up on the other side of the country. Someone’s going to have to do something.
Now, again, you could decide you’re going to split it: One person takes Monday and Wednesday, one takes Tuesday and Thursday. You could decide that one person would rather stay at home. But again, it’s this obligation that, in our society, all too often falls on one gender rather than the other.
Now it’s the end of the day. Your kid has been home all day. They haven’t learned very much. You have high expectations for your children. Who’s going to sit down, not to help them for a half hour or an hour of homework, as many parents already do, but to make up for an entire missed school day? That may be three hours or four hours. And so now you’ve piled all of that on, and then you add to it the other chores around the house. It’s easy to see how eight to 10 hours a week may be an understatement of the added work that’s been done, unless you’re in a shared type of relationship where the work is split, in which case both parents are probably going to be pretty exhausted. But at least it will be a shared responsibility and not an asymmetrical one.
Kevin Pho: Now, you mentioned having a conversation. You’ve obviously written pieces, and I’ve read pieces in The New York Times and other major newspapers about this issue. Is that enough to rectify the situation? Should there be any policy solutions, like better paid time off or paid child care? Any policy prescriptions that can address this issue?
Robert Pearl: I separate this into two parts. I believe we do a bad job from a policy perspective at, let’s say, raising and protecting the next generation. And absolutely, we lag behind every other country around time off, particularly after delivery. We don’t have a very good sick leave policy. In fact, there are workers who are totally unprotected. We don’t have the child credit. We don’t do the type of pre-kindergarten education.
George Halvorson, who is a good friend of mine, has written extensively about how the brains of children have to be fed words and reading prior to the age of three or four, and that if it doesn’t happen, the individual never catches up. But we don’t have any means to provide that unless the individual families are able to accomplish it. So yes, there need to be major policy changes to improve the health and well-being of both the current generation and the next.
But I don’t think you can have policy about how two people in a couple split the work that’s there. I think that’s a different conversation. I think that we all have to own it and acknowledge it. And once you acknowledge it and realize how unfair it is, that it is, I’ll say, culturally imposed, now you can at least come up with some ideas and solutions. But I suspect that, particularly in COVID, with the isolation that existed, people didn’t talk as much about the consequences. And when you look at the burnout survey, you can see the results.
This is, I’ll say, the finest measure of change. That’s why I look at it every single year. Again, some of it was expected. I thought the ER docs and the critical care physicians would be the most burned out. You know, I talked to physicians who lost four patients in a single day. How, as a doctor, can you continue to function in that way? I spoke to residents who started the month with seven patients in the ICU, and by the end of the month, they were all dead. I mean, these are the types of things that just tear us apart as doctors. So I expected that. But I have to tell you, Kevin, I was totally surprised when I saw OB/GYN as number three.
Kevin Pho: We’re talking to Robert Pearl. He’s a professor of surgery and business at Stanford. He’s the author of the book Uncaring: How the Culture of Medicine Kills Doctors and Patients, and proceeds from that book go to Doctors Without Borders. His latest KevinMD article, which we’re talking about today, is “Gender inequality is making burnout worse.” Robert, what are some of your take-home messages that you want to leave with the KevinMD audience?
Robert Pearl: We need to have a broader conversation about burnout. Burnout is a massive problem, both for doctors and patients. We have to understand the systemic changes that need to occur and work together hard to see that they happen. We have to understand some of the cultural ones that I wrote about, as you said, in the book Uncaring. It’s on my website, RobertPearlMD.com. And now I’m introducing a third notion, which is that we have to understand the societal impact that exists, that was made worse, or maybe more visible, during the COVID era, but that currently exists.
And for us to fail to acknowledge the complexity and the comprehensiveness of the etiology isn’t going to solve the problem for us. No one’s going to do it for us. The more we yell about it, we think it might make a difference. At least so far, it hasn’t, and I’m pessimistic that it will. We need to take the lead to make the changes occur.
I think that maybe the biggest message I’d say to people is that burnout is a chronic disease, and that if we fail to find ways, both in the short term and long term, to address it, it is going to wear away at American medicine even more than today. All of your listeners know that. They’re people living it every day and talking about it. If I can add something to the conversation, though, it’s going to be: Let’s have a more comprehensive view of the problem, and let’s have a multipronged attack to try to address the systemic, the cultural, and the societal.
Kevin Pho: Robert, insightful as always. Thank you so much for sharing your time and coming back on the show.
Robert Pearl: Thank you, Kevin, for the education you provide to your audience. It is invaluable. You do a great job. Thank you very much.
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