Why are women leaving medicine? Gaslighting. [PODCAST]

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“We cannot change societal norms, gender biases, childhood needs, the education system, or stop a pandemic. But, we can stop gaslighting 50% of the population. We can start acknowledging that the simple fact of gender does greatly affect patient and support staff expectations, time, power, compensation, and career trajectory. Women physicians have gained much ground, but this world and life are nowhere near a level playing field yet. When we all work together to allow our women physicians some flexibility in schedules, 10 to 20% more administrative time, transparent salary offerings, remote work options, extra “flex days” for children’s medical appointments, on-site childcare, and considerate timing of “mandatory” meetings we can set us all up for success. These are radical proposals that are not “fair and equal,” but they address the reality of unequal experiences. Maybe then we can stop the hemorrhaging of women physicians from health care. When we acknowledge and tweak current systems and structures to accommodate the 50% of medical students graduating, we are setting ourselves up for success.”

Dawn Sears is a gastroenterologist and can be reached on Twitter @GutGirlMD, YouTube, and at GutGirlMD Consulting.

She shares her story and discusses her KevinMD article, “Why are women leaving medicine? Gaslighting.”

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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 to the show Dawn Sears. She’s a gastroenterologist. Her most recent KevinMD article is titled “Why are women leaving medicine? Gaslighting.” Dawn, welcome back to the show.

Dawn Sears: Thanks so much, Kevin. This is so perfect, because it’s September, the very beginning of September here, and it’s Women in Medicine Month. So I love that we’re doing this talk today.

Kevin Pho: Fantastic. And your article got a lot of traction, over 2,000 social media shares. Now, for those of you who get a chance to listen to our first episode together, that was about a year ago. Just briefly share your story and journey to where you are today.

Dawn Sears: Yeah. I’m a gastroenterologist, and gastroenterology, when I started, was about 10 percent women, so I was often the only woman in the room. I was successful because I was a servant leader, taking care of my colleagues. As a result of that, I was asked to be on lots of committees and lots of leadership opportunities. Then I ended up finding myself in the boardroom, finding myself on executive committees, finding myself as the chair or the chief of the division.

And so everyone came to me: “Dawn, how are you doing it?” I’m like, “What do you mean? You just show up and you do it.” And people wanted a road map for that, so I put together Women Leaders in Medicine. It was never my intent. My intent was just to cure hep C and remove some polyps along the way. But instead, my career transformed in the last 10 years to empowering women physicians and helping them to see that there is a way, and they’re not doing it wrong; maybe the system wasn’t designed for them.

Now I am able to be a gastroenterologist. I’m also a coach, and I do a lot of discussion, talking, and mentoring, and I’m really honored to be able to mentor groups of women, nationally and internationally, in finding their voice. So there’s a need for this, and apparently I’m one of those who can offer that service. So I’m very blessed to be in that position.

Kevin Pho: So give us a story or an example of how giving women physicians their voice moves the needle in terms of advocating for women in the profession.

Dawn Sears: Oh my goodness, so many ways. So we put together a group where we met every six months to teach women about the elevator pitch, to teach them about negotiations, to teach them about asking for what they needed, and about standing up when they’re discriminated against. As a result, we followed those women physicians, and there were 3,000 of them, through a three-year program, and we found that engagement, retention, and burnout all improved for those who participated versus those who didn’t. So it’s just getting them in the room, reminding them of who they are, reminding them of the permission that they can have, and then creating those relationships.

Another way is just making the relationships go further than that meeting. Men often get together on the golf course, and they get together and discuss committees and opportunities, things like that. We don’t have that opportunity, because on the weekends we often are busy; 85 percent of us are mothers, taking care of children and families. And so it’s about having the opportunities to elevate each other and pull each other up. As a result, the other women that I’ve gotten together with over the last 10 years, we nominate each other for national committees and for awards, the things that the men have been doing this whole time, but we just didn’t know how to do it. So we’re giving permission and modeling for each other how to do that. And as a result, I recently got promoted to full professor, and I directly link that back to some of my women who are in New York and L.A. and other places who were elevating me for different things.

Kevin Pho: All right, let’s go straight into your KevinMD article. It’s titled “Why are women leaving medicine? Gaslighting.” Now, for those who didn’t get to read the article, just walk my audience through it. Share the story of why you decided to write it.

Dawn Sears: Yeah, I decided to write it because, as I talk about at the beginning, not a week goes by that a woman physician doesn’t come to me and say, “I think I’m going to quit.” Maybe there are some other options, maybe we can find a way, and maybe you’re not doing anything wrong. So it was about putting out the facts, the reality of what we’re living, and making women feel like they’re not crazy, that they’re not the only one who’s experiencing this.

So the first part I talk about is the part that a lot of people know a lot about, which is the pay gap. Women physicians straight out of training, with the exact same training as the men, are offered less money 96 percent of the time, in all specialties. Boom, mind-blowing. And then when you follow them 10 years later, the same thing is happening, but it’s actually worse: Up to 98 percent of women physicians are being paid less than male physicians in the same line of work, doing the same job, working the same hours, all of those things. So we put that out there, that these are just the facts, and numbers don’t lie. So it is what it is.

And then we go a little deeper in the article, talking about the frustration all of us feel in medicine in working the system, and one of the biggest ones is the electronic medical record. We know we all feel married to it, on our phones, on our devices, and we can never escape, and it’s never enough, and it’s constantly chirping at us. In reality, it’s chirping at the women physicians to a higher degree, and the men are like, “What are you talking about?”

This is a beautiful study looking at a family medicine practice, and it was equal male to female, and they found that the women physicians received 26 percent more messages from the patients than the male physicians. So I have patients all the time say, “Oh, Dr. Sears, I’m so sorry, it was my brother’s funeral and I drank two beers.” OK, according to my institution, I have to respond to that within 24 hours. And the guys look at me and go, “Ah, my patients would never tell me that.” But they want to be edified; they want to please me. There’s a different relationship, a different expectation.

They also looked further into that and said it wasn’t just the patients who were biased to expect more from the women physicians. They found that the staff gave the women physicians 24 percent more messages. And so this happened to me twice yesterday: I had two pharmacists come to my door and ask if I really wanted this dose of this medicine or if I really wanted this thing. And I’m like, “Would you have ever done that to that male predecessor?” I have a feeling the answer is no. And so this shows that 25 percent of the time, we are doing uncompensated extra work, and we know mental burden is real, and we feel it.

And then we dive into the areas of specialty-specific differences. As a gastroenterologist, I attract female patients, and we don’t have as many female gastroenterologists; in some areas, such as my own in the Deep South, less than 10 percent of gastroenterologists are women, while 60 percent of patients who see gastroenterologists are women. So when women come in, they actually have longer colons, so it physically takes longer to get through their colons, and women make fewer polyps. So then I bill for a diagnostic colonoscopy, whereas my male colleagues, who are seeing mostly male patients, are billing for therapeutic ones, and they get more RVUs. So I work harder, it takes more time, and I make less money. So they may say it’s equal, but in reality, I’m expected to see these women patients, and I can’t decline them. All I can ask is, “Can we spread the wealth and let the males also see them?” But there’s some pushback on that.

An example of that is an orthopedic surgeon who shared a recent story where she met with a patient multiple times and did the pre-op, and then the patient went to her male colleague for the actual knee surgery, and then called her afterwards and said, “You’re such a better communicator than Dr. Smith. Can you help me with my issues?” And she’s like, “What? Dr. Smith’s the one who operated on you. You need to go with him.” So at the end of the day, she ends up with fewer RVUs, more patient complaints, and a lower patient satisfaction score. Mr. Smith looks like the hero, and she got to deal with all the stuff. So these are the realities of being a woman physician.

And then when we talk about the gap at home, we’ve got the famous Jolly study, which showed that women physicians, even in a dual-physician relationship where the man is folding laundry and doing dishes and things like that, still put 8.5 more hours a week into child care and domestic chores. We also have a Lebanese study that recently came out showing the same thing: double the parenting time for the woman physician, even when the male physician is stepping up. But again, it’s double the time. Where does that time come from? We also have studies showing women need more sleep. We’re not getting the sleep, because we’re taking care of the house and the kids and all the things.

And then you look at the productivity, you look at the outcomes. You look at the emergency room studies from Florida, 10 years of time: A female physician coming in with a heart attack had better outcomes if she was taken care of by a woman physician. We also have the surgical data out of Canada showing better postoperative complication rates. We’ve got the internal medicine data coming out of the Northeast showing fewer readmissions for a woman physician. So we want to stop women physicians from leaving. So at the end of the article, I talk about solutions. So we can complain about it, but let’s talk about that.

Kevin Pho: I just want to ask a few questions before we get into the solutions. So there are a lot of studies, a lot of data that you cited, and that manifests in a lot of female physicians coming to you, as a department head, saying that they want to leave clinical medicine. So what kind of reasons do they give you? I know you listed a lot of studies, but on a story level, what kind of reasons do they give you when they say, “I want to leave clinical medicine”?

Dawn Sears: “I can’t do it all. I’m expected to do more than everybody else. I am not compensated fairly. Every time I ask for help, or ask for a raise, or ask for a schedule change, they act like I’m needy. They act like they’re doing me a favor and allowing me to have a job. I feel like I’m being taken advantage of. I can’t get ahead. I’m irritable, I’m angry. My relationship with my partner’s bad, my relationship with my kids is bad. I don’t like the person I’ve become, because I’m so stressed out trying to please the world. It feels like a setup that I’m never going to win, and so I guess I’m out.”

Kevin Pho: So you’re hearing this as a department head, and you’re obviously in a leadership position. Can you move the needle, and how much can you move this needle?

Dawn Sears: Yes, we can move the needle. I believe that. I have to believe that, and I’ve seen it. So many of the women, when we’ve gotten together to meet regularly, whether it’s coaching or doing conferences together, are literally weeping at the back of the room, saying, “Now I feel like I can do this. Now I don’t feel alone. Now I feel like I have a tribe. Now I feel like I’m not the only one messing this up, and this has nothing to do with me. It’s about the system, and we’re all struggling together in the system.”

And if I leave, I don’t have the opportunity to fix the system, tweak the system, change the system, or stand up and call out these things for the next generation behind me. So I’m going to stick around, because I’m going to keep bringing these issues up: Maybe when we look at a hospitalist schedule where it’s one week on, one week off, we still have to put maternity leave in there. Don’t just assume it’s built in. You can’t build in maternity leave to take off every other week. So we need to think about these things.

So if you’re not in the room to bring these things up, often the leaders who are making these decisions may be a different gender and may have a different viewpoint. And when you open their eyes, they’re not trying to be malicious; they’re just not making wise decisions, because they don’t see the world through the lens of the women physicians who are 50 percent of those coming out of med school right now. And if we want to keep them employed, we have to offer this pair of glasses to those leaders and say, “Oh, by the way, look at it from this view.” And they go, “Oh yeah, of course. Why did we set it up that way?” Because it worked for you in the past, but now things are different.

Kevin Pho: So let’s talk about more solutions. So what other things do you tell these women physicians who come to you? What other solutions do you offer?

Dawn Sears: Yeah. I love talking about systemic solutions, because it’s a systemic problem, and if we go back to individual solutions, then we’re doing the victim-blaming thing. So I definitely work on self-compassion and getting a coach, getting a therapist, working through that, having realistic expectations for yourself, self-compassion, and we talk about meditation, goals, and all of that. So that’s one thing, and that’s what I work on individually with a lot of clients.

But what I love talking about is empowering entire institutions and saying, “We can fix this,” because that’s where the problem is. The problem isn’t that we are hiring non-resilient women physicians. For the love of God, we’ve had babies and we’re nursing and we’re running to a code, all at the same time. What I offer is three super easy solutions that are like no-brainers, and then three really brave, courageous solutions that will really move the needle, but that very few people have the guts to do yet. But if we continue to have these conversations, maybe we’ll get there.

So the first one, of course, is just transparent compensation: Just let everybody know who’s getting paid what, and why. And it doesn’t have to be by individuals, but by genders, putting it out there. So if we know that the female orthopedic surgeon is paid 30 percent less than the male orthopedic surgeon, let’s talk about why, and let’s talk about what we can do to level that playing field. So that’s one thing.

The second thing is having remote options. If COVID has taught us anything, we moved from 10 percent telemedicine visits in February 2020 to April 2020 being 90 percent telemedicine visits. We claim medicine doesn’t move fast, that this is an archaic system and it’s built this way. We just proved it wrong. We blew the system up in a matter of 60 days in 2020. So we can do that again. We can create some remote options. It doesn’t have to be every day of the week, it doesn’t have to be all day, every day, but allowing women who do have all these obligations, or the primary parent, to have more of these options will just set them up for success and longevity and loyalty. So it can be done.

The third one is a flexible FTE. This is something I love talking to female gastroenterologists about, because they say, “I’ve asked everywhere for a part-time job, and nobody will give me a part-time job. They say it can’t be done as a gastroenterologist.” And I go, “I’ve been part time my entire career, and I’ve been chief. It can be done. And I’ve been a teacher and a researcher.” So it just has to be creative, and you have to think about it and imagine it. I’ve worked 70 percent, I’ve worked 60 percent, I’ve worked 80 percent, I’ve worked 90 percent. It can be done. So it’s giving permission for people to do that. And when I was chief, actually, the majority of the men worked part time, because they wanted to learn to play saxophone, they wanted to hang out with their grandkids, they wanted to build a barn, whatever. It’s not always a gender-specific issue.

So my three brave solutions are these. The first is to give women physicians, and this is crazy talk, I understand, five extra days a year for their health care. Boys and girls are different. We have to get mammograms every year, we have to get cervical checks. And when you look at children, 85 percent of the time they’re accompanied by a woman when they get health care. You look at the elderly: 85 percent of the time, they’re accompanied by a woman at their visits. So if we’re the sandwich generation taking care of both, let’s set us up for success. Is it fair? No. But I have two teenagers who drive, and they pay different rates. There’s a reason: It’s data-driven. And my life insurance is different; males have a higher rate because they die at a younger age. Medical insurance is different depending on how old you are and on your gender, whether you’re more likely to have babies or not. So the insurance industry knows this, other industries know this. They know that two genders have two different needs. Why don’t we just set up our time off in that way, so we don’t act like it’s a shock that she took off to get a mammogram? Like, we knew this was going to happen. In fact, Tait Shanafelt said the other day at the Joy and Wholeness conference, “I know to the point how many women are going to ask for maternity leave next year at Stanford, but we act like it’s a shock every year. We don’t plan for this.” So we can do that.

The second one is to give 10 to 20 percent more admin time to women physicians, knowing that we’re going to have uncompensated requests from our staff as well as from our patients. So let’s just build that in. Again, that won’t feel fair, but it also doesn’t feel fair that I had to lactate, I had to deliver the babies, I miscarried during work. That’s not fair, but that’s just reality. So I don’t fight reality. I just accept reality, and I wish that more leaders would accept reality too.

And then the next one is to level the field, whether we want to call it a handicap or call it a leveling-the-field tax, because we know that women are going to have fewer RVUs in certain fields, for certain reasons, as I’ve outlined. And we also know that women physicians are graded worse on their Press Ganey scores, especially by women patients, ironically. We also know that women who give lectures are graded worse, even if all you do is put the name of a woman on the lecture. There’s the famous Howard versus Heidi study with the applications, but they’ve also done the same thing for lectures, and they find that students rank women professors lower. So for all the things that we put all these sentences to, we already have the data to show where there’s a bias there. And if we can put in a bias tax, we can change the world so that we’re not handicapping women even more.

Kevin Pho: So of those six solutions, three brave and three lower-hanging fruit, tell us which of those have gained traction in terms of stories that you’ve heard.

Dawn Sears: Oh, the days off, the five extra days off. The women are so stressed. They won’t get their mammogram, they won’t get their teeth cleaned, they won’t go, because they’re just so nervous that one of the kids is going to get sick: “And now I’m going to have to use my sick day to stay home with them with COVID, and so I’m not going to do my own self-care.” And then they delay their colonoscopy, they delay their breast cancer screening, they delay their primary care checkup, their cholesterol checkup. So the impact of “They acknowledge I’m different, and I have different needs,” I think, would be huge, to just allow that. And it’s going to cost the health care system very little, because then we end up with emergencies and emergency scheduling. So in reality, it’s the lowest cost with the highest return on investment.

The one that I see on a day-to-day basis is the flexible schedule that the women are demanding. And being that I’ve lived it and I’ve modeled it, it doesn’t seem hard to me, because I know it can be done. So it’s continuing to acknowledge that, and then giving more and more institutions permission to do it, and to find out the world doesn’t fall apart when somebody works four days a week and one day remotely. It still works. The world floats around, and we saw that through COVID, and I’m not sure why we have this cognitive dissonance that it wasn’t real or something.

Kevin Pho: We’re talking to Dawn Sears. She’s a gastroenterologist, and we’re talking about her KevinMD article, “Why are women leaving medicine? Gaslighting.” Dawn, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Dawn Sears: My take-home message is: Be brave. Ask for what you want. Build your tribe and ask for it together. Expect a no, ask again. Expect a no, ask again. “Are we there yet? Are we there yet? Are we there yet? Can we go to Disney? Can we go to Disney? Can we go to Disney?” Keep asking, and then pretty soon the leaders are going to see, “Wait, this isn’t just one whiny person. This is a movement, and we need to do the right thing.”

Kevin Pho: Thanks again for coming back on the show and sharing your time and insight.

Dawn Sears: Thanks so much, Kevin. Thanks so much for highlighting this, especially during Women in Medicine Month. This is outstanding. I appreciate your collaboration and partnership.

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