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Characteristics of Women US Family Physicians
Erica Frank, MD, MPH;
Lawrence J. Lutz, MD, MSPH
Arch Fam Med. 1999;8:313-318.
ABSTRACT
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Context There have been no national studies comparing women family physicians (FPs) with other physicians; determining FP characteristics is useful in workforce and health systems planning and may also be of inherent interest to FPs and others.
Design and Participants A comparison of the FP (n=347) and other (n=4154) respondents to the Women Physicians' Health Study.
Main Outcome Measures Personal and clinical practices.
Results Women FPs are more likely to be US-born and self-defined as politically liberal than were other women physicians. Those graduating from medical school in the 1950s through 1970s were less and those graduating in the 1980s were far more likely to be board certified than were other women physicians. Although their personal and household incomes were significantly lower, their professional satisfaction was similar to those of other women specialists, and they reported a lesser frequency of severe work stress. Personal health-related habits and health status of women FPs were similar to those of other women physicians. For all 14 counseling practices examined, the amount of counseling they reported performing, the clinical relevance they ascribed to those practices, their self-confidence in performing the practices, and the amount of training they received was as high as or higher than that of other women primary care practitioners and usually exceeded those of non–primary care physicians outcomes at the P<.001 level.
Conclusions Although women FPs resemble other women physicians in some respects, they are more liberal, are professionally well-satisfied, and are relatively avid preventionists.
INTRODUCTION
THE FACE OF family medicine is changing, and that face is increasingly often female. Paralleling national trends for all women physicians, the number of women general physicians and family physicians (FPs) doubled from 1970 to 1980, and again from 1980 to 1990.1 In 1994, there were nearly 14,000 women general practitioners and FPs in practice, and women represented 39% of family practice residents.1
Although physician characteristics are important predictors of patient outcomes2 and may also be inherently of interest, there have been few national studies of personal health choices or other characteristics of women or men FPs. As the number of women FPs grows, it is increasingly important for workforce and health care systems planners to understand the personal and practice characteristics of these physicians. To help fill this gap, we conducted the Women Physicians' Health Study (WPHS), a large (N=4501) national survey of US women physicians. In this article, we examined data from the 347 FP respondents and compared them with other women physicians, to help answer an a priori question in the study: Are there important ways in which women physicians vary by specialty?
SUBJECTS AND METHODS
The design and methods of WPHS have been more fully described elsewhere, as have basic characteristics of the population.3-5 The WPHS surveyed a stratified random sample of US women MDs; the sampling frame is based on the Physician Masterfile, a database intended to record all MDs residing in the United States and its possessions, compiled by the American Medical Association (AMA), Chicago, Ill. Using a sampling scheme stratified by decade of graduation from medical school, the AMA randomly selected 2500 women from the graduating classes of each of the last 4 decades (1950 through 1989). The WPHS oversampled older women physicians, a population that would otherwise have been sparsely represented by proportional allocation because of the recent increase in the number of women physicians. The WPHS included active, part-time, professionally inactive, and retired physicians, aged 30 to 70 years, who were not in residency training programs in September 1993, when the sampling frame was constructed. In that month, the first of 4 mailings was sent out; each mailing contained a cover letter and a self-administered, 4-page, 716-item questionnaire. Enrollment was closed in October 1994 (final enrollment, N=4501).
Of the potential respondents, an estimated 23% were ineligible to participate because their addresses were wrong or they were men, deceased, living out of the country, interns, or residents. Our response rate was 59% of physicians eligible to participate. We compared respondents and nonrespondents in regard to a large number of key variables using our telephone survey (comparing our telephone-surveyed random sample of 200 nonrespondents with all the written survey respondents), the AMA Physician Masterfile (contrasting all respondents with all nonrespondents), and an examination of survey mailing waves (all respondents, from waves 1 through 4). From these 3 investigations, we found that nonrespondents were less likely than respondents to be board certified. However, respondents and nonrespondents did not consistently or substantively differ on other tested measures, including age, ethnicity, marital status, number of children, alcohol consumption, fat intake, exercise, smoking status, hours worked per week, frequency of being a primary care practitioner, personal income, or percentage actively practicing medicine.
Based on these findings, we weighted the data by decade of graduation (to adjust for our stratified sampling scheme) and by decade-specific response rate and board-certification status (to adjust for our identified response bias). Using these weights allowed us to make inference to the entire population of women physicians who graduated from medical school from 1950 to 1989. All analyses ( 2, t, and median split tests) were performed using SUDAAN.6 Due to multiple testing, only characteristics significant at P .01 are discussed in the Tables. Other or non-FPs refers to all physicians who are not FPs; other primary care physicians refers to general practitioners, general internists, obstetrician-gynecologists, and specialists in public health working at least 5 clinical h/wk.
RESULTS
Table 1 examines personal characteristics of women FPs. Women FPs were more likely to be US-born and to self-designate as politically liberal than were other physicians. Their age, ethnic composition, prevalence of having children, mean number of children, and percentage who were their children's primary preschool caregiver were similar to those of other physicians. They were as likely to be married, though less likely to be married to a physician and more likely to be married to someone without an advanced graduate degree.
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Table 1. Demographic and Personal Characteristics of US Women Physicians*
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Table 2 shows personal health habits. Other than for eating more fruits and vegetables than did other physicians, women FPs were not significantly more or less likely to report healthy habits or good health. They were modestly more likely never to have smoked and not to smoke cigarettes at present and to comply with examined US Preventive Services Task Force recommendations.7
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Table 2. Personal Health Practices of US Women Physicians*
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Table 3 describes their training- and practice-related characteristics. Women FPs graduating from medical school in the 1950s to 1970s were less likely to be residency trained than were non-FPs. Family physicians graduating from medical school in the 1950s to 1970s were equally likely, but FPs graduating in the 1980s were far more likely, to be board certified than were non-FPs. Family physicians were less likely than others to be board eligible in their principal specialty or to be board certified in another specialty and not in their own principal specialty. Family physicians were more likely to be in 2-person or group practices and less likely to be in hospital-, medical school–, or government-based practices. They were less likely to practice in an urban and more likely to practice in a rural environment. Their personal and household incomes were significantly lower (even on an hourly basis), although they worked similar numbers of clinical hours per week and took similar amounts of on-call time. They reported less continuing medical education, especially less use of medical texts. They were no more likely to be professionally inactive than were other physicians.
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Table 3. Training and Practice Characteristics of US Women Physicians*
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Table 4 describes professional satisfaction. Satisfaction of women FPs was similar to that of other specialists, with the exception of work stress; fewer FPs reported severe work stress.
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Table 4. Career Satisfaction of US Women Physicians*
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Table 5 describes reported patient counseling practices of women FPs. For all 14 counseling practices examined, the amount of counseling FPs report performing, the clinical relevance they ascribe to those practices, their self-confidence in performing the practices, and the amount of training they have received was as high as or higher than that of other primary care practitioners, and usually exceeded that of non–primary care physicians at the P<.001 level. Family physicians counseled significantly more than other primary care physicians on skin cancer and sunscreen use, risks for human immunodeficiency virus, influenza vaccine, and alcohol use.
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Table 5. Practices, Perceived Relevance, Self-confidence, and Amount of Training Concerning Prevention-Related Screeninga
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COMMENT
To our knowledge, this is one of the first national studies directly and specifically comparing large numbers of women FPs with other women physicians. We found that women FPs differed from other women physicians in a number of interesting personal and professional dimensions.
First, regarding personal characteristics, we found that women FPs were more liberal than were other physicians. We believe this may be so because the discipline of family medicine selects for and cultivates those with community-based solutions to individual problems, a typically liberal approach to problem resolution.
We were not surprised to find that those women FPs graduating from medical school in the 1950s through 1970s were less likely to be residency trained than were other women physicians, since residency training in family medicine was less available to most of these individuals. It was, however, interesting that graduates from the 1980s (when residency training became required for board certification) were far more likely to be board certified than were other physicians. This may be because FPs perceive board certification as an important way to distinguish themselves from general practitioners.
Several practice-related characteristics were of particular concern. It is worrisome that women FPs were half as likely to be employed in medical schools as were other women physicians. This could have considerable implications for role modeling and for training future generations of women and men FPs. Income and wage differentials were also striking, discouraging, and consistent with those of previous reports.8 Reported professional satisfaction was quite similar to that of other specialists, with the exception of reporting less severe work stress. Family medicine may attract individuals who are better able to handle the stress of work; its emphasis on treating the entire patient may produce individuals who have a more holistic approach to their own personal health; or it may have fewer stresses than other specialties.
We found that for virtually all 14 counseling practices examined, the amount of training women FPs reported receiving, their self-confidence in performing the practices, the clinical relevance they ascribe to those practices, and the amount of counseling they report performing was highly significantly greater than that of non–primary care physicians, and often greater than that of other primary care practitioners. We believe that these outcomes build on each other: training promotes confidence and the perception of relevance; these in turn help lead to a greater likelihood to perform a given practice. These are encouraging findings, as family medicine residencies have historically aspired to produce good and avid preventionists.9
Unlike many other attributes, the counseling practices of FPs have been previously examined, but findings have varied. A 1991 study of 514 North Carolinian primary care physicians10 found that 19% reported counseling more than 80% of at-risk patients about poor diet; 35%, about alcohol abuse; 50%, about drug abuse; and 52%, about cigarette smoking; unlike our findings, they found that the 218 FPs did not consistently differ from other primary care physicians. A 1995 study11 found that among patients of 37 North Carolinian FPs, 75% had undergone cholesterol testing in the past 5 years, 81% had received the American Cancer Society's mammographic recommendations, and 60% of female patients had received a Papanicolaou smear in the past year. A 1985 national survey of 350 FPs reported that 67% reported advising more than half of their patients who smoked to quit, 58% reported discussing health risks of obesity and recommending a specific diet to more than half of their obese patients, and 39% reported discussing the health risks of a sedentary lifestyle and gave advice for increased activity to at least half of their patients. The 4 major obstacles cited for treating patients' lifestyle health risks were pessimism about the abilities of people to change their lifestyles (64%), patient resistance to referral to mental health specialists or self-help groups (61%), insufficient time to treat the problems (49%), and a need for further training (48%). Only 24% blamed a lack of insurance reimbursement.
Although this is to our knowledge the first time many of these findings have been explored in physicians of either sex or any specialty, our study is limited by only including women. Physicians' personal health habits may differ by sex, although the limited previous research on FPs suggests that this differential may be small for several personal health practices. A 1987 study12 of 466 family medicine residents found that women and men residents were unlikely to be cigarette smokers (5% of women and 4% of men residents). A 1987 study13 of 106 graduates from 2 Iowa family medicine residencies found a 2% current smoking rate, with 93% of respondents believing that physicians have an obligation not to smoke. A study12 of family medicine residents (363 men and 103 women) in 6 states found that women residents were less likely than men residents to report abstaining from alcohol (8% vs 16%; P<.05), although they were significantly less likely to drink more than 2 drinks on any occasion. Exercise more than once a week was reported by 35% (with nonsignificant women-men differences). Both groups were unlikely to be cigarette smokers (5% of women and 4% of men; differences were not significant).
Clinical practices may be more affected by sex. A 1980 study14 found that female patients were 1.5 times more likely than were male patients to choose women FPs, and male patients were 1.1 times more likely to choose men FPs. Women FPs had 66% female and men FPs had 54% female patient panels (n=12,447 patients of 9 women physicians and n=37,571 patients of 29 men physicians). A 1995 study11 found that patients (n=1850) of women FPs (n=5) were 47% more likely to be up-to-date on their Papanicolaou tests and 56% more likely to have had a cholesterol test in the past 5 years than were patients of men FPs (n=32). Similar findings for more preventive services being provided by women than by men primary care physicians have also been reported.10, 15-16 Others have also found other demographic and practice-related differences between men and women FPs.17-19
We found that, although women FPs may resemble other women physicians in some respects, they significantly differ in others. Particularly noteworthy, they are more liberal, less likely to practice in a medical school setting, less well compensated but professionally well satisfied, and relatively avid preventionists.
AUTHOR INFORMATION
Reprints: Erica Frank, MD, MPH, Department of Family and Preventive Medicine, Emory University School of Medicine, 69 Butler St SE, Atlanta, GA 30303-3219 (e-mail: efrank{at}fpm.eushc.org).
Accepted for publication June 22, 1998.
This research was supported in part by the Education and Research Foundation, American Medical Association, Chicago, Ill; the American Heart Association, Dallas, Tex; Institutional National Research Service Award 5T32-HL-07034 from the National Institutes of Health, National Heart, Lung, and Blood Institute, Bethesda, Md; the Emory Medical Care Foundation, Atlanta, Ga; and the Ulrich and Ruth Frank Foundation for International Health, Newtown, Pa.
Lisa Elon, MPH, Rollins School of Public Health, Emory University, Atlanta, served as statistical advisor.
From the Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Ga.
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