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Women in Psychiatric Training

Ann M. Bogan, M.D.Debra L. Safer, M.D.

Drs. Bogan and Safer are with the Department of Psychiatryand Behavioral Sciences, Stanford University Medical Center,Stanford, California. Address correspondence to Dr. Bogan, 550Hamilton Avenue, Suite 208, Palo Alto, CA 94301; annbo-ganmd@gmail.com (E-mail).

Copyright � 2004 Academic Psychiatry.

In 1849, Elizabeth Blackwell became the firstwoman in the United States to graduate from medi-

cal school (Geneva Medical College, later Hobart Col-lege, in New York) (1). January 2003 marked the 154thanniversary of Dr. Blackwell’s graduation. Over theintervening years, women have certainly becomemuch more highly represented in medical schools na-tionwide. The number of female medical students hasgrown with a near constant acceleration since 1969.For example, in the 1949–1950 academic year only7.2% of the total enrolled medical students in theUnited States were women. By the 2000–2001 aca-demic year, 44.6% were women (2).

The increasing percentage of female medical stu-dents is a trend evident among female residents aswell though the numbers, as would be expected, lagbehind medical school enrollments by several years.In 2000, 38% of all residents were women. The per-centage is higher in psychiatry residency programswhere, in 2000, women achieved statistical paritywith men by comprising 49.8% of all psychiatricresidents. The only medical specialties with higherpercentages of women residents were dermatology,medical genetics, obstetrics and gynecology, and pe-diatrics (3).

Though statistics can demonstrate the approachtowards or achievement of numerical equality, theydo not reveal information about whether the concernsparticular to women medical students and residentsare being addressed. It is quite possible that the dem-ographic shift has not been accompanied by a corre-sponding cultural shift. Unfortunately, there are littledata on the particular issues facing women residentsin psychiatry. Interestingly, more of the academic ar-ticles on this subject were written in the 1970s and1980s. More current writings on the topic appear inpsychiatric newsletters. One might assume that incore aspects, women psychiatry residents’ concernsare similar to their female counterparts in other de-

partments and of female physicians in general.Among the major concerns for female physicians arework-life balance and career opportunities (4). Be-cause of the limited literature available relating spe-cifically to women psychiatry residents, this articlewill include information from more general sourcesbut will focus to the extent possible on the concernsof women psychiatry residents.

BALANCING WORK AND FAMILY

For female psychiatric residents, the issue of balanc-ing work and home resonates especially loudly whenconsidering pregnancy. Typically, residency occursduring a woman’s prime child bearing years. It istherefore not surprising that a sizeable number of res-idents will become pregnant. Women psychiatry res-idents, like their medical counterparts, are affected bythe regulations of the American Medical Associa-tion’s (AMA) maternity leave policy (H-420.967). Thissuggests that residency training programs grant aminimum of six weeks of maternity leave, with theunderstanding that no woman should be required totake a minimum leave (5). Furthermore, the AMA’spolicy regarding maternity leave for residents (H-420.987) encourages flexibility in manpower levelsand scheduling to allow for coverage without creat-ing intolerable increases in residents’ work loads (6).In addition, as employers, training programs are reg-ulated by the Family and Medical Leave Act of 1993,a law requiring employers to grant 12 workweeks ofunpaid leave during any 12-month period for medi-cal events, including pregnancy (7).

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Despite this option, there are key reasons womenresidents wishing to spend more time with their in-fants will not do so. One is primarily financial. Takingunpaid leave, given the combination of low residentsalaries and the high levels of debt that many resi-dents carry, may be impractical. But in addition, so-cial pressure within the programs often makes takingadvantage of this opportunity difficult as well (8).Whether or not a training program has a formal leavepolicy, many institutions do not have universally es-tablished plans for the specific details of handling aresident’s pregnancy. Instead, pregnancies and ma-ternity leaves are handled on an ad hoc or case-by-case basis (9). This usually results in the reassignmentof the extra work load to the residents who were notaway on leave (10).

THE STRUCTURE OF PSYCHIATRY TRAINING

The structure of the 4 years of psychiatric residencymakes it likely that any planned pregnancies will oc-cur during the third or fourth year of residency. Theadvantages to having a child during this time are thatmore senior residents generally are assigned lessnight call and have fewer, if any, responsibilities onthe inpatient units. However, this also means that aresidency program may have up to half of its seniorresidents on maternity leave in the same year.

In addition to pregnancy, child rearing duringresidency may also be a difficult proposition. Sched-ules are quite demanding and “flex-time” is generallynot available. In a 1983 study on combining mother-hood with psychiatric training (11), female residentsand early career psychiatrists were surveyed regard-ing number of children and child-care experiences.Moreover, they were asked to provide suggestions formaking child rearing less difficult. Unfortunatelymany of these suggestions (statistical analyses werenot performed because of the broad and varied na-ture of their suggestions), such as obtaining domestichelp, are not viable for residents with limited in-comes. A more practical and less expensive sugges-tion pertained to the attitude of supervisors and staff.Of critical importance to the respondents were su-pervisors’ understanding, flexibility, and encourage-ment. Additionally, respondents asked for substan-tive discussion between staff and residents regardingthe issue of balancing parenting and residency, moreeducation on the inherent conflicts between work and

child-rearing, and the inclusion of successful rolemodels in the programs. Finally, respondents sug-gested the development of programs with formalpart-time or time-sharing positions. For example,psychiatry residents in their third and fourth years atStanford’s residency program are given the option ofworking half-time. Though this option extends thelength of training for the resident, this has been anattractive feature of the program to both applicantsand current residents.

Many years after the survey cited above, theseissues and suggestions are still pertinent. Balancingmotherhood with one’s career often means limitingone or the other. In academic psychiatry, where ad-vancement is based largely on peer-reviewed publi-cations and research productivity, faculty who do nothave to divide their attention between family and ca-reer may have an advantage. For example, BarbaraSommer, M.D., a Stanford Assistant Professor, de-scribes her curriculum vitae as one similar to that of aphysician many years her junior. Because of her com-mitment and focus on her family’s needs over theyears, her career has been negatively affected (12).

Compromises between one’s personal and pro-fessional roles are not issues faced solely by women.Justin Birnbaum, M.D., a staff psychiatrist and Direc-tor of Outpatient Geriatric Psychiatry at Stanford,states that on occasion his decisions to spend timewith his child have resulted in less time available topursue professional goals. Dr. Birnbaum is an exam-ple of what seems to be a growing trend. A currentmale resident at Stanford has taken leave and is cur-rently working part-time in order to spend more timewith his family.

SHARING A RESIDENCY POSITION

Shared residency positions have often been suggestedas a way to alleviate the competing demands of workand home. This option, which differs from attendingresidency part-time, involves two applicants apply-ing through the National Residency Matching Pro-gram as one unit and sharing a single residency po-sition. In a shared residency, the two residents wouldusually alternate months on clinical rotations (13).Section 709 of the U.S. Health Professions Educa-tional Assistance Act of 1976 (P.L. 94-484) mandatesthat shared schedule positions be available to feder-ally-assisted residency programs (14). However,

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these specific programs did not include psychiatry.The only included programs were family practice,obstetrics/gynecology and pediatrics—fields wherewomen in 2000 held at least 47.7% of residency po-sitions (15). While establishing a shared-time resi-dency position in psychiatry seems to be a practicalmeans for reducing the conflicts between residencyand parenthood, there are logistical barriers to actu-ally obtaining such a position, were it even to beavailable. One is that such an option has generallynot been well publicized to potential residents. An-other is the difficulty of pairing up with a colleaguewith similar needs. Additionally, applying in thismanner forfeits all rights to apply individually forfull time positions. Because of these obstacles, this op-tion would likely be attractive and viable for rela-tively few applicants.

CAREERS IN ACADEMIA

Career success is important for all residents. Becauseof biology and culture, women face a more compli-cated path to this success. Women in residency arelikely to have family commitments and to take timeaway from their academic career aspirations to focuson these commitments.

A study published in 2000 in The New EnglandJournal of Medicine followed women who had gradu-ated medical school from 1973 to 1993. Women weremore likely to initially pursue careers in academicmedicine than their male counterparts but subse-quently had diminished interest in academia. Thenumber of women who had advanced to associateand full professors was significantly lower than ex-pected. It was speculated that women had lower pro-ductivity (e.g., publications, grants), worked fewerhours, or had fewer resources provided by the school.The authors also considered the possibility thatwomen may be more likely than men to join depart-ments where the likelihood of promotion is low orthat women may pursue more career opportunitiesoutside of academia (16). Another explanation, of-fered by DeAngelis, is that some women became dis-heartened by the slow advancement of women fac-ulty (17). Though such ideas may be speculative,there do appear to be forces that limit the number ofwomen in academia.

CAREERS IN ACADEMIC PSYCHIATRY

From a psychiatry resident’s standpoint, the ideal ac-ademic role-model is presented as being a clinician,teacher and researcher, with career advancement inacademic psychiatry dependent on being successfulin each of these roles. Residents transitioning out oftraining begin to develop and cultivate their profes-sional identity. Granet and Cooper noted that duringthis time, residents who may be contemplating a ca-reer in academia “devalue their potential professionalworth” (18). For women psychiatry residents, the de-sire to have and raise a family may also be an addedfactor during this transition period. An ad hoc surveyof current senior female residents at Stanford re-vealed that women who plan to pursue full time ac-ademic psychiatry either have grown children or lackheavy child-rearing commitments. Whether the se-nior resident is interested in academia or pursuing anon-academic career, the presence of a role model ormentor would be valuable during this time of evo-lution from resident to practitioner.

LIMITED ROLE MODELS FOR WOMENPSYCHIATRY RESIDENTS

Comparing 1989 and 2000, the total proportion ofwomen psychiatric residents increased from 40.6 to49.8% of the total number of residents respectively. Incontrast, only 29% of associate professors and 14% offull professors in psychiatry were women in 2001(19). It would be expected that the percentage ofwomen faculty members would lag behind the per-centage of women residents by several years. But ifone assumes that a typical academic career path leadsfrom residency to an associate professorship positionin 12 years (i.e., 4 years of residency, two years offellowship, and 6 years as an assistant professor) andthat women were entering academic medicine in thesame proportion as men, the percentage of womenpsychiatric residents entering academia in 1989should match the percentage of women associate pro-fessors in 2001. However, there is more than a 10 per-centage point difference.

Statistically, women are advancing in academicpsychiatry at lower rates than men and have assumedfewer leadership positions (20). According to theEarly Career Women Faculty Professional Develop-ment Seminar organized by the Association of Amer-

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ican Medical Colleges in December 2001, residencyprograms can help promote the successful transitionof their women graduates into academic careers byoffering courses on compiling effective curriculum vi-tae that are not too conservative in listing their accom-plishments. Other useful courses might include sem-inars on the culture of academia, career-buildingstrategies, grant writing, conflict management andnegotiation skills (21).

THE ROLE OF MENTORSHIP

In 1993, Leah Dickstein, M.D., in her inaugural ad-dress to the American Medical Women’s Association,stressed the importance of finding role models andmentors (22). According to a 1992 survey at the Uni-versity of California—San Francisco, women, espe-cially among house staff and junior faculty, had fewermentor relationships and role models (23). As dem-onstrated in a 1988 survey, there was a significant as-sociation between having a mentor of either sex dur-ing training and number of publications, time spenton research, and career satisfaction (24). More currentliterature continues to attest to the value of mentor-ship and networking for women’s advancement (25–27).

It has been suggested that mentorship is moreimportant for women than for men (28). Men appearto be more willing to involve senior individuals inaccessing career opportunities, while women tend tolook for mentoring relationships outside of the work-place or outside the formal lines of authority (29). Thegender of the mentor does not appear to be important(30). However, despite the evidence that men areequally effective in mentoring female psychiatristsabout career progression, it is possible that mentor-ship with respect to personal development and bal-ancing family and career may be more effective fromsame-sex mentors or role models. Men may be lesslikely to fully appreciate a woman’s perspective onwork-family conflicts and issues of child bearing, andwomen residents may feel more comfortable raisingsuch issues with a female mentor. Additionally, somemen perceive that a close relationship with a womanat work may be misinterpreted (31). It should be em-phasized that this in no way implies that womenshould not seek out male mentors. Rather, a valuablestrategy for the woman resident is to seek out bothmale and female mentors.

MENTORSHIP IN PSYCHIATRY RESIDENCY

Formal mentoring programs have been shown to beof great benefit for psychiatry residents (25, 32). Res-idents and training programs may find the followingresources helpful:

• Association of Women Psychiatrists. P.O. Box570218, Dallas, TX 75357; Phone: 972-686-6522;Email: womenpsych@aol.com

• American Psychiatric Association: Office of CareerDevelopment and Women’s Programs. 1000 Wil-son Boulevard, Suite 1825, Arlington, VA 22209-3901; Phone: 703-907-7300; Email: apa@psych.org;Website: www.psych.org/mem_groups/women/

• Faculty Mentoring Guide. Virginia CommonwealthUniversity, Medical College of Virginia. Website:http://www.medschool.vcu.edu/intranet/facdev/facultymentoringguide/fmguide.pdf

CONCLUSION

This article has focused on women residents in psy-chiatry and the issues of pregnancy, child-rearing, ca-reer advancement in academia and mentorship.While many issues faced by women residents areshared equally by their male colleagues, women res-idents have particular concerns in each of the issuescovered. These concerns have been longstanding andremain unresolved, though residency training pro-vides an excellent opportunity for women psychiatryresidents to gain the knowledge and skills useful fortransitioning to an academic career as well as foreventually assuming leadership roles.

Despite the challenges, women are continuing toenter psychiatry residency programs in increasingnumbers. Higher percentages of women residentsmay mean that their unique concerns will increas-ingly be brought to the forefront. This has value forboth men and women residents struggling to balancecareer and family. Thus, paying attention to these is-sues is likely to enhance the overall quality of resi-dency training programs and postresidency careerchoices. As psychiatrists, we specialize in improvingthe emotional and mental health of our patients.However, we must also continue to look for creativeand effective ways of tending to the well-being of ourpsychiatry residents and colleagues.

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