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From medicine to management: the female physician executive.

From Medicine to Management: The Female Physician Executive

To understand the status of women in medicine and management, it is necessary to understand the historical, economic, and societal trends that have led to the present state of affairs. Physicians in management today, typically 54.2-year-old males,[2] often see only the present; Few women physicians are colleagues. This article will briefly explain why this condition exists, what the situation for women physicians in management is now, and what might happen in the future.

The Past[3-8]

In many past cultures, health care, including work as physicians, was a suitable role for women. After about 1500 in Europe, the usual model for developments in the United States, women practitioners became much less evident. Few European physicians emigrated to colonial America in the 17th century, and American women became responsible for their families' health care. Some American women, successful in caring medically for their families, set up practices of "physick and chirgurie." American medical schools opened after 1765, and more European-trained physicians began to arrive. Female practitioners shifted to caring for the poor.

Early medical care was in patients' homes. Few therapies were available. These were usually quite severe, typically bleeding, purging, and cupping. American hospitals developed after 1752 to care for those who had no homes or no one to care for them. Hospitals in the beginning were strictly charitable institutions for the "moral" poor. Hospital trustees, not physicians, usually determined which patients could enter the hospital, after an evaluation of the patients' moral life.

Because hospitals existed only for the homeless, "moral" poor, they became suitable areas for women's work. Many hospitals were run by powerful matrons, who did the everyday management. The board of trustees did the fund-raising, the doctors managed the patients' medical therapy (such as it was at the time), and so-called boards of lady visitors visited patients weekly to be sure they received moral and religious counseling. Books were written on hospital administration for women, and management of a hospital was compared to running a large home. In addition, hospitals run by religious orders offered exceptional, socially acceptable opportunities for women to manage hospitals.[9]

American women began to reenter medicine in the 19th century. As the country became urban and industrial, social problems developed, along with demands for their reform. Movements such as women's rights, abolition, temperance, and reform in personal hygiene, combined with the dismal level of medical practice in the first half of the 19th century and the limited economic opportunities for women who had to support themselves or their families, led women to become physicians.

The first to do so was Harriot K. Hunt, who began practice in Boston, Mass., in 1835, after serving a Thomsonian apprenticeship.[10] Next was Elizabeth Blackwell, the first American woman to receive an MD degree, in 1849 from Geneva Medical College in upstate New York. Other women began to enter medicine, in spite of social and economic obstacles.

Once women got past the barrier of medical training, they faced equally difficult problems. Socially, they were shunned. Personally, few of them married. Professionally, they were not allowed to join medical societies and, in many cases, were unable to even get consultations on difficult patients with other doctors.

Because of social and professional isolation, the first generation of women physicians banded together for support and to improve opportunities for other women seeking to enter medicine. Their most important achievement was establishing female medical institutions. Between 1850 and 1910, 17 women's medical colleges were founded. As hospital training became more important, women founded their own hospitals. At least eight hospitals founded and run by women physicians opened during that period. These female medical institutions provided more opportunities for women in medicine, both in medical training and in running hospitals and clinics.

The importance of these institutions is revealed in an article written in 1922 by the daughter of one of the founders of Children's Hospital of San Francisco (founded in 1875 by 3 women physicians). At that time, the University of California medical school was trying to take over the hospital. The author gave a half-page listing of all the positions to which women physicians trained at that hospital had risen, such as "Director of the Child Hygiene Division of the Children's Bureau in Washington" and "now in charge of the laboratories at the San Francisco Hospital." She continued:

"You may ask me, Why hold the Children's Hospital for women? And I ask you where else you as women will get a chance at heading a service? Assistants' positions are waiting at every turn for women, but a chance to rise, to be chief after 10 years of such service does not materialize. Men pass over your heads or pass on to other chief positions.... Therefore to have this type of experience we must perpetuate the hospital we have created and preserve it for the advanced opportunities of women physicians. Without leaders, we will be allowed to serve by our professional brothers, but the experience of running a power, in dealing with interns and nurse, we will get very little of except in hospitals we create. The value of such opportunities, we certainly all realize."[11]

As the second generation of women physicians took advantage of these new opportunities, the number and percentage of women physicians increased, peaking at 6 percent in 1910. There was marked geographic variation. For example, Boston had large numbers of women physicians, 18 percent of the physician population, between 1900 to 1910. [9] After 1910, the number and percentage of women physicians dropped and did not reach 6 percent again until 1950. World War II presented a few more opportunities, because of the lack of male students and physicians. Social changes in the '60s led to a tremendous increase in women physicians. Currently, women are 15.2 percent of practicing physicians and 30 percent of medical students.

A major reason for the end of the 19th century female medical institutions, and the resultant drop in women physicians, was the growth of scientific medicine. The women's medical schools did not have the economic resources to teach scientific medicine.

As new therapies were developed and more operations performed, it was harder to give medical care in patients' homes. Gradually, medical care for all social classes shifted to the hospital, and the cost of medical care began to increase. Because many patients were unable to pay for care, private health insurance became common after World War II.[12] Government health insurance for the poor and elderly began in 1965. These two payment systems allowed explosive growth of medical care, especially in hospitals, leading to enormous increases in health care costs. They also allowed a tremendous increase in physicians' incomes, which previously had been low.

The Present

Health care is now a significant part of the economy, accounting for 11 percent of the gross national product. This percentage is expected to rise yearly. Strong attempts to control costs are being made by the government and private insurance. These cost control efforts are failing, due to increasing use of expensive technology, consumer demand for health services, and physician lobbying to pressure the status quo. Competition for the health dollars available is fierce, and only half of all U.S. hospitals are making money.

Socioeconomically, America's health care system is served by low-paid female workers managed by mostly male decision makers.[13] Better opportunities for women in other areas have led to the shortage of nurses and other health care workers, such as medical records technicians.

Health care is becoming increasingly "corporatized," and large physician groups are being formed to better compete. In this new situation, many physicians have become production, or line, workers, controlled or managed by others. Even if physicians practice independently, their contracts with HMOs, PPOs, or IPAs take away their true independence.

Although much has been written recently about the increase in physician managers, the available data are surprising.[14] Although there has been an increase in the total number of physicians listing administration as their primary professional activity, the percentage of the physician population in administration actually fell between 1970 and 1986 (figure 1, page 15) from 3.6 percent to 2.5 percent. This may have been due to an increase in the physician pool during that time, but could also reflect a relative decrease in opportunities.

Between 1970 and 1986, the percentage of women physicians in medical administration rose from 7.5 percent to 11.2 percent (figure 2, page 16). However, because of the huge increase (240 percent) in the number of women physicians during that time (figure 3, page 16), the percentage of available women physicians in administration fell from 3.6 percent to 1.8 percent (figure 1).

The 1986 age distribution revealed a much younger group (figure 4, page 17) of women physicians in administration compared to men, as might be expected because of the only recent increase in the numbers of women physicians available to enter administration.

Other studies on characteristics of physician administrators found that 91.2 percent are male. The average physician in administration is 54.2 years old, has been in administration 18.6 years, and has been in his current position 7.2 years.[2] The only study of women physicians in medical administration unfortunately was comparable, focusing mostly on social characteristics such as marital status.[15]

The Future

Women will make up a larger portion of the pool from which management is drawn. Currently, women physicians are underrepresented in medical management. Will these increasing numbers bring increasing representation of women among physicians making the critical decisions in medicine in the future? Many factors might operate against this. The formation of large medical groups could lead to exclusion of "pushy" female physicians and economic exploitation of those who need to work part-time because of family responsibilities.

Also, the increase in corporate medicine may decrease opportunities for women physicians in management. America's corporations do not favor women in management roles. The increasing internationalization of America's economy, especially the pressure from Japan, has not affected health care yet, but this is probably just a matter of time. This would also lead to an unfavorable culture for women physicians wanting to move into management. Entrepreneurship may, as it has in business, be the critical area for women physicians' success as managers. Finally, the past solution used by women physicians, formulation of female medical institutions, is not realistic, given the economic stress on medical institutions today.

It is obvious that women are interested in learning about management. The female membership of ACPE has increased rapidly in the past 2 years (figure 5, below). Can this interest lead to opportunities? How can the status quo be changed? Some have argued for social justice, advocating that older male leaders have a duty to bring women and minority physicians into management positions. A more compelling reason for change, given the economic stresses on U.S. medical institutions, is the contributions that might be made. Management skills are not carried on the Y-chromosome; there are many talented women physician administrators who can "deliver the goods." Leaders of medical organizations will be losing a significant amount of management talent if they do not consider women physicians as candidates for management, and thus be less competitive in a very competitive time.

REFERENCES

[ 1.] Bonbrest, H. "Encouraging Women and

Minorities to Enter Medical Management."

Physician Executive 14(2):21-2, March-April

1988.

[ 2.] Kindig, D., and Lastiri, S. "Administrative

Medicine: A New Specialty?" Health

Affairs, 5(5):146-56, Winter 1986.

[ 3.] Anderson, O. Health Services in the

United States: A Growth Enterprise Since

1875. Ann Arbor, Mich.: Health Administration

Press, 1985.

[ 4.] Morantz-Sanchez, R. Sympathy and

Science: Women Physicians in American

Medicine. New York, N.Y.: Oxford University

Press, 1985.

[ 5.] Rosenberg, C., Ed. The Structure of

American Medical Practice, 1875-1941.

Philadelphia, Pa.: University of Pennsylvania

Press, 1983.

[ 6.] Starr, P. The Social Transformation of

American Medicine. New York, N.Y.: Basic

Books, 1982.

[ 7.] Vogel, M., and Rosenberg, C., Eds. The

Therapeutic Revolution: Essays in the

Social History of American Medicine.

Philadelphia, Pa.: University of Pennsylvania

Press, 1979.

[ 8.] Walsh, M. Doctors Wanted: No Women

Need Apply. New Haven. Conn.: Yale

University Press, 1977.

[ 9.] Dempsey-Polan, L. "Women: Once and

Future Leaders in Health Administration."

Hospital and Health Services

Administration 33(1):89-98, Spring 1988.

[10.] Thomsonianism was an irregular medical

sect that advocated severe vomiting

induced with lobelia and also vapor baths.

Given the state of regular medical therapy

in the mid-19th Century, it possibly was

not as radical as it seems today. Many

early women physicians were attracted to

irregular medical sects because they often

used less radical therapy than regular

medicine. Apprenticeship was a common

way to become a physician until the last

quarter of the 19th Century, because there

were few licensing laws until then.

[11.] Brown, A. "The History of the Children's

Hospital in Relation to Medical Women."

In Who's Who among the Women of

California. San Francisco, Calif.: Security

Publishing Co, 1922, pp. 171-2.

[12.] There had been attempts at health

insurance from colonial times. Immigrant

groups, for example the French in Gold

Rush California, would hire a physician to

provide care for a monthly fee, an early

prepaid plan known as "contract practice."

Industries, such as the railroads, did

the same thing.

[13.] Brown, C. "Women Workers in the

Health Service Industry." International

Journal of Health Services 5(2):173-84,

1975.

[14.] Roback, G., and others. Physician Characteristics

and Distribution in the United

States. Chicago, Ill.: American Medical

Association, 1987.

[15.] Dickstein, L., and Stephenson, J. "A

National Survey of Women Physicians in

Administrative Roles." Journal of

American Medical Women's Association

42(4):108-11. July-Aug. 1987.

PHOTO : Figure 1 - MDs in Administration, Percentage of All U.S. Physicians

PHOTO : Figure 2 - U.S. MDs in Administration, 1970, 1986[9]

PHOTO : Figure 3 - Number of Physicians, Total and by Sex[9]

PHOTO : Figure 4 - Age Distribution, 1986, MDs in Medical Administration[9]

PHOTO : Figure 5 - Women Members of ACPE since Organization Founded

Selma Harrison Calmes, MD, is Chief Physician, Anesthesiology, Olive View Medical Center, Sylmar, Calif. She is a member and former chair of the College Forum on Women in Medicine and Management.
COPYRIGHT 1991 American College of Physician Executives
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Title Annotation:status of women doctors as administrators
Author:Calmes, Selma Harrison
Publication:Physician Executive
Date:Jan 1, 1991
Words:2374
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