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SPECIALFEATURE | December 01, 2004

Women in U.S. Psychiatric Training

Shaili Jain, M.D.; Bhawani Ballamudi, M.D.

Academic Psychiatry 2004;28:299-304. 10.1176/appi.ap.28.4.299

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Drs. Jain and Ballamudi are with the Department of Psychiatry, Medical College of Wisconsin; and the Department of Psychiatry, University Of Wisconsin, Madison. Address correspondence to Dr. Jain, P.O. Box 320346, Franklin, Wisconsin 53132; jainshaili@hotmail.com (E-mail).

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Abstract

OBJECTIVE: The number of women in psychiatric training is predicted to increase over time. This article aims to review and evaluate the existing literature on the topic and identify present areas of concern and recommend future areas for research. METHOD: A Medline search from 1964 to the present day was conducted. Literature on female physicians in psychiatry, internship and residency, career choices, and medical education was reviewed. RESULTS: Much has changed, for the better, to accommodate the needs of this population. The areas of role integration, career choices, and pregnancy remain issues of concern. These concerns will continue as the percentage of female physicians increases. CONCLUSIONS: The multiple issues surrounding the pregnant resident need to be formally addressed and recognized to avoid strain on all residents, patients and departmental systems. Political, social, and departmental issues need to be addressed to help female residents with role integration. Psychiatry should lead the way among medical specialties in advocating for excellent family leave policies and childcare. Academic psychiatry will have to use creative strategies to effectively recruit and maintain female faculty.

Figures in this Article

A significant body of literature about the problems of women in psychiatric residency training was observed during the late 1960s to the early 1990s. The number of women in psychiatric training has since increased, and it is predicted that this number will continue to do so. In the last decade, however, little has been written about this segment of the psychiatric workforce. This article aims to review and evaluate the existing literature and identify immediate areas of concern for women in training as well as to recommend future areas for research.

METHOD

Abstract | METHOD | RESULTS | CONCLUSIONS | References

A Medline search from 1964 to the present was conducted. English language literature on female physicians in psychiatry, internship and residency, career choices and medical education was reviewed. A review of the reference lists from articles retrieved was also conducted. Articles that used analytical designs were considered to be of higher methodological quality. Pertinent issues and previous recommendations were combined into a single document that concisely defines key elements of the topic and suggestions for future areas of research. Search strategy was limited to U.S. and Canadian literature secondary to our belief that differences in sociopolitical, economic, and training environments play a pivotal role in understanding the topic, and to compare different countries would, consequently, complicate result interpretation.

RESULTS

Abstract | METHOD | RESULTS | CONCLUSIONS | References

Women Residents Entering Psychiatry

In the 1970s, a woman in psychiatry training would often find herself alone among her peers (1). By the late 1980s, the number of women in psychiatry had grown by 913 (61%), compared with an increase of 229 (7%) among male residents (2). By 2003, 50.7% of U.S. psychiatric trainees were women (3). Furthermore, for a number of years prior to this period, women constituted nearly 50% of training populations. (Personal communication [B.B.] with Judith H. Carrier, Ph.D. 2004).

Historically, women have selected psychiatry in a greater proportion than men (4). Given that the number of women entering medical training continues to increase, we can speculate that the numbers of women entering psychiatry will continue to climb also.

Supervision of Women Residents in Psychiatry

Supervision forms the core of psychiatric training and allows the trainee the opportunity to learn by identification, modeling and education (1).

A 1974 APA survey of the role of women in training programs found that teaching and supervision of female and male residents by female senior staff were rare or nonexistent. A similar survey conducted in North Carolina in 1976 showed a different picture, with "60% of respondents reporting adequate supervision and teaching by female psychiatrists and 88% believed that there were women available with whom they could share their personal concerns" (5).

In a 1977 opinion-based paper, Benedek et al. (1) reported that the "paucity of female supervisors available to trainees is undisputed." Particular problems on the supervision of female residents by women were, "Unrecognized and unresolved conflicts between female resident and female supervisor (that) may include problems about the handling of gender identity, as well as sexuality and aggression (1)." Between the male supervisor and female trainee Benedek et al. noted that "male supervisors tend to view the female trainee as a stereotypic[al] female, either warmly nuturant and passive or cold and castrating" (1).

Bieniek et al. raised similar concerns in 1981 when they published data obtained from interviewing 15 female therapists, including psychologists, social workers, and psychiatry residents (6).

In a 1983 study, Lyacki et al. conducted a semistructured interview with 10 female and 10 male psychiatric residents from a mental health training facility to evaluate their relationship with six supervisors (36 women, 84 men). Both male and female residents believed that male supervisors expressed gender role stereotyping about women. Neither group, however, believed that this affected their training (7).

The Female Administrator Trainee

Providing opportunities for the female trainee to assume positions of leadership is an important training issue. Benedek et al. noted that "[female trainees] are often invited to do the committee work associated with social occasions, decorating or libraries but seldom are they considered appropriate candidates for chief resident" (1).

More than one decade later, Kessler et al. (8) investigated to find whether any changes had occurred. They cited their own experience of "an increasing number of female chief residents and relatively rare reports of overt discrimination" (8). They surveyed 10 former female chief residents and 10 male residents and found that female residents were no longer hindered from assuming the position of chief resident. Furthermore, the obstacles encountered by chief residents appeared to be more a function of the role itself rather than gender related.

The Pregnant Resident

In 1988, Phelan (9) was the first to study issues surrounding pregnant residents on a national basis. She surveyed obstetricians and gynecologists, surgeons, and psychiatrists who were currently attending or who had recently graduated from a residency program. Phelan found that "almost 50% of married female residents become pregnant during residency. The desire to have a baby and concern about age influence the decision to become pregnant. Career concerns, financial issues, and child care were found to be less important" (9).

In her study, Tinsley (10) explored the effect that the pregnant resident therapist had on patients. She stated that "times during the psychiatrist pregnancy that threaten abandonment are pivotal in the therapeutic relationship with vulnerable patients." The announcement of the therapist’s pregnancy, the final appointments before leave, the beginning of leave, and the return to practice are instances that may threaten abandonment. Tinsley found that patient anger about the pregnancy often stemmed from themes of rejection, sibling rivalry, oedipal strivings, and identification with the therapist or the baby (10).

A 1994 study (11) analyzed the impact of pregnancy during training on a psychiatric resident cohort in which the majority of residents were pregnant during an 18-month period. The authors chose to conduct open ended interviews with nine PGY-4 residents in the cohort. Among the female residents, six were women and five were pregnant within an 18-month period. The same interviewer interviewed all residents privately. It is unclear to what extent anonymity was preserved in such a small group. Conflict occurred when the nonpregnant residents felt that the pregnant residents were receiving preferential treatment. Psychological defenses utilized by the residents included projection and denial (11).

There is anxiety generated interpersonally as well as in systems about work coverage for an absent trainee (11, 12). Tinsley suggested steps the pregnant resident could take to help ease workplace tension "notify colleagues of her pregnancy as early as possible to allow ample time for rescheduling and for coverage to be arranged and be openly appreciative of those who help to cover during her absence" (10).

The responses of medical institutions to the pregnant resident have changed over the years. In 1989, only 52.2% of the 366 teaching hospitals surveyed had official maternity leave policies (11). Surveys conducted in the early to mid-1990s estimated that 15%—25% of training programs did not have written maternity leave policies (13, 14). A 2002 survey of teaching hospitals reported that 99% of respondents had official Family and Medical Leave Act (FMLA) policies in place, and 85% of respondents reported that their house-staff had utilized these policies (2004, personal communication, S.J. with Jared Abramson, Council of Teaching Hospitals). Tinsley maintains that "psychiatric residencies have been among the best in providing leave guidelines" (10).

Role Integration

Since the 1960s, the need to recruit female physicians who were married and raising families back into psychiatry training and the ability of psychiatrist mothers to function well in both their roles has been recognized (15, 16). A residency program designed specifically to increase the number of physicians entering graduate training in psychiatry was described. The program design modified the conventional time sequences of the psychiatric residencies to facilitate training for physicians who were also mothers (17).

One of the first formal psychiatric acknowledgements to the concept of "role integration" was at the meeting "Psychiatrist-wife-mother: Is Serenity Possible?" The meeting was held at the 126th annual meeting of the American Psychiatric Association in 1973. The panel was comprised of six female psychiatrists, and they proposed that a career in psychiatry combines marriage and motherhood more readily than others and that "she [the woman psychiatrist] must feel each role is her right as a creative and talented human being" (18).

Potter reiterates these sentiments and describes several advantages for women who choose psychiatry as a career, which include "the relative flexibility of one’s schedule, the possibility of regular hours, challenge and nature of the work, the less frequently encountered prejudices and the possibility of meeting of affiliation needs by working with people" (19).

A 1973 pilot study by the APA Taskforce on Women compared 35 male and 35 female psychiatrists and found significant differences in the area of family-career conflicts. Almost 50% of the women reported concerns about combining profession and marriage and profession and motherhood. The men did not report such concerns. The Task Force reported that "the women [have] handled the family career conflict by reducing their career demands, working fewer hours, changing to less strenuous and less time consuming areas of practice or giving up care of the children to a housekeeper or parent" (20).

Tinsley characterized effective role integration: "The early career psychiatrist who is trying to build a healthy marriage and family simultaneously may be akin to the tortoise who travels at a slower pace but keeps on maintaining steady progress toward that goal" (10).

In a 1984 study, Kashtan and Dickey (21) surveyed 122 recent psychiatry graduates to determine whether previously reported differences in career patterns between the sexes persist in younger psychiatrists. There was a 67% response rate, with a higher proportion of women responding than men. Kashtan and Dickey noted the most striking differences centered on child rearing: "despite the notion that men’s and women’s roles are becoming less differentiated, the women in this study reported taking primary responsibility for caring for their children" (21). This trend was not related to child rearing alone, as women without children worked fewer hours than men.

Another change from earlier years was that women took only short periods of time away from work for child rearing. Encouragingly, they found that women were no longer underpaid compared with men, and men were showing a growing awareness of the conflicting demands between career and family (21).

Stewart et al. (12) conducted a survey in the mid 1980s that aimed to identify some of the experiences of combining child bearing with career among a large group of female psychiatric residents and staff psychiatrists. They reported that a "general frantic balancing of home and work responsibilities with personal desires receiving a low priority" was observed (12). Stewart et al. also noted that the increase in part-time training in the U.S. and Canada was an attractive option for residents, especially if their children were still young. Furthermore, it was believed that supervisors who were understanding, flexible, and encouraging were instrumental in combining the two careers of residency and motherhood (12).

Career Choices for the Female Psychiatry Resident

Self-employment

Historically, women in private practice have expressed more satisfaction with relationships and colleagues, had fewer complaints, and indicated less conflict about roles than did women in the three other practice settings of organizations, academic departments, and training settings (22, 23).

Organizational psychiatry

There are aspects of organizational medicine that appear to be a "safe haven" for women, and traditionally women are found in nonadministrative positions in mental health facilities (22, 23).

Academic psychiatry

In a 1985 survey, Penfold (24) conducted a survey of all psychiatry departments in Canada. In comparing these departments to those of the previous 10 years (since 1975), Penfold found that "the average percentage of female faculty had increased from 11.4% to 14.3% but the percentage of female residents had increased from 23.5% to 43.4%" (24). The discrepancy between female residents and faculty was explored, and it was found that "only 2 departments were actively recruiting female faculty and there was a continued concentration of women in the lower ranks." Barriers included a lack of academic role models, job adverts not designed specifically to attract women, women’s lack of access to male corridors of power, cultural stereotypes about female competence, and female socialization that does not lend itself readily to roles of authority and role strain (24). Additionally Kessler et al. (8) noted that female chief residents were less likely to embark on academic careers than their male counterparts, and further research was needed to identify and correct the more subtle factors in systems that might create these obstacles.

Reiser et al. (25) examined department educational records at the Yale Residency Program to determine the professional interests expressed before psychiatric residency and training focus during residency for 355 residents in 1970—1983 graduating classes. A 1984 follow up study focused on their post residency careers. The results showed that after residency, "their [female] practice pattern was different, they spent more hours teaching and had fewer publications in peer reviewed journals. This divergence was not accounted for by differences in pre training interests or training focus during residency" (25). Reiser et al. (25) noted that many talented and accomplished female medical students aim for career destinations in academic psychiatry but then disappear midcourse in the years following residency. They even compared this puzzling fate to the disappearance of sea and aircraft traversing the Bermuda Triangle! Their recommendations to attract and retain more female psychiatrists in academia and research included "structural changes in tenure policies, restructuring academic rewards and incentives to ensure recognition of the essential work that women tend to undertake and also to bring women back to academic careers after time away from academia during the post residency years" (25).

Benedek (26) summarized 20 years of work by the APA Taskforce on Women and highlighted the lack of women in leadership positions in the academic and research community. She wrote about the need for creative and mold breaking solutions that "require our coming to the problem from an entirely different perspective." Benedek pointed out that "historically success in academia was defined from men’s point of view--men who had few day to day responsibilities and who were expected to devote the larger part of their lives to their profession." She maintained that "work" and "family" (26) should be viewed as complimentary and to modify the value system for what is rewarded in academia.

CONCLUSIONS

Abstract | METHOD | RESULTS | CONCLUSIONS | References

There have been many major improvements for women in psychiatric training in the last two to three decades. With political factors such as the Women’s Movement, the APA’s Taskforce on Women, and widespread implementation of FMLA policies in teaching hospitals, psychiatric residency has become an environment supportive of female trainees. In 2002, 37% of psychiatry faculty members were women (27). With this increase in female presence in academic departments we can assume that female supervisors and role models are much more accessible than previously reported. Furthermore, with the encouraging data on female trainees assuming leadership roles in the 1980s we would suggest that this trend has continued further in a positive direction in the 21^st century.

Little has been written in the medical literature in the last decade, but we would argue that this is not because all issues have been resolved.

As the number of women in psychiatric training increases, so will the number of residents who become pregnant. The increased availability of flexible training schedules and the legal and social sanctioning of the rights of the pregnant worker have helped to relieve some of the burdens placed on the pregnant resident. However, the impact of an absent trainee on colleagues, systems, and patients must be addressed formally at the administrative and teaching levels. Leave policies and plans for coverage before and after the pregnancy should be explicitly stated to everyone instead of in an ad hoc manner. Residencies must help all residents talk openly and respectfully about issues raised by pregnancy. This will, in turn, prepare them for dealing with pregnancy and pregnant colleagues when they themselves transition to practice. Payment of residents covering for pregnant residents may be an option to explore (10, 11).

Role integration remains a complex area with widespread societal impact. As a nation, we have yet to evaluate the impact on a generation of children raised in households where both parents work full time. Issues for advocacy include paid maternity leave to be increased to 20 weeks in line with other industrialized nations (12). Additionally, as more men become actively involved with child care responsibilities, appropriate accommodations should be made for residents who are fathers. Psychiatry must continue advocating for children and family relationships (10). A 2001 survey (28) of nearly 600 female psychiatrists and 4,000 other female physicians found that female psychiatrists work fewer hours than other female physicians. How this fact is related to effective role integration, and the impact of this on the workforce and specialty as a whole are issues warranting further investigation.

Academic departments across all specialties as well as psychiatry continue to experience difficulty in attracting and maintaining residents to become faculty. Women who work part time or take extended leave may be at a disadvantage in academia, where publication and continual research funding are key factors in obtaining tenure (29). Some academic institutions have begun to recognize these disadvantages and have delayed tenure decisions for female and male primary caretakers, but many have not (30). More creative solutions are needed to accommodate women in academia if the field is to grow in an optimal way (26).

Finally, a large part of the data presented in this article has been limited by small sample sizes, low response rates, and the absence of controls. To accurately assess the situation today, there is a need for national surveys of men and women in training to revisit the issues addressed in this article. Direct comparisons of male and female perceptions will help control for those issues specific to training as opposed to gender related. Additionally, with the changing roles of men and their increasing involvement in child care and dual career marriages, the evolving needs of male residents may be addressed in this way.

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