In 1849, Elizabeth Blackwell became the first woman in the United States to graduate from medical school (Geneva Medical College, later Hobart College, in New York) (+1). January 2003 marked the 154th anniversary of Dr. Blackwell’s graduation. Over the intervening years, women have certainly become much more highly represented in medical schools nationwide. The number of female medical students has grown with a near constant acceleration since 1969. For example, in the 1949—1950 academic year only 7.2% of the total enrolled medical students in the United States were women. By the 2000—2001 academic year, 44.6% were women (+2).

The increasing percentage of female medical students is a trend evident among female residents as well though the numbers, as would be expected, lag behind medical school enrollments by several years. In 2000, 38% of all residents were women. The percentage is higher in psychiatry residency programs where, in 2000, women achieved statistical parity with men by comprising 49.8% of all psychiatric residents. The only medical specialties with higher percentages of women residents were dermatology, medical genetics, obstetrics and gynecology, and pediatrics (+3).

Though statistics can demonstrate the approach towards or achievement of numerical equality, they do not reveal information about whether the concerns particular to women medical students and residents are being addressed. It is quite possible that the demographic shift has not been accompanied by a corresponding cultural shift. Unfortunately, there are little data on the particular issues facing women residents in psychiatry. Interestingly, more of the academic articles on this subject were written in the 1970s and 1980s. More current writings on the topic appear in psychiatric newsletters. One might assume that in core aspects, women psychiatry residents' concerns are similar to their female counterparts in other departments and of female physicians in general. Among the major concerns for female physicians are work-life balance and career opportunities (+4). Because of the limited literature available relating specifically to women psychiatry residents, this article will include information from more general sources but will focus to the extent possible on the concerns of women psychiatry residents.

For female psychiatric residents, the issue of balancing work and home resonates especially loudly when considering pregnancy. Typically, residency occurs during a woman’s prime child bearing years. It is therefore not surprising that a sizeable number of residents will become pregnant. Women psychiatry residents, like their medical counterparts, are affected by the regulations of the American Medical Association’s (AMA) maternity leave policy (H-420.967). This suggests that residency training programs grant a minimum of six weeks of maternity leave, with the understanding that no woman should be required to take a minimum leave (+5). Furthermore, the AMA’s policy regarding maternity leave for residents (H-420.987) encourages flexibility in manpower levels and scheduling to allow for coverage without creating intolerable increases in residents’ work loads (+6). In addition, as employers, training programs are regulated by the Family and Medical Leave Act of 1993, a law requiring employers to grant 12 workweeks of unpaid leave during any 12-month period for medical events, including pregnancy (+7).

Despite this option, there are key reasons women residents wishing to spend more time with their infants will not do so. One is primarily financial. Taking unpaid leave, given the combination of low resident salaries and the high levels of debt that many residents carry, may be impractical. But in addition, social pressure within the programs often makes taking advantage of this opportunity difficult as well (+8). Whether or not a training program has a formal leave policy, many institutions do not have universally established plans for the specific details of handling a resident's pregnancy. Instead, pregnancies and maternity leaves are handled on an ad hoc or case-by-case basis (+9). This usually results in the reassignment of the extra work load to the residents who were not away on leave (+10).

The structure of the 4 years of psychiatric residency makes it likely that any planned pregnancies will occur during the third or fourth year of residency. The advantages to having a child during this time are that more senior residents generally are assigned less night call and have fewer, if any, responsibilities on the inpatient units. However, this also means that a residency program may have up to half of its senior residents on maternity leave in the same year.

In addition to pregnancy, child rearing during residency may also be a difficult proposition. Schedules are quite demanding and "flex-time" is generally not available. In a 1983 study on combining motherhood with psychiatric training (+11), female residents and early career psychiatrists were surveyed regarding number of children and child-care experiences. Moreover, they were asked to provide suggestions for making child rearing less difficult. Unfortunately many of these suggestions (statistical analyses were not performed because of the broad and varied nature of their suggestions), such as obtaining domestic help, are not viable for residents with limited incomes. A more practical and less expensive suggestion pertained to the attitude of supervisors and staff. Of critical importance to the respondents were supervisors' understanding, flexibility, and encouragement. Additionally, respondents asked for substantive discussion between staff and residents regarding the issue of balancing parenting and residency, more education on the inherent conflicts between work and child-rearing, and the inclusion of successful role models in the programs. Finally, respondents suggested the development of programs with formal part-time or time-sharing positions. For example, psychiatry residents in their third and fourth years at Stanford's residency program are given the option of working half-time. Though this option extends the length of training for the resident, this has been an attractive feature of the program to both applicants and current residents.

Many years after the survey cited above, these issues and suggestions are still pertinent. Balancing motherhood with one's career often means limiting one or the other. In academic psychiatry, where advancement is based largely on peer-reviewed publications and research productivity, faculty who do not have to divide their attention between family and career may have an advantage. For example, Barbara Sommer, M.D., a Stanford Assistant Professor, describes her curriculum vitae as one similar to that of a physician many years her junior. Because of her commitment and focus on her family’s needs over the years, her career has been negatively affected (+12).

Compromises between one's personal and professional roles are not issues faced solely by women. Justin Birnbaum, M.D., a staff psychiatrist and Director of Outpatient Geriatric Psychiatry at Stanford, states that on occasion his decisions to spend time with his child have resulted in less time available to pursue professional goals. Dr. Birnbaum is an example of what seems to be a growing trend. A current male resident at Stanford has taken leave and is currently working part-time in order to spend more time with his family.

Shared residency positions have often been suggested as a way to alleviate the competing demands of work and home. This option, which differs from attending residency part-time, involves two applicants applying through the National Residency Matching Program as one unit and sharing a single residency position. In a shared residency, the two residents would usually alternate months on clinical rotations (+13). Section 709 of the U.S. Health Professions Educational Assistance Act of 1976 (P.L. 94-484) mandates that shared schedule positions be available to federally-assisted residency programs (+14). However, these specific programs did not include psychiatry. The only included programs were family practice, obstetrics/gynecology and pediatrics—fields where women in 2000 held at least 47.7% of residency positions (+15). While establishing a shared-time residency position in psychiatry seems to be a practical means for reducing the conflicts between residency and parenthood, there are logistical barriers to actually obtaining such a position, were it even to be available. One is that such an option has generally not been well publicized to potential residents. Another is the difficulty of pairing up with a colleague with similar needs. Additionally, applying in this manner forfeits all rights to apply individually for full time positions. Because of these obstacles, this option would likely be attractive and viable for relatively few applicants.

Career success is important for all residents. Because of biology and culture, women face a more complicated path to this success. Women in residency are likely to have family commitments and to take time away from their academic career aspirations to focus on these commitments.

A study published in 2000 in The New England Journal of Medicine followed women who had graduated medical school from 1973 to 1993. Women were more likely to initially pursue careers in academic medicine than their male counterparts but subsequently had diminished interest in academia. The number of women who had advanced to associate and full professors was significantly lower than expected. It was speculated that women had lower productivity (e.g., publications, grants), worked fewer hours, or had fewer resources provided by the school. The authors also considered the possibility that women may be more likely than men to join departments where the likelihood of promotion is low or that women may pursue more career opportunities outside of academia (+16). Another explanation, offered by DeAngelis, is that some women became disheartened by the slow advancement of women faculty (+17). Though such ideas may be speculative, there do appear to be forces that limit the number of women in academia.

From a psychiatry resident's standpoint, the ideal academic role-model is presented as being a clinician, teacher and researcher, with career advancement in academic psychiatry dependent on being successful in each of these roles. Residents transitioning out of training begin to develop and cultivate their professional identity. Granet and Cooper noted that during this time, residents who may be contemplating a career in academia "devalue their potential professional worth" (+18). For women psychiatry residents, the desire to have and raise a family may also be an added factor during this transition period. An ad hoc survey of current senior female residents at Stanford revealed that women who plan to pursue full time academic psychiatry either have grown children or lack heavy child-rearing commitments. Whether the senior resident is interested in academia or pursuing a non-academic career, the presence of a role model or mentor would be valuable during this time of evolution from resident to practitioner.

Comparing 1989 and 2000, the total proportion of women psychiatric residents increased from 40.6 to 49.8% of the total number of residents respectively. In contrast, only 29% of associate professors and 14% of full professors in psychiatry were women in 2001 (+19). It would be expected that the percentage of women faculty members would lag behind the percentage of women residents by several years. But if one assumes that a typical academic career path leads from residency to an associate professorship position in 12 years (i.e., 4 years of residency, two years of fellowship, and 6 years as an assistant professor) and that women were entering academic medicine in the same proportion as men, the percentage of women psychiatric residents entering academia in 1989 should match the percentage of women associate professors in 2001. However, there is more than a 10 percentage point difference.

Statistically, women are advancing in academic psychiatry at lower rates than men and have assumed fewer leadership positions (+20). According to the Early Career Women Faculty Professional Development Seminar organized by the Association of American Medical Colleges in December 2001, residency programs can help promote the successful transition of their women graduates into academic careers by offering courses on compiling effective curriculum vitae that are not too conservative in listing their accomplishments. Other useful courses might include seminars on the culture of academia, career-building strategies, grant writing, conflict management and negotiation skills (+21).

In 1993, Leah Dickstein, M.D., in her inaugural address to the American Medical Women’s Association, stressed the importance of finding role models and mentors (+22). According to a 1992 survey at the University of California—San Francisco, women, especially among house staff and junior faculty, had fewer mentor relationships and role models (+23). As demonstrated in a 1988 survey, there was a significant association between having a mentor of either sex during training and number of publications, time spent on research, and career satisfaction (+24). More current literature continues to attest to the value of mentorship and networking for women's advancement (+25—+27).

It has been suggested that mentorship is more important for women than for men (+28). Men appear to be more willing to involve senior individuals in accessing career opportunities, while women tend to look for mentoring relationships outside of the workplace or outside the formal lines of authority (+29). The gender of the mentor does not appear to be important (+30). However, despite the evidence that men are equally effective in mentoring female psychiatrists about career progression, it is possible that mentorship with respect to personal development and balancing family and career may be more effective from same-sex mentors or role models. Men may be less likely to fully appreciate a woman’s perspective on work-family conflicts and issues of child bearing, and women residents may feel more comfortable raising such issues with a female mentor. Additionally, some men perceive that a close relationship with a woman at work may be misinterpreted (+31). It should be emphasized that this in no way implies that women should not seek out male mentors. Rather, a valuable strategy for the woman resident is to seek out both male and female mentors.

Formal mentoring programs have been shown to be of great benefit for psychiatry residents (+25, +32). Residents and training programs may find the following resources helpful:

This article has focused on women residents in psychiatry and the issues of pregnancy, child-rearing, career advancement in academia and mentorship. While many issues faced by women residents are shared equally by their male colleagues, women residents have particular concerns in each of the issues covered. These concerns have been longstanding and remain unresolved, though residency training provides an excellent opportunity for women psychiatry residents to gain the knowledge and skills useful for transitioning to an academic career as well as for eventually assuming leadership roles.

Despite the challenges, women are continuing to enter psychiatry residency programs in increasing numbers. Higher percentages of women residents may mean that their unique concerns will increasingly be brought to the forefront. This has value for both men and women residents struggling to balance career and family. Thus, paying attention to these issues is likely to enhance the overall quality of residency training programs and postresidency career choices. As psychiatrists, we specialize in improving the emotional and mental health of our patients. However, we must also continue to look for creative and effective ways of tending to the well-being of our psychiatry residents and colleagues.