Better care, shorter careers: Women physicians leave clinical practice 15 years earlier than men

Women physicians may provide better patient care than their male counterparts — but for less money, and it turns out, for shorter career duration.

A national study found women physicians leave the clinical practice workforce far earlier than men. Their median age of departure was 49, compared with age 64 for male doctors. That difference held across both rural and urban settings and across every specialty category examined.

Lisa Rotenstein, M.D., MBA, M.Sc., an internal medicine physician, is the corresponding author of the study, “Sex Differences in Physician Attrition from Clinical Practice Across Specialties: A Nationwide, Longitudinal Analysis,” published in the Journal of General Internal Medicine. When she’s not caring for patients at UCSF Health in San Francisco, she directs the Center for Physician Experience and Practice Excellence funded by The Physicians Foundation, and she has co-authored dozens of studies on the physician workforce and their workplace conditions.

This transcript has been edited for length and clarity.

Medical Economics: The study found that female primary care physicians leave clinical practice at a hazard ratio of 1.55 compared with their male counterparts, and that was one of the higher differentials across specialties. For a woman physician in primary care practice right now, what does that actually mean for a career outlook?

Lisa Rotenstein, M.D., MBA, M.Sc.: It means that female physicians are more likely to leave clinical practice, and so let me talk about what we meant by leaving clinical practice. We looked at those physicians no longer billing for their patients’ care, and specifically we looked at Medicare patients because we know that the vast majority of physicians do accept Medicare payment. We asked that those physicians not have evidence of any billing for three consecutive years. That eliminated those physicians who may have taken a break and come back and it told us that these physicians were likely no longer seeing patients in the traditional ways. We don't know if they went to concierge practice, for example, and were no longer billing insurance. Those physicians could have gone on to industry, to a teaching role only, but they were no longer delivering clinical care to patients, and that's really what we care about. We care about access for our patients. And it functionally means that we are training physicians — the training of physicians is long, we are training them, and then that means that our patients don't get access to their expertise.

We also know that female physicians have better clinical outcomes in some circumstances, and they deliver care differently. My colleagues have shown that female physicians spend more time with their patients. They receive more messages from their patients. They write longer notes than male colleagues. They spend more time on the electronic health record (EHR). You asked specifically about female primary care physicians: That means that they are doing all these things that are right for their patients, but it might be leading them to a work situation that is not tenable, and then they choose to leave clinical practice despite that excellent care delivery.

Medical Economics: What's happening in the careers of women physicians in their 40s, that makes it a critical decade to their careers, and then maybe influences their decisions to leave the workforce?

Lisa Rotenstein, M.D., MBA, M.Sc.: We are seeing this earlier peak of attrition in the 40s for female physicians, and if you look at the graphs in the paper, they're actually pretty striking in that the male physicians have this peak around the time of retirement, right before retirement, maybe they're retiring a few years early. But the female physicians almost have a bimodal distribution, in that when they're leaving, some of them are leaving around a regular retirement age and some of them are leaving earlier. And so it does make that first decade and a half of practice really, really critical.

We can't know exactly what is happening in every specialty, but we do know that female physicians experience a different workplace in their male counterparts. Their patients may expect different things of them. Their colleagues may expect different things of them, they may not have as much support as their male colleagues, for example, in terms of concrete resources, the number of staff that they work with, the amount of administrative support. There continue to be compensation differences for female versus male physicians. And so there are multiple factors in the workplace that are driving these choices. And the reality is that we know that female physicians continue to experience disproportionate caregiving demands, both related to younger and older generations. While certainly that can be present for male physicians, the unfortunate reality is that female physicians continue to experience those to a greater extent. So there are both workplace and societal pressures that are making clinical practice no longer tenable for a portion of our workforce, with real implications for our patients.

Medical Economics: In the study, the data showed that the sex-based attrition gap held fast in both rural and urban settings. What does that finding tell you?

Lisa Rotenstein, M.D., MBA, M.Sc.: It tells us that this is an issue, again, across the workforce. It's important to retain female physicians across the workforce, but particularly if we are trying to address issues of access to care in rural areas, we have to think long and hard about what would make that job sustainable to all members of the workforce. And the specifics will vary based on the specialty, the type of institution. But to your point, that is an area where we really need to retain our workforce, and so we should be paying particular attention into how to sustain the workforce so it’s not leaving early.

Medical Economics: In the study, you also suggest that alternative payment models, such as time-based billing and value-based payment could help retain female physicians by better rewarding their care. What does that mean in primary care? What would you like to see happen?

Lisa Rotenstein, M.D., MBA, M.Sc.: There are studies that show that female physicians practice differently and likely it's good for our patients. They spend more time with both male and female patients. In a fee-for-service system, functionally, what that means is that they see fewer patients, and then that means less revenue, and then they're compensated less. One of my colleagues did a study showing that female physicians are generating 80 cents of revenue for every dollar of male PCPs, even when they're spending more time with their patients. Ideally, time-based billing would help compensate female physicians for the time that they're spending in the visit. But also we know that they bear a disproportionate burden of asynchronous work, of messages, of paperwork, of calls. Some of that has already been put into place, for example, with the E/M coding changes. Value based care s a different but related topic in that ideally, we should be paid for the cadre of patients that we care for, whether we're seeing them in front of us synchronously, or we are caring for them in asynchronous ways. My team has shown, for example, that the more time one spends on the electronic health record, including on in-basket messages that's associated with better panel level quality outcomes, like better disease control for diabetes, more appropriate mammography. That care that happens outside the visit is valuable care. It's just not routinely compensated. In a value-based payment system where you are being compensated for the panel of patients you care for, and ideally even being incentivized for quality outcomes, it would reward that type of appropriate care delivery that meets the patient wherever they are and where is most convenient for them.

Medical Economics: Some of your research examines how artificial intelligence (AI) programs may affect some physicians, especially with electronic health records and records management. Is that going to be the solution that can help keep women physicians in the workforce?

Lisa Rotenstein, M.D., MBA, M.Sc.: I think it's a really promising solution. I think there will not be one single solution that keeps women physicians in the workforce, but I do think it's a solution that can help bring joy back into practice. So we published a study funded by The Physicians Foundation this past fall, and it showed reductions in burnout across two health systems associated with use of AI scribes. The qualitative comments were really revealing. Folks were saying, I can pay attention to my patients again, I can look them in the eye, I can call my patients back before 7 or 8 p.m. There's probably a question there of, is that timing sustainable? But let's start with improvements. And so that is great that people are feeling better about their work.

We also have some data suggesting that the clinicians who have a relatively greater burden of documentation at baseline benefit proportionally more from ambient documentation technology, and so that does include female clinicians. It also includes primary care clinicians, advanced practice providers. So certain groups that are spending more time at baseline on documentation are likely to benefit more. This is a great, great start. I do think we have to move beyond just documentation into the rest of the work of medicine that doesn't feel like the work of medicine. And so, for example, AI drafted inbox responses haven't been quite as successful, but we know that that asynchronous work is a major driver of burden. Prior authorizations I think our next frontier that I really do hope that AI can help us with. General paperwork I hope we will be able to tackle with AI and so I hope that ambient documentation is just the beginning.

Medical Economics: Can you talk about the findings in relation to independent practice? Is there a chance that the stresses of independent practice may be forcing some women physicians to reconsider their careers and leave early? Or is that invigorating and exciting when the doctor has a chance to be their own boss?

Lisa Rotenstein, M.D., MBA, M.Sc.: We know that fewer physicians are working for themselves, and I actually think that that is a driver of attrition across the workforce, and certainly it might be a greater driver of attrition among female physicians. I'm not sure that I've seen the research to demonstrate that. But what we do know is that physicians who feel less control over their work environment, are more likely to say they want to cut back on clinical care or they want to leave. So that has been demonstrated, and there's other ways in which that plays out. We did a study some years ago showing that physicians who worked for themselves were more likely to be happier with their EHR regardless of which EHR they used. And so what it tells us is that ,it's not actually about the EHR, it's about their choices in their clinical practice. We have done research showing that clinician-owned practices have lower burnout rates overall, and they're more likely to be able to improve quality of care without increasing burnout, so to make changes in practice without increasing burnout. And we think, again, that that is because physicians or clinicians are in charge of how care is delivered, and they feel agency. I think that is a real opportunity for improvement.

Physicians are working for themselves less and less. So then the opportunity is to find out how we can empower physicians, even within the large systems in which they work, to control key aspects of their life. Maybe it's their schedule, maybe it's who's on their clinical team, maybe it's one aspect of their practice that really matters to them, the technology that they're using every day. But we have to figure out how to give physicians back control, even when the trends are moving against that.