Some years ago, I noted a trend in my practice. More and more patients requested to switch their care to me for a single reason: They wanted a doctor who would answer their emails.
To my surprise, that was how I learned some of the other doctors — all male — in the practice did not respond to patient emails. (The kind that patients are allowed, and encouraged, to send through the electronic health record [EHR] system).
Interestingly, patients didn’t hold it against my male colleagues for not answering their emails. “He’s just too busy,” was a common sentiment expressed.
The unexpressed corollary was that somehow, I, as a female physician, was not too busy.
Please don’t get me wrong. I have never minded responding to my patients’ questions by email. I enjoy the opportunity to correspond with my patients. What I have minded — and why I suspect those male colleagues didn’t answer their patients’ emails — is we have no time in a typical clinical day allotted to address those messages.
It was thus not uncommon for me to respond to my patients’ emails at midnight. This, somehow, didn’t worry my new patients but instead impressed them. “Wow, Doc, I saw the time you responded to that email! It was 2:00 AM!”
For years, I’ve never been able to articulate precisely what bothered me most about this.
Until I read this paper from January 2022: Primary Care Physician Gender and Electronic Health Record Workload, by Rittenberg and colleagues, in the Journal of General Internal Medicine.
In this paper, the authors presented their findings that female primary care physicians spend substantially more time in the EHR than do their male colleagues. In their electronic in-baskets, they receive substantially more staff messages and patient messages.
The authors then undertook an exploration of why this occurs. Is it because staff and patients of all genders contact female physicians more frequently? Alternatively, are female PCPs simply less efficient? Or do female PCPs have disproportionately female panels, and female patients take more time?
(Of note, the authors used the terms “female” and “male” to describe physician and patient gender because those were the terms that had been used in the relevant literature. They acknowledged that the hospital database they used to identify physician gender required respondents to identify themselves as male or female; therefore, they could not capture information on physicians who were transgender or nonbinary. Similar limitations applied to patient gender [legal gender as listed in Epic]).
Their data showed that female PCPs receive significantly more messages from both patients and staff than do their male counterparts. The authors concluded that “this finding suggests gendered expectations of physician accessibility, leading to a lower threshold to contact a female physician than a male physician.”
As soon as I read this, the recollection of my early practice experience came back to me. Not only was it somehow accepted that the male physicians didn’t have to respond to their patients’ emails because they were already “too busy,” but paradoxically, patients and staff saw nothing wrong with the fact that for the female physicians to keep up with the number of messages sent to us, we needed to do so at all hours of the night.
The importance of this paper cannot be understated for female physicians. The value of this research is in its validation of female physicians’ lived experience of gender-biased workloads, especially when it comes to the EHR.
But it goes beyond the EHR. As the authors state, “[p]atients communicate differently towards female physicians than towards males; patients speak more, make more partnership statements, and disclose more medical information to female physicians than to male physicians.”
I can sum this up in a single anecdote.
I will never forget the time I met a new patient who had transferred her care to me after her prior oncologist, a male physician, retired. She had been on adjuvant endocrine therapy for breast cancer for several years. She had many concerns for me about the chronic side effects of this medication and the effects on her quality of life. I asked her what she and her prior oncologist had discussed and tried so far, and her answer rendered me momentarily speechless. “Oh,” she said, “I never told him any of this.”
She had been his patient for years and never told him any of the medication side effects affecting her quality of life. Yet, within 5 minutes of meeting me, she had a long list of concerns she expected me to immediately address.
Again, don’t get me wrong. This is one of the things I love about being perceived as highly approachable. I want all my patients to feel comfortable talking to me about anything and everything, and I derive great satisfaction in ensuring their concerns are listened to and addressed.
But it made me realize that my daily clinic experience is vastly different from that of many of my male counterparts.
Not only are my patients disclosing more to me in the exam rooms and expecting more out of each clinic visit, but they are sending me more messages in the in-basket and expecting those to be addressed, while the clinic staff also are sending more messages because I’m perceived as more approachable, and I have all the same charting burden as my male colleagues, yet less time to accomplish it because of these competing messages.
As the authors of the paper put it, “Gendered expectations and practice styles may contribute to time pressure during visits and excess work hours [my emphasis], that in turn affect burnout rates.”
Because here’s the real kicker of this paper: “Despite increased message volume, we found that there were no significant differences in the time female physicians took to respond to patient or staff messages.”
This will surprise no female physician. Even if our workloads are higher, we will compromise our personal and family lives to make sure we keep up.
As the authors explain, the solution is thus not training female physicians on being “more efficient” in the EHR. We already are more efficient.
“Instead, developing support systems and team-based care to respond to inbox messages offers a potential avenue to mitigate burnout in female physicians.”
And suppose female physicians need more support staff devoted to our in-baskets, commensurate with the number of messages we receive. In that case, that is what should be done.
Originally published on Medscape Blogs, April 21, 2022