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Impact of gender-based career obstacles on the working status of women physicians in Japan
Social Science & Medicine 75 (2012) 1612e1616
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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Short report
Impact of gender-based career obstacles on the working status of women physicians in Japan Kyoko Nomura a, *, Kengo Gohchi b a b
Department of Hygiene and Public Health, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan Sharicho National Health Insurance Hospital, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 31 July 2012
Research has shown that women physicians work fewer hours and are more likely to become inactive professionally and to switch to part-time labor, compared with their male counterparts. The published literature suggests that a gender disparity still exists in medicine which may decrease work motivation among women physicians. The authors investigated whether the experience and the perception of gender-based career obstacles among women physicians in Japan are associated with their working status (i.e., full-time vs. part-time). The present cross-sectional study is based on surveys of alumnae from 13 private medical schools in Japan conducted between June 2009 and May 2011. Of those who agreed to participate in this study, 1684 completed a self-administered questionnaire (overall response rate 83%). Experience of gender-based obstacles was considered affirmative if a woman physician had been overlooked for opportunities of professional advancement based on gender. Perception of genderbased obstacles referred to the self-reported degree of difficulty of promotion and opportunities for a position in higher education. Approximately 20% of the study participants responded that they experienced gender-based obstacles while 24% answered that they were not sure. The scores for perception of gender-based career obstacles were statistically higher among part-time workers compared with full-time workers (mean difference ¼ 1.20, 95% CI: 0.39e2.00). Adjusting for age, marital status, the presence of children, workplace, board certification, holding a PhD degree, overall satisfaction of being a physician, and household income, stepwise logistic regression models revealed that physicians with the strongest perception of gender-based career obstacles were more likely to work part-time rather than full-time (OR, 0.59; 95% CI: 0.40e0.88). Although the experience of gender-based obstacles was not associated with working status among women physicians, the results demonstrated that a strong perception of gender-based obstacles was associated with part-time practice rather than fulltime practice. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Full/part-time workers Gender-based career obstacles Women physicians Working status Japan
Introduction The number of women entering the field of medicine is increasing worldwide, and women currently account for approximately half of all medical students enrolled in many Western and developing countries, including countries such as Mexico and Bangladesh (Reichenbach & Brown, 2004). However the increase in the number of women physicians does not guarantee an increase in the physician workforce. Previously research has demonstrated that women physicians work fewer hours, retire earlier, and are more likely to be inactive professionally compared to their male counterparts (Reed & Buddeberg-Fischer, 2001). It is not known
* Corresponding author. Tel.: þ81 3 3964 1211x2730; fax: þ81 3 3964 1058. E-mail address: [email protected] (K. Nomura). 0277-9536/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2012.07.014
why they are still under-represented in a number of disciplines and in the higher echelons of medicine, so more research is required. The latest Japanese Ministry survey (Ministry of Health Labor and Welfare, 2010) estimated the number of women physicians at 55,897, or 18.9% of all physicians. A survey conducted by the Japanese Ministry (Nomura, Yano, & Fukui, 2010) revealed that young female medical residents had less confidence in their clinical competency compared with their male counterparts. Lower confidence levels among women physicians have also been reported in Western countries; despite performing at a level equivalent to their male counterparts, women physicians tend to report less confidence in their academic ability (Bakken, Sheridan, & Carnes, 2003) and their clinical competence (Minter, Gruppen, Napolitano, & Gauger, 2005) compared with male physicians. This difference in confidence levels between men and women physicians has been studied and the literature suggests that females are more
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susceptible to stress (Hojat, Glaser, Xu, Veloski, & Christian, 1999; Toews et al., 1997), pre-existing personal factors (Richman & Flaherty, 1990), and gender discrimination including sexual harassment (Witte, Stratton, & Nora, 2006). Among these factors, we focused particularly on gender disparities in medicine. Previously published literature, including a study conducted in Japan (Sugiura, Arai, Umemiya, & Sugiura, 2000), have reported that gender disparities still appear in the field of medicine: men are more likely than women to achieve the rank of associate professor or higher (Kvaerner, Aasland, & Botten, 1999; Nonnemaker, 2000; Sugiura et al., 2000), to receive higher salaries (Ness et al., 2000), and to have more publications and receive more grants (Carr, Friedman, Moskowitz, & Kazis, 1993). A national study of faculty members at US medical schools (Tesch, Wood, Helwig, & Nattinger, 1995) reported that women were much less likely than men to be promoted in academic medicine; this gender difference persisted even after controlling for work schedule, specialty, and academic productivity, suggesting the existence of a glass ceiling for women physicians. Additionally, two studies (Carr et al., 2000; Carr, Szalacha, Barnett, Caswell, & Inui, 2003) have suggested that gender disparities in medicine may have an adverse psychological effect on working motivation. Carr et al. (2003) reported that perceived disparity in professional advancement leads to lower selfconfidence, making it difficult to achieve one’s full potential in medicine. In an earlier study, Carr et al. (2000) investigated 3332 full-time faculty members at American medical schools, and found that women who reported experiencing negative gender bias in both the academic environment and professional advancement had lower career satisfaction compared with other women. Given that the number of women entering medicine is increasing worldwide, the impact of gender disparities on working patterns among women physicians is largely unstudied. Here, we investigated what proportion of women physicians had experienced gender-based career obstacles or perceived such obstacles, and whether such experiences or perceptions of genderbased career obstacles were associated with their working status (i.e., full-time or part-time). Our research hypothesis was that if a female physician experiences such career obstacles or has a strong perception of such obstacles, she is more likely to work part-time. If an individual feels she has little likelihood of career development, we assume that she would rather work part-time. The Global Gender Gap Report 2011 (World Economic Forum, 2011) ranked female economic participation and opportunity in Japan ranked 100th out of 135 countries, making Japan among the lowest of OECD countries. Thus, the results of this study targeting the female medical profession may provide new insights about how to bring more women into the labor force. Methods Study subjects This cross-sectional study is based on surveys of alumnae from private medical schools in Japan, which were sequentially conducted between 1 June 2009 and 31 May 2011. A total of 9544 women physicians who graduated from 13 private medical schools located in the north-eastern regions of Japan were recruited. Japan has 80 medical schools, 29 of which are private. The private schools are geographically divided into east (n ¼ 18) and west regions (n ¼ 11). This study was initially conducted for a keynote presentation at the 43rd annual meeting of members of private medical school alumni associations. Of the 2029 individuals who agreed to participate in the study, 1684 completed the self-administered questionnaire (response rate: 83%). We excluded any individuals
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aged 60 years or older and accordingly, 1513 became subjects for analyses (mean age: 42 8.7). All participants gave written informed consent. The protocol was approved by the institutional review board at Teikyo University School of Medicine (No. 08-107). Questionnaire The questionnaire collected data about baseline characteristics, working conditions, satisfaction and motivation at work, experience and perception of gender-based career obstacles, and menstruation and pregnancy abnormality. The information collected included factors that determined working status (fulltime/part-time/not working), age, marital status, parenthood, household income (low/middle/high), board certification (obtained/not obtained), Doctor of Medical Science (obtained/not obtained), experience and perception of gender-based career obstacles, general satisfaction with being a physician (satisfied/not satisfied). Experience of gender-based career obstacles was based on a question from a previous American medical faculty survey asking “In your professional career, have you ever been overlooked for opportunities in professional advancement based on gender?” (Carr et al., 2000). To measure perception of gender-based career obstacles, we reviewed previous domestic surveys and relevant literature through a PubMed search using key terms including ‘women physician,’ ‘gender,’ ‘obstacle,’ ‘discrimination,’ ‘career,’ and ‘part/full-time.’ Based on the review, we developed 14 questions, which were each rated on a five-point Likert scale, where 1 ¼ never and 5 ¼ very frequently. These were further analyzed by principal component analysis in our pilot study (Nomura, Sato, Tsurugano, & Yano, 2011). Of the two factors identified via Varimax rotation, ‘gender-based career obstacles’ (nine items, Cronbach’s alpha coefficients ¼ 0.926) was included in this study as an explanatory variable in logistic regression analyses (Table 2). Questions were structured as statements to which respondents indicated their level of agreement on a five-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree.’ Data analyses The association between each variable and working status was assessed using the chi-square test. Student’s t-test was used to investigate differences between the two types of working status with respect to the nine items, as well as the total score of genderbased career obstacles. Finally, logistic regression analyses were used to calculate univariate and adjusted odds ratios (OR) along with 95% confidence intervals (95% CI) for working status (full-time vs. part-time ¼ 0). Age and the perception of gender-based career obstacles were categorized into quartiles. In multivariate analyses, explanatory variables were selected using a stepwise model. In the final model, we investigated whether age, marital status, and children affected the relationship between career obstacles and working status. p-values were calculated using the SAS CATMOD procedure for categorical variables that had more than two levels (e.g., marital status and experience of gender-based career obstacles). Trends in p-values were calculated in quartiles for age and the perception of gender-based obstacles. Otherwise, p-values were calculated based on the Wald test (e.g., children). All analyses were conducted using SAS software Version 9.12 (Cary, NC), and statistical significance was set at p < 0.05. Results Among the 1513 women physicians, 1029 (mean age, 42 8.7 years) were employed in full-time positions, and 425 (28%, mean
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Table 1 Characteristics of women physicians according to working status, n(%).a
Age (means SD, years) Marital status Never married Married Divorced/ widowed Children No Any children aged 0e6 y/o Any children aged 7 or older y/o Board certification Yes No PhD Yes No Experience of gender-based career obstacles Yes Do not know No Perception of gender-based career obstacles 1st quartile (lowest) 2nd quartile 3rd quartile 4th quartile General satisfaction of being a physician Satisfied Middle Not satisfied Household income Low Middle High
Total (n ¼ 1513)
Full-time workers (n ¼ 1029)
Part-time workers (n ¼ 425)
42 9
43 9
42 7
304 (20) 1084 (72) 111 (8)
273 (27) 652 (64) 98 (9)
29 (7) 378 (90) 12 (3)
503 (34) 386 (27)
436 (42) 200 (19)
67 (16) 186 (44)
565 (39)
393 (38)
172 (41)
1090 (72) 423 (28)
744 (72) 285 (28)
308 (73) 117 (27)
542 (38) 877 (62)
380 (39) 588 (61)
144 (37) 251 (63)
p value
0.16 <0.001
<0.001
0.95
0.34
0.02
291 (20) 346 (24) 812 (56)
207 (21) 210 (21) 570 (58)
74 (18) 116 (54) 221 (28) 0.006
324 (23)
248 (25)
68 (17)
348 (24) 401 (28) 357 (25)
232 (24) 259 (27) 236 (24)
101 (25) 125 (31) 111 (27) 0.86
1343 (90) 102 (7) 44 (3)
915 (90) 70 (7) 32 (3)
382 (90) 29 (7) 11 (3)
228 (16) 290 (20) 934 (64)
150 (15) 205 (21) 631 (64)
69 (16) 74 (18) 275 (66)
obstacles were more likely to work full-time compared with those who were classified into the highest quartile (p ¼ 0.006). Although the data are not shown, those who had experienced gender-based career obstacles were more likely to have a strong perception of such obstacles followed by those who responded ‘no’ and those who responded ‘do not know’ (p < 0.0001). Respondents were in general agreement with each genderbased career obstacle condition and rated all items above 3 points, with the exception of appreciation from their boss and mentoring opportunities (Table 2). Part-time workers were more likely to have a stronger perception of the obstacles in 5 of the 9 items. These items were related to the difficulty of promotion to management positions, obtaining salaried positions (both in teaching hospitals and academia), having the opportunity to study abroad, and being perceived as an unwanted member of the clinical department. Total scores were higher among part-time workers compared with full-time workers (mean difference 1.20, 95% CI: 0.39e2.00), indicating that part-time workers were more likely than full-time workers to perceive gender-based career obstacles. Table 3 shows univariate and adjusted odds ratios for working status (Table 3). Stepwise logistic regression model selected age, marital status, the presence of children, and the experience and the perception of gender-based career obstacles as explanatory variables for the working status of women physicians. Multivariate analyses showed that factors associated with working full-time were older age (p ¼ 0.001), single marital status (p < 0.001), no children (p < 0.001), and being in the lowest quartile in terms of perception of gender-based career obstacles (p ¼ 0.02). Individuals with the strongest perception of gender-based career obstacles were more likely to work part-time compared with those with the lowest levels of perception (OR, 0.59, 95% CI: 0.40e0.88). Experience of gender-based career obstacles was not significantly related to working status. No interaction effects appeared for age, marital status, and children between gender-based career obstacles and working status. Discussion
0.39
a The number of respondents for each characteristic may be less than the total due to missing values.
age, 42 7.3 years) were employed part-time. According to the Employment Status Survey 2007 in Japan (Ministry of Internal Affairs and Communications), nearly the same proportion (28%) of females in the labor of medicine and welfare work part-time. Table 1 lists the characteristics of women physicians according to working status (Table 1). Compared with those in part-time positions, individuals in full-time positions were more likely to be single (including ‘never married’ and ‘divorced/widowed’; p < 0.001), and to be childless (p < 0.001). Although the data are not shown, those who were divorced/widowed were more likely to report experiencing and perceiving gender-based career obstacles, followed by those who were married and those who were never married (both p < 0.01). Respondents with children were more likely to report experiencing or perceiving such obstacles (both p < 0.01, data not shown). Approximately 20% of all respondents, regardless of working status, reported experiencing gender-based career obstacles. In fact, more part-time workers responded ‘do not know’ compared with full-time workers (54% vs. 21%; p ¼ 0.02). Women physicians in the lowest quartile in terms of perception of gender-based
The results of this study demonstrated that being married and having children were significantly associated with part-time practice, indicating that domestic responsibilities still act as strong obstacles that may discourage women physicians from working full-time. Furthermore, a strong perception of gender-based obstacles was associated with part-time practice compared with full-time practice, even after adjusting for age, marital status, and number of children. Approximately 20% of our survey participants reported experiencing gender-based career obstacles. Our previous research (Nomura et al., 2011) revealed that of 452 men physicians, only 3% reported experiencing such obstacles. Therefore, women appear to be more likely than men to experience gender-based obstacles in the field of medicine. The direction of association between working status and the perception of obstacles does not contradict our research hypothesis. If women physicians perceive that they have hit a ‘glass ceiling,’ they are more likely to work part-time. However, experience of career obstacles did not follow this trend: respondents who had actually experienced gender-related obstacles were not more likely to work part-time. This unexpected result may be the result of two factors. First, the section of the questionnaire about experiencing obstacles referred to individual opportunities for professional advancement, whereas the section about the perception of obstacles referred to general perceptions of career opportunities compared with men physicians. Thus, these two variables did not measure comparable domains of genderbased career obstacles. Second, because experiencing obstacles is
K. Nomura, K. Gohchi / Social Science & Medicine 75 (2012) 1612e1616 Table 2 Perception of gender-based career obstacles according to working status.a Perception of gender-based career obstacles (Cronbach alpha coefficient ¼ 0.89)
Full-time Part-time Mean difference (n ¼ 1029) (n ¼ 425)
Women physicians are less likely to be: 1) Promoted to a management 3.48 position in medicine. 2) Promoted to board member 3.27 of a medical society. 3) Employed in a salaried position 3.25 in a teaching hospital. 4) Employed in a salaried position 3.14 in academic medicine. 5) Promoted in academic 3.30 medicine. 6) Obtain an opportunity to study 3.19 abroad. 7) Welcomed as a member of 3.40 a clinical department, compared with men physicians. 8) Receive appreciation for work 2.65 performance from employer, compared with men physicians. 9) Have mentoring opportunities 2.53 for research. Total score (max 45 points) 28.2
3.62
0.14 (0.02e0.26)
3.37
0.11 (0.01e0.23)
3.44
0.20 (0.08e0.31)
3.28
0.14 (0.01e0.26)
3.39
0.09 (0.04e0.21)
3.33
0.13 (0.01e0.26)
3.56
0.17 (0.03e0.30)
2.73
0.08 (0.04e0.20)
2.58
0.05 (0.07e0.17)
29.4
1.20 (0.39e2.00)
a
Each question was rated on a five-point Likert scale, where 1 ¼ never and 5 ¼ very frequently.
likely to occur in the area of professional advancement, younger physicians might be less likely to have encountered such experiences. Our additional analyses revealed that more than one-third of respondents who reported experiencing obstacles were in the oldest age group, whereas more than half of the respondents who answered ‘never experienced’ or ‘do not know’ were in the youngest or second-youngest age group. Furthermore, the unemployment rate in the oldest age group was the lowest among the age strata (data not shown). This may have instilled ‘pioneer pride’ in older respondents, which they needed to survive in the era when women physicians were a minority. Thus, our research hypothesis may have made it difficult to explore the preponderance of respondents in the older age group among those who reported experiencing obstacles. Our study had several limitations that need to be considered. First, the sensitive nature of the topics explored may have led to a response bias. In this regard, we compared our results with the demographic data of the 2010 Survey of Physicians, Dentists, and Pharmacists (Ministry of Health Labor and Welfare, 2010) to assure generalizability. We found similar proportions of participants who were out of work: 1.2% in the governmental survey and 2% in the present study. Second, our analyses excluded women physicians aged 60 years and older, which might have affected our results. Before the Equal Employment Opportunity Law took effect in Japan in 1986, there were very few women physicians and they were more likely to encounter gender-based obstacles. By excluding older women physicians, we might have underestimated the effect of gender-based obstacles on working patterns. Third, causal relationships could not be identified due to the study’s cross-sectional design. Likewise, although we observed an association between perception of gender-based career obstacles and working status, it is not clear whether having a strong perception indicates that the respondent encountered a glass ceiling. Fourth, there might be unknown factors related to the professional environment, which determine working patterns among women physicians. Future studies will be needed to elucidate these issues. Finally, we found
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that most part-time physicians were satisfied with their career choice, so it might be difficult to encourage these physicians to move into the full-time workforce. Related studies conducted in Western countries have reported diverse individual preferences in career paths. Buddeberg-Fishers et al. (2010) found that women physicians are less career-oriented and aspire more to a balance between work and personal life; Heiligers & Hingstman (2000) reported that home domain characteristics did not predict a parttime preference. Although part-time physicians are generally considered to be professionally inactive, part-time practice is very common and well-functioning in some countries, such as the Netherlands: part-time physicians are more likely to have a higher salary and to be a non-hospital-based specialist, with 39% of all general practitioners (McMurray et al., 2005). This finding indicates that part-time practice does not necessarily limit promotion and career opportunities, and can be successfully incorporated into the leadership structure of academic medicine. Therefore, Japan may need to establish a new infrastructure to allow physicians to reach their potential regardless of their working status. Gjerberg (2002) previously reported that family responsibilities differ between men and women physicians and that the transition from full-time to part-time work is primarily an accommodating strategy to family responsibilities among women. Structural inflexibilities, including heavy work loads with duties and ‘nights on call’ make it difficult for women to combine family responsibilities and work (Gjerberg, 2003). Very few studies have focused on structural inflexibilities in Japan, but a study (Li, Yang, & Cho, 2006) involving Chinese physicians reported that job control (measured by the Karasek job strain model) was significantly higher among men compared with women. This indicates that men physicians have a greater degree of decision-making ability about how to perform work. Gender disparities still exist in medicine, and perception of gender-based obstacles may have adverse psychological effects on the working patterns of women physicians. To fulfill the potential of women physicians, any gender disparities including salary, job
Table 3 Univariate and adjusted odds ratios (95% confidence intervals) for working status (full-time vs. part-time workers ¼ 0).
Age 50e59 43e49 35e42 23e34 Marital status Never married Divorced/widowed Married Children No Any children aged 7 or older y/o Any children aged 0e6 y/o Experience of gender-based career obstacles Yes Do not know No Perception of gender-based career obstacles 4th quartile 3rd quartile 2nd quartile 1st quartile (lowest)
Unadjusted OR
Adjusted ORa
1.24 (0.86e1.78) 0.61 (0.44e0.86) 0.50 (0.36e0.69) 1.00
1.15 (0.70e1.90) 0.68 (0.44e1.06) 0.60 (0.41e0.87) 1.00
5.46 (3.65e8.17) 4.74 (2.57e8.74) 1.00
2.67 (1.60e4.46) 3.77 (1.96e7.25) 1.00
6.05 (4.37e8.38) 2.13 (1.63e2.78)
3.08 (2.03e4.67) 1.55 (1.06e2.27)
1.00
1.00 e
1.09 (0.80e1.48) 0.70 (0.53e0.92) 1.00
1.23 (0.85e1.76) 0.76 (0.56e1.03) 1.00
0.58 (0.41e0.83) 0.57 (0.40e0.80) 0.63 (0.44e0.90) 1.00
0.59 (0.40e0.88) 0.59 (0.40e0.85) 0.65 (0.44e0.95) 1.00
a Adjusting for age, marital status, children, worksite, and experience and perception of gender-based career obstacles.
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opportunities, and promotions need to be rectified while simultaneously addressing gender role burden and structural inflexibilities. Early education about the gender gap in medical schools can help young women physicians prepare in advance for the challenge, which will ideally increase their clinical confidence and motivation to work. Conflict of interest None of the authors have any financial conflicts of interest. Acknowledgments This study was supported by the Ministry of Education, Science, Sports and Culture, Grand in. Scientific Research (C), No. 21510290 and the Pfizer Health Research Foundation. We would like to thank the alumni board members of 13 medical schools for their collaboration in conducting the sequential surveys, the staff in the Department of Hygiene and Public Health, Teikyo University School of Medicine for their feedback and advice in developing the questionnaire, Miss Megumi Yukawa for her assistance in collecting data, and Mr. Yu Nomura for his assistance in developing the dataset. References Bakken, L. L., Sheridan, J., & Carnes, M. (2003). Gender differences among physicianscientists in self-assessed abilities to perform clinical research. Academic Medicine, 78, 1281e1286. Buddeberg-Fischer, B., Stamm, M., Buddeberg, C., Bauer, G., Häemmig, O., Knecht, M., et al. (2010). The impact of gender and parenthood on physicians’ careers e professional and personal situation seven years after graduation. BMC Health Services Research, 10, 40. Carr, P. L., Ash, A. S., Friedman, R. H., Szalacha, L., Barnett, R. C., Palepu, A., et al. (2000). Faculty perceptions of gender discrimination and sexual harassment in academic medicine. Annals of Internal Medicine, 132, 889e896. Carr, P. L., Friedman, R. H., Moskowitz, M. A., & Kazis, L. E. (1993). Comparing the status of women and men in academic medicine. Annals of Internal Medicine, 119, 908e913. Carr, P. L., Szalacha, L., Barnett, R., Caswell, C., & Inui, T. (2003). A “ton of feathers”: gender discrimination in academic medical careers and how to manage it. Journal of Women’s Health (Larchmt), 12, 1009e1018. Gjerberg, E. (2002). Gender similarities in doctors’ preferenceseand gender differences in final specialisation. Social Science & Medicine, 54, 591e605. Gjerberg, E. (2003). Women doctors in Norway: the challenging balance between career and family life. Social Science & Medicine, 57, 1327e1341. Heiligers, P. J., & Hingstman, L. (2000). Career preferences and the work-family balance in medicine: gender difference among medical specialists. Social Science & Medicine, 50, 1235e1246.
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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Short report
Impact of gender-based career obstacles on the working status of women physicians in Japan Kyoko Nomura a, *, Kengo Gohchi b a b
Department of Hygiene and Public Health, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan Sharicho National Health Insurance Hospital, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 31 July 2012
Research has shown that women physicians work fewer hours and are more likely to become inactive professionally and to switch to part-time labor, compared with their male counterparts. The published literature suggests that a gender disparity still exists in medicine which may decrease work motivation among women physicians. The authors investigated whether the experience and the perception of gender-based career obstacles among women physicians in Japan are associated with their working status (i.e., full-time vs. part-time). The present cross-sectional study is based on surveys of alumnae from 13 private medical schools in Japan conducted between June 2009 and May 2011. Of those who agreed to participate in this study, 1684 completed a self-administered questionnaire (overall response rate 83%). Experience of gender-based obstacles was considered affirmative if a woman physician had been overlooked for opportunities of professional advancement based on gender. Perception of genderbased obstacles referred to the self-reported degree of difficulty of promotion and opportunities for a position in higher education. Approximately 20% of the study participants responded that they experienced gender-based obstacles while 24% answered that they were not sure. The scores for perception of gender-based career obstacles were statistically higher among part-time workers compared with full-time workers (mean difference ¼ 1.20, 95% CI: 0.39e2.00). Adjusting for age, marital status, the presence of children, workplace, board certification, holding a PhD degree, overall satisfaction of being a physician, and household income, stepwise logistic regression models revealed that physicians with the strongest perception of gender-based career obstacles were more likely to work part-time rather than full-time (OR, 0.59; 95% CI: 0.40e0.88). Although the experience of gender-based obstacles was not associated with working status among women physicians, the results demonstrated that a strong perception of gender-based obstacles was associated with part-time practice rather than fulltime practice. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Full/part-time workers Gender-based career obstacles Women physicians Working status Japan
Introduction The number of women entering the field of medicine is increasing worldwide, and women currently account for approximately half of all medical students enrolled in many Western and developing countries, including countries such as Mexico and Bangladesh (Reichenbach & Brown, 2004). However the increase in the number of women physicians does not guarantee an increase in the physician workforce. Previously research has demonstrated that women physicians work fewer hours, retire earlier, and are more likely to be inactive professionally compared to their male counterparts (Reed & Buddeberg-Fischer, 2001). It is not known
* Corresponding author. Tel.: þ81 3 3964 1211x2730; fax: þ81 3 3964 1058. E-mail address: [email protected] (K. Nomura). 0277-9536/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2012.07.014
why they are still under-represented in a number of disciplines and in the higher echelons of medicine, so more research is required. The latest Japanese Ministry survey (Ministry of Health Labor and Welfare, 2010) estimated the number of women physicians at 55,897, or 18.9% of all physicians. A survey conducted by the Japanese Ministry (Nomura, Yano, & Fukui, 2010) revealed that young female medical residents had less confidence in their clinical competency compared with their male counterparts. Lower confidence levels among women physicians have also been reported in Western countries; despite performing at a level equivalent to their male counterparts, women physicians tend to report less confidence in their academic ability (Bakken, Sheridan, & Carnes, 2003) and their clinical competence (Minter, Gruppen, Napolitano, & Gauger, 2005) compared with male physicians. This difference in confidence levels between men and women physicians has been studied and the literature suggests that females are more
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susceptible to stress (Hojat, Glaser, Xu, Veloski, & Christian, 1999; Toews et al., 1997), pre-existing personal factors (Richman & Flaherty, 1990), and gender discrimination including sexual harassment (Witte, Stratton, & Nora, 2006). Among these factors, we focused particularly on gender disparities in medicine. Previously published literature, including a study conducted in Japan (Sugiura, Arai, Umemiya, & Sugiura, 2000), have reported that gender disparities still appear in the field of medicine: men are more likely than women to achieve the rank of associate professor or higher (Kvaerner, Aasland, & Botten, 1999; Nonnemaker, 2000; Sugiura et al., 2000), to receive higher salaries (Ness et al., 2000), and to have more publications and receive more grants (Carr, Friedman, Moskowitz, & Kazis, 1993). A national study of faculty members at US medical schools (Tesch, Wood, Helwig, & Nattinger, 1995) reported that women were much less likely than men to be promoted in academic medicine; this gender difference persisted even after controlling for work schedule, specialty, and academic productivity, suggesting the existence of a glass ceiling for women physicians. Additionally, two studies (Carr et al., 2000; Carr, Szalacha, Barnett, Caswell, & Inui, 2003) have suggested that gender disparities in medicine may have an adverse psychological effect on working motivation. Carr et al. (2003) reported that perceived disparity in professional advancement leads to lower selfconfidence, making it difficult to achieve one’s full potential in medicine. In an earlier study, Carr et al. (2000) investigated 3332 full-time faculty members at American medical schools, and found that women who reported experiencing negative gender bias in both the academic environment and professional advancement had lower career satisfaction compared with other women. Given that the number of women entering medicine is increasing worldwide, the impact of gender disparities on working patterns among women physicians is largely unstudied. Here, we investigated what proportion of women physicians had experienced gender-based career obstacles or perceived such obstacles, and whether such experiences or perceptions of genderbased career obstacles were associated with their working status (i.e., full-time or part-time). Our research hypothesis was that if a female physician experiences such career obstacles or has a strong perception of such obstacles, she is more likely to work part-time. If an individual feels she has little likelihood of career development, we assume that she would rather work part-time. The Global Gender Gap Report 2011 (World Economic Forum, 2011) ranked female economic participation and opportunity in Japan ranked 100th out of 135 countries, making Japan among the lowest of OECD countries. Thus, the results of this study targeting the female medical profession may provide new insights about how to bring more women into the labor force. Methods Study subjects This cross-sectional study is based on surveys of alumnae from private medical schools in Japan, which were sequentially conducted between 1 June 2009 and 31 May 2011. A total of 9544 women physicians who graduated from 13 private medical schools located in the north-eastern regions of Japan were recruited. Japan has 80 medical schools, 29 of which are private. The private schools are geographically divided into east (n ¼ 18) and west regions (n ¼ 11). This study was initially conducted for a keynote presentation at the 43rd annual meeting of members of private medical school alumni associations. Of the 2029 individuals who agreed to participate in the study, 1684 completed the self-administered questionnaire (response rate: 83%). We excluded any individuals
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aged 60 years or older and accordingly, 1513 became subjects for analyses (mean age: 42 8.7). All participants gave written informed consent. The protocol was approved by the institutional review board at Teikyo University School of Medicine (No. 08-107). Questionnaire The questionnaire collected data about baseline characteristics, working conditions, satisfaction and motivation at work, experience and perception of gender-based career obstacles, and menstruation and pregnancy abnormality. The information collected included factors that determined working status (fulltime/part-time/not working), age, marital status, parenthood, household income (low/middle/high), board certification (obtained/not obtained), Doctor of Medical Science (obtained/not obtained), experience and perception of gender-based career obstacles, general satisfaction with being a physician (satisfied/not satisfied). Experience of gender-based career obstacles was based on a question from a previous American medical faculty survey asking “In your professional career, have you ever been overlooked for opportunities in professional advancement based on gender?” (Carr et al., 2000). To measure perception of gender-based career obstacles, we reviewed previous domestic surveys and relevant literature through a PubMed search using key terms including ‘women physician,’ ‘gender,’ ‘obstacle,’ ‘discrimination,’ ‘career,’ and ‘part/full-time.’ Based on the review, we developed 14 questions, which were each rated on a five-point Likert scale, where 1 ¼ never and 5 ¼ very frequently. These were further analyzed by principal component analysis in our pilot study (Nomura, Sato, Tsurugano, & Yano, 2011). Of the two factors identified via Varimax rotation, ‘gender-based career obstacles’ (nine items, Cronbach’s alpha coefficients ¼ 0.926) was included in this study as an explanatory variable in logistic regression analyses (Table 2). Questions were structured as statements to which respondents indicated their level of agreement on a five-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree.’ Data analyses The association between each variable and working status was assessed using the chi-square test. Student’s t-test was used to investigate differences between the two types of working status with respect to the nine items, as well as the total score of genderbased career obstacles. Finally, logistic regression analyses were used to calculate univariate and adjusted odds ratios (OR) along with 95% confidence intervals (95% CI) for working status (full-time vs. part-time ¼ 0). Age and the perception of gender-based career obstacles were categorized into quartiles. In multivariate analyses, explanatory variables were selected using a stepwise model. In the final model, we investigated whether age, marital status, and children affected the relationship between career obstacles and working status. p-values were calculated using the SAS CATMOD procedure for categorical variables that had more than two levels (e.g., marital status and experience of gender-based career obstacles). Trends in p-values were calculated in quartiles for age and the perception of gender-based obstacles. Otherwise, p-values were calculated based on the Wald test (e.g., children). All analyses were conducted using SAS software Version 9.12 (Cary, NC), and statistical significance was set at p < 0.05. Results Among the 1513 women physicians, 1029 (mean age, 42 8.7 years) were employed in full-time positions, and 425 (28%, mean
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Table 1 Characteristics of women physicians according to working status, n(%).a
Age (means SD, years) Marital status Never married Married Divorced/ widowed Children No Any children aged 0e6 y/o Any children aged 7 or older y/o Board certification Yes No PhD Yes No Experience of gender-based career obstacles Yes Do not know No Perception of gender-based career obstacles 1st quartile (lowest) 2nd quartile 3rd quartile 4th quartile General satisfaction of being a physician Satisfied Middle Not satisfied Household income Low Middle High
Total (n ¼ 1513)
Full-time workers (n ¼ 1029)
Part-time workers (n ¼ 425)
42 9
43 9
42 7
304 (20) 1084 (72) 111 (8)
273 (27) 652 (64) 98 (9)
29 (7) 378 (90) 12 (3)
503 (34) 386 (27)
436 (42) 200 (19)
67 (16) 186 (44)
565 (39)
393 (38)
172 (41)
1090 (72) 423 (28)
744 (72) 285 (28)
308 (73) 117 (27)
542 (38) 877 (62)
380 (39) 588 (61)
144 (37) 251 (63)
p value
0.16 <0.001
<0.001
0.95
0.34
0.02
291 (20) 346 (24) 812 (56)
207 (21) 210 (21) 570 (58)
74 (18) 116 (54) 221 (28) 0.006
324 (23)
248 (25)
68 (17)
348 (24) 401 (28) 357 (25)
232 (24) 259 (27) 236 (24)
101 (25) 125 (31) 111 (27) 0.86
1343 (90) 102 (7) 44 (3)
915 (90) 70 (7) 32 (3)
382 (90) 29 (7) 11 (3)
228 (16) 290 (20) 934 (64)
150 (15) 205 (21) 631 (64)
69 (16) 74 (18) 275 (66)
obstacles were more likely to work full-time compared with those who were classified into the highest quartile (p ¼ 0.006). Although the data are not shown, those who had experienced gender-based career obstacles were more likely to have a strong perception of such obstacles followed by those who responded ‘no’ and those who responded ‘do not know’ (p < 0.0001). Respondents were in general agreement with each genderbased career obstacle condition and rated all items above 3 points, with the exception of appreciation from their boss and mentoring opportunities (Table 2). Part-time workers were more likely to have a stronger perception of the obstacles in 5 of the 9 items. These items were related to the difficulty of promotion to management positions, obtaining salaried positions (both in teaching hospitals and academia), having the opportunity to study abroad, and being perceived as an unwanted member of the clinical department. Total scores were higher among part-time workers compared with full-time workers (mean difference 1.20, 95% CI: 0.39e2.00), indicating that part-time workers were more likely than full-time workers to perceive gender-based career obstacles. Table 3 shows univariate and adjusted odds ratios for working status (Table 3). Stepwise logistic regression model selected age, marital status, the presence of children, and the experience and the perception of gender-based career obstacles as explanatory variables for the working status of women physicians. Multivariate analyses showed that factors associated with working full-time were older age (p ¼ 0.001), single marital status (p < 0.001), no children (p < 0.001), and being in the lowest quartile in terms of perception of gender-based career obstacles (p ¼ 0.02). Individuals with the strongest perception of gender-based career obstacles were more likely to work part-time compared with those with the lowest levels of perception (OR, 0.59, 95% CI: 0.40e0.88). Experience of gender-based career obstacles was not significantly related to working status. No interaction effects appeared for age, marital status, and children between gender-based career obstacles and working status. Discussion
0.39
a The number of respondents for each characteristic may be less than the total due to missing values.
age, 42 7.3 years) were employed part-time. According to the Employment Status Survey 2007 in Japan (Ministry of Internal Affairs and Communications), nearly the same proportion (28%) of females in the labor of medicine and welfare work part-time. Table 1 lists the characteristics of women physicians according to working status (Table 1). Compared with those in part-time positions, individuals in full-time positions were more likely to be single (including ‘never married’ and ‘divorced/widowed’; p < 0.001), and to be childless (p < 0.001). Although the data are not shown, those who were divorced/widowed were more likely to report experiencing and perceiving gender-based career obstacles, followed by those who were married and those who were never married (both p < 0.01). Respondents with children were more likely to report experiencing or perceiving such obstacles (both p < 0.01, data not shown). Approximately 20% of all respondents, regardless of working status, reported experiencing gender-based career obstacles. In fact, more part-time workers responded ‘do not know’ compared with full-time workers (54% vs. 21%; p ¼ 0.02). Women physicians in the lowest quartile in terms of perception of gender-based
The results of this study demonstrated that being married and having children were significantly associated with part-time practice, indicating that domestic responsibilities still act as strong obstacles that may discourage women physicians from working full-time. Furthermore, a strong perception of gender-based obstacles was associated with part-time practice compared with full-time practice, even after adjusting for age, marital status, and number of children. Approximately 20% of our survey participants reported experiencing gender-based career obstacles. Our previous research (Nomura et al., 2011) revealed that of 452 men physicians, only 3% reported experiencing such obstacles. Therefore, women appear to be more likely than men to experience gender-based obstacles in the field of medicine. The direction of association between working status and the perception of obstacles does not contradict our research hypothesis. If women physicians perceive that they have hit a ‘glass ceiling,’ they are more likely to work part-time. However, experience of career obstacles did not follow this trend: respondents who had actually experienced gender-related obstacles were not more likely to work part-time. This unexpected result may be the result of two factors. First, the section of the questionnaire about experiencing obstacles referred to individual opportunities for professional advancement, whereas the section about the perception of obstacles referred to general perceptions of career opportunities compared with men physicians. Thus, these two variables did not measure comparable domains of genderbased career obstacles. Second, because experiencing obstacles is
K. Nomura, K. Gohchi / Social Science & Medicine 75 (2012) 1612e1616 Table 2 Perception of gender-based career obstacles according to working status.a Perception of gender-based career obstacles (Cronbach alpha coefficient ¼ 0.89)
Full-time Part-time Mean difference (n ¼ 1029) (n ¼ 425)
Women physicians are less likely to be: 1) Promoted to a management 3.48 position in medicine. 2) Promoted to board member 3.27 of a medical society. 3) Employed in a salaried position 3.25 in a teaching hospital. 4) Employed in a salaried position 3.14 in academic medicine. 5) Promoted in academic 3.30 medicine. 6) Obtain an opportunity to study 3.19 abroad. 7) Welcomed as a member of 3.40 a clinical department, compared with men physicians. 8) Receive appreciation for work 2.65 performance from employer, compared with men physicians. 9) Have mentoring opportunities 2.53 for research. Total score (max 45 points) 28.2
3.62
0.14 (0.02e0.26)
3.37
0.11 (0.01e0.23)
3.44
0.20 (0.08e0.31)
3.28
0.14 (0.01e0.26)
3.39
0.09 (0.04e0.21)
3.33
0.13 (0.01e0.26)
3.56
0.17 (0.03e0.30)
2.73
0.08 (0.04e0.20)
2.58
0.05 (0.07e0.17)
29.4
1.20 (0.39e2.00)
a
Each question was rated on a five-point Likert scale, where 1 ¼ never and 5 ¼ very frequently.
likely to occur in the area of professional advancement, younger physicians might be less likely to have encountered such experiences. Our additional analyses revealed that more than one-third of respondents who reported experiencing obstacles were in the oldest age group, whereas more than half of the respondents who answered ‘never experienced’ or ‘do not know’ were in the youngest or second-youngest age group. Furthermore, the unemployment rate in the oldest age group was the lowest among the age strata (data not shown). This may have instilled ‘pioneer pride’ in older respondents, which they needed to survive in the era when women physicians were a minority. Thus, our research hypothesis may have made it difficult to explore the preponderance of respondents in the older age group among those who reported experiencing obstacles. Our study had several limitations that need to be considered. First, the sensitive nature of the topics explored may have led to a response bias. In this regard, we compared our results with the demographic data of the 2010 Survey of Physicians, Dentists, and Pharmacists (Ministry of Health Labor and Welfare, 2010) to assure generalizability. We found similar proportions of participants who were out of work: 1.2% in the governmental survey and 2% in the present study. Second, our analyses excluded women physicians aged 60 years and older, which might have affected our results. Before the Equal Employment Opportunity Law took effect in Japan in 1986, there were very few women physicians and they were more likely to encounter gender-based obstacles. By excluding older women physicians, we might have underestimated the effect of gender-based obstacles on working patterns. Third, causal relationships could not be identified due to the study’s cross-sectional design. Likewise, although we observed an association between perception of gender-based career obstacles and working status, it is not clear whether having a strong perception indicates that the respondent encountered a glass ceiling. Fourth, there might be unknown factors related to the professional environment, which determine working patterns among women physicians. Future studies will be needed to elucidate these issues. Finally, we found
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that most part-time physicians were satisfied with their career choice, so it might be difficult to encourage these physicians to move into the full-time workforce. Related studies conducted in Western countries have reported diverse individual preferences in career paths. Buddeberg-Fishers et al. (2010) found that women physicians are less career-oriented and aspire more to a balance between work and personal life; Heiligers & Hingstman (2000) reported that home domain characteristics did not predict a parttime preference. Although part-time physicians are generally considered to be professionally inactive, part-time practice is very common and well-functioning in some countries, such as the Netherlands: part-time physicians are more likely to have a higher salary and to be a non-hospital-based specialist, with 39% of all general practitioners (McMurray et al., 2005). This finding indicates that part-time practice does not necessarily limit promotion and career opportunities, and can be successfully incorporated into the leadership structure of academic medicine. Therefore, Japan may need to establish a new infrastructure to allow physicians to reach their potential regardless of their working status. Gjerberg (2002) previously reported that family responsibilities differ between men and women physicians and that the transition from full-time to part-time work is primarily an accommodating strategy to family responsibilities among women. Structural inflexibilities, including heavy work loads with duties and ‘nights on call’ make it difficult for women to combine family responsibilities and work (Gjerberg, 2003). Very few studies have focused on structural inflexibilities in Japan, but a study (Li, Yang, & Cho, 2006) involving Chinese physicians reported that job control (measured by the Karasek job strain model) was significantly higher among men compared with women. This indicates that men physicians have a greater degree of decision-making ability about how to perform work. Gender disparities still exist in medicine, and perception of gender-based obstacles may have adverse psychological effects on the working patterns of women physicians. To fulfill the potential of women physicians, any gender disparities including salary, job
Table 3 Univariate and adjusted odds ratios (95% confidence intervals) for working status (full-time vs. part-time workers ¼ 0).
Age 50e59 43e49 35e42 23e34 Marital status Never married Divorced/widowed Married Children No Any children aged 7 or older y/o Any children aged 0e6 y/o Experience of gender-based career obstacles Yes Do not know No Perception of gender-based career obstacles 4th quartile 3rd quartile 2nd quartile 1st quartile (lowest)
Unadjusted OR
Adjusted ORa
1.24 (0.86e1.78) 0.61 (0.44e0.86) 0.50 (0.36e0.69) 1.00
1.15 (0.70e1.90) 0.68 (0.44e1.06) 0.60 (0.41e0.87) 1.00
5.46 (3.65e8.17) 4.74 (2.57e8.74) 1.00
2.67 (1.60e4.46) 3.77 (1.96e7.25) 1.00
6.05 (4.37e8.38) 2.13 (1.63e2.78)
3.08 (2.03e4.67) 1.55 (1.06e2.27)
1.00
1.00 e
1.09 (0.80e1.48) 0.70 (0.53e0.92) 1.00
1.23 (0.85e1.76) 0.76 (0.56e1.03) 1.00
0.58 (0.41e0.83) 0.57 (0.40e0.80) 0.63 (0.44e0.90) 1.00
0.59 (0.40e0.88) 0.59 (0.40e0.85) 0.65 (0.44e0.95) 1.00
a Adjusting for age, marital status, children, worksite, and experience and perception of gender-based career obstacles.
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opportunities, and promotions need to be rectified while simultaneously addressing gender role burden and structural inflexibilities. Early education about the gender gap in medical schools can help young women physicians prepare in advance for the challenge, which will ideally increase their clinical confidence and motivation to work. Conflict of interest None of the authors have any financial conflicts of interest. Acknowledgments This study was supported by the Ministry of Education, Science, Sports and Culture, Grand in. Scientific Research (C), No. 21510290 and the Pfizer Health Research Foundation. We would like to thank the alumni board members of 13 medical schools for their collaboration in conducting the sequential surveys, the staff in the Department of Hygiene and Public Health, Teikyo University School of Medicine for their feedback and advice in developing the questionnaire, Miss Megumi Yukawa for her assistance in collecting data, and Mr. Yu Nomura for his assistance in developing the dataset. References Bakken, L. L., Sheridan, J., & Carnes, M. (2003). Gender differences among physicianscientists in self-assessed abilities to perform clinical research. Academic Medicine, 78, 1281e1286. Buddeberg-Fischer, B., Stamm, M., Buddeberg, C., Bauer, G., Häemmig, O., Knecht, M., et al. (2010). The impact of gender and parenthood on physicians’ careers e professional and personal situation seven years after graduation. BMC Health Services Research, 10, 40. Carr, P. L., Ash, A. S., Friedman, R. H., Szalacha, L., Barnett, R. C., Palepu, A., et al. (2000). Faculty perceptions of gender discrimination and sexual harassment in academic medicine. Annals of Internal Medicine, 132, 889e896. Carr, P. L., Friedman, R. H., Moskowitz, M. A., & Kazis, L. E. (1993). Comparing the status of women and men in academic medicine. Annals of Internal Medicine, 119, 908e913. Carr, P. L., Szalacha, L., Barnett, R., Caswell, C., & Inui, T. (2003). A “ton of feathers”: gender discrimination in academic medical careers and how to manage it. Journal of Women’s Health (Larchmt), 12, 1009e1018. Gjerberg, E. (2002). Gender similarities in doctors’ preferenceseand gender differences in final specialisation. Social Science & Medicine, 54, 591e605. Gjerberg, E. (2003). Women doctors in Norway: the challenging balance between career and family life. Social Science & Medicine, 57, 1327e1341. Heiligers, P. J., & Hingstman, L. (2000). Career preferences and the work-family balance in medicine: gender difference among medical specialists. Social Science & Medicine, 50, 1235e1246.
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