Nomura, Kyoko MD, MPH, PhD; Yano, Eiji MD, MPH, DMSc; Fukui, Tsuguya MD, MPH, PhD
Today in Japan, women constitute approximately 30% of all medical students (except at Tokyo Women's Medical College, which has only women students) and nearly half of the young physicians in some specialties such as obstetrics, gynecology, and pediatrics. In spite of the increasing number of women in medicine, one study reported a marked decline in workforce participation, especially among women physicians in their late 20s and 30s.1 Not limited to Japan, low participation rates among women physicians have also been reported in Western countries.2 Women are more likely to work fewer hours and to be in part-time practice.2–4 Thus, it is anticipated that the increase in number of women physicians may lead to a decrease in the full-time workforce.
Because women physicians may also have the social roles of housewives and mothers, they may devote more of their time to family responsibilities rather than to work. However, their low participation rates may not simply be accounted for by family constraints. On the contrary, Heiliger and Hingstman5 reported that home domain characteristics did not predict a part-time preference in women physicians. McMurray et al6 reported that the presence of children was associated with less work-related stress for women under the age of 45, and Frank et al7 reported that physicians with children were more interested in again working as physicians. These studies suggest that multiple roles may bring benefits that mitigate work strain.
Nevertheless, many reports agree that women physicians work fewer hours than do their male colleagues.2–4 Several studies reported that women physicians were more likely to receive fewer rewards for their work, both in academic advancement and monetary compensation.3,4,8–12 Such gender inequity favoring men may undermine women's self-esteem and result in difficulty in developing their potential competencies. For example, McMurray et al6 reported that women physicians were more likely to have a lower level of work control in hospital practice than men, and this was significantly associated with burnout in women. Frank et al7 also reported that women with work stress, lack of work control, and experience of harassment had a lower likelihood of being satisfied with their careers and of wishing to become physicians again even if given the choice.
The purposes of our study were (1) to determine whether a difference exists between men and women in levels of confidence about clinical competency among second-year residents in Japan and (2) to investigate the effect of gender on confidence levels after adjusting for basic resident characteristics, satisfaction, future career, and perspectives on life and work. The workplace in Japanese medicine is a male-dominated society, and there are still very few women professors in university settings or hospital director positions. Studying gender differences in self-perceptions of clinical confidence may reflect the impact of a male-oriented society on career development among women physicians. The results of our study may have important implications for potential involvement and retention of women physicians in the workforce.
Japanese postgraduate medical education
In Japan, according to the Japanese Medical Practitioners Law, medical residents are not allowed to perform medical procedures independently until they have completed a six-year undergraduate program at a medical school and passed the National Board Examination to obtain a doctor's license. Therefore, the new Japanese postgraduate medical education (PGME) was designed to provide various clinical opportunities that allow residents to obtain primary care skills and knowledge.13 In this regard, the Japanese PGME may be equivalent to the clinical rotation program for third- and fourth-year medical students in the United States.
During fiscal years 2005 through 2007, the Ministry of Health, Labor, and Welfare (the Ministry) organized a scientific study committee to evaluate the new, two-year, variable rotation PGME program. In each of the three years, the committee conducted surveys of residents and hospitals; scientific papers based on the surveys in 2006 and 2005 have already been published.14,15
The data from our study were obtained from the second-year survey conducted in March 2007. We sent the questionnaire to the 813 teaching hospitals accredited by the Ministry that year, asking the program directors to recruit one out of five of the 7,495 second-year residents (i.e., every fifth resident from the top of the roster in sequence). When fewer than five residents were listed on a roster, the first resident on the roster was asked to answer the questionnaire. As a result, 1,880 residents became our target sample. Because the academic calendar in Japan starts on April 1 and ends on March 31 of the following year, our study participants were about to complete the two-year PGME program. The Ministry gave ethical approval for the study, and all participants provided informed consent.
The questionnaire consisted of 16 sections with a total of 23 questions. Sections included basic characteristics, hospital information, rotation schedule, on-call information, number of patients experienced, satisfaction, consultation, course after PGME, specialties, intention to obtain DMSc and specialist qualification, areas of interest, whether one is work- or life-oriented, the most important thing in life, clinical confidence, and clinical experience (including basic skills and knowledge, and medical documents). Of these, the variables we investigated in this study were basic characteristics including age, gender, and types of hospitals (i.e., university or community hospital); clinical experience; clinical competency; residents' satisfaction with residency conditions (“satisfied”/“not satisfied”/“do not know”); attributes related to satisfaction; future career, including areas of interest and an intention to obtain a DMSc and specialist qualification; and perspective on life and work (i.e., “work- or life-oriented” and “the most important thing in life”).
Residents were queried regarding the number of cases they had encountered for 82 conditions, including the most common disorders and symptoms such as headache, infection, edema, difficulty breathing, hypertension, cardiopulmonary arrest, abdominal pain, liver and kidney disease, genital organ disease, trauma, burn, and suicide. Each item had four choices (1 = none, 2 = 1–5 cases, 3 = 6–10 cases, 4 = 11 or more cases), and the average of the 82 items was defined as the “clinical experience.”
The clinical competency confidence scale included 99 items and measured residents' confidence levels based on a four-point Likert scale (i.e., 1 = “not confident at all/cannot perform at all,” 2 = “not very confident/cannot perform independently,” 3 = “somewhat confident/may be able to perform independently,” and 4 = “very confident/able to perform independently”).
Residents were asked to rate satisfaction with residency conditions (options provided). Attributes included educational opportunities (i.e., excellence in teaching, clinical opportunities, teaching resources, and consultation system) and working conditions (i.e., workplace atmosphere, distasteful work, salary, cooperation among departments, and coordination with paramedical staff). Questions regarding areas of interested allowed the following options: “clinical practice,” “education,” “research,” “administration,” “others,” and “do not know.” Residents were asked whether they were work- or life-oriented using the question, “Which are you oriented to, work or life?” with the five-point Likert scale (1 = “very much work-oriented” to 5 = “very much life-oriented”). Options for the most important thing in life included “professional commitment,” “academic records,” “income,” “skill improvement,” and “family.”
Responses to the clinical experience items were further divided into two groups according to their respective medians and treated as binary variables. The clinical competency confidence scale was developed into a questionnaire to reflect the theoretical concepts of the new PGME. The new PGME13 had three guiding principles: (1) to improve basic skills and knowledge of primary care and build core clinical competency in evaluating a patient as a whole, (2) to improve salary, and (3) to cultivate physicianship. Consequently, irrelevant items were excluded. The excluded items were those related to orthopedic surgery and radiology, because these subjects were not core requirements, and those related to pediatrics, psychiatry, and obstetrics–gynecology, because items in these areas are skewed on a specific domain of content. We grouped the remaining items into four skill categories: physical exams (8 items), procedural skills (8 items), interpretation of clinical tests (11 items), and physician–patient relationships and social service application (7 items).
Each score, as well as overall scores, in the four clinical skill sets were assessed for gender by a t test. The internal consistency reliability of the confidence questionnaire was calculated using item-total correlation and Cronbach alpha. The content validity of the questionnaire was assessed by 10 PGME experts. These experts were asked whether each item (1) reflected the theoretical concepts of PGME, (2) evaluated basic skills and knowledge in primary care, and (3) was clearly understandable. The expert group consisted of a professor at a national university, a professor at a private university, two deans of teaching hospitals, two PGME program directors at teaching hospitals, two medical officers from the Ministry's Office for Clinical Training Medical Professions, and two primary care physicians. Residents' basic characteristics, satisfaction, future career, and perspectives on life and work were assessed between men and women by chi-square tests for categorical variables and t tests for continuous variables. The details of each variable are shown in Table 1. Finally, to investigate the effect of gender on resident confidence levels, we used general linear regression models, adjusting for age, types of hospitals, clinical experience, and satisfaction with residency conditions. We computed beta coefficients that reflected an increase or decrease in a unit of clinical confidence levels in the four skill areas.
We conducted analyses using SAS version 8.12 for Windows (SAS Institute, Cary, North Carolina). All tests were two sided, with a significance level of 0.05 using the Wald chi-square test.
A total of 1,124 residents agreed to participate in this study (a response rate of 60%). Nevertheless, we were unable to determine the sex of four of the residents, and therefore the number of the study participants for analyses was 1,120.
Scores for confidence levels in the four skill sets between men and women
The scores of the responding 1,120 residents are reported in Table 2. The internal consistency values of the four skill sets for measures of clinical competency were adequate: α = 0.83 in physical exams, α = 0.86 in procedural skills, α = 0.88 in interpretation of clinical tests, and α = 0.87 in physician–patient relationships and social service application. The item-total correlations were all positive and ranged from 0.41 to 0.70 for physical exams, 0.55 to 0.73 for procedural skills, 0.40 to 0.73 for interpretations of clinical tests, and 0.48 to 0.70 for physician–patient relationships and social service application. Because the deletion of any item would not result in an increase in Cronbach alpha of more than 0.01, we decided to retain all items in each group of competency skills. The content validity of the questionnaire was confirmed by the independent decision of all 10 PGME experts. Each expert felt that every question for each item reflected the theoretical concepts of PGME, evaluated basic skills and knowledge in primary care, and was clearly understandable.
The overall mean confidence scores in the four skill sets ranged between 2.9 and 3.1. When stratified by gender, the scores were generally higher in men than in women in physical exam skills, procedural skills, and interpretation of clinical tests. In contrast, the gap of scores between men and women narrowed in physician–patient relationships and social service application.
Basic characteristics, satisfaction, future career, and perspectives on life and work between men and women
Basic characteristics of the responding residents, comparing men and women, are shown in Table 1. The mean age of the residents was 28 years, and the majority of the participants were male (n = 776, 69%) and chose community hospitals (n = 706, 63%). The mean level of clinical experience was 3.15 on an ordinal scale where 3 indicated “6–10 cases” and 4 indicated “11 or more cases.”
Women were found to be younger than men (P = .001) and more likely to choose university hospitals for their residency (P = .029). Men were more likely than women to be satisfied with residency conditions (P = .020), and their attribution for their satisfaction was significantly different in the areas of workplace atmosphere, salary, and cooperation between departments. Both men and women chose clinical practice as area of interest, but men were found to be more interested than women in education/research/administration (P = .001). Similarly, more men than women reported that they intended to obtain a DMSc degree (P = .001). On the other hand, with regard to perspectives on life and work, nearly half of both men and women reported that they value both their personal lives and work; among the others, 30% of men (n = 231) versus only 13% of women (n = 45) reported that they were more work-oriented (P < .001). A markedly greater proportion of women than men chose “family” (70% versus 54%) as “the most important thing in life,” followed by “professional commitment” (18% versus 26% for women and men, respectively, P < .0001).
General linear model results of the gender effects on residents' confidence levels
Table 3 presents general linear model results of the gender effects on residents' confidence levels. After adjusting for age, clinical experience, types of hospitals, satisfaction with residency conditions, future career, and perspectives on life and work, women were found to be less confident compared with men about all skill sets except for physician–patient relationship and social service application (all P < .05). Although identification as “life- or work-oriented” was not a significant contributor to confidence levels, designation of “the most important thing in life” was marginally significant (data not shown); compared with residents who reported “academic records,” “income,” or “skill improvement” as most important, residents reporting “family” were found to be less confident about their interpretation of clinical tests (P = .086). No significant interaction of confidence levels with gender and other factors was found.
Our results demonstrate that women were less likely than men to be confident about the majority of clinical skill sets except for physician–patient relationships and social service application, even after adjusting for number of clinical opportunities experienced. Gender differences were also identified in the basic characteristics of residents' satisfaction with residency conditions, future career, and perspectives on life and work. We discuss our results in light of their strengths and limitations while referring to the previous literature.
Previous studies both at clinical practice settings16,17 and at research settings18 reported that women tend to underestimate their abilities, although they perform better than men.16–18 Such lower self-perceptions of competency among women may be accounted for by psychological vulnerability in women. Two studies reported that such vulnerability starts during medical school. Moffat et al19 reported that female students had greater stress about workload and personal competence, and Dahlin and Runeson20 reported that women worried about their future workload, citing issues like long working hours and responsibility in their careers. Gude et al21 suggested that the role of the doctor is traditionally more male than female in its characteristics of being active, dominating, and responsible as opposed to passive, submissive, and dependent, and women may therefore have a lower level of role identification than do men. Alternatively, such vulnerability may result from gender inequity in the workplace. For example, McMurray et al6 reported that women had less work control than men, which significantly contributed to burnout among women physicians. A few studies investigating gender inequity reported that women receive less institutional support for research,9 fewer mentoring opportunities,22 and fewer academic resources23 than men. In this regard, our study showed that women seemed to be less satisfied with residency conditions than were men. However, no gender difference was found in educational opportunities. Women seemed to be more satisfied than men with the “workplace atmosphere,” and this relationship contradicted the idea that gender climate favors male physicians. These findings may be explained by the characteristics of our study subjects; they were second-year residents who were not yet eligible to do research and who were in a rotation period too short for them to yet perceive the gender climate in the workplace that might create specific obstacles to professional development.
Lower levels of clinical confidence among women residents were observed in the majority of clinical skill sets; however, the gap between men and women narrowed in the area of the physician–patient relationship (i.e., understanding of patients' interpretative models, nonverbal communication performance, psychosocial care of patients, and health education in compliance with the levels of patient knowledge and interests). Although the scores for confidence in physician–patient relationship seemed lower among men than those of other skill groups, such narrowed differences between men and women may be explained by the findings of previous studies that women physicians are good at listening and counseling, that is, at skills that build trusting relationships between physicians and patients.24–26 Women physicians facilitate patient participation in the medical exchange more effectively than do men and are more likely to engage their patients in discussions of their social and psychological contexts and to deal more often with feelings and emotions. This is consistent with the results of previous studies, most of which were conducted in Western countries, verifying the clinical advantage of women physicians in this domain.
The strength of this study is that it is a nationwide survey with a relatively large sample size, but several study limitations need to be discussed. First, the gender differences we observed might be accounted for by a selection bias. Overconfident residents may have been preferentially selected among male peers relative to their female peers. However, this scenario is unlikely because the study is a nationwide resident survey with a random sampling method. According to the Ministry,27 5,019 (66%) men and 2,549 (34%) women passed the National Board Examination for a doctor's license in 2005 and started residency. Although the number of responses by gender was not available in our dataset, the gender ratio in 2005 was comparable with that of our study subjects. Second, our study showed that only 13% of women residents reported they were more work- than life-oriented; a significant proportion of women residents chose “family” as “the most important thing in life.” These findings might have been due to generational differences. The Women Physicians Health Study7 reported that older women physicians in the United States attained greater job satisfaction and had only vague recall of training's rigor, showed “pioneer pride,” or belonged to a cohort of “survivors.” By contrast, our study participants were limited to young residents, a fact that requires careful interpretation. Third, although one of our hypotheses included the possibility that lower confidence levels may have a negative impact on career development, the findings indicated that perspectives on life and work were not significantly associated with confidence levels. In this regard, it is suggested that a more precise and direct measure to assess the negative impacts of lower confidence levels needs to be developed. Finally, because of the cross-sectional nature of this study, a causal relationship is difficult to determine. Our results might not truly demonstrate definite relationships but, rather, reflect surrogate indicators of unknown factors.
In spite of these limitations, our study demonstrated that women residents in Japan are less likely to be confident about some basic skills and knowledge than are men, even adjusting for the number of clinical experiences. Previous studies suggested that lower confidence levels may have negative impacts on career satisfaction and even on decision making about continuing in the profession. The gender difference in clinical confidence may thus indicate an additional barrier women face in academic career development. Given that the number of women entering medicine is increasing, to attract and retain more women into the physician workforce, studies in this area require careful monitoring of self-confidence and further assessments. In this regard, quantitative research is useful for investigating the impact of lower confidence levels among women on their professional development, whereas qualitative research is useful for unveiling factors that influence the underestimation of self-confidence. In addition, an education program incorporated into the residency program that addresses gender difference is also important for helping young women physicians overcome barriers to career development in their future.
The authors thank the reviewers and editor of Academic Medicine for their helpful comments, and Dr. Shunsaku Mizushima, Dr. Makoto Aoki, Dr. Hiroyoshi Endo, and Dr. Osamu Takahashi for their support of collecting data.
This study was supported in part by grant H17-Iryo-015 from the Ministry of Health, Labor, and Welfare of Japan.
This study was approved by the institutional review board of the Japanese Ministry of Health, Labor, and Welfare.
The opinions expressed in this article are those of the authors alone and do not reflect the views of the Japanese Ministry of Health, Labor, and Welfare.
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