S P E C I A L F E A T U R E

P e r s p e c t i v e s i n E n d o c r i n o l o g y

Female Physicians and the Future of Endocrinology

Elaine Pelley, Ann Danoff, David S. Cooper, and Carolyn Becker

Division of Endocrinology, Diabetes and Metabolism (E.P.), University of Wisconsin School of Medicine
and Public Health, Madison, Wisconsin 53705; Department of Medicine (A.D.), Division of
Endocrinology, Corporal Michael J. Crescenz (Philadelphia VA) Medical Center and Perelman School of
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Endocrinology,

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Diabetes and Metabolism (D.S.C.), The Johns Hopkins University School of Medicine, Baltimore,
Maryland 21287; Division of Endocrinology, Diabetes and Hypertension (C.B.), Brigham and Women’s
Hospital and Harvard Medical School, Boston, Massachusetts 02115

Context: Given that approximately 70% of current endocrinology fellows are women, female
physicians will compose the majority of the future endocrinology workforce. This gender shift
partly reflects an apparent waning of interest in endocrinology among male trainees. It also
coincides with a projected shortage of endocrinologists overall. Female physicians face unique
challenges in the workplace. To continue to attract trainees to the specialty and support their
success, it is imperative that these challenges be recognized, understood, and addressed.

Evidence Acquisition: A PubMed search using the terms “female physician” and “physician gen-
der” covering the years 2000 –2015 was performed. Additional references were identified through
review of the citations of the retrieved articles. The following topics were identified as key to
understanding the impact of this gender shift: professional satisfaction, work-life balance, income,
parenthood, academic success, and patient satisfaction.

Evidence Synthesis: Several changes can be predicted to occur as endocrinology becomes a female-
predominant specialty. Although professional satisfaction should remain stable, increased burn-
out rates are likely. Work-life balance challenges will likely be magnified. The combined effects of
occupational gender segregation and a gender pay gap are predicted to negatively impact salaries
of endocrinologists of both genders. The underrepresentation of women in academic leadership
may mean a lesser voice for endocrinology in this arena. Finally, gender biases evident in patient
satisfaction measures— commonly used as proxies for quality of care—may disproportionately
impact endocrinology.

Conclusions: Endocrinology is predicted to become the most female-predominant subspecialty of

internal medicine. The specialty of endocrinology should take a lead role in advocating for changes
that support the success of female physicians. Strengthening and supporting the physician work-
force can only serve to attract talented physicians of both genders to the specialty, which will be
key to meeting the needs of the increasing numbers of patients with endocrine disorders. (J Clin
Endocrinol Metab 101: 16 –22, 2016)

emale physicians are increasing in number: women
F now make up nearly one-half of United States medical
school graduates, up from just 7% 50 years ago (1). This
often overshadows that, at least in the United States, med-
icine currently remains a male-predominant occupation.
As of 2013, women made up only 33% of practicing phy-
sicians in this country (2).
As a natural consequence of the current medical student
gender ratios, gender equity is much closer in graduate
medical education training programs, where women com-

ISSN Print 0021-972X ISSN Online 1945-7197

Printed in USA
Copyright © 2016 by the Endocrine Society
Received September 12, 2015. Accepted November 10, 2015.
First Published Online November 17, 2015

16 press.endocrine.org/journal/jcem J Clin Endocrinol Metab, January 2016, 101(1):16 –22 doi: 10.1210/jc.2015-3436
doi: 10.1210/jc.2015-3436
pose approximately 46% of residents/fellows (2). How-
ever, within these programs there are large differences in
gender composition: for example, more than 80% of
trainees in obstetrics and gynecology are female, whereas
the proportion is less than 10% for vascular and inter-
ventional radiology or interventional cardiology (2). Even
within the subspecialties of internal medicine, wide gender
differentials exist. Women are highly represented in en-
docrinology, rheumatology, and geriatrics fellowships,
while they remain a minority of cardiology and pulmonol-
ogy trainees (3). Factors such as time for family or non-
work activities, interest in long-term patient relationships,
and a desire to provide a needed service were found to be
more important to subspecialty choice for female internal
medicine residents, whereas financial considerations held
higher importance for males (4). Gender differences in
specialty preferences have been identified from the very
start of medical school (5, 6).
Gender Trends in Endocrinology
Although women currently compose a higher percent-
age of practicing endocrinologists (44%) than of physi-
cians in general (33%), endocrinology remains a male-
predominant specialty (2). In sharp contrast, the entering
cohort of 2013 endocrinology fellows was 72% female
(3). If this trend continues, over the next several decades,
endocrinology will become a female-predominant
specialty.
Data from the Electronic Residency Application Ser-
vice (Table 1, reproduced with permission) reveal that the
proportion of female endocrinology fellowship applicants
has gradually risen over the past several years to 75% in
2014. This is due to a steep decline in male applicants
rather than an increase in female applicants. The number
of male applicants decreased 43% over a period of 4 years,
with an overall decline in female applicants of only 12%.
These declines are occurring in the setting of a projected
Table 1. Number of Applicants per Year to
Endocrinology, Diabetes, and Metabolism Fellowship
Programs by Gender
2010 2011 2013 2014
Male 185 184 140 106
Female 355 388 348 311
No answer 1 0 0 0
Total 541 572 488 417
Note that endocrinology did not recruit for the 2012 season because
the recruitment cycle changed from 18 to 12 months.
©2014 Association of American Medical Colleges. These data and
charts may not be reproduced or distributed without prior written
permission.
press.endocrine.org/journal/jcem 17
endocrinology workforce shortage. The deficit of adult
endocrinologists is currently estimated at 1500 and is pre-
dicted to nearly double to 2700 by 2025 unless additional
recruitment efforts are made (7).
Given the increasing prevalence of endocrine disorders,
attracting and supporting a strong future endocrinology
workforce in both clinical practice and research is para-
mount. With trends suggesting this workforce will be pre-
dominantly female, understanding challenges and
strengths characteristic of female physicians will be key to
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the success of the specialty as a whole. Rather than an
exhaustive review of the implications of gender in medi-
cine generally, the goal of this paper is to highlight the
potential impacts of this anticipated gender shift on the
specialty of endocrinology.
Professional Satisfaction and Burnout
Higher income, working fewer than 50 hours per week,
and having a more controllable lifestyle are associated
with greater career satisfaction for physicians (8). Overall,
physician career satisfaction does not differ by gender (8,
9); however, compared with male physicians, female phy-
sicians are less satisfied with mentoring, career advance-
ment opportunities, and salary (9).
Compared with other specialties, the professional sat-
isfaction of endocrinologists has been found to be average
(8) or below average (10). Only 45% of surveyed endo-
crinologists reported that they would select the specialty
again (10). According to the 2015 Medscape Physician
Compensation survey (10), endocrinology has the lowest
compensation of any subspecialty, with salaries equal to
general internal medicine and ranking above only family
medicine and pediatrics. Although overall career satisfac-
tion for endocrinologists was not delineated by gender,
satisfaction with salary was poor for endocrinologists of
both genders (38% for females; 45% for males) (10).
In general, increasing educational attainment equates
to decreased burnout risk. Compared with high school
graduates, burnout risk is progressively lower with each
advanced degree obtained (11). Medicine, however, is an
exception to this: those with an MD degree have a 36%
higher risk of burnout compared with the high school
graduate (11). Superimposed on this, despite working
fewer hours (12, 13), female physicians have been found
to have similar (12) or even higher (14) rates of burnout
compared with male physicians. Risk of burnout for fe-
male physicians increases as work hours increase and as
workplace control decreases (14).
It is puzzling how studies can simultaneously report
that female physicians have equivalent professional satis-
18 Pelley et al Female Physicians and the Future of Endocrinology
faction but higher burnout rates than male physicians.
This phenomenon is not exclusive to medicine and has
been termed “the paradox of the contented female
worker.” This phrase was coined in 1982 (15) to describe
the frequent finding that women report similar job satis-
faction to men despite objectively poorer work situations
(less prestige, fewer rewards, lower pay).
Physician burnout has been shown to correlate with a
greater intent to decrease clinical workload or to leave
current clinical practice (16). If higher rates of burnout
among female endocrinologists result in a reduction in
work hours, a change in career, or early retirement, this
may worsen the projected endocrinology workforce short-
age (7).
Work-Life Balance
According to data from the American Time Use Survey
from the Bureau of Labor Statistics, Americans have dif-
ferential workloads by gender (17). Women spend less
time at work but more hours per day on childcare and
household-related activities. This appears to be true for
physicians as well. On average, female physicians, includ-
ing adult endocrinologists (7), work fewer hours per week
than their male counterparts (12, 13) but perform more
household and childcare activities. One study (18) found
that 46% of female physicians (compared with 17% of
males) reported performing more than 10 hours per week
of domestic activities. Notably, 55% of female physicians
(compared with 9% of males) reported doing more than
30 hours per week of childcare. Long work hours may take
a disproportionate toll on female physicians: divorce rates
are 50% higher for female physicians than their male phy-
sician counterparts and longer work hours correlate with
divorce for female physicians only (19).
Again, somewhat paradoxically, despite data suggest-
ing a much higher at-home workload for female physi-
cians, about one-half of both male and female physicians
report satisfaction with work-life balance (12). Higher sat-
isfaction with work-life balance is associated with having
more control over work schedule and with working fewer
hours (12). The highly inequitable distribution of house-
hold and childcare activities presents a significant chal-
lenge to workplace efforts to improve work-life balance
for female physicians. However, a workplace culture that
is perceived as supportive has been shown to decrease
work-family conflict, even without changing actual work-
load (20).
Occupational Segregation and the Gender
Pay Gap
Gender-based salary inequity has been demonstrated
across occupations (21, 22). The difference in pay between
J Clin Endocrinol Metab, January 2016, 101(1):16 –22
male and female workers is commonly referred to as the
gender pay gap (21, 23). Although much of this gap can be
explained by various factors, a large fraction remains un-
explained (23). Based on their average higher educational
attainment, women should earn more than men (23). Ac-
cordingly, higher education does not protect women from
the gender pay gap: a similar gap is seen in all ranges of
educational attainment from “less than high school di-
ploma” to “doctoral degree” (21).
The 2015 Medscape Physician Compensation Survey
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of nearly 20 000 physicians indicates a substantial gender
pay gap (about 22%) among full-time physicians (10).
Older data (13) revealed that 60% of the gender pay gap
(or ⬎$37,000 per year) across all medical specialties re-
mained unexplained after adjusting for hours worked,
specialty, experience, and other practice characteristics.
Other studies have confirmed gender-based salary ineq-
uity among physicians persists even after adjusting for
various factors (24 –26), and this can begin as early as the
initial entry into the workforce after residency (27).
The unequal distribution of male and female physicians
across medical specialties described here is a form of oc-
cupational gender segregation. This phenomenon has
been shown to be detrimental to women’s wages across all
occupations (28) and to the wages of workers of both
genders in “female-predominant” occupations (29). The
impact of occupational segregation on men’s and women’s
wages across the spectrum of educational attainment has
been studied (22, 29). At each level of skill (low ⫽ high
school or less, medium ⫽ some college or other significant
training, and high ⫽ bachelor’s degree or greater), female-
predominant occupations have lower hourly wages than
male-predominant occupations (22, 29). The negative ef-
fect of female-predominance on earnings is most pro-
nounced in high-skill occupations (22). Superimposed on
this, within all of these categories except one, there was a
gender wage gap, with men in that category earning more
per hour than women (29). The one exception was female-
predominant high-skill occupations (29), such as elemen-
tary school teachers, registered nurses, and social workers
(22). Here, men and women have very similar hourly earn-
ings, although a wage gap may be masked by the relative
seniority of the women in these occupations (29).
Among full-time endocrinologists, a $38,000 –$66,000
annual gender wage gap was seen depending on practice
type (not controlled for hours worked) (10). As noted pre-
viously, endocrinology is one of the subspecialties of in-
ternal medicine in which there is substantial gender seg-
regation. As such, in addition to the wage gap
disadvantaging female endocrinologists, this occupa-
tional segregation is predicted to detrimentally impact the
salaries of male endocrinologists as well. Because male
doi: 10.1210/jc.2015-3436
residents disproportionately select to train in specialties
with higher salaries (30), this can create a vicious cycle. As
fewer males enter the specialty, endocrinology will be-
come more female-predominant, enhancing the effect of
occupational gender segregation on salaries and further
deterring male residents from choosing the specialty. The
recent data showing an approximately 40% decline in
male applicants to endocrinology over the past 4 years
(Table 1) require ongoing monitoring, but are concerning.
The Motherhood Penalty
The key years for establishing a career frequently co-
incide with the childbearing years. Survey results show
that female physicians delay childbearing by seven years
compared with the general population and also face in-
creased rates of infertility (31). Reproductive challenges
have been associated with burnout risk in female physi-
cians (32). Overall, female physicians are less likely to be
parents than their male counterparts (18).
Professional women who do become mothers may face
biases in the workforce. In an experimental model (33),
study participants assessed fictional equivalent job appli-
cants as less committed, less competent, and less desirable
to hire if they were noted to be mothers (compared with
nonmothers). “Mothers” were held to higher punctuality/
attendance standards and were less likely to be considered
candidates for promotion. The salary recommended was
also lower. Both male and female participants rated moth-
ers lower on all variables studied.
In contrast, the fictional “father” applicants were
deemed equally competent but more committed than non-
fathers. More flexibility was given for punctuality/atten-
dance. “Fathers” were more likely to be recommended for
hire and deemed likely to be promoted. “Fathers” were
recommended a higher salary than nonfathers.
Superimposed on the gender wage gap, an additional
“motherhood” wage gap (ie, a wage gap between women
with and without children) has been demonstrated across
the workforce (34 –36). In contrast, a salary premium for
men who are married has been demonstrated (37). The
extent to which this occurs in medicine is not clear. How-
ever, in one study of two-physician couples, the physician
fathers were found to have 35% higher salaries than child-
less male physicians, whereas their wives (physician moth-
ers) were found to have slightly lower salaries than female
physicians without children (37).
Gender and Success in Academic Medicine
The gender gap in academic medicine is well-described
(38, 39). Academic productivity has been found to be
press.endocrine.org/journal/jcem 19
lower for female faculty, particularly early in their careers
(39), and a gender gap has been demonstrated in author-
ship in the medical literature (40, 41). Although the num-
bers of women and men are similar at the instructor level
and women are approaching parity to men at the assistant
professor level, the proportion of women declines sharply
at the associate and full professor levels (1). Women are
overrepresented in clinician educator tracks and under-
represented in traditional tenure tracks (42). Promotion of
faculty members on clinician educator tracks lags behind
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those on tenure tracks (43).
These gender disparities help explain the poor repre-
sentation of women in academic medicine leadership,
where the gender imbalance extends to the very top. In
2010, only 13% of US medical school deans were female
(for comparison, 20% of law school deans and 23% of
college/university presidents were female) (44). Female
deans took longer to be promoted to full professorship and
were more likely to have short (⬍3-year) deanships than
their male counterparts (70% vs 39%) (44).
Female physicians in academic medicine face similar
issues relating to work-life balance and gender-based sal-
ary inequity. Among physician-researchers who are mar-
ried/partnered and have children, women were found to
spend 8.5 hours more per week on parenting or domestic
tasks than men (45). Even after adjusting for multiple rel-
evant factors, large deficits in academic rank (46) and sal-
ary (46, 47) have been found for female faculty. The wage
gap worsens with time: women with greater seniority had
larger wage gaps of approximately $5000/year for every
10 years of seniority (46).
Despite these challenges, women remain committed to
academic medicine. A study of academic physicians (48)
found that women and men report similar levels of pro-
fessional engagement and leadership aspirations. How-
ever, female faculty expressed less confidence in being able
to advance in their careers. Compared with their male
counterparts, they scored more negatively regarding feel-
ings of inclusion, perceptions of gender equity, and insti-
tutional support for work-life integration.
Gender and the Physician-Patient
Relationship
In the clinical practice setting, there are no gender dif-
ferences in biomedical information exchange or social
conversation with patients (49). However, female physi-
cians are more likely to engage patients as active partners
in care and to offer more psychosocial counseling and
emotionally focused discussion (49, 50), which may con-
tribute to the frequent finding that visits with female phy-
20 Pelley et al Female Physicians and the Future of Endocrinology
sicians are longer (49 –51). These communication dynam-
ics illustrate patient-centeredness (49). Patient-centered
care approaches have shown promising links to increased
patient satisfaction (52). However, despite delivering
more patient-centered care (53), female physicians do not
have a clear edge in terms of patient satisfaction (54, 55).
It has been hypothesized (54) that patients expect
women to exhibit these communication styles and may
attribute patient-centeredness in female physicians to a
stereotypical gender expectation rather than to a partic-
ular style of practicing medicine. As a consequence, they
may not give female physicians appropriate credit for this
as a professional strength (54). This theory is supported by
a study in which participants were asked to view students
interacting with standardized patients and to then assess
competence. Unless the viewers were specifically told that
patient-centeredness is a component of competence, in-
creased competence ratings correlated with increased pa-
tient-centeredness only when the student was male (56).
Similarly, in identical scripted encounters of variable pa-
tient-centeredness, patient satisfaction correlated with pa-
tient-centeredness much more strongly when the actor was
male than when the actor was female (57).
Patient perceptions of nonverbal behaviors have also
been explored (58). It is significantly more important for
female physicians to allow longer patient speaking time
and to be dressed formally (eg, white coat) than it is for
male physicians. Several behaviors correlate positively
with satisfaction when done by female physicians but neg-
atively when done by male physicians. These include gaz-
ing, a forward lean, and a “medical” atmosphere in the
examination room. Conversely, other behaviors—includ-
ing looking at the patient chart, talking while doing some-
thing else, and gesturing— correlate with increased patient
satisfaction with male physicians but decreased satisfac-
tion with female physicians. Expression of medical uncer-
tainty has been found to negatively impact patient satis-
faction only when the physician is female (59). It is clear
that patients harbor different expectations of female vs
male physicians (60).
Patient satisfaction surveys are a variant of customer
satisfaction surveys. Striking gender bias in customer sat-
isfaction has been found in a study looking across various
service providers, including physicians (61). Customer
satisfaction was higher and correlated more strongly with
objective measures of quality when the service provider
was male. Accordingly, in medicine, objective measures of
quality (measured by statin and angiotensin-converting
enzyme inhibitor prescriptions for coronary artery dis-
ease) correlated with patient satisfaction only when the
physician was male. Because patient satisfaction is increas-
ingly being used to inform compensation (62), intrinsic
J Clin Endocrinol Metab, January 2016, 101(1):16 –22
biases such as these may disproportionately impact
endocrinology.
Looking to the Future: What Can Be Done?
Although the increase in the proportion of female phy-
sicians overall reflects a positive trend, the recent increase
in the proportion of female endocrinology fellows primar-
ily reflects an apparent waning of interest in endocrinol-
ogy among male residents. Because male residents have
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been shown to weigh future compensation more heavily in
specialty choice, the relatively low earning potential of
endocrinologists may be impacting the long-term viability
of the specialty. This trend must be monitored closely be-
cause talented physicians of both genders are needed for
the specialty to thrive.
Although endocrinologists’ professional satisfaction is
likely to remain stable with this shift in gender composi-
tion, burnout may become a more significant problem.
Leaders in endocrinology should seek to increase work-
place control, allow more flexible hours, and create more
collegial and supportive environments for all in order to
decrease burnout. In addition, work-life balance is a crit-
ical area to address for both genders. Although the un-
equal division of labor at home cannot be addressed by
changes in the workplace, increased workplace flexibility
and a more supportive culture may help alleviate work-
family conflict for both genders.
If occupational gender segregation and gender-based
salary inequities persist within endocrinology, a further
downward spiral in salaries may ensue despite increased
demand for endocrinologists. The comparatively low sal-
ary for endocrinologists today is largely related to the non-
procedural nature of the specialty. The transition of Medi-
care payments to value-based models means that, by 2018,
90% of fee-for-service payments will be tied to quality and
50% of all Medicare payments will be tied to alternative
payment models, such as Accountable Care Organizations
(63). The reduced emphasis on high patient volume and
procedures coupled with an increased focus on quality and
value should mesh well with a patient-centered care style
and the cognitive nature of endocrinology. This is an im-
portant opportunity for endocrinology to redefine its
value in the health care system as a model of patient-cen-
tered care deserving of fair compensation. However, we
must use the results of social science research to advocate
for better quality measures and improved patient (“con-
sumer”) satisfaction surveys that are free of gender bias.
In the academic setting, the current underrepresenta-
tion of women in senior leadership positions predicts that
endocrinologists will be underrepresented in future aca-
doi: 10.1210/jc.2015-3436
demic leadership roles. Filling the pipeline with high pro-
portions of women at the trainee and young faculty levels
does not ensure promotion of women into academic lead-
ership. It has been observed in the business world that
high-potential women have mentors that are more junior
and have lower clout than the mentors of their male peers.
Males are more likely to have mentors who can serve as
“sponsors,” or powerful career advocates, not simply ad-
visors (64). High-potential female faculty members should
be matched with senior faculty members who can serve
both as mentors and as strong advocates for career ad-
vancement. Finally, endocrine division chiefs and others in
positions of power must advocate for gender salary equity
in academic medicine, both out of fairness and to attract
top talent.
The projected transition of our field to a “female pre-
dominant” medical specialty offers great challenges and
enormous opportunities. Fortunately, this issue is gaining
attention in the endocrine community (65). If we as a spe-
cialty—female and male alike—face these realities to-
gether, we can better ensure the success of current and
future generations of endocrinologists as well as the health
and well-being of the rapidly expanding number of pa-
tients whom we serve.
Acknowledgments
Address all correspondence and requests for reprints to: Elaine
Pelley, Division of Endocrinology, Diabetes and Metabolism,
University of Wisconsin School of Medicine and Public Health,
4170 Medical Foundation Centennial Building, 1685 Highland
Avenue, Madison, WI 53705. E-mail: emp@medicine.wisc.edu.
Disclosure Summary: The authors have nothing to disclose.
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