Changing Demographics in Pediatric Endocrinology Physicians: Impact on practice, on the patient-physician relationship and on patient satisfaction.

A live conversation between

Cheri Deal, Montreal, Canada

And Paul Saenger, New York, NY, USA

October 17, 2020.

Comments by Lars Sävendahl, Ze’ev Hochberg. Harvey Guyda and Michael Ranke

Cheri Deal: According to the WHO European Health Information Gateway, the number of women of all ages in medicine has increased steadily in European countries since 1980 when the statistics became available.  Looking at the most recent mean data in 2014 for 27 countries of the EU, 52% of physicians are women (1).  This month in Academic Medicine, Pelley and Carnes published the data for the US physician workforce, which has gradually reached a steady state of near 50% (2).  In Canada, according to the CIHI (3), the number of female specialists has increased steadily from 9% in 1978; currently 54% of physicians under the age of 40 are women.  My graduating class in 1985 was the first class in Canadian medical schools to have an equal ratio of male and female students. While these data demonstrates an overall improvement for diversity with respect to gender, the statistics in the US and Canada for other minority groups are far less reassuring.

I will focus the talk today primarily on what this changing gender demographic means at several  levels, including gender segregation across specialties, evolution of pay scales as a function of gender, implications for the future endocrinology workforce, career trajectories particularly in academic medicine, and finally, what we know about  patient preferences and satisfaction.  I have based the observations that I will share with you today on a literature review and include pertinent articles in a reference list to the transcript of this discussion.  Most of the data comes from a North American context, some from the European context, and a bit from Asian countries.

Women and our Societies

Let’s start with a quick recap of the history of ESPE and LWPES/PES to see how women have contributed to these medical societies from the beginning.  I apologise in advance for not commenting on data from sister societies in other parts of the globe!  I invite readers from these societies to send in their comments to EDGE.

As I learned from reading Wolfgang Sippell’s excellent history of 50 years of ESPE (4), this society began as a club of 26 members, invited by Andrea Prader to a meeting in Zurich – at the time only 2 women were invited, and these happened to be Swiss colleagues of Dr. Prader.  The official birth of ESPE was in 1965, with the founding members now expanded to 30 but with only Ruth Illig from Switzerland representing the fair sex… As of 2020 there were 1332 members with roughly equal numbers of Males, Females and ‘undisclosed  gender’ (data obtained from ESPE office, courtesy of Anita Hokken-Koelega and Joanne Fox-Evens).   This makes it difficult to track gender-specific data, although I suppose it is being done in a conscious effort to show that we no longer think of the world in a binary fashion.  I was unable to find the gender distribution for past ESPE Secretary Generals on the ESPE website, but looking at the ESPE Annual Meetings since 1990, it is only more recently that there are two Presidents of each meeting, one male and one female, and I do not have the statistics.  This said, 4 of the current 10 ESPE Council members are women, including Anita Hoeken-Koelega, the Secretary General.

LWPES, later the PES, was founded in the early 70s by Robert Blizzard and Claude Migeon, but I could not find a list of the names of the founding members.  Del Fisher’s 2004 ‘Short History of Ped Endo in North America’ (5) does name the early presidents: from 1972 to 1988, there were 4 women (13%), but in the last 18 years, 50% of PES Presidents have been women. Membership now tops 1300 and is probably close to 45% female – I was unable to obtain the current gender breakdown from PES.

How are Academic Female Pediatric Endocrinologists doing in ESPE and PES?

One of the ways we can follow the impact of the feminisation on career progression of women pediatric endocrinologists is to look at the proportion of women receiving awards.  An indicator of the health of our specialty will be to see the number of female awardees rise with the numbers of women members. I looked at the previous winners of the ESPE Andrea Prader Prize for career contributions over the period of 1988-2019 and noted 4 women (8% of the awards), but in last 8 years this has climbed to 25% .  Turning to the ESPE Young Investigator Award Winners from 1993-2019 – there were 18 women/38 total awards with equal distributions in first and second half of this time period (47%).  Interestingly, in the 10 years where two awards were given, only once was it not to both a man and a woman (most recently, in 2018, it was given to 2 women).

PES has awarded 14 Jud Van Wyk Prizes for career achievements between 2006-2019, with only 1 woman, Maria New, granted this prestigious award.  Of the 67 LWPES/PES Clinical Scholar Awards for Junior investigators (from 1987-2019), 44% of the first 32 awards went to women.  Considering only the more recent 37 awards, 65% of these awards went to women.

From the ESPE and the PES data, it is clear that young female endocrinologists are being recognised for their career potential but it remains to be seen if they will persist in their career aspirations and be judged as worthy of our Societies highest honours in the near future.

How does Pediatric Endocrinology compare to other specialty and subspecialty training with respect to gender ratios?

Over the last 2 decades, specialty choices have remained consistent according to the AMA data of 2019, with the highest numbers of FEMALE trainees going into ObGyn (83%), Allergy and immunology (73.5%), Pediatrics (72%), Medical genetics and genomics (67%), Hospice and palliative medicine (66%), and Dermatology (60%).  As we have seen in the past as well, MALE physicians heavily dominate the surgical specialties and radiology.  When the salary is plotted against the female share of the specialty, two things need mentioning: first, there is a strong negative correlation between earnings and the % of females in the workforce, explaining 64% of the variation in salaries and, secondly, Pediatrics and Endocrinology (along with Psychiatry and Family Medicine) received the lowest salaries of the 35 medical specialties shown (2).

Data from an Endocrine Society White Paper in 2014 (6) showed that the adult US physician workforce in 2011 consisted of about 38% women board-certified in Adult Endocrinology. Board certified Pediatric Endocrinologists were comprised of 51% women.   US training programs, however, between 2010 – 2014 showed that between 65% and 75% of Endocrine trainees were female (7).  Our Canadian workforce data (CAPER)  for Pediatric Endocrine trainees (excluding visa trainees) between 2015 and 2019 gives a consistent female predominance reaching over 80% with only slightly less female trainees (but over 70%) in Adult Endocrinology (8).

Katai et al and The Japan Endocrine Society Women Endocrinologists Associations noted in their 2019 report in the Endocrine Journal that Japan has the lowest number of women medical doctors (21%) of all OECD countries. However, among the youngest physician population of Japanese Endocrinologists (under age 40), this has now reached almost 50% (9). This is an example of an international gender trend that is touching even the more conservative countries with regards to supporting women in the medical workforce, specifically in Endocrinology.

Elaine Pelley, a U.S. Endocrinologist, had previously warned about the impact of the gender shift on the future of Endocrinology in a special feature article in JCEM, 2016, based on a non-systematic literature review and access to workforce statistics from various sources (10).  The main message of Pelley and colleagues to the community of adult endocrinologists was that, at least for the period from 2010 to 2014, the total number of applicants to endocrine fellowships fell , but principally because of a drop in the number of MALE applicants, contributing to the projected adult endocrinologist shortage also documented by an Endocrine Society workforce report in the same year.  This occupational segregation,  where there was also a documented  gender annual pay gap of between 38,000 and 66,000$ per year, would be expected to lead to further declines in male applicants since male physicians prefer higher-paying specialties, even upon entrance to medical school according to data in the literature.  If you would like to hear Dr. Pelley interviewed by Toni Gallo, listen to this recent Podcast (Gender segregation by specialty in medicine. Academic Medicine Podcast. https://podcasts.apple.com/us/podcast/gender-segregation-by-specialty-in-medicine/id1112697692?i=1000488347677 )

The Cost of Caring – Why do salaries drop when women enter a profession?

The observation that there is a gender-based salary inequity is not new; it has been demonstrated not only across occupations, but also throughout history.  Consider, for instance that secretaries were traditionally male and as a profession, it carried a very high status and an excellent remuneration.  This was true throughout history until the 1880’s, and coincided with the advent of the typewriter where women’s skills were found more valuable – particularly their manual dexterity.  Teaching became another preferred female profession only in the late 19th century, in part because they could be paid less than males and in part because with the advent of male-populated school boards who deemed women would be more compliant with authority and with rules.

‘Caring work’, such as child care, teaching, physical and psychological therapy and nursing, has drawn more women than men since women entered the labor force. Caring work, according to England and Folbre (11) involves providing face to face work, a relationship with the person receiving the service, a certain degree of altruism on behalf of the caregiver, and a belief that the personal rewards in terms of job satisfaction cannot be ‘priced’.  Caring labor has been culturally devalued, since the implicit bias in our western culture is that the skills required are 1) those of a woman and mother, 2) are biologically based and come naturally and 3) occur regardless of the degree of education required for the job.  Caring professions have been termed the ‘sacred cow’ because to ‘commodify’ love and care seems offensive.  As England and Flobre conclude – the principle that money cannot buy love and caring may have the unintended and perverse consequence of perpetuating low pay for caring work.

This seems to be the case for physicians in the most ‘caring’ specialties, classically, Pediatrics and ObGyn.  And, as I previously stated, these are two of the most feminised specialties, with Pediatrics being the least well remunerated and ObGyn also at the lower end of the pay scale despite being a technique and surgery-oriented specialty. Will this feminisation see the salaries of Pediatric Endocrinologists fall as well, as governments seek to curb health-care costs?  If so, this will potentially have implications for continuing to attract male candidates to our specialty.

Let’s get back to the GENDER PAY GAP:  What factors contribute to the gender pay gap in Academia (which continues to be worse than in other clinical settings)?

Several studies mostly from the UK and the US, and this summer from Canada (12) have shown a clear gender pay gap whether in clinical, research or teaching environments. Interestingly it persists after adjustment for factors like physician age, specialty, number of hours worked and type of practice.  Even in the UK, where there is not a fee-for-service model, NHS salaried female MD employees have consistently earned less per hour than their male colleagues (13).  Women are more likely to work part time, particularly during the time they are raising young children, and there is increasing acceptance of longer maternity leaves which in the past, were frowned upon.

According to some studies, the difference in income is most likely due to the type of work performed and the amount of time providing counselling and addressing psychosocial issues.  Visits may be longer, with less patients seen per hour. The completeness of history taking and clinical note taking has also been suggested to differ by gender although data is less available.  In one audit of clinical care in China published in the Lancet in 2018 (14), 309 primary care providers were audited for their adherence to check-lists based on international guidelines for 3 common clinical problems, in a standardised setting.  Female MDs completed 15% more of checklist items than male MDs, and were also 15% more likely to prescribe the correct treatment, however no comment was made concerning the length of the visits by gender.

In academic settings, data has also shown that women spend more time teaching and providing clinical care, and have less protected research time.  It is beyond the scope of our discussion to summarise all the data on Gender-Equity and progression in an academic careers, but it is clear that there are multiple factors contributing to gender bias and to the long-standing underrepresentation of women in major leadership positions and in tenured faculty positions. For those who wish to read further, there was a review of empirical data by Edmonds et al in the Lancet (15) looking at the question of why fewer women choose research careers, and 4 major and 4 minor themes were recurrent.  Many of these themes have continued to be researched.  For example, insufficient advocacy of women by their sponsors (16) and differential scoring of NIH or CIHR grant applications (17) have been shown to be contributing factors.  Lastly – Starmer and colleagues (18) used data from the American Academy of Pediatrics Pediatrician Life and Career Experience study, based on questionnaires answered by 1300 participants.  A significantly greater number of male pediatricians still had stay-at-home partners and married women pediatricians do proportionately more of household and childcare related chores (and also have a higher divorce rate, in passing).  Even if they are able to maintain a high-powered career, concerns about female physician burn-out are discussed in most academic centers, and it is a growing concern as the physician work-force becomes feminised.

In particular, the current COVID-19 Pandemic has already proven to weigh more heavily on female healthcare providers as discussed by Jones and colleagues this summer (19).  They noted that women are more likely to be in the ‘frontline’ clinical positions AND less well represented in leadership positions where they can impact on decision-making, thus they are more exposed to feelings of powerlessness.  Increasing demands at home because of school closures and care of elderly parents who may also be sick can add to the workload of female physicians.  Competition between spouses for ‘work-time’ can add stress to the couple, and guilt that physicians may be exposing their own families to risk is also frequently voiced.  Jones et al offer recommendations to monitor and help offset this collateral damage to colleagues, including understanding the potential decline in research productivity while recognising institutional contributions and seeking to fairly compensate physicians, male and female, for increased work demands during the pandemic.

My concerns from reading much of this data is whether or not we can encourage and nurture an increasingly feminised workforce to pursue a life-long career in Pediatric Endocrinology.  If we fail to do this, will we see a decline in the historic trend of significant academic and research contributions to the field of Pediatric Endocrinology in the future?

Endocrinology and Projected Workforce Needs

You may have seen the special commentary published by Robert Vigersky in JCEM in 2014 (20), giving the projections of supply and demand considerations of the adult and pediatric endocrinology workforce compiled by the LEWIS GROUP for the Endocrine Society.  The data came from the American Medical Association, the American Board of Pediatrics and the American Board of Internal medicine, the American Association of Medical Colleges and US Mortality census.  In addition, data was collected by a survey sent to 1689 randomly sampled board-certified endocrinologists; response rate was 21%.

In reviewing the factors affecting the supply and demand of Pediatric Endocrinologists, there was an increase of 6.6% per year in first year fellows between 1998 and 2011, resulting in over twice as many first-year trainees during this time period. The number of third year fellows had approximately tripled over a similar time period.  Taking into account 1) projected attrition (deemed small since pediatric endocrinologists are in generally very satisfied with their profession), 2) retirement ages based on their questionnaires, 3) a slightly contracting proportion of patients in the pediatric age group, and 4) smaller increases in the number of patients requiring endocrine care (certainly relative to the projected increase adult endocrinologists will see because of obesity) – they felt that the US would rapidly enter into a situation of excess Pediatric Endocrinologists, citing 2015 as the break even point.  There were, of course, many factors that could not be factored in, notably user rates in a non-universal healthcare system, insurance payouts, lifestyle trends, reliance on educators and nurse practitioners, patient demands for new medications and new technologies, guidelines for optimal care and regulatory requirements.  Most notably, in contrast to their consideration of the obesity epidemic’s repercussion on demand for adult endocrinologists,  other than small increases in T1D, little thought was given to the increased endocrine demands  of pediatric cancer survivors, pediatric obesity, SGA children and intersex patients, not to mention the increasing numbers of patients being treated with GH, pubertal blockers,  whether justifiably or not.  It is therefore not clear if this scenario is becoming a reality in the US as of yet.

This projected excess supply after 2016 was not the case for Adult Endocrinologists.  Vigersly et al suggest that it would take until  2025 for supply to match demand if fellowship positions were increased by 5.5% per year.

The Gender Gap and the Adult Endocrinology Workforce

Since the Endocrine Society’s LEWIS report and Vigersly’s article 6 years ago, Romeo et al (21) explore the situation in another JCEM commentary this summer.  It does not focus on gender, but more on the implications for the decline in the ratio of application-to-available-positions, now at 1.1.  What this means for gender diversity and for the quality of the trainees given the smaller pool of applicants is difficult to assess at this point.  Also noted was that the numbers of first year fellows in Adult Endocrinology graduating from US medical faculties has declined from 56 % to 40%, with now the majority of fellowships going to foreign medical graduates, often representing minority groups.  This is definitely a positive trend towards cultural diversity, and presumably will occur in Pediatric Endocrinology as well but as noted above, it is mostly male applications that are on the decline in adult endocrinology.

Canada has handled both the Adult and the Pediatric Endocrine workforce supply differently, owing to the fact that positions are strongly limited by the provinces and the fact that we have fewer training programs than the US – only  7 Pediatric Endocrine training programs, and 12 Adult Endocrinology training programs.  The most recent CAPER data (8) shows a small increase in the numbers of Ped Endo fellows in training, in 2005 there were 25 and in 2019, 29; this is in contrast to the Adult Endocrinology trainees where numbers have steadily increased  since 2005 from 48 to 78.  Canadian programs still have more applications than positions (or funds in the case of non-Canadian applicants), and we are also seeing a small rise in the number of foreign trained Pediatricians seeking to train in Pediatric Endocrinology.  The financial impact of medical training is far less in Canada than in the US, and this may be one reason that the specialty remains attractive for both Adult and Pediatric Endocrinology hopefuls.

Canada is also seeing a small increase in the numbers of Pediatric Endocrinologists going into community hospital practice. Prior to the beginning of the 21st century, 95 of Pediatric Endocrinologists in Canada practiced in Academic centers; those who continue to be employed by University Centers are now on salary or on mixed models of payment.  What this means for remuneration of community Pediatric Endocrinologists is hard to guess, although community pediatric endocrinologists may see proportionately more patients with ISS, early puberty and obesity. Will increasing numbers of community Pediatric Endocrinologists mean that they may become more proactive with treatments because of a need for income generation, thus moving away from a more conservative approach to treatment?

What is the data on the Impact of Physician Gender on Practice of Ped Endo?

Dr Smuel (22) did a survey of 155 pediatric endocrinologists to determine whether hormonal treatments for frequent clinical cases – in particular ISS, early and delayed puberty – were delivered with different frequencies based on gender (M 37% F 63%), age and place of practice (28% Israeli, 72% international). There were striking gender differences in willingness to treat among the Israeli Pediatric Endocrinologists with female physicians being more proactive, and overall, Israeli physicians were more likely to offer treatment than those from other countries despite guidelines that tend to be more conservative.  Factors driving the treatment were hypothesized to include differences in cultural norms and gender-influenced personal belief systems, but I do not know the proportion of independently practicing physicians sampled versus those practicing in academic centers, and how the types of remuneration may have influenced the results of this study.

Impact of Physician Gender on Patient Satisfaction

I will end this talk with a brief review of some of the data examining whether gender impacts on patient satisfaction, although little has been researched in the context of the pediatric endocrine patient.

As an anecdote, let me mention an article in a February issue of the New York Times in 2001, describing the case of a male obstetrician that was fired from his group practice because of his inability to attract patients.  He was suing his colleagues for gender bias and the practice of honoring patients’ requests to have female physicians over equally-qualified male physicians.

This article was mentioned in a nice review by Debra Roter in the same year (23), which looked at how physician gender can shape communication dynamics.  She pointed out that previous studies reveal only a weak preference for gender-same physicians, particularly when the health complaint is not gender-specific.  However, data does show that there is a preference for same sex when gynecologic or obstetrical care is considered.  This was also examined in the context of pediatric consultations (24), using questionnaires of 125 parent-child pairs after an outpatient visit at a University Teaching Hospital.  While 54% cited no preference, 38% wanted female doctors and 8% wanted male doctors.  When female patients age 9 and older were polled, thus within pubertal age groups, 98% wanted female doctors, and when they were able to have a consultation with a woman, they reported greater satisfaction with the visit and feeling more comfortable.

One of the first papers to discuss physician gender effects on the doctor-patient relationship was written by Judith Gray, a specialist in Community Medicine with the Manchester Area Health Authority in the early 80s (25).  She pointed out that classic medical training prior to the 1980s emphasized a mechanistic, analytical and rational approach which counseled keeping an emotional distance.  This contrasts with female socialization emphasizing caring, emotional involvement and nurturing.  At the same time that the paternalistic and more distant medical model was being taught, studies found that patients preferred that their doctors to be understanding, take more time, explain more completely and take a personal interest. Grey also highlighted studies that showed that patients speak up more to female physicians, and felt that their female doctors were ‘friendly’.  Hers was one of the wake-up calls that stimulated another 3 decades of research into gender-based differences in verbal and  non-verbal communication styles and the impact this has on patient satisfaction, resulting now in almost all Universities incorporating reflective and observational teaching methods  of effective and non-effective communication.

Medical visits are actually very complex social interactions which are both dynamic and reciprocal, and different physician qualities may be valued or be beneficial depending on the gender of both the physician and the patient.  In the context of the pediatric visit, communication is tripartite with the gender of the caregiver accompanying the patient also to be taken into consideration.  Empirical data exists showing a link between patient satisfaction and outcome measures including compliance, so it behooves us to be cognisant of how we can contribute to increased patient satisfaction. 

Communication styles thus can influence the therapeutic relationship in several ways, including the degree of partnership in the relationship, the extent to which psychosocial issues are openly discussed, and the patient expectations and judgement (26). Gender-based communication stereotypes do have support in the literature, with women being found to be more accurate in understanding nonverbal communication and in physically expressing more positive behavior with smiles, nods and gazes. Data suggests that they are also more comfortable with emotional closeness and less hierarchical in social relations. Hall and Roter pointed out (27) that the differences are not large, but it is not clear whether medical education can level the communication field.

Concerning patient expectations, a Swiss study by Mast and colleagues (28) had 163 volunteer patients look at a series of pre-set physician-patient interaction videos, and grade what they perceived to be the degree of patient satisfaction based on seeing the physician but only hearing the patient speak.   The viewers were most satisfied with the female physicians who behaved in line with a female gender role, whereas for male physicians satisfaction was high for a broader range of behaviors only some of which were more in line with a male gender role suggesting that inherent biases are may have been at play.  The Implicit Association Test (IAT) is being increasingly used to examine implicit gender biases in medicine, both in health care professionals and in patients. If you have not yet taken it, it is worth a look (https://implicit.harvard.edu/implicit/canada/takeatest.html).

Furthermore, inherent physician attributes may also affect patient satisfaction, as shown by an enormous analysis of almost 52,000 in-patient surveys on 914 physicians, 76% of whom were male so female physicians were inadequately represented in all the specialties (29).  No significant associations were found between patients and physician gender, ethnicity and race but were associated with physician specialty (ObGyn’s scored the highest) and age (older physicians fared better) –  with no pediatricians or pediatric endocrinologists represented in their sample.

Evidence also supports the importance of providing diversity within the pool of physicians when possible, in order to increase patient-physician partnerships.  This in turn has been shown to increase patient satisfaction.  Based on a large dataset of white, African American and other minority adult patients and an equally diverse group of primary care physicians, they showed by telephone questionnaires that participatory decision making was highest in relationships that were race and gender concordant – again emphasizing the complexity of the interactions at play (30).

I will stop here and simply conclude by saying that I hope that the future of Pediatric Endocrinology sees increasing diversity among our trainees but a more equal balance between genders.  I do not want to see Pediatrics and Pediatric Endocrinology becoming uniquely the domain of women. The literature shows that male and females bring different strengths to the table, and a gender-diverse physician team offers better chances of successfully serving their patients with regards to satisfaction and ultimately with better clinical outcomes.

Paul Saenger: Thank you Cheri.  I had a paper to review, which was forecasting the death of  Pediatric Endocrinology and showed  that the number of applicants is declining. And this is just for the last five years. And it’s a self-fulfilling prophecy  although they didn’t say that our sub-specialty will abolish itself. Some things that these authors quoted that need to be fixed include 1) The pay scale. We are, as you remarked correctly, down at the bottom of the pay scale with psychiatrists and that needs to be fixed. Certainly, we don’t have any procedures, you know. And 2) The training has to be shortened and they have to do away with this academic paper that you have to submit in order to complete the requirements for the fellowship in the US. I do not know how it is in other countries. We have these highest quality structured Fellowship programs in Canada and in the US. I think in the rest of the world it’s more loosely defined and it’s not as rigid as what we have here.  This was a paper painted a very bleak picture. And I’m not sure from listening to you that that is truly the case.

Deal: I don’t think it’s the case in Canada. I know that the US is extremely concerned. And again, I think there are both cultural and workforce factors at play here; the three year

requirement to training is not the case in Canada, although anyone wanting to be an academic physician will not be recruited in general  unless they’ve done at least three years of pediatric training and have had some exposure  to medical or pedagogical research or another advanced degree say in Ethics or Law .  I don’t have that same sense that factors at play in the US are the same in Canada.  Remuneration has changed for all us, however. We used to be able to bill for radioimmunoassays that we supervised but hormone assays are now taken over by the Clinical Biochemists and high throughput analytics. In Canada, we have highly subsidized medical education, so that we do not graduate with crushing debt as in the US.  Most academic centers in Canada have some sort of practice plans or practice pools and do not work strictly on fee-for-service; this has certainly helped us in my center.  In Quebec, we have mixed funding (hourly salary and modest additional fee for services); we can also bill for telephone consultations.  We are working hard to get bone age reading being a billable expense in Canada, although more and more centers are using relatively high cost computer-based assessments of bone age films.  Currently diabetes care is very well remunerated now that we are using pumps – but granted, the care of these patients is more intense.  I don’t know about Europe, and I don’t know how things will evolve.

But to me, what wasn’t mentioned in that article and I think is one of the most threatening aspects for pediatric endocrinology in Canada is not that we’re going to phase ourselves out but that we’re going to move from an academic to a community type of practice as is seen in many, many countries around the world, particularly if the government restricts the number of academic positions but Universities continue to train more fellows.  Academic medicine might also be seen as undesirable if you are carrying a very large debt and you need a revenue-generating type of practice, not as easy to have when you are seeing complex cases in tertiary/quaternary care academic hospitals. Community practice often involves solo clinics, and I have always felt that this is a fast track to loosing skill sets and does not serve patients well.  More heads are always better than one.  I think in the past century that if you look at the Chiefs of Internal Medicine, Chiefs of Pediatrics and even Deans, these were very often held by endocrinologists or pediatric endocrinologists. We have a very challenging specialty, which requires interactions with many other specialties for our complex cases, and this means that we are good at seeing the perspective of other non-endocrine colleagues.  But where are the pediatric endocrinologist chairs – particularly women but also men –  now? I think their numbers are declining. Personally, I know they are in Canada. So there are threats, but I don’t think that ours in Canada are necessarily those in the medical system in the US.

Lars Sävendahl: Thank you very much Cheri for an excellent lecture. If you agree, I will make a few points. First, regarding the association between salaries and gender distribution in Peds Endo. Supporting such an association is my personal experience from running many international courses in Peds Endo over the last 2 decades including the Advanced Postgraduate Course on Growth and Growth Disorders which was started by Martin Ritzén. We have seen a continuous increase in female to male ratio where this year almost 90% of the applicant fellows were female. It is also clear that the female predominance is less pronounced in the Nordic countries where salaries are quite even between specialities/sub-specialities. This observation further supports your point that salary, at least partly, determines what speciality young doctors choose. Second, regarding female representation in our professional societies. I believe a huge change has taken place over the last decade. For example, ESPE in 2014 introduced mandatory dual presidency where the President and vice President must be of opposite sex.

Deal: I looked really hard to try to find the names of the female presidents and they’re not traceable on the website.  It  would be very helpful to put those up. I personally was interested in looking at them.

Ze’ev Hochberg: A question for you, Cheri. Do you feel that it makes a difference whether a child is being seen by a male or female doctor? Particularly in the cases of precious puberty in a girl or a boy with delayed puberty? I hear from a colleague that she finds it difficult to sympathize with a boy with delayed puberty. What do you think?

Deal: This is an interesting question, and we did a little informal internal audit to look at how frequently female colleagues prescribe testosterone for delayed puberty in males versus how frequently it is given it is given by male colleagues.  My impression is that we actually, as women, prescribe testosterone a little bit more frequently. How do female physicians relate to precocious puberty in little girls? All I can say is that from my own personal experience, the parents always tell me, either as they walk into the room and see me or when they walk out: ‘Oh, our daughter is/was so happy that she could see a woman.’ So there’s something about little girls going through puberty being conscious of their bodies that I think makes them extremely anxious about being examined by a male physician.  On the contrary, I think boys with delayed puberty look upon the female physician as a little bit of a mother. They actually like being reassured that there are normal by a mother figure  and I think their own mothers (thankfully) are not comfortable pulling down their adolescent’s pants!  So I wasn’t surprised to see this.  Data does show that older physicians tend to be less interventionist particularly within the range of normal constitutionally delayed or early puberty.

Harvey Guyda: I wondered at the gestation of your EDGE topic, as I have always been surrounded by highly successful women in Ped Endo, most of whom raised a family as well. Here are some examples (from the second half of the 20th century, now retired or deceased):

  • Eleanor McGarry – one of earliest to study use of GH in Canada (therefore linked to Ped Endo), with John Beck at RVH and preceded Henry Friesen. Received CSEM DSA.
  • Beverly Murphy – a pioneer in steroids and pregnancy, origins of Fetal Endocrinology. CSEM Distinguished Service Award (DSA) 1993.
  • Sonia Salisbury – adult endocrinologist by training who succeeded in Ped Endo. CSEM DSA 1994. (two females in a row!)
  • Cindy Goodyer, PhD, who provided leadership with CSEM DSA 2000, an adult organization that accepted her PhD and Ped Endo affiliation.
  • Heather Dean, you know her accomplishments. CSEM DSA 2001 (another two females in a row!)
  • Eleanor Colle – one of earliest to study Ped Endo in USA. One of my main mentors. Raised 5 kids and knitted thousands of items without blinking an eye. Broke the women’s barrier to leadership at McGill. First office at MCH was in a centrifuge room, that I also shared!
  • Ruth Illig – German pioneer in Ped Endo, one of founders of ESPE. I note that the Joint meeting has become ICPE, but that CPEG is not a member. Strange, given that we hosted it in 2001!
  • Selna Kaplan, sidekick to Mel Grumbach, but strong in her own right. One of earliest to treat with GH in USA, principal author in earliest GH reports. Endocrine Society DSA and Koch Award with Grumbach.
  • Jo Anne Brasel (unmarried)- despite her severe medical disability that ultimately claimed her life. She excelled as a teacher and mentor, including to me. President of SPR in1978 and of LWPES in 1992.
  • Ann Johanson (unmarried)- my colleague at Hopkins, died earlier this year. Over 15 years, she developed Ped Endo at University of Virginia and was first female full professor there. Bob Blizzard, her and my mentor, followed her there as Chaiman of Peds. Ann then joined Genentech as first female Director of Endocrinology and was in senior management when they launched their first synthetic GH in 1995.

Deal: Thanks for compiling this list, and as you know, many of them were mentors for me during my training and early career.  I am always happy to honor excellence, and these women deserve cudos.  But we are speaking of statistics, not of stars, when we examine how women are doing globally in medicine.  As you see from the transcript from our EDGE discussion, the data is there, and it is concerning.

The topic of the feminisation of medicine was actually suggested to me by Ze’ev Hochberg (I presumed that not many male colleagues would have accepted to tackle it so I agreed), and as I read more and more, it actually made me sad to see how we are evolving.  This in no way means that I am not proud and often in awe of smart and successful women that I have had the pleasure of working with, just that I believe that everything should be in balance.  And if I am honest – I have always had the most fun on committees and executive boards where there were almost equal gender ratios.  I felt that the thinking was more out of the box, the discussions were more civil (less testosterone-driven??) and there was usually an evolution of the group dynamics in a very positive manner.  So my concerns now are how to keep the guys in Pediatrics…  The point made my Lars Sävendahl is interesting, and suggests that the Nordic countries are on the right track…we need to learn from them.  You may find the references below of interest.

Michael Ranke: Congratulations! This is a wonderful article dealing with numerous aspects of this complex issue. And having not known the content of your presentation in advance my loose comments appear to be not completely appropriate within the context. We need to investigate the gender difference from the disease perspective in children (not only during adolescence). I still think this is somewhat neglected. However, more importantly, about the points you have addressed, it is clear that the gender issue within medicine -specifically ped. endo – is of basic relevance for the development of the specialty in terms of   providing care as well as research and teaching. It is therefore that I think that the societies should embark on joint structured project evaluating the development of the structures – including the gender of health providers – in a selected number of countries with diverse medical systems. A specific aspect within such a project in ped-endo is the academic research settings since these are driving the progress in the field and the structures of education. The discussion of academic developments in males/females certainly plays on the background of the changing qualifications/ techniques which are required to have a successful academic career. The changing demands may also have a different impact on males/female who experience a changing role in private and professional settings.  The information collected will serve the ped-endo societies in their strategic outlook and would greatly help our medical systems in their planning. I can only encourage you to lead such an initiative. Due to the relevance, I assume that there will be funding (if fighting Covid-19 has not used -up all resources).

Deal: Thanks Michael.  As I mentioned in the talk, one of the interesting changes in the data collection of public and private bodies, including medical societies, is the trend not to declare gender, or to drop the question entirely.  Our governments have wrestled with the impact of dropping gender statistics and ethnicity data in an effort to move away from a binary and racist society.  In France, for example, the government does not collect labour force data based on ethnicity. I liken this to trying to treat a patient without a diagnosis: how do you decide if there is a problem to address?  It is suspected that youth unemployment among the Maghrébin (North Africans) in the Paris suburbs is  50%…but where are the solutions if we can’t measure either the scope of the problem or the effectiveness of our interventions?

Returning to your call for the need to collect data within our Pediatric Endocrine societies – I agree of course. The addition of additional boxes to check such as ‘other’ or ‘prefer not to state’ is laudable in that it respects those individuals in the LGBTQ community whose numbers are growing.  However, I really think that it is important that people do have a chance to mark ‘male’, ‘female’ or ‘other’ and that they should not choose a third answer purely for political reasons as I suspect is being done by many ESPE members.  Data on ethnicity is equally important.  How to reassure prospective members that this information is precisely to avoid discrimination and how to explain the importance of these data to them is not easy, but we cannot plan our workforce needs or determine if discrimination exists without the data – for any group – including males!

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