I could start this article by telling you about the disparity between female and male physicians’ salaries. I could tell you that while some female doctors end up in marriages with other physicians, some will end up with a partner who makes significantly less income.  I could even point out that a growing number of female physicians are paying alimony, and the new tax rules of 2019 state that ‘the individual who pays alimony to an ex-spouse will no longer be able to deduct those payments.”  I may mention that being a woman MD makes it harder for us to climb the ladder, especially when our ambition and assertions are often labeled with microaggressions such as “having an attitude” but I won’t be making this my focus. While these things are as real as “man-splaining” they are only a small part of the True Cost of being a female physician. The sacrifices many of us have made, or are making go far beyond the financial.

Lets examine those sacrifices.  I asked a group of amazing female physicians “ what are some of the sacrifices you made to pursue medicine?”

1. Time:

It is by far the greatest sacrifice.  Moments with family and friends slip through our fingers as we try to grasp the pathophysiology of the human body.  Focusing on our goals pull us away from best friend’s weddings and the funerals of loved ones. It is a sacrifice not unique to women in this profession however, time takes from women something so fragile and precious, Fertility.

2. Fertility:

While we are in the trenches of training the tunnel vision places having kids on a back burner.  By the time we realize it is something we would like, it is often too late. The average female physician graduating medical school is between 26-28 years of age. By the time this woman finishes residency she can be anywhere from 29-33 years of age. This of course does not factor in non-traditional students. Fertility begins to take a steep decline by age 32 and advanced maternal age is defined as past the age of 37 . My advice, knowing what I know now, if you are not sure but would like the option to have children in the future, discuss all of your options with your gynecologist prior to the age of 30 even if you are not in a committed relationship.

3. Friendships:

Especially my relationships with non-doctors suffered. The women I still can call a friend to this day I have either known since I was a child, or I met in medical school or residency.   It takes hard work to maintain friendships through the stressors of training.

4. Dating: ( I had to split this in two)
a. Meeting someone is difficult enough, try doing it when you only have limited time and a scarce pool to select from.  The nature of the NRMP (National Residency Match Program) is that we have no real control of where we go for our postgraduate training. You may end up in an area where there is limited cultural diversity and an even more limited dating pool.
b. While men say they are ok with a woman who makes more money than they do, unfortunately most are not.  Often times female physicians will hide their occupations while dipping in the dating pool. I’ve heard fellow docs use flight attendant, nurse, or any occupation to explain their odd working hours.

5. Life Experiences: 
While our peers go travelling and seeing the world, we are focused on visiting perspective schools, and building our resumes to be attractive to potential programs. While some of the things we choose to do are a reward in and of itself, there is nothing quite like experiencing another culture or seeing the stars in a different hemisphere. 

6. Family: 
Because of the grueling schedule and the fact that we may have had to relocate away from our family unit for training, we are not able to share in all of the major family events (weddings, funerals, baby showers etc.) which creates a divide between us and our extended and immediate family members.

7. Mental Health: 
We avoid this conversation like the plague. “In a survey of more than 2,100 female physicians who are also mothers, nearly half believed they met the definition for a mental illness at some point in their careers but had not sought treatment. Two-thirds reported that fear of stigma drove them to keep worries quiet. ” It is time to strip the stigma away. Women of color in particular experience a disproportionate amount of stress especially within the current paradigm that is designed to incriminate and blame physicians for system wide problems rather than accepting fault and addressing issues with policy changes. The long hours worked and the intensity of care coupled with unaddressed emotional and mental stressors can lead physicians to burnout.

8. Money: 
a. Deferred earning. Plain and simple. We make money much later than our non-medical peers.
b. Student Loans: According to the AAMC the average debt for a medical student is $200,000. Some argue that this underestimates the real figures given that this does not truly represent a large number of students, including those who had existing undergraduate debt, or those that attended for-profit medical schools.  Unfortunately, for-profit medical schools are more likely to increase tuition and this is because their incentive structure is wrapped around the focus of rewarding it’s investors. So factoring in these students, the average debt is closer to $400,000. many people equate it to a mortgage, it is not! Unlike a mortgage it is not backed by an asset, it doesn’t vanish in bankruptcy, it has a huge interest rate and it is non-deductible.  If women physicians are making less than male counterparts then they are at a far greater disadvantage with this financial burden. It will make us late to saving for retirement and investments
c. The absence of generational wealth:  Not all of us are born with a silver spoon. Most of us will not have medical school paid for by our parents. Most of us will not inherit a property or a trust fund and so we are starting from scratch. This separation of the haves and have-nots creates dis equity.  That Dis-Equity makes it difficult for us to build future wealth, and so the cycle continues. 
d. Female Tax:  Yes the fact remains that women physicians make an average of 26.5% less than their male counterparts  while it has improved since 2017 the gap still exists especially among the specialties.

This list by no means covers all of the sacrifices but lists those most mentioned.  

I am one of the number of female doctors who are unmarried and have no children.  I put my career and education first, and I don’t regret it.   Someone reading this copy, right now, is shaking their head and cynically thinking “what problems does she have? She’s better off than most of the population.”  Well, there are a few things that I am grappling with, like the possibility that I may never know the blessing of motherhood. I haven't given up completely but I wish I had been more proactive when it came to matters of my fertility.  I am also tackling student loan debt.  Some of you will say, “you don’t have to pay off your student loans right away”, and my answer to you is yes you do.  While they cannot repossess my brain or take back the knowledge I acquired, they can negatively impact my credit score. The same credit score that will be used to determine my ability to buy a home and affect all future purchasing power. A credit score that I have spent a great deal of time building.  And if you understand how building wealth works, debt is your enemy.  I’ve read so many different articles about physicians giving financial advice. And to my disbelief many of these sources have not had to deal with the “boogie monsters” that haunt many of us. Some of us are grappling with student loans the size of mortgages, and rising to a tax bracket and not understanding how to avenue the treacherous new landscape.  There is no class in medical school for money management, investments or creating your financial strategy. Most of us are learning as we go and as we read.  I am not Susie Orman or Benjamin Graham I am not here to tell you how to. I am here to help everyday people, who just happen to be our patients, understand that doctors are feeling it too.  Most of our patients are under this clouded illusion that physicians are automatically rich. This is not the case, especially in 2020. MD does not equal money!

It is my hope that this article sparks a dialogue that brings about a positive change.  I am here to offer a shoulder to my fellow sister MDs and say “You are not alone.”  Each and every one of us made sacrifices to get to where we are.  While we were pursing this lover called medicine, many other things fell to the wayside. By the time we reached a point where we could relax and breathe, many opportunities, we weren’t even aware that we wanted, have evaded us.  It is time to talk openly and honestly regarding this as more female physicians are graduating.  We remain underpaid and experience “burnout” earlier and more frequently than our male counterparts.  While we are outcompeting our male peers and getting higher ratings from our patients, the healthcare sector has yet to close the gap in pay and come up with reasonable solutions for retaining female physicians.

The True cost of being a female physician, is much more than money.  It is a combination of time, relationships and unrealized dreams.  All of which increase stress and anxiety and put a strain on our physical, emotional and mental health.  And because so many times we are seen as superwomen, even by those closest to us, we fight this fight alone.

As Langston Hughes so aptly asked “What happens to a dream deferred? ”

Sources for Part 1 and 2:

1. https://www.vox.com/policy-and-politics/2018/8/6/17657994/men-women-doctors-salaries-pay-gap-voxcare

2. https://money.cnn.com/2018/03/14/news/economy/gender-pay-gap-doctors/index.html

3. Female age-related fertility decline. Committee Opinion No. 589. American College of Obstetricians and Gynecologists. Obstet Gyne-col 2014;123:719–21.

4. https://opmed.doximity.com/articles/the-difficulties-of-dating-while-being-a-female-doctor?_csrf_attempted=yes. Chioma Udemgba, MD • Medicine/Pediatrics
Oct 1, 2018. The Difficulties of Dating While Being a Female Doctor.

5. https://labblog.uofmhealth.org/industry-dx/study-physicians-dont-report-or-treat-their-own-mental-illness-due-to-stigma

6. https://s3.amazonaws.com/s3.doximity.com/pres/doximity_third_annual_physician_compensation_report_round4.pdf. 2019 Physician Compensation Report Third annual study MARCH 2019

7. Hughes, Langston, 1902-1967. (1994). The collected poems of Langston Hughes. New York :Knopf : Distributed by Random House