Burnout in Women Physicians: Prevention, Treatment, and Management

629 Pages·2020·5.274 MB·English

by  Cynthia M. Stonnington, Julia A Files

Burnout in Women
Physicians
Prevention, Treatment,
and Management
Cynthia M. Stonnington
Julia A Files
Editors
123
Burnout in Women Physicians
Cynthia M. Stonnington
Julia A Files
Editors
Burnout in Women
Physicians
Prevention, Treatment,
and Management
Editors
Cynthia M. Stonnington Julia A Files
Department of Psychiatry Division of Women’s Health
and Psychology Internal Medicine
Mayo Clinic Mayo Clinic
Scottsdale, AZ Scottsdale, AZ
USA USA
ISBN 978-3-030-44458-7 ISBN 978-3-030-44459-4 (eBook)
https://doi.org/10.1007/978-3-030-44459-4
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Foreword
Sex as a Biological Variable
Medicine is experiencing a remarkable, truly historical change.
For most of the last 500 years or so, western medicine operated on
the assumption that, outside the body parts directly related to
reproduction (i.e., outside “the bikini zone”), women and men
possessed fundamentally identical biology. We assumed that
when it comes to hearts, livers, bones, immune systems, brains,
you name it, one need not worry about potential sex differences
because, frankly, they did not exist. Any differences that were
detected (such as in sex hormone function) were relegated to non-
fundamental status, something we can figure out after we under-
stand the supposedly fundamental (meaning “shared”) features of
human biology.
It is truly hard to overstate how deeply imbedded was this
view, thus how large is the change now occurring. Driven by an
ever-growing body of research findings, medicine is discovering
that its 500-year-old assumption about sex differences is just
plain wrong. Recognizing this fact, on January 25, 2016, the
United States National Institute of Health (NIH) for the first
time ever established a policy (called Sex as a Biological Vari-
able, or SABV) requiring all research funded by them to care-
fully incorporate the study of potential male/female differences.
And while this policy naturally generated resistance from many
who do not want their research disturbed by having to consider
females, it is truly a landmark moment. The NIH, we promise
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vi Foreword
you, will not abandon this policy, and in effect tell all scientists/
medical doctors that it’s ok to simply go back to ignoring poten-
tial differences in females compared to males.
It is now incumbent on all of us to explore sex influences on
biology assiduously, and responsibly. Fear that sex differences
research might be misused is no more a valid reason to avoid
studying the topic than the fact that genetics has been misused
historically is reason to stop studying genetics. Here we explore a
portion of the burgeoning neuroscience literature especially rele-
vant to the experience of women in the medical field, namely, sex
differences in the neurobiology of stress responses, in particular
social stress.
Fortunately, “social neuroscience” as a field is growing along
with interest in sex influences. More and more studies, both
involving animal and human subjects, examine stress responses
not in subjects in isolation but in response to real social settings.
These studies are of course particularly helpful in understanding
sex differences in response to social situations encountered by
those in the medical field. Both clinical and subclinical (animal)
studies inform the discussion.
Animal research, sometimes dismissed by some as irrelevant
to understanding sex differences in humans, in fact is a powerful
tool for exploring biologically based sex differences in mam-
mals that, while likely influenced to some degree by human cul-
ture, cannot be simply explained by human culture. And stated
simply, these studies are beginning to identify sex-specific vul-
nerability as well as resilience in the brain mechanisms respond-
ing to stress.
Debra Bangasser and her colleagues at Temple University are
among the leaders in this area. They have found that the center of
the brain’s arousal system, a small but powerful brainstem nucleus
called the “locus coeruleus” (literally “blue place”), is far more
sensitive to endogenous stress hormones, and less adaptable to
their chronic hyper-secretion, in females than in males, effects
that becomes apparent during puberty, and are strongly influenced
by sex hormones. Other evidence suggests that females may be
less sensitive than males to the disruptive effects of stress on
attention. Evidence indicates that ovarian hormones can reduce or
Foreword vii
block the impairing effects of stress hormones on the functioning
of attention- related brain systems seen in males. Many of these
findings are relatively recent, since the original research was
almost exclusively done in males.
Several lines of research reveal parallel findings in animal and
human subject work, which of course are especially interesting.
H. Elliot Albers and colleagues at Georgia State University exam-
ine similarities and differences between females and males in the
effects of social interaction with either the same sex or the oppo-
site sex. The existing data suggest that in both rodents and humans,
females find same-sex interactions more rewarding than do males,
a difference some evidence suggests is related to a differential
action of the hormone oxytocin on brainstem circuits.
Also interesting and relevant are recent studies comparing the
consequences of social defeat stress in females and males. Brian
Trainor and colleagues at the University of California, Davis,
were among the first to examine the effects of a social-defeat in
female mice (almost all previous work having been done in male
mice), and found clear differences. Social defeat induced social
withdrawal in female, but not male, mice, an effect which was not
related to circulating sex hormones. They next found that social
defeat elevated levels of a key brain protein (called “BDNF”) only
in female mice. Social withdrawal is a key component of anxiety/
depression disorders which predominate in women, thus these
findings are likely relevant to understanding heightened suscepti-
bility to depression in females.
Trainor and colleagues also report that stress reduces cognitive
flexibility, but mainly in males. They first discovered that, in mice,
social defeat stress reduced “cognitive flexibility” (i.e., the ability
to adapt to novel learning situations), but only in male mice.
Females were not impaired. They then showed the same effect in
humans: An acute social stressor (called the TSST) elevated corti-
sol levels equally in healthy women and men, yet only impaired
cognitive flexibility in the men.
In an interesting summary of their work, Trainor and col-
leagues observe that in females, the effects of social defeat are
generally more consistent with reactive coping strategies (such as
social withdrawal and reduced aggression), whereas behaviors in
viii Foreword
stressed males are generally more consistent with proactive cop-
ing strategies (such as social approach and aggression.)
These studies and many others prove the point: Sex matters,
and it matters in ways we are only beginning to truly grasp, hav-
ing avoided the issue for so long. Having advocated for the sex
difference issue for almost 20 years now, I feel that what is truly
needed now is a clear expression of the experiences of women,
their individual successes and struggles moving into previously
male-dominated fields like medicine. We need acknowledgement
and acceptance and even celebration of sex differences, not their
continued ideological denial. Consider this: If the entire structure
of doctoral medicine was indeed created by and for its almost
entirely male constituency (as it was), and if sex differences truly
do matter, then it is essentially impossible that women should not
have endured far greater distress than males on average in adapt-
ing to that structure. Thus I feel what is really needed at this junc-
ture is a book like this – something that begins to blend the
growing science with the already extensive personal experiences
of women in medicine. Both are needed to fully realize the poten-
tial women offer to medicine and to address those drivers of burn-
out that affect women differently than men. The reader will no
doubt find this book to be satisfying from both a scientific and
personal experience perspective and as a road map to more
rewarding careers for both women and men in medicine.
Larry Cahill, PhD
Professor, Neurobiology and Behavior
University of California
Irvine, USA
Preface
A Commentary on Gender and Nomenclature
We sit at a very interesting and pivotal time in history when it
comes to the understanding of gender. While our awareness of the
social construction of gender itself grows, so do our questions
about the binary attribution of gender characteristics and the divi-
sions of work and talent based on previous notions of those divi-
sions. Social construction of gender refers to those elements of
culture, some that were historically taken as biologically based,
that are now being reevaluated and reconfigured. Saying such
things as “boys don’t cry” or “women should smile more” means
participating in those old constructions of gender that do not apply
to many of the societies we live in anymore. With increasing fre-
quency, individuals problematize those assumptions.
To acknowledge all of the above is not the same as to say there
are no ramifications to being of a certain gender in the world or in
professions, and this book provides ample evidence that being a
woman and a doctor in this time and place presents unique chal-
lenges and risks for burnout, the very subject discussed in these
pages. But how do we conduct these discussions in an increas-
ingly diverse environment regarding the understanding of gender
and gender relations? How do we focus on the challenges to be
dealt with if we do not agree on the language that preambles the
discussions about them in the first place?
First of all, we acknowledge that we are in a social environ-
ment in flux. That means not all members of particular groups,
ix
x Preface
what linguists like myself call “speech communities,” are in
agreement with or at the same stage of understanding of social
phenomena at any given point in time. We conduct research in
highly cross-cultural environments, and understandings of gender
are a part of our cultural considerations. Because this volume is
collaborative and the editors wanted to respect the style and point
of view of each contributing author, every effort was made to
maintain the original stance of the writer. This has repercussions,
for example, for nomenclature. What do we call a woman who is
a physician? Is she a “female doctor”? Perhaps a “woman doctor”?
How do those choices impact the very construction of the
phenomena they describe? The expression “man doctor” is
virtually absent from academic circles, being that “male doctor”
is used almost exclusivey in situations where establishing the
gender is part of the argument and thus necessary. On the other
hand, “female doctor,” some will contend, highlights the biologi-
cal aspects of womanhood sometimes to the detriment of the
social ones.
However, to make decisions about which terms to use to refer
to women based on the terms historically used to refer to men
would be to replicate the same binary I am trying to dismantle in
this text (e.g., women in relation to men, and the absence of
everyone else). Finally, the choice I made in this preface to use
“a woman and a doctor” or “a woman who is a doctor” is less
intuitive and fluent especially when repeated many times, and so
it is understandable that it does not always figure in these
c hapters.
As a result, a decision was made to honor the linguistic choices
expressed in each individual chapter. Some of them do indeed
speak more closely of the biosocial impact of being female (e.g.,
pregnancy, post-partum, hormonal profile). Others might focus on
the more attitudinal aspects of the construction of womanhood,
and might therefore call for different language selections. That is,
both sex and gender play a role in issues faced by women physi-
cians, and the editors wanted to leave each author free to make
those elections based on their unique outlooks and themes of each
chapter. The editors recognize the challenges of editing the work