Yalda Jabbarpour MD, Melina K. Taylor PhD, MPH, Coffman MS, Aimee R. Eden PhD, MPH
Introduction
The COVID-19 pandemic ushered in an era of change throughout society. We have changed how we work, how we attend school, and how we socialize and interact with others. The news media has tracked the ways in which the pandemic has increased domestic and child-related labor due to stay-at-home guidelines, school and childcare facility closures, and intermittent access to basic resources (Boteach, 2020; Graves, 2020; Mystal, 2020). Women in heterosexual relationships continue to shoulder a larger proportion of these increased home and childcare responsibilities, with women reporting reducing work hours by 4 or 5 times as much than men (Collins et al., 2021). Because of the pandemic, women are leaving the workforce at higher rates than men and are reporting higher rates of depression and anxiety (Calarco et al., 2020; Kashen et al., 2020). This “she-cession” has not only brought the ratio of women working to the lowest point since 1988 (at less than 57% as of January 2021), but has implications for stalling career advancement, decreasing diversity in the overall workforce, and eliminating mentorship opportunities for women, with women of color being hit especially hard (Warrell, 2021).
Physicians, like everyone else, have faced these changes and challenges in their personal and professional lives, but have also faced dramatic changes in their delivery of healthcare. The four walls of the exam room no longer existed in an increasingly virtual world. When the four walls remained, they no longer represented a safe space to foster a patient-physician relationship, but instead a barriered new world of communicating through personal protective equipment. International surveys have demonstrated the psychological impact of COVID-19 on physicians, with over half of respondents reporting depression and anxiety (Elbay et al., 2020). Media reports in the US have highlighted the personal sacrifices physicians are making, the rising rates of burnout, depression, anxiety, and even suicide attempts attributed to the pandemic (Khullar, 2020; Pappa et al., 2020; Roy, 2020). While COVID-19 has impacted all physicians and healthcare workers, the pandemic compounded the pressures on women physicians, particularly those who are also mothers (Brubaker, 2020; Delaney et al., 2021).
As the largest employment industry in the U.S., the healthcare sector is dominated by women workers (Luthra & Carrazana, 2021). While physicians are among the most economically privileged (Occupational Outlook Handbook, 2021), women physicians still face gendered challenges, including unique gendered pandemic-related ones (Brubaker, 2020; Jones et al., 2020). Women physicians are more likely to be employed in lower paying specialties such as family medicine, pediatrics, and gynecology to be junior physicians; and to reduce their work hours to part-time or leave their jobs entirely six years after residency (Luthra & Carrazana, 2021). Studies that have examined the impact of COVID-19 on women physicians found decreased scholarly productivity which is predicted to contribute to future delayed academic advancement (Society of General Internal Medicine’s Women and Medicine Commission et al., 2020; Kibbe, 2020). Medical societies have held panel discussions on the differential effects on the pandemic on women physicians and have published recommendations for helping women physicians tackle the challenges they have faced, particularly in academia (Berg, Sara, n.d.; Das et al., 2020). But, few studies to date have examined the work-life experiences of women physicians, and particularly physician-mothers, during the COVID-19 pandemic on a national scale. In primary care, where women are entering the workforce at higher rates than men, it is especially important to understand the impact of COVID-19 on women physicians (Association of American Medical Colleges. 2019 Fall Applicant, Matriculant, and Enrollment Data Tables, 2019; Wilkinson & Jabbarpour, 2021). Our objectives were first to explore the gendered professional and personal experiences of being a woman primary care physician during the COVID-19 pandemic in the U.S., and second to understand how motherhood impacted those experiences.
Theoretical Framing
Our paper uses O’Reilly’s (2019) concept of “matricentric feminism” to understand the unique experiences of women who are also mothers in the healthcare workforce during a heightened peak of stress and anxiety. Matricentric feminism establishes a feminist perspective that recognizes the unique position of mothers as doubly oppressed – as both women and as mothers – under a patriarchal system. This intersection between woman and mother allows an exploration of the particular experiences, forms of work, and layers of oppression faced by mothers (O’Reilly, 2019). This line of critique is built upon Rich’s “two meanings of motherhood:” the experience of mothering through embracing reproduction and her relationship to children, and the institution of “motherhood” which defines and reinforces patriarchal systems of control (Rich, 1995) . While Rich’s second-wave feminist theory was initially proposed in the mid-1970s, the institutional guiding framework of “motherhood” is still deeply engrained in our patriarchal-capitalistic society, as illuminated by the COVID-19 pandemic and the gender-binary roles of domestic duties and childrearing that have forced hundreds of thousands of women out of the workforce within the last year.
In this study, we employ a matricentric feminism perspective to examine the experiences of women and mothering primary care physicians at work and at home during the COVID-19 pandemic, a period of increased uncertainty, stress, and anxiety. Centering the experiences of mother-physicians during the pandemic allows us to interrogate the patriarchal social and biomedical system in which mothers work and to identify the ways in which the system needs to be modified to ensure that physician-mothers are supported and valued in their multiple caregiving roles—in the work they do as physicians and as mothers.
Methods
The research team, which consisted of two family physicians, two medical anthropologists trained in mixed methods research, and an experienced qualitative researcher, created a survey distributed via Google Forms to physicians in the United States during the early stages of the COVID-19 pandemic. The survey was open from May 1 to June 5, 2020 and consisted of 16 demographic questions, two Likert scale questions, and six open ended text response questions designed to explore the work and home experiences of physicians during the pandemic (Appendix). We included analyses of five of these open response items for the purposes of this paper.
To get a rapid response and reach a targeted population of primary care physician-mothers, we used a multifaceted purposive, social media-based, sampling strategy to distribute the survey (Thornton et al., 2016). First, we posted a recruitment message with a link to the survey to a closed Facebook group comprised of women physician-mothers. Two members of the research team, both women physicians, are members of the Facebook group (and one is the Facebook page’s moderator); they posted the recruitment message once every other week for 6 consecutive weeks. The link was also shared via Twitter by The Robert Graham Center for Policy Studies in Primary Care (RGC), and via email listservs by the RGC and the American Board of Family Medicine (ABFM) research team. Participants consented to participate prior to completing the survey. This study was approved by The American Academy of Family Physicians’ Institutional Review Board.
We conducted basic descriptive statistics on the demographic questions and Likert scaled items. Thematic analysis of four of the open-ended responses was conducted by five members of the research team, led by two experienced qualitative methodologists. A priori codes were defined based on the survey questions and initial research hypotheses informed by existing literature. Using an immersion and crystallization approach, additional emerging codes were identified through reading the comments (Crabtree & Miller, 1999). The research team discussed and refined these emergent themes during regular group analysis meetings. Next, teams of two researchers worked together to code all participant responses to each of the five long-form open-text survey questions, and discrepancies were discussed by the full team for consensus and to reach inter-rater agreement. Coding was conducted in Excel, and code frequencies were generated. We did a simple word frequency count for the open-text question that asked for “one word or phrase to summarize the last month.”
Results
Surveys were completed by 119 physicians, 89.2% (n=106) of whom were primary care physicians (Family Medicine, General Pediatrics and General Internal Medicine physicians). Of the primary care respondents, the majority were family physicians (92.5%, n=98/106). Most (84.0%) respondents were female married or in a committed relationship (88.2%), and had children living in the home (67.2%). Because the aim of this paper was to understand the impact on female primary care physicians, male (n=19) and female non-primary care (n=11) respondents were excluded, leaving 89 women primary care physicians in our sample.
Of these 89, 68.5% had children living in the household. The average number of children for respondents was 2.2. Table 1 presents demographic information of the participants, broken out by those with and without children living in the household. For purposes of this study, respondents with children who did not live in the home during the pandemic were considered participants without children. Compared to women physicians without children, those with children were slightly older, more likely to be White, married or in a committed relationship, have a working partner, practice in a hospital or health system, and practice in a rural or micropolitan area.
Table 1. Participant Demographics
| all PC women (n=89) | with children (n=61) | without children (n=28) | ||||
| CHARACTERISTIC | n | % | n | % | n | % |
| PRIMARY CARE SPECIALTY | ||||||
| Family Med | 83 | 93.3% | 55 | 90.2% | 28 | 100.0% |
| General Internal Med | 4 | 4.5% | 4 | 6.6% | 0 | 0.0% |
| General Pediatrics | 2 | 2.2% | 2 | 3.3% | 0 | 0.0% |
| AGE | ||||||
| 30-39 | 43 | 48.3% | 26 | 42.6% | 17 | 60.7% |
| 40-49 | 27 | 30.3% | 23 | 37.7% | 4 | 14.3% |
| 50-59 | 13 | 14.6% | 10 | 16.4% | 3 | 10.7% |
| 60-69 | 6 | 6.7% | 2 | 3.3% | 4 | 14.3% |
| RACE/ETHNICITY | ||||||
| White | 69 | 77.5% | 53 | 86.9% | 16 | 57.1% |
| Asian | 8 | 9.0% | 4 | 6.6% | 4 | 14.3% |
| Black | 6 | 6.7% | 1 | 1.6% | 5 | 17.9% |
| Other | 5 | 5.6% | 2 | 3.3% | 3 | 10.7% |
| Hispanic | 4 | 4.5% | 3 | 4.9% | 1 | 3.6% |
| Missing | 1 | 1.1% | 1 | 1.6% | 0 | 0.0% |
| FAMILY | ||||||
| Married or Committed Relationship | 77 | 86.5% | 58 | 95.1% | 19 | 67.9% |
| Partner working | 59 | 66.3% | 44 | 72.1% | 15 | 53.6% |
| Children living in household | 61 | 68.5% | 61 | 100.0% | 0 | 0.0% |
| PRACTICE TYPE | ||||||
| Federal or Govt | 31 | 34.8% | 16 | 26.2% | 15 | 53.6% |
| Hospital/Health System | 31 | 34.8% | 23 | 37.7% | 8 | 28.6% |
| Independently owned medical practice | 14 | 15.7% | 10 | 16.4% | 4 | 14.3% |
| Academic/Residency | 4 | 4.5% | 3 | 4.9% | 1 | 3.6% |
| Other or missing | 9 | 10.1% | 9 | 14.8% | 0 | 0.0% |
| PRACTICE SIZE | ||||||
| 6-20 | 34 | 38.2% | 25 | 41.0% | 9 | 32.1% |
| >20 | 30 | 33.7% | 19 | 31.1% | 11 | 39.3% |
| 2-5 | 19 | 21.3% | 14 | 23.0% | 5 | 17.9% |
| solo | 5 | 5.6% | 2 | 3.3% | 3 | 10.7% |
| missing | 1 | 1.1% | 1 | 1.6% | 0 | 0.0% |
| PRACTICE SETTING: GEOGRAPHY | ||||||
| Rural (<20,000 population) | 18 | 20.2% | 15 | 24.6% | 3 | 10.7% |
| Micropolitan (20,000-250,000 population) | 31 | 34.8% | 24 | 39.3% | 7 | 25.0% |
| Urban (250,000+ population) | 40 | 44.9% | 22 | 36.1% | 18 | 64.3% |
Many physicians in our sample reported that gender impacted their experiences during COVID-19, particularly at home. Nearly 55% of respondents rated the impact that gender had on their home experiences a 4 or 5 on a 1-5 scale with 5 representing greatest impact (Figure 1).
Figure 1. Extent to which gender impacts experiences at work and at home during the pandemic
When stratifying this data to account for motherhood, those with children in the household reported a greater impact of COVID-19 at both home and work. While 67% of women physicians with children rated the impact COVID-19 had on their home life as 4 or 5, only 25% of women physicians without children did. A similar pattern was seen when asked about the impact of gender on their work lives. Forty-one percent of women physicians with children rated the impact COVID-19 had on their work life as a 4 or 5, as opposed to 17% of women physicians without children (Figure 2).
Figure 2. Extent to which gender impacts experiences at work and at home during the pandemic, by motherhood status
For each open text question, multiple themes emerged. Table 2 presents the primary theme, identified by frequency, that emerged for the four open text questions included in this paper. A more nuanced discussion of these primary and other themes by survey question follows.
Table 2. Frequency of Primary Themes from Open Text Responses
| Open text question | Primary Themes | Frequency |
| Describe the changes you have had to make at home or in your personal life due to the pandemic. | Physical/processual changes to ensure safety of family, patients, and selves Logistical changes related to care and education of children | n=72 n=39 |
| What are you most anxious/ nervous/ worried about with work (as it relates to COVID-19)? | Concern about the health or exposure to COVID-19 of self, family, staff/colleagues, and/or patients | n=68 |
| Since COVID-19, describe the challenges you are facing at work and/or home? | Emotional toll—stress, fear, exhaustion, burnout Childcare –supervision/homeschooling Impact of COVID-19 on work hours | n=43 n=31 n=26 |
| Describe how COVID-19 has impacted your work-life balance. | Negative direction—blurred lines between home/work | n=44 |
Changes to home and personal life
The question “Describe the changes you have had to make at home or in your personal life due to the pandemic” prompted three types of comments. First, many communicated changes that were largely physical or processual, related to safety measures; second, respondents described changes that were practical or logistical, primarily related to care and education of children, but also to domestic duties and work location; and third, many expressed changes that had a socio-emotional element, related to social isolation from family and friends or finding new ways to maintain emotional and mental health.
Most respondents described physical and processual changes in their behaviors to ensure the safety of their families, patients, and themselves. For example, 39 physicians mentioned some form of social distancing:
“We are staying home to eat every meal where we used to eat out most nights. We are only going out to work and food shopping once per week and wearing masks for the grocery store.” (50’s, one child at home)
Many (n=25) described adding the process of decontamination to their routine to keep everyone safe. The vast majority (22/25) were mothers:
“My coming home routine: I am either at the office doing telemed or at the hospital doing maternal-child care (deliveries, newborn care). I wear a mask in and out of work to my car. I use hand sanitizer in my care on my hands, steering wheel, and shifter. I come home and shower immediately. I spray all doorknobs and my phone. I don’t touch my kids until after I shower.” (30s, two children at home)
Another described her pandemic routine:
“I get undressed from my work clothes in our garage. I place my clothes and shoes directly in the washing machine there. Then I scrub my hands and arms in the sink in the laundry room in case I need to touch anything in the house. Then I head straight for the shower as soon as possible before coming in contact with my husband or children.” (30’s, two children at home)
Logistical changes were noted by many. Participants with young children living in the home often discussed changes and challenges related to childcare (n=25). For example, one physician said:
“I made the hard decision to keep our young kids at home even though daycare remained opened. I felt the exposure not only at school, but also my own children’s exposure to me that they would bring to school was too much. Every day is a challenge trying to figure out work and balancing childcare. My husband and I have lots of discussions and contingency plans if my risk changes at work and how that would look. We have plans in place if I have to be separated from my family, thankfully that hasn’t happened yet.” (30’s, two children at home)
Another noted:
“Biggest change was finding emergency childcare. The only option was through the YMCA.” (40’s, one child at home)
For physicians with school-aged children, changes related to school and homeschooling were noted (n=9). One commented:
“I try to get as much homeschooling done in the mornings prior to doing telemedicine in the afternoons. Whatever schoolwork my kids do not get done just doesn’t get done.” (30’s, three children at home)
Even physicians with adult children noted changes associated with COVID-19 (n=5):
“My two children who were away at college came home to do their spring quarter studies from their bedrooms.” (50’s, two children at home)
Changes in how domestic duties such as cooking, cleaning, and laundry are completed were noted by 18 women physicians, both with and without children. One said, “Can’t have cleaning lady in until we know more. More cooking. More cleaning.” (40s, two children at home), while another provided a bit more detail:
“Our babysitter is elderly and can’t safely work with us. She did the laundry, walked the dog, and watched my son 2-3 nights a week. We now do most of these things ourselves again. I typically do more of the work. My husband does less of the work.” (30’s, one child at home)
Work-related logistical changes were also described (n=18); for example, one physician noted:
“I live with my partner and we have navigated working from home well. Sectioning off each room to have a purpose, staying on task together.” (30’s, no children at home)
Many respondents described social changes that often included an emotional aspect. Changes associated with social isolation were commonly noted (n=50) by women physicians with and without children; some examples include:
“Loneliness from inability to participate in get together with family and friends.” (40’s, two children at home)
“For a long while I did not visit my 92-year-old mother but after a while I started going over there with a mask because it seems to really help her.” (60’s, two children at home)
“Staying at home, avoiding the dog park, not going to church, seeing my therapist remotely, not being able to walk with friends or meet people for coffee or dinner. Not being able to go to coffee shops to write.” (30’s, no children at home)
Other social changes described by many physicians with and without children revolved around activities or events (n=17) or health habits (n=12).
“Started to exercise at home, cook more, clean more. Working from home means I have to force myself to walk outside for my sanity.” (30’s no children at home)
“Not going to restaurants, decreased socializing, and decreased overall entertainment (canceled concerts, travel, etc).” (40’s, no children at home)
For women physicians with children, spousal support during the pandemic was sometimes described (n=12).
“My husband just gave notice at his job so he can be home full time with the kids. With the uncertainty of camp and what school in the fall will look like, the current situation of having two full-time working parents was very stressful and so we had to make a change. As a result, I will need to increase my hours at work as a PCP.” (40’s, two children at home)
And:
“We have no childcare and both my husband and I work full time. We have developed schedules to trade off childcare/home school with designated working hours. In my nonclinical weeks I take the majority of those hours, while he does so during my clinical weeks.” (40’s, three children at home)
Work Worries
The question, “What are you most anxious/nervous/worried about with work (as it relates to COVID-19)?” elicited concerns about everything from personal safety to hospital surge capacity limits. Personal health (n=32), family health (n=32), and patient health and healthcare (n=30) were the most frequently cited concerns described in the context of their work. “I don’t want to get sick with Covid-19, and don’t want to bring it home,” (50’s, one child at home) is reflective of many of the stated concerns women physicians listed.
Women physicians were worried about a wide range of issues related to their personal health and the health of their family. Mothers mentioned how their exposures at work would impact their children. One specified, for example, “Dying and leaving my children motherless,” (40’s, two children at home) was her largest concern. Many of the health concerns mentioned were tied into the safety of the workplace. One physician mentioned that she was anxious because she was “pregnant with a history of recurrent [pregnancy] losses and seeing patients in clinic with just a surgical mask,” (30’s, six children at home).
Some respondents focused on how the pandemic would affect primary care, the healthcare system, and the health of their patients. Although not directly related to their caregiving activities at home, this highlighted the caregiving roles women physicians also take in the workplace. Women physicians voiced concern over their patients and how they would be cared for, or not cared for during the pandemic, and the long-term catch-up that will need to happen to maintain people’s health.
“The breakdown of primary care, the loss of long term relationships as we continue telephone based care, large shifts in patient expectations, exacerbations in health disparities among my patients of color, and the many years of “catch up” that will be required to make people healthy again that have been avoiding routine chronic disease management.” (30’s, no children at home)
Other respondents expressed specific concern for their patients of color who are being disproportionately harmed by COVID-19. One physician stated,
“I’m worried about coworkers and patients dying. I’m primary care in an urban underserved area and most of my colleagues and patients are people of color and at higher risk of dying.” (30’s, two children at home)
COVID-19 Related Work and Home Challenges
In response to the prompt, “Since COVID-19, describe the challenges you are facing at work and/or home,” physicians described a variety of challenges and concerns that spanned the realm of work experiences and domestic responsibilities; often the work and life challenges overlapped. The three most frequently mentioned themes were the emotional toll of the pandemic on their mental health (n=43), childcare issues, including supervision and homeschooling (n=31), and the impact of COVID-19 on their work hours (n=26).
The emotional toll the women physicians experienced during the early months of the pandemic was prominent in their responses addressing the challenges they were facing. Common themes of managing anxiety, increased stress from both work and home, and social isolation from friends and family highlight the mental burdens women physicians were dealing with daily. The emotional toll the pandemic was taking on women was evident in those with children and those without. One physician noted, “Finding balance between work and home is more difficult than ever before,” (30’s, two children at home) and another said they were experiencing, “changes in social life leading to increased feelings of isolation,” (30’s, no children at home). Another stated,
“Will I be able to keep my job? Can I possibly buy or afford a house [deleted area] and be outside a little more? Will I become infected? I have health risk factors and one mask for work. There’s too much work to do as a medical educator during this time, but higher expectations and there just isn’t as much time.” (40’s, no children at home)
This emotional toll was also mentioned in responses regarding childcare issues, including feeling anxious or guilty about decision-making concerning who to leave children with while at work, how to homeschool while simultaneously working, and how these decisions may impact their children for years to come. One physician addressed the difficulties of planning long-term during the pandemic, “Anxiety about not being able to make future plans for childcare,” (40s, three children at home). Another commented on difficult decisions she had to make:
“Balancing children, especially young children, and work is tough! I think daycare is open for essential workers but making the decision that it’s the best choice for our children is tough.” (30s, two children at home)
The women physicians who had children expressed the additional emotional burden of raising children during this stressful time.
“I also feel very guilty not having time to homeschool my child (whose school is closed) because I’m still working full-time.” (30s, two children at home)
Closely associated with all these themes were comments related to the amount of time physicians were working, with some working increased amounts of hours, while others had their hours cut.
“Productivity. We all want to keep the lights on and keep our jobs. I work in a large group practice and we have had to furlough people, which feels horrible. We have to focus on budgets and seeing patients, but we also have docs who do inpatient work and the realities of surge planning…I do OB care, and I live close to the hospital. Normally, I would go home if a patient was remote from delivery, but I don’t want to expose my family going back and forth to the hospital. So, I just stay there. I am currently waiting for a patient to deliver and had been here for a delivery yesterday, so I haven’t been home in over 36 hours.” (30’s, two children at home)
The issue of time led many respondents to note the impact of time at work on their personal lives and mothering role.
“Rolling out new schedules, PPE rules, enforcing physical distancing at work. Office in the midst of preparations for FQHC transition and all that work continues. Work has way overwhelmed the work/life balance and it feels like in order to keep an income, I will have to keep working more and more. My kids are teens, but they still need some guidance and supervision.” (40’s, two children at home)
COVID-19 impact on work-life balance
When asked to describe how the pandemic impacted work-life balance, there was a mix of responses. While most felt that their ability to balance work and life had worsened (n=44), some felt it had improved (n=30), and others described a fluctuation throughout the beginning of the pandemic (n=23). Those who felt that their work-life balance was worse overwhelmingly described the idea of blurred lines now that their work environment had moved home.
“Everything is a bit blurred. The most challenging thing has been trying to complete my charts – after patient visits are done, or even in-between them, I am constantly jumping up to try to attend to the needs of my kids, and charting tends to get pushed to later and therefore piles up.” (40’s, two children at home)
For those with children, these blurred lines made the work/home balance increasingly stressful.
“There is no work-life balance. Increasingly I am doing work tasks at home. And when I am at home trying to complete tasks, my children who are very young, want to interact and play. This increases tension in some aspects.” (30’s, two children at home)
Some mothers even alluded to the notion that now they are constantly in a caregiving role, both at work and at home. “With my children not going to daycare, my day is either spent in clinical care or taking care of them.” (30s, two children at home)
The pandemic resulted in better work-life balance for more than a third of women physician respondents (n=30), with and without children, for a variety of factors including lower patient volume (n=25) and less commute time (n=10).
“I actually feel like my work life balance has perversely improved with Covid. I do more telehealth (no need to commute) and I have way more empty slots in my roster because many people are afraid to come in.” (30s, two children at home)
“I am surprised to say it, but my work-life balance has improved. I am seeing less patients than normal, so I have more time to talk with them and more time to get my notes done before the end of the day.” (30’s, one child at home)
Another common response was the concept that regardless of the number of hours worked or whether they had children in the household, they were more emotionally exhausted (n=25). For example, one physician said, “Working overall less, but feeling more drained,” (30’s, no children at home) and another commented, “I am at the point of complete emotional and mental exhaustion,” (30’s, no children at home).
Early COVID-19 Experience
A final question asked participants to provide “one word or phrase to summarize the last month,” which would have been late April through late May 2020. Figure 3represents the frequency of terms used and shows that a sense of uncertainty and chaos along with exhaustion and stress, were common sentiments at that point in time.
Figure 3. Word Cloud showing frequency of response to “one word or phrase to summarize the last month” (April-May 2020)
Discussion
During the summer of 2020, women primary care physicians in our study had a variety of experiences during the COVID-19 pandemic. For some, the pandemic brought improvements into their work-life balance, but for most the pandemic caused increased stress and anxiety at work and home. These responses did not follow any obvious patterns based on the physicians age, race, or rural/urban setting. Uncertainty was the dominant theme nearly all the respondents used to describe their pandemic experience. However, while mothers reported concerns about work stressors in similar ways as their colleagues without children, mothers described additional concerns and challenges associated with childcare, and more frequently reported concerns about bringing COVID-19 home to their family members.
Physicians are caregivers at work, though caregiving in this formal and professional role is undertheorized (Boumans & Dorant, 2014). Physicians who are mothers are also caregivers at home, and during the COVID-19 pandemic, reconciling these double-duty caregiving responsibilities (Ward-Griffin et al., 2005) became increasingly difficult. Physician-mothers were balancing patient care with childcare since schools and daycares were closed. Meanwhile, at work, many respondents highlighted the lack of protocols to keep themselves and their patients safe and worries regarding bringing COVID-19 home to their family members. The stress and anxiety of managing the caregiving roles was obvious throughout the comments in our study both from mothers and non-mothers. But, for mothers, the dual experience of womanhood and motherhood as described by O’Reilly and Rich exacerbated the caregiving burden during the COVID-19 pandemic. This disproportionate caregiving burden has affected the mental health and wellbeing of women worldwide, and has impacted their ability to stay in the workforce (Hillier & Greig, 2020). As our study demonstrates, in primary care, where women already reported high rates of burnout pre-pandemic, women physicians perceived higher levels of stress and anxiety to the personal and work lives due to COVID-19, threatening to exacerbate the already growing problem of physician burnout and turnover.
As the physician workforce, particularly in primary care, becomes increasingly dominated by women, attention to gendered experiences in the workforce has gained more attention. It has well been established that women shoulder the burden of parenting and related domestic responsibilities in heterosexual relationships (Thistle, 2006). In order to keep women physicians in the workforce there needs to be more investment into the social safety net in the United States (Calarco, 2020). Likewise, employers of women physicians have a role in ensuring that mothers and all parents have support to care for their families while continuing to care for patients. Childcare options at work should not be an exception, but the rule. Nearly 40 years ago, the Journal of the American Medical Association published an editorial calling for improved childcare options for healthcare workers (Ricks & Ricks, 1983). The pandemic proved that, unsurprisingly, little to no progress had been made towards this goal in the last four decades. Parents were scrambling to find childcare so that they could provide a public good of caring for sick patients during a pandemic. Medical students throughout the country were filling the void of childcare as their clinical rotations shut down (Lee, 2020). Some jurisdictions were allowing daycares to stay open for essential workers only when schools closed down (Poon et al., 2020). But these makeshift solutions do not solve the long-term issue of supporting mothers in the workplace. Interventions such as childcare on site, flexible schedules and job shares have been tried by some healthcare systems as more effective solutions and should be replicated throughout the country (Choo et al., 2016).
A matricentric feminism perspective highlights the need for long overdue investment in social safety net and community support and provides a clear distinction between the needs of women in the workforce and the needs of women who are also mothering while working. Policies for affordable and accessible childcare, paid family leave, flexible work schedules, and caregiving support are all social initiatives that can directly impact the unique needs of women who are mothers (Jones et al., 2020).
An interesting finding to our study is that some women physicians, including some mothers, reported doing better during the pandemic. Because this survey was administered in the earlier months of the pandemic, it is hard to know if this sentiment persisted. Some attributed these improvements to life slowing down in general with less activities. But others mentioned that the decrease in patient volumes allowed them to spend more time with the patients, and for those providing care via telehealth, the lack of commute allowed for more time with family or doing other activities. Incorporating telehealth cuts down on commutes and transitioning to payment models allows for lower patient volumes and lessens the burden on clinicians, and these are changes that health systems might incorporate as they recalibrate patient care post-pandemic to support women and mothers in medicine.
Our study had a few limitations. Because of the nature of social media and email listservs as a recruitment tool, we did not have a good sense of how many physicians were sent the survey, so a response rate could not be calculated. We did have respondents in all demographic categories, across every geographic setting, and in every type of practice setting, yet some demographics were underrepresented. The small sample size prevented us from being able to stratify responses by demographics and may not represent the experiences of all women primary care physicians. Additionally, since our survey specifically asked whether respondents had children in the home, we did not capture the unique experiences of mothers with children who live outside the home. Finally, our survey was conducted in the early months of the pandemic and therefore may not reflect the current experiences of women primary care physicians given the evolution of the pandemic over time.
Conclusion
Primary care physicians, a growing number of them women, play a critical role in the U.S. healthcare system. As the primary care physician workforce shifts and a larger proportion are women, more physician-mothers will face the challenges and lack of institutionalized support inherent in the current patriarchal biomedical system. The stories told by this group during the pandemic highlighted issues in the healthcare system and society that impact the experiences of women physicians and demonstrated how mother-physicians face unique and additional challenges. Future studies should evaluate the role the COVID-19 pandemic had on the primary care workforce in the U.S. with a specific emphasis on how the pandemic impacted mothers, and should more intentionally consider the further intersections of race and ethnicity in the experiences of physician-mothers. Understanding the negative and positive impacts of the pandemic can help enable health system changes that will prevent burnout and sustain these essential members of the healthcare workforce.
Acknowledgments: The authors would like to thank Elizabeth Wilkinson, BS and Kim Yu, MD for their contributions to the study on which this manuscript based.
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Appendix 1. Survey Questions
| Individual Demographic Questions (Multiple choice) |
| What is your specialty? |
| Do you practice in the United States? |
| Which of the following describes your principal practice site? |
| What is the setting of your principal practice? |
| How many hours did you spend on work in the last week? |
| What is your age? |
| Select the race with which you most identify. |
| What is your ethnicity? |
| What is your gender? |
| Family and Motherhood Related Questions (Multiple Choice) |
| Are you married or in a committed relationship? |
| Is your partner working? |
| Do you have children living in your household full or part time? |
| If you do have children, how many children live in your household full or part time? (Fill in) |
| What are the ages of the children who live in your household full or part time? (Select all that apply.) |
| Open-Text Questions |
| Describe the changes you have had to make at home or in your personal life due to the pandemic. |
| What are you most anxious/nervous/worried about with work (as it relates to COVID 19)? |
| Since COVID 19, describe the challenges you are facing at work and/or home? |
| What strategies are you using to cope during this challenging time? |
| Describe how COVID 19 has impacted your work-life balance. |
| Limited Text Response |
| If you could use one word or phrase to summarize the last month, what would it be? |
| Likert Response |
| During this pandemic, to what extent do you think your gender impacts your experiences at work? |
| During this pandemic, to what extent do you think your gender impacts your experiences at home? |
- JourMS - 