Cite as: Lawrence KR, Sharma G, Graaf V. The pain medicine paradox: why women avoid this field, and what can be done about it. ASRA Pain Medicine News 2022;47. https://doi.org/10.52211/asra110122.049 

Current Trends

It is a well-known fact that there are some medical specialties where females are woefully underrepresented.¹ Whether due to the stigma surrounding these specialties or the work-life balance that working women wish to achieve, there may always be a lack of female representation in medical fields that are procedural heavy. In line with the recent trend, interventional pain medicine is one of the subspecialties lacking representation. Out of all currently practicing pain physicians, only 18% are women.² Among pain fellows, that number is only 23%.² The 2021 match results have not been encouraging either, with only 26% of female fellows matching into pain management according to the National Resident Matching Program statistics.²

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With the increased awareness and action taken toward gender equity over the past 100 years, why is this still a problem in pain medicine? 

Pain medicine as a fellowship can be achieved through the successful completion of anesthesiology, physical medicine and rehabilitation, neurology, internal medicine, emergency medicine, or psychiatry residencies. There are striking differences in the ratio of males to females among each of these individual specialties, which seems to have no bearing on the ratio of males to females that pursue pain management fellowships. In anesthesiology, only 32.8% of all residents are female. Similarly, only 34.8% of all residents are female in physical medicine and rehabilitation. Contrast that with neurology, where 46.5% of all residents are female, and psychiatry, where 49.1% of all residents are female.²  Furthermore, the two specialties that contribute the most matched fellows into pain medicine are anesthesiology and physical medicine and rehabilitation, which further exacerbates the lack of fellows that are female.

Statistics show that the lack of representation of female physicians with respect to leadership roles or academia extends to positions including program director, division chief, professors, and researchers in pain medicine. Out of 109 accredited pain management fellowships that the authors researched across the country, only 29 had female program directors and only 19 had female division chiefs. Similarly, a survey in 2014 showed that only 18% of full professors in pain management departments and 10% of academic anesthesiology department chairs were female. This trend is in line with other procedural specialties over the past 10 years.³

Why Is This the Case?

With the increased awareness and action taken toward gender equity over the past 100 years, why is this still a problem in pain medicine? The proportion of male-to-female residents is significantly higher in procedure-heavy specialties.¹ This distribution alone is multifaceted: women have historically prioritized patient relationships over financial compensation, and whether by choice or perceived obligation, women have historically worked fewer hours overall due to the concurrent childcare and household responsibilities.¹

Pain medicine, therefore, is somewhat of a paradox in the medical world. In a specialty where physician quality of life, clinic hours, call schedule, and operating room/procedure time are highly customizable from one practitioner to another, the proportion of women that enter this field is still comparatively small. Pain medicine is one of the most conducive specialties to women who have other life obligations but still desire a fulfilling career.¹ If the nature of the career has been ruled out as a cause of few female applicants, one could reason internal factors may contribute more to the dearth of women than external factors such as lifestyle.

The lack of women in pain medicine may indeed be a self-perpetuating problem. Potential applicants may view the lack of female representation as a sign that this career path is unfriendly to female physicians and may, therefore, avoid applying. This perceived hostility is perpetuated  by the fact that pain physicians tend to share patients with male-dominated specialties such as orthopedic surgery and neurosurgery.¹  Additionally, a lack of role models of one’s own gender in a specialty of interest is often enough to deter medical students and residents from pursuing a career in pain medicine.⁴ One could argue that these medical students should seek out role models and mentors regardless of their gender; however, there are perceived challenges to this approach as well.

Barriers to entrance into a pain medicine career also extend into the relationships that men and women have in a professional setting in general. The tendency for women’s pain complaints to be exaggerated or blamed on psychosocial factors⁴, combined with incidences of sexual harassment in the workplace, are unfortunate but still common. Unequal networking opportunities for women, the tendency for accomplished women to have their titles ignored or misrepresented, and a general lack of women on hiring committees also occur.⁵ All of these factors combine into the perfect storm that creates a hostile perception toward women in certain careers, with pain medicine being among them.

Notably, national organizations like ASRA Pain Medicine have increased their efforts over the past few years to increase representation for their female members, including the Mentor Match Program, increased networking opportunities, and increased numbers of role models of the same gender.  

Importance of Change

Interestingly, women constitute the majority of the chronic pain population.⁶ Pain itself is a subjective and nebulous experience, with expression, perception, description, and coping mechanisms being very different between the two genders. Historically, men have been described as stoic and women have been described as emotional, which we know now is not the case, nor should it be.⁶ What should be the case, however, is for patients to feel understood and listened to by their physicians and for physicians to have empathy and the ability to connect with their patients, which will almost certainly achieve better treatment outcomes.

Female patients tend to feel more comfortable when discussing personal issues and diagnoses with physicians that are women themselves.¹ Additionally, there are many other aspects of women physicians that can lend themselves to an improvement in the overall quality of pain medicine and treatment outcomes for its patients. For example, female physicians tend to spend more time on average with each patient which has been shown to improve patient satisfaction and retention.¹ Furthermore, female physicians tend to have fewer litigation issues and have been shown to follow evidence-based practice guidelines more often than their male counterparts.¹ All of these attributes would help to improve the field as a whole and foster trust between patients and physicians if a more proper balance of men and women in pain medicine could be attained.

How Can We Implement Change?

A multifaceted and stepwise approach is essential to facilitate change and attract more female physicians into pain medicine. The first step is to increase visibility of, exposure to, and awareness of the field. Leaders within the pain medicine community should be taking strides to reach out to female trainees and enlighten them on all the exciting aspects as well as the work-life balance pain medicine has to offer. Many medical students have no exposure to certain specialties the entire time they are enrolled, and reaching trainees at an early stage is a great way to change both perceptions and awareness. Programs should be put in place for medical students to seek shadowing opportunities, mentors, role models, research opportunities, and volunteer experiences within the field so that interests can be fostered early. These opportunities enable future physicians, female and male alike, to appreciate the subspecialty and more in-depth understanding of the lifestyle of a physician in the subspecialty. This facilitates making an informed decision regarding a future career path with fewer misconceptions. 

Furthermore, there needs to be a paradigm shift on how the culture of pain management is viewed, which is much easier said than done. Male colleagues need to be willing to step up and advocate for their female colleagues in the field. There needs to be more mentorship for junior members of the field, especially female faculty, which can be challenging as there is already a misrepresentation of gender in pain medicine. The culture within pain medicine should be more cohesive and united, rather than competitive, to cultivate a nurturing environment enabling all faculty, regardless of gender, to strive toward the ultimate goal of improving patient outcomes and furthering advancements in the field.

Lastly, there ought to be more female pain physicians in leadership roles or management positions within hospitals and societies that represent pain medicine and regional anesthesia. They can act as role models and offer resources for junior faculty, female medical students, or residents-in-training. This can attract more female physicians in the field who, in turn, can be inspired to take on leadership roles themselves and strengthen the subspecialty. The accomplishments and contributions of female pain physicians, such as Dr. Isabella Herb, the first woman anesthesiologist, and Dr. Aileen Adams, the first woman to become dean of the Royal College of Anaesthetists, should be celebrated, because these pioneers in the field have paved the way for current young women to pursue fulfilling careers in both anesthesiology and pain medicine.⁷

As previously mentioned, ASRA Pain Medicine has implemented changes to recognize women in the profession, such as the 2020 Trailblazer Awards to recognize the achievements of women in the Society and subspecialty, as well as the development of the Women in Regional Anesthesia and Pain Medicine Special Interest Group. These examples are the first steps in the right direction in the journey to gender equality within this subspecialty.

Conclusion

The field of pain medicine has much work to do to ensure that it is welcoming and supportive of female members. Women in this field have so much to offer and can significantly improve the quality of care for chronic pain patients, as well as contribute to research breakthroughs. The barriers surrounding women entering into this field ought to be addressed in a stepwise fashion, so that there are no inorganic causes left that can be the culprit of a vast gender discrepancy in the field. Although a gender gap may still exist due to organic differences between the career interests and goals of men and women, these barriers must first be broken down to determine how this field can reach its full potential and how its female members can thrive.

Kelsey R. Lawrence, DO, MBS, is a resident physician PGY-I in the department of anesthesiology at University Hospitals Cleveland Medical Center in Cleveland, OH.

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Gautam Sharma, MD, is a resident physician PGY-IV in the department of anesthesiology at University Hospitals Cleveland Medical Center in Cleveland, OH.

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Veena Graff, MD, MS, is an assistant professor of anesthesiology and critical care at the University of Pennsylvania Perelman School of Medicine, in Philadelphia, PA.

References

1. Doshi TL, Bicket MC. Why aren’t there more female pain medicine physicians? Reg Anesth Pain Med. 2018;43(5):516–20. https://doi.org/10.1097/AAP.0000000000000774
2. Accreditation Council for Graduate Medical Education. Data Resource Book Academic Year 2020-2021. Chicago, IL: Accreditation Council for Graduate Medical Education; 2021. Available at: https://www.acgme.org/globalassets/pfassets/publicationsbooks/2020-2021_acgme_databook_document.pdf. Retrieved June 21, 2022.
3. Bosco L, Lorello GR, Flexman AM, et al. Women in anaesthesia: a scoping review. Br J Anaesth. 2018;124(3):e134–47). https://doi.org/10.1016/j.bja.2019.12.021
4. DelVentura J, Steiner J. (2019). Gender Disparities in Pain and Pain Care. In Southern Pain Society. https://southernpainsociety.org/gender-disparity
5. Farrugia, G., Zorn, C. K., Williams, A. W., & Ledger, K. K. A qualitative analysis of career advice given to women leaders in an academic medical center. JAMA Network Open. 2020;3(7):e2011292. https://doi.org/10.1001/jamanetworkopen.2020.11292 
6. Samulowitz, A., & Gremyr, I. (2018). “Brave Men” and “Emotional Women”: A Theory Guided Literature Review on Gender Bias in Health Care and Gendered Norms Toward Patients with Chronic Pain. In Pain and Research Management (Vol 2018, pp.1-14). https://doi.org/10.1155/2018/6358624
7. Amponsah G. Women in anaesthesia. J West Afr Coll Surg. 2018;8(2):10-4.