By Susan Bennett, MD

Early in the morning of December 13, 2023, I dragged myself to the computer at my kitchen island after a terrible night of interrupted sleep. While I had experienced neck pain and stiffness for four months, it was much worse on that particular morning. I tried to prepare notes for my clinic scheduled later that day. Although I knew my patients well, there was much preparation that needed to be done prior to seeing them in the 30-minute appointment slots allotted. The pain was so severe that I almost fainted. However, after a few cups of coffee and some food, I was able to finish my preparation and headed to the hospital-based practice in Boston where I had worked for most of the prior thirty years. When I arrived, I looked so uncomfortable that my nurse insisted on taking me to the emergency department where I spent the following nine hours lying on a stretcher in a hallway. I had a thorough evaluation of my condition and spent a great deal of that time contemplating my situation. At seventy-seven years of age, I had started preparing for a retirement that was to take place at the end of 2024. It occurred to me that my body was starting to break down due to the confluence of stress and age. My neck pain continued unabated and without explanation for another nine months.

Two months after my emergency room evaluation, Dr. Vishal Patel and his colleagues at the Massachusetts General Brigham hospitals published a paper reporting higher mortality for women in the health care professions. The study was based on an analysis of death certificates from the National Vital Statistics System “among adults aged 25 to 74 years” derived from January 2020 to December 2022. Notably, these years coincided with the first two years of the COVID-19 pandemic and with the addition of occupation to the demographic information on death certificates. Among the study’s most disturbing findings was the strong association between race, gender, and mortality for women in the health professions, including physicians. While women have lower mortality than men in the general population, and physicians have a lower mortality rate overall, subgroup analysis in the study showed that the survival advantage for women was absent when comparing white women physicians to white male physicians. Black female physicians had higher mortality than white physicians of both sexes, and higher mortality than Black women in the general population.

Why did women physicians have higher mortality than their male counterparts? Among the hypotheses offered in the Patel study were the deleterious stress women experienced from the “second shift” imposed by the demands of child care and other domestic responsibilities. The researchers recommended better support for women physicians though one might be forgiven for concluding the implication of the study was that becoming a physician was bad for one’s health, especially for Black women. These themes were also discussed in a subsequent Harvard Medicine article, “The Surprising Demographics of Physician Mortality.”

The notion that women are at risk for harm due to the stress of practicing medicine is not, of course, a new idea. Nineteenth-century “experts” recommended against women becoming physicians, warning, among other dangers, that higher learning risked damaging their reproductive potential. It took the better part of a century for women to overcome such biases which are far from extinct in some circles today.

The study raised many questions, as the authors acknowledged, that need to be answered by additional research. The pandemic is itself a potentially confounding variable given that the study’s conclusions rest on a data set derived from the first two years of COVID-19. Death certificates may reveal, in part, how the pandemic claimed its victims. However, it has been hypothesized that in the pandemic’s early years, death certificates underestimated COVID-19 as a cause of mortality for a host of reasons, including the unavailability of pre- and postmortem testing, comorbidities that obscured the role of the virus, and novel presentations of the disease. A misplaced sense of shame no doubt led some families to ask physicians not to enter COVID as a cause of death.

Did the COVID pandemic impact the excess mortality for women physicians? If so, were they more exposed to SARS-CoV-2 than male physicians? Black female physicians more frequently had COVID listed as a cause of death. Was there a geographic association with higher mortality, such as rural versus urban? Personal protective equipment (PPE) was in short supply in many rural hospitals and practices during the early years of the pandemic, the period covered by the study. Were primary care providers more likely to die than women physicians in specialties?

The latter question is particularly important given the prevalence of women physicians in primary care medicine, which encompasses general internal medicine, pediatrics, and family medicine. Their growing presence in these fields coincided with structural and institutional changes in the health care system that I both witnessed and experienced and that vastly increased the administrative and bureaucratic burdens imposed on the practice of primary care. This overlooked context may represent a “third shift” that deserved further attention in the Patel study.

These issues certainly resonated for me in reading the article as a primary care physician working in a hospital-based internal medicine practice during the pandemic and a woman physician with nearly fifty years of experience. Because I was seventy-three years old in 2020, I was not allowed to work in the respiratory clinic like my younger colleagues at the Massachusetts General Hospital. I can attest to the courage of these younger physicians during the early days of the pandemic. I saw my young colleagues furtively pacing the hospital halls unrecognizable in scrubs, masks, gloves, goggles, and terror. We were all in a state of disbelief in those early days.

The COVID pandemic exposed many of the vulnerabilities in the health care system. In its wake, ongoing sociopolitical changes continue to make the world seem unstable and unsafe. Primary care itself is now an endangered species. For-profit companies and subscription practices have replaced traditional primary care in many places, simply walking right into the devastation left by the pandemic. Even though I was privileged to work in a world-class medical institution, the ripple effects of these sweeping changes in health care were unmistakably in evidence. After my retirement at the end of 2024, it took an entire year to recover from the physical and emotional toll exacted by a bureaucratic system that had increased my administrative, as opposed to clinical, responsibilities exponentially.

In fact, as I look back on my fifty years of medical practice, I can see that the rising pressure on me was almost imperceptible. I was easily persuaded to put patients first because I was trained to do so. This ethos started to guide me in 1971 during the third year of medical school in San Francisco when I began doing clinical rotations. It became clear very early in my first rotation that patients’ needs were sacrosanct. During my training, I learned that my personal needs had to be ignored when I was on call. Responsibility, when assigned, was solely mine to carry. While I could ask for help, I needed to own the task and apply diligence and sustained effort to see the problems through to the best possible outcome. This training intensified during internship and residency. I was not unique in this experience. My internship group went on to clinical careers that were characterized by strong professional identities that were centered on putting patients’ needs first.

In the 1980s, the professional identity that many of us adopted early in our careers was expropriated by managed care insurance products that assigned patient panels to primary care physicians. The term “gatekeeper” emerged to describe the administrative role of the PCP in giving patients access to their health insurance. Although managed care was marketed as a patient-centered model laudably aimed at improving the continuity and quality of care while controlling costs, it created vast new reporting and documentation requirements that landed squarely on the shoulders of physicians. This system was especially consequential in primary care specialties where salaries have steadily declined.

Not surprisingly, administrative burdens gradually crowded out time for direct patient care and personal time. With the introduction of the electronic medical record system Epic at our hospital in 2016, “charge capture” was maximized. Every time a patient sought urgent care, emergency care, inpatient care, surgical procedures, prescription renewal, office visits, telephone management by nurses, the primary care physician was asked to approve, deny, review, or edit the action. Insurance coverage for medical care was increasingly contingent on such approval. This virtual stranglehold on primary care is contributing to its collapse. Medical students are increasingly avoiding careers in primary care. Doctors are retiring earlier than necessary. It occurred to me that my severe neck pain was caused by many hours of daily computer work. By the end of my work life as a physician, I spent an average of ten hours daily in my patients’ records most days, including weekends. My neck pain subsided without explanation and has been completely absent since my retirement.

I took pride in the diligence and effort involved in putting my patients first. I believe my patients benefited from that commitment. I loved being a physician and, now retired, I miss all of it, although I might still be seeing patients if the administrative burden did not overwhelm me. The true burdens were driven not by my gender or by catastrophes such as the COVID-19 pandemic. They devolved from structural changes in the health care system that remain unaddressed. Despite the pressure I experienced as a female physician and my difficulties managing medical practice with advancing age, doctoring did not kill me.

Susan Bennett is a retired primary care physician who cared for patients in the Boston area for more than fifty years. Her academic and hospital affiliations include Harvard Medical School and Massachusetts General Hospital, and she practiced at a range of Harvard-affiliated hospitals over the course of her career.

Her clinical work spanned both hospital-based clinics and inpatient settings, and she taught medical students and medical residents in both. She also conducted clinical research and was active as a health care activist.