Abstract As the numbers of female physicians continue to grow, fewer medical marriages are comprised of the traditional dyad of male physician and stay-at-home wife. The “two-career family” is an increasingly frequent state for both male and female physicians’ families, and dual-doctor marriages are on the rise. This qualitative study explored the contemporary medical marriage from the perspective of male spouses of female physicians. In 2010, we conducted semi-structured, in-depth interviews with nine spouses of internal medicine resident and faculty physicians. Interviewers queried work-home balance, career choices, and support networks. We used an interpretive, inductive, iterative approach to thematically analyze interview transcripts and develop broad, consensus-derived themes. A conceptual framework based on three major themes emerged: “A time for us? Really?”, “Supporting and protecting her, sometimes at my expense,’” and “Hers is a career, mine is a job.” This framework described the inflexibility of physicians’ time and its impact on spousal time, career development, and choices. Having a set time for synchronizing schedules, frequent verbal support, and shared decision-making were seen as important by the husbands of female, full-time physicians. This exploratory study examined the contemporary medical marriage from the male spouse’s perspective and highlights specific strategies for success. Keywords: Academic Medicine, Gender, Career, Qualitative Research, Work-Life Balance, Medical Marriage Introduction According to the Association of American Medical Colleges, women accounted for over 47% of matriculated students, 37% of all medical faculty, and 20% of full professors (AAMC, 2012; Nivet, 2011). Because of the inpouring of women into the medical profession, the face of the medical marriage is changing. As more women enter the physician workforce, fewer medical marriages are comprised of the traditional dyad of male physician and stay-at-home wife (AAMC; Levinson & Lurie, 2004). Papanek (1973) described the “two-career family” (as an increasing occurrence for both male and female physicians’ families which includes an increasing number of dual-doctor marriages (Schrager, Kolan, & Dottl, 2007; Sobecks et al., 1999; Woodward, 2005). This relatively new social phenomenon has not been examined from the perspective of male spouses of female physicians. Previous research on medical marriages primarily focused on the physicians’ lives (Dyrbye, West, Satele, Sloan, & Shanafelt, 2011; Jovic, Wallace, & Lemaire, 2006; Schindler et al., 2006; Shanafelt et al., 2009; Warde, Moonesinghe, Allen, & Gelberg, 1999). The few studies that included physicians’ spouses focused on the traditional male doctor’s wife and provided little information on female physicians’ partners (Bates, 1982; Sotile & Sotile, 2004; Spendlove et al., 1990). The limited data on female physicians' spouses has been captured in studies of dual-doctor marriages. Sobecks et al. (1999) found in a survey of physicians from two Ohio medical schools that, compared to physicians with non-physician wives, husbands of female physicians worked comparable hours, had lower personal income (but higher family income), were more likely to describe themselves as the primary or equal caregiver for children and to arrange their work schedules around childcare responsibilities, and reported that their wives worked more hours. They were as likely as men with nonphysician spouses to report achieving their career goals. They also reported that shared work interests with their spouse was enjoyable and had helped their career advancement (Sobecks et al., 1999). Physician surveys find that female physicians are more likely than men to work part time, particularly if they have children (Buddeberg-Fischer et al., 2010; Schrager et al., 2007; Stamm & Buddeberg-Fischer, 2011). We are interested in the experiences of male spouses in relationships where the physician wife continues to work full time. Previous studies that have qualitatively explored the perspectives of the spouses of female physicians were undertaken more than 20 years ago or were limited to physicians in residency training (Kelner & Rosenthal, 1986; Schiebel, 2006; Wagner, 2002). This study explores what makes the medical marriage satisfying from the current experiences of husbands whose female physician spouses work full time. This is an important area of inquiry because of the paucity of research during a time when women represent nearly half of the medical students and future physicians. The research team for this study included: an experienced qualitative researcher (CI) with a background in educational leadership and healthcare management,1 two medical students (KP, MS) with interest in work-life balance, a qualitative researcher with experience with physician burnout (LBM), a career theory associate professor in medicine (ABW) and a physician professor (MC) with extensive knowledge of the extant research on implicit gender stereotypes. The impetus of this study stemmed from a previous study (Isaac et al., 2013) where a common response during the interviews was, “you should ask my spouse,” and so we developed this study the next year. Method All study procedures were approved by the University of Wisconsin (UW) Institutional Review Board and subjects provided written informed consent. We recruited spouses using chain sampling, a type of purposeful sampling strategy (Patton, 2002). The study investigators sent an email message to 48 faculty and resident physicians in the UW Department of Medicine who had been participants in a previous study on physician career-life balance (Isaac et al., 2013). The message asked them to extend an invitation to their spouse or partner to participate in an interview about medical families. Those who were interested could contact the investigators to schedule an interview. Two medical students (KP, MS), who received funds for research training during the summer of 2010, administered the interviews at locations convenient for participants. The students received training in qualitative methods and were supervised by an experienced qualitative researcher (CI). Many of the interview questions (Table 1) mirrored those used in the previous study on physician career life-balance, but were framed to elicit the spouse’s point of view (Isaac et al., 2013). The question about the positive aspects of being with a physician was added after three interviews because of the overwhelming negativity up to that time. The interviews, which averaged 45 minutes, were digitally audio-recorded, transcribed verbatim, and de-identified. Each interview was available for analysis within one week after data collection. Each participant reviewed and approved his or her transcript. Table 1 Interview Questions Tell me a little bit about your background? Reflect a bit on how your spouses/partner’s job affects you. What factors affect you the most? How many hours per week does your spouse/partner usually work? What factors were important in influencing your career decisions? What are the most positive aspects of being with a partner who is a physician?* What are your future plans? Why? What strategies do you use to ensure work-life balance? Can you identify some of the most memorable situations that looking back may have influenced your career decisions? What are the consequences of the choices you have made? Any regrets? Who provides the most support to you personally and professionally and in what way? How do your personal life and professional life intersect? How do you keep them separate? Describe a balanced life for you and your spouse/partner. What does it look like? How do you divide household duties and parenting?* If you had a child in medical school, what advice would you give? What would you tell your son? Your daughter? Do you have anything to add? Open in a separate window *Question added after several interviews. We (CI, KP, MS) imputed all textual data into qualitative software and consequentially coded the text line by line, incorporating a data driven inductive approach as researchers create code categories as they analyze and interpret the data (Boyatzis, 1998; Fereday & Muir-Cochrane, 2006; Hesse-Biber & Nagy Leavy, 2011) We chose to use a systematic, inductive, open-ended thematic analysis for identifying, analyzing and presenting categorical patterns within the data (Attride-Stirling, 2001; Boyatzis, 1998; Braun & Clarke, 2006). Inductive coded text were placed into an iterative cycle of data collection, analysis and comparison with previously collected data looking for coherence until unifying and recurrent themes emerge. Categories that were viewed as conceptually linked were integrated and synthesized together into unifying themes. The data was said to be saturated when no new codes or themes are identified. Weekly debriefings with research team members assisted in data analysis and the identification of categories, integrating all our data to compare relationships among these patterns to make sense of variations that occur in the data. Discrepancies in coding were resolved during weekly discussions until the research team reached consensus. Once the final coding scheme was established, three authors (KP, MS, CI) independently coded five interviews achieving an intercoder agreement ranging from 81 to 99% with an average of 96%. NVivo software was used for all coding, data retrieval, and analyses (Richards, 2006). Validation of the analysis was enhanced by the presence on the research team of experienced qualitative researchers (CI, LBM), a career-development researcher (ABW), and an investigator (MC) with extensive knowledge of the extant research on implicit gender stereotypes.. Our sample of nine interviews approached saturation and the review of the literature confirmed our findings. Results Seventeen responses resulted from the 48 emailed invitations. We could not contact spouses directly because of ethical issues. Of these, 11 spouses agreed to participate, one physician relayed his spouse’s refusal to participate, three physicians responded that they were neither married nor partnered, and two physicians reported that their spouses were physicians who had been interviewed as part of the earlier physician study. The 11 spouses who participated included nine men and two women. This paper focuses solely on the nine male spouses, three of whom were physicians themselves. Of these nine interviewees, three were married to physician educators, two to physician researchers, one to a physician fellow, and three to resident physicians. All participants were in their first marriages. The five faculty marriages ranged from 21 to 35 years, and the four residents’ marriages ranged in length from 4 to 7 years. All of the participants had children except for two residents. There were 38 initial codes that were combined into six focused codes with a resulting conceptual framework based on three unifying themes: “A time for us? Really?”, “Supporting and protecting her, sometimes at my expense,’” and “Hers is a career, mine is a job” (figure 1). A time for us? Really? Although husbands enjoyed the status, security, access to reliable medical information, and advantage of having a spouse with a stimulating, interesting job and a good income, all agreed that the greatest challenge to a medical marriage is time negotiation, exacerbated by long work hours and lack of scheduling flexibility. “Everything has to be scheduled around her work; you can't tell her that she has to go and do stuff because…she has patients or research subjects coming in.” When asked how many hours per week their spouses worked, responses varied between 50 and 80. One husband stated, “Dangerous question; it’s like asking how much she weighs (laugh).” Another spouse, an academic himself, questioned the value of his spouse’s time commitment: She’d [as a resident] work anywhere between 80 and 90 [hours], occasionally upwards of that, per week…as a fellow, it’s much better, it’s closer to 60 or 70…which is still not particularly…acceptable … It looks very much like the process of making a Marine…the sort of hazing. An older spouse, nearing retirement, illustrated the intentional compromise spouses often make around time: The patients always come first. I phrased this to myself as the ‘moral high ground’. The spouse of a physician never has the moral high ground, no matter what the spouse’s obligation is, it’s always trumped by the duty to the patients. And so I learned early on…that if you're going to marry a physician then you have to be ready to accept that fact. All nine men listed their spouse first as a source of personal and professional support, with the caveat, “My wife provides the most support in every way–when she's around.” One spouse stated that men whose wives were physicians need to be, “Wildly independent and able to be on their own for long stretches of time and not dependent on your spouse for a lot of the key support and entertainment and time together...” Husbands acutely felt a lack of companionship, with, “It would be really nice to have more time to spend with her…if she was working less it'd be fantastic, so that…she wasn't tired and rushed all the time” and “Now we're getting to the point where we can do [other things] - after 20 years”. Comments by the three men who were also physicians reflected a much greater understanding and appreciation of the demands required of their wives. They expressed no negativity when describing their spouses’ careers, noting that becoming a physician is challenging, time consuming and expensive. Dual-physician spouses had a particularly empathetic perspective in a system where “time isn’t your own.” “Residency tells you all sorts of things that you can and can't do. The hundredth thing is, you just can't miss work.” In these dual-physician marriages, support was described as ‘understanding’, spousal comments focused on the time together rather than the time apart, and comments reflected the freedom of “not worrying about when you get home necessarily, within reason.” These spouses appreciated the bidirectional benefits of having “somebody who knows exactly what it is that you’re going through.” Supporting and protecting her, sometimes at my expense Of the six spouses who were not physicians, four of the remaining six whose wives were well into their careers expressed more supportive statements than those whose wives were still in the resident or fellow stage. These men perceived that they themselves had more time, so they worked to protect their spouses’ time. Two, who were or had been a stay-at-home dads, stated, “My [wife] provides the most support personally–but it has to be something important before I'll let it be seen–she's got plenty on her plate.” Another stay-at-home dad stated, “I don’t want to dump any little goofy things that I might have onto somebody who's been at work for 12 hours and still has three more hours of work and hasn’t been with their [children] all day long.” This protective attitude can also be seen when these men talk about household duties: “I didn't want her to have to think that she needed to clean the house on the weekend or vacuum when she came home from a long day at work.” One husband with a very flexible job related: I have more time and I'm able to do more than she does, and so–not that I’m looking for her to spend more time at home so she can help out [with household chores], but–that she didn't feel like she had to do that stuff all the time. Spouses with younger children, or who were married to resident physicians, however, did not display similar equanimity when it came to assuming the bulk of the housework. As this academic husband noted, “If our kid was sick, I was the one who left work and spent the day home with him because she had no flexibility.” Another husband, also an academic, stated: I've found that I couldn't control my own schedule, in terms of being places I had to be or especially being away from home, because I couldn't depend on when my spouse was going to be there. Yet another academic became “a real good juggler of domestic duties–I’m a professional.” He understood that his career became secondary as it was easier for him “to dodge out” of things. He suffered repercussions, however: When I was working, what I did basically was to shrink down my obligations more and more every year as my family obligations increased, and this was detrimental to my research output which plummeted. For the last decade or so of my career I was getting almost no research done at all, I was just teaching my classes. With regard to housework and childcare, those men who were in dual-physician marriages, and were also parents, had either family geographically close by, a “good babysitter”, or “someone as a live-in nanny.” Because work time for two full-time physicians is constant and relatively inflexible, a paid person handled a good deal of the household care and childcare duties. Mine is a job, hers is a career There were six spouses who were not physicians that felt that they had sacrificed a good part of their early careers to support their wives’ careers. Some felt that they had no choice: It was understood from the beginning that if she needed to move we were going to move…I walk out [of my job] and I'm done and I would guess that there are lots and lots of doctor spouses that have…Their job is a job and not a career. They expressed the most dissatisfaction of all spouses because of the lack of portability of their careers: “I regret that I have as much education as I do, because I can’t get the job I want now because of it.” Having a less-demanding job allowed this group to leave work at work, at the expense of their job satisfaction and sense of accomplishment. Individuals who perceived greater input into the decision-making in their family life had more positive comments. Two stay-at-home fathers stated that they had “gradually decreased their work responsibilities,” but were careful to emphasize that doing so was their decision. One dad stated: I slowly, from that point on, cut back on my work from full-time to three days a week to two days a week to where I am now–to one day a week…It’s worked out really well for both of us, and I was ready for it. I'd had, at that point, 12 years of working…I think the key was that it was my decision to slowly cut back, or we decided together. One family had a nanny for a few months but later “came to the decision that that's not what we wanted for our kids.” This academic spouse who earlier had stated that his research output had “plummeted” noted: In terms of the choice I made to stay home and take care of my kids, I really do believe that's the most important thing I could do and I did it. So that's that. I don't regret that at all. Another academic, who had geographically moved to follow his wife, pinpointed the pivotal decision that impacted his career path: I had to decide whether I was going to follow her to [city] and find a job there or whether I was going to decide what the best lab in the world was for me and just go there. So, making that decision to be with her was critical, because that steered my scientific direction and the rest of my life. Spouses who had more choice in their career-life decisions expressed less regret. One husband, who chose to be stay-at-home dad and work part-time, expressed his satisfaction with this choice: I say to myself all the time, I'm the luckiest guy on earth. I get to stay at home. I get to do a lot of things I want to do and I get to spend time with my kids…I'm extremely grateful for what we have today and we couldn't do that without [wife]. Spouses in dual-physician marriages were pleased with their career choice except for being “saddled with enormous debt.” All three of the couples were together during medical school and made compromises so each could obtain the training they desired. A fellow married to a chief resident reflected on their mutual support: We’re both very open to allowing the other to do whatever it is they’re passionate about …when we sit down and have those conversations we definitely take each other’s interests and desires and life goals into account before we make big decisions. Again, the bidirectional understanding inherent in a dual-physician relationship enhanced their ability to arrive at an acceptable compromise. She’s my best friend. We confide in each other about everything and she just knows me so well…it's really inspiring to have a spouse who is a physician–not only a physician, but a very talented one and somebody who’s a leader. It makes you want to do better yourself and I'm just really proud of her. Discussion The iconic view of a physician entails a man “married” to his practice, typically with a supportive wife whose unpaid employment was as “the doctor’s wife” (Bates, 1982; Helitzer, 2009). With the entry of women into the physician workforce, this image has started to change although the work demands have not (AAMC; Armstrong et al., 2009). In this first systematic, qualitative exploration of the experiences and perceptions of male spouses of full time female physicians, we found that the long and inflexible physician work hours continue to dominate the contemporary medical marriage. We found that the physician wife’s support for her husband’s career is critical. This is consistent with results from a survey by Spendlove et al. of graduating doctors, lawyers, and their spouses which found that emotional support for one another’s career had the biggest effect on the quality of the marriage (Spendlove et al., 1990). This is an “important protective variable” for mediating stress in the medical marriage (Rovik et al., 2007). As illustrated by individuals in the dual-physician couple category in our study, mutual understanding of career stressors can enhance appreciation of the spouse. All of the male spouses in our study who were not physicians assumed the role of primary household caretaker. Some embraced the decision; others resented a perceived lack of choice. Those who looked most favorably on the role talked of “choosing” or “deciding” to take it on, often in collaboration with their spouses. Another important finding is that spouses who had a professional career, or those who were full-time homemakers (including stay-at-home fathers), expressed a higher level of parental satisfaction than spouses with a nonprofessional job of lower status. Thus, satisfaction seems to be reciprocal for these variables. We also found that husbands with more flexible time tended to adapt more readily to the role of primary caretaker for the household and children much like women who historically adapt their work hours based on family needs (Maume, 2006). Because divorce rates among physicians have been reported to be 10% to 20% higher than those in the general population (Sotile & Sotile, 2000) especially among women physicians (Robinson, 2003), there is a need to highlight concerns affecting couples. Historically, dissatisfaction in the medical marriage has been associated with feelings of work-home imbalance and unreciprocated career sacrifices on the part of female spouses of male physicians (Sotile & Sotile, 2004). This stereotype is changing as more women enter the U.S. workforce. Spouses in our study reported greater satisfaction in general when decisions regarding job relocation and hiring household help are made with their physician partners. The importance of communication, compromise, and carving out time for joint decision-making is of utmost importance, especially for husbands who are assuming roles that violate social norms such as full-time homemaker (Eagly, Eastwick, & Johannesen-Schmidt, 2009; Eagly, Mitchell, & Paludi, 2004). Source
