Medicine, the Patriarchy, and My EPIC Inbox

August 18, 2022

So in the midst of the sleep-related comments (will report back on that in a few days), a kind reader forwarded me this blog post, which references this article. It ended up in the comments, but I wanted to bring it front and center because I think it’s interesting, important, tricky, and (to some extent) depressing.

The key finding:

Female PCPs receive 24% more staff messages (9.6 messages/month), and 26% more patient messages (51.5 messages/month) (p values 0.03 and 0.004, respectively). The differences in EHR time are not explained by the percentage of female patients in a PCP’s panel.

Rittenberg, E., Liebman, J.B. & Rexrode, K.M. Primary Care Physician Gender and Electronic Health Record Workload. J GEN INTERN MED (2022). 

One might argue this is a good thing — patients feel comfortable asking their female doctors questions!

And to some extent, it might be, for patient care (in fact – this is something the literature suggests, as referenced in this article).

But dear god, it is not easy from the perspective of the manager of one of these inboxes. And when you add this burden of work (because that’s what it is, work!) to other challenges like:

  • having to be on the defensive at meetings because you are much more likely to be questioned, argued with or interrupted
  • getting paid less overall
  • being less likely to be offered directorships or paid for extra committee work (okay, I don’t have a study to support this, but it has been my personal observation)
  • being far more likely to be doing the bulk of the home management work (ditto)

Well, you can see where I’m going with this.

I felt validated by the article. But also mad. Because I don’t see a good way out. I don’t WANT patients to be afraid to contact me, and I also don’t think it’s easy to just deflect questions because – as a female – I am so much more likely to be seen as standoffish or rude. I did recently have someone ask me for a ‘pre appointment phone conference’ (which likely would have been fairly long, and entirely for free) and told them very politely that I’d prefer to have our conversation at the (soon) upcoming appointment.

And I felt a lot of anxiety about that.

I am sure this translates quite easily to other fields. But unlike an attorney, inbox minutes are not billable minutes. AND, as it goes with email, I find that more messages lead to more messages. And more time. And more work.

Finally, this is a quantitative study. I also wonder if the tone patients feel comfortable using and the types of things they feel comfortable asking for are different. I bet male physician are less likely to receive messages that are purely administrative, for a number of reasons.

Anyway. I still like my job. And these complaints are not in any way specific to my institution. But damn, there’s a lot here to think about.


On an entirely unrelated note, back to school went well!

DAY 1! Now to do it over again ~180 times.


  • Reply Lori C August 18, 2022 at 6:43 am

    Yes, yes, and yes. It’s frustrating. And not something easily changed. But all of us can take small steps to change this. Example- I was recently given feedback that I was “aggressive, angry, and unapproachable” – by a female manager. I am 100% confident that if I were male, I would not have gotten this feedback. In talking with my peers they agree that is not accurate. I ask tough questions, and I’m not afraid to speak my mind, but I always do it in a positive manner and I am a warm friendly person. I accepted the feedback with a grain of salt and asked for specific timely feedback in the future. (She couldn’t give examples). Perhaps I could have taken it a step further and asked if the feedback would be the same if I were male? But that didn’t feel right. Obviously no silver bullet here. But frustrating nonetheless.

    • Reply Sarah Hart-Unger August 18, 2022 at 7:38 am

      It sounds like you handled that really well. I think your instinct that a male colleague would be unlikely to receive that feedback for the same behavior is dead on.

    • Reply Alba August 18, 2022 at 3:53 pm

      I can confirm this issue is universal (i work in Finance, based in Europe and dont bill my hours).
      For example, just today i received a 30min meeting request with HR to provide my feedback on a 3 days leadership training organised at my company. Worth mentioning that 1) i already have provided written feedback via the usual post-event survey we all received and 2) proportionally, the amount of male to female participants was like 70/30.
      I fully relate to the comments that it is difficult to say no, even when appropriate. I sent a counter proposal invitation for just 15min instead. But could not fully deny it…

  • Reply Gillian August 18, 2022 at 6:47 am

    I feel this! I get soooooo many requests for “quick calls” that I know will turn into visit length conversations but that can’t be billed, or requests to review and discuss labs drawn by another physician (also unpaid). My EMR inbox is also full of billing questions, requests for records, complaints about some office policy, all of which I have to take the time to forward to the appropriate staff member. I have tried over the last two years to form reasonable but firm boundaries with patients and staff to keep my workload manageable. As I see it this allows me to focus on those message from patients who really need my assistance and expertise outside of their office visits.

  • Reply omdg August 18, 2022 at 7:43 am

    Everyone says that all of this can be solved if women create better boundaries, but you bring up the great point that saying no can be really challenging, even if it is totally appropriate. Every time I set an appropriate boundary (e.g., No, giving a resident lecture at 6:30 in the morning post-call is not a reasonable request. No, when I am on vacation I should not have to call a parent back immediately when the parent looked up my email online and emailed me about their kid’s upcoming totally routine low risk surgery just because they were anxious. No, I do not have to accept being ignored by my mentor for over a month.) I worry that someone will complain or that I will be told that I am being a Karen. So no: Saying no is not simple at all.

    At the same time, at work every single day, I see women falling all over themselves to accommodate men, and if the man happens to be tall, white, and look good in a scrub cap, x10,000. So we ourselves perpetuate this nonsense, it is totally ridiculous, and kind of makes me feel like, “Well ladies, you’ve made your bed — now lie in it.”

    • Reply Sarah Hart-Unger August 18, 2022 at 7:57 am

      Yep. Hey, at least you have the tall part 🙂

      • Reply omdg August 18, 2022 at 8:20 am

        Are you saying I’m not hot? I am offended. 😉

    • Reply DVResident August 19, 2022 at 3:04 pm

      “if the man happens to be tall, white, and look good in a scrub cap, x10,000”-or as my (incredible) fellow on my last rotation once said, “White Man Magic”.

  • Reply Diana August 18, 2022 at 7:54 am

    My husband is a pcp and we often talk about this. When he covers other provider’s inboxes he notices that some get a lot more messages than others (and oftentimes the requests are not reasonable!) and sadly it is mostly female providers that this happens with. I think women naturally do feel more of a pull to be available and truly want to be very helpful (which as you mentioned is great) but the downside is that it takes a toll (which you also mentioned). Another thing: my husband feels no qualms about a patient leaving his practice if they are rude and unreasonable. He sees this as no reflection on himself and is unaffected when they tell him they’re going to find another doctor (because he knows the relationship is not a good fit). Maybe that’s a hang up for some women (just speaking personally I think it would be a learned skill for me to have that way of thinking but it comes very naturally to him).

    • Reply omdg August 18, 2022 at 8:53 am

      He probably feels no qualms about this because he has never been written up for something like this, or told he needed to “change his tone” to “be more accommodating” or “stop being so aggressive” in a performance review. Maybe you haven’t either, but if you did lose a patient, they might complain to someone that you were rude or unavailable, and I promise you that would come back to bite you somehow.

    • Reply Abby Meyers August 18, 2022 at 9:00 am

      I feel all of this – I’ve started insisting on a telehealth visit for anyone who requests to talk to me. That way they can’t get mad that I wouldn’t talk to them, but I get to bill for it – I usually sell it to the patient as “this way we both have time blocked on our schedules”. I’m sure at some point I’ll get a complaint about an extra co pay for that telemed, but I feel justified when I think about my husband’s consulting billable hours.

      • Reply Gillian August 18, 2022 at 9:28 am

        I wish I could do that! I was doing it for a while, but I practice in NYC which means many of my patients are not in New York State (lots of patients live in NJ, CT and PA) and so you have to have a license in the state the patient is in at the time of the visit. This was waived during Covid but not any more…

  • Reply Lisa of Lisa’s Yarns August 18, 2022 at 9:07 am

    For my rheumatologist, I can be charged for questions I send in if it’s a certain number of days after my visit. Maybe that is the approach that should be taken more so there is value/$$ assigned to patient emails? I have no issues paying for a response. I haven’t paid attention to how/whether it is billed since I meet my out of pocket max in the first half of every year thanks to my RA meds! I have used mychart messages a lot, but some doctor’s have their nurse respond, like my OB during pregnancy. I happen to only have female physicians but I think I would ask the same questions of a male physician. But it is too bad that women get more messages and then spend more time responding. It’s another source of unseen/unpaid work.

    I tend to have the opposite experience in my field of finance. People are more likely to go to the male colleagues on my team for questions or request them to do meetings. There are a couple of men I work with who are great at pushing people to ask me questions or schedule meetings with me, though. We have had more conversations around D&I within our team and I think it is helping. Because in my case, male allies really help.

  • Reply Katherine B August 18, 2022 at 9:14 am

    Writing as an English lawyer and long time manager of a branch office, this is by no means confined to either the medical profession or the US. If you are helpful, approachable, willing to listen etc, clients will contact you when they have a problem and junior staff will ask for your help. Much of this is not billable in the real world of an ordinary law firm. Men are not expected to be the same, or criticised for things that women are criticised for. Man: “assertive/positive/go-getting”. Woman displaying same behaviours: “aggressive/difficult/typical lawyer”. And yes sometimes women themselves are an issue. My young, female, brilliant paralegal, has to be so careful about how she asks older, female administrative staff for the help it is their job to provide, and has been accused of being “bossy” (!!!) but her male equivalent can throw his weight around and ask them to do anything and they comply – and he’s not hot at all – see OMDG above. I think they want to mother him he is so nerdy!

  • Reply Kari August 18, 2022 at 9:34 am

    As a female PCP that article rings 100% true with my experience. I’ve been out of residency for 3 years and I’m finding my work increasingly unsustainable, and I think this absolutely plays a role. I’m planning to send the article to my male bosses as food for thought, at least. I work in a massive health system so it’s hard for me to feel like anything will substantially change, but even some acknowledgement of the extra burden would be a start.

  • Reply EF August 18, 2022 at 10:46 am

    This is definitely the case in all industries! I am the CFO of an industrial business-literally the second most senior person at the company besides the CEO. Yet I am for some reason saddled with the admin aspects of all of the Executive team. Who is running all the slides? Me. Who is coordinating meals/printing of presentations/dialing into the calls etc.? Me.
    It’s honestly bizarre-I was on PTO for one of our board calls and they were helpless without me-couldn’t dial in, gets the slides to show etc. Was a good opportunity for me to remind them that I AM NOT YOUR ADMIN! Put on your big boy pants and do this stuff for yourself.

    • Reply Kat August 18, 2022 at 11:43 am

      Wow this comment makes me feel all the rage for your! That is so not an appropriate use of your time/skills as CFO! Sending you a hug. Can you get a helpful admin/support person to perform these tasks at your exec team meetings instead? My company has an exec assistant do all this stuff.

    • Reply Nelle August 19, 2022 at 8:07 am

      Oh goodness. I saw this dynamic in a job where I was a few years ago and eventually the #2 quit and went to do something else, and she should have done so way earlier. Props to you and these men should know better.

  • Reply Rebecca August 18, 2022 at 11:32 am

    I’m not in medical either but that article was fascinating. I just left a job and am starting a new job shortly – it’s a career step-up but I tried for months to have career progression with my current employer instead. When I left it was noted by so many that I am “ambitious”. I heard the word at least 6 times. I wondered, when men leave jobs are they told they are being “ambitious”? It felt like I was being told I had asked for more than a woman should, and now I was leaving. A male on the same level as me 5 years ago is almost director now. Watching him grow while I stagnated was such an eye opener since we were basically the same, although I had more education and more children. Ugh, the patriarchy.

    • Reply Amanda August 18, 2022 at 4:11 pm

      I am yet another career woman in a non-medical field who can say yes, it happens in my industry, too [commercial real estate]. Unfortunately I can relate to Rebecca’s comment that “A male on the same level as me 5 years ago is almost director now. Watching him grow while I stagnated was such an eye opener since we were basically the same, although I had more education”. In fact, earlier in my career, my education was often viewed as a negative! That seems to have abated but I’m still sensitive to that.

  • Reply Megan August 18, 2022 at 1:28 pm

    I am not in the medical profession but have been called aggressive and loud at an annual review and am 99% sure those terms would not be used for men with my traits of being assertive, speaking up and presenting with confidence. The double standards are everywhere, so much so that most men do not see them. In the corporate world you get recognized for doing a great job by getting more work, especially smart women who can be counted on.

  • Reply Sarah August 18, 2022 at 2:28 pm

    Ooooooh this is FASCINATING. I definitely send questions via EPIC inbox to my own doc (woman) and the kiddos’ pediatrician (also a woman). I checked my app, and I absolutely messaged their former (man) pediatrician (who retired) much less than I messaged the current doc. YIKES. But! She also responds more frequently and with better answers than he did (because of the image management factor you mentioned, I am sure).

    But also our HMO has changed quite a bit in the 18 years since I became a patient– more mid-level providers, harder to see your PCP, the pandemic!– and the culture has skewed toward messaging with questions that might have warranted a face-to-face visit in Before Times. I am thinking especially of weird kid rashes that someone can look at via image first.

    My husband NEVER EVER messages his doc (man) or the kids’ doc. I wonder about this, too. Are women patients more likely to send messages than men?

    • Reply Sarah Hart-Unger August 18, 2022 at 3:03 pm

      I’m guessing yes . . . and for me, 99% of messages are sent in by women. BUT I’m in a pediatric field and that just has to do with who is managing the kids’ health care . . .

    • Reply Sarah Hart-Unger August 18, 2022 at 3:04 pm

      and yeppppp I’m so glad you admitted this. Perhaps you felt more comfortable messaging her too like she seemed more approachable. This isn’t a failure on your part at all! I’d probably feel the same way!!!! BUT it should be acknowledged that . . well, she’s doing extra work compared to her male partner.

  • Reply Brooke August 18, 2022 at 2:30 pm

    I found this article fascinating when it was posted the other day and have been thinking it about it since then. I’m not in the medical field. The comments on today’s thread are blowing my mind. It would NEVER occur to me to ask to chat on the phone with my doctor outside of an appt except in the case of an emergency through the on-call number, which there is often a small charge for. If I have a question, I call the nurse line and they are always wonderful about getting it answered. I got labs from another doctor I wanted to chat with my PCP about. I’d call the nurse line to ask if I needed to schedule a special appt to discuss or if it could wait until our next appt. I respect my doctors as the professionals they are and would never ask them to give away their services. Maybe it’s just because I’m blessed with great insurance and low co-pays, and am in a good enough financial position to afford to pay for healthcare with it impacting our budget.

    I do wonder – are women patients more likely to ask questions? And for PCPs, are women more likely to select women physicians and thus add to the burden?

    • Reply Sarah Hart-Unger August 18, 2022 at 3:00 pm

      fascinating. I think this VERY much varies from patient to patient and probably on how practices are set up. According to the study, the EMR burden was not driven by a higher % of female patients!

    • Reply Amy August 18, 2022 at 9:03 pm

      Same, I have literally never messaged my doctor and would never expect her to answer me in a context outside a scheduled visit. Are there no nurse lines elsewhere? I have to admit I didn’t even know this was a thing, being able to message your doctor whenever you want and then expecting a response.

  • Reply Erica August 18, 2022 at 3:07 pm

    While this may be worse (and/or easier to quantify) in the medical field, I imagine this issue is universal. I worked in software for several years, and I was endlessly being tapped for “soft” jobs like taking prospective hires out for lunch, setting up and running meetings, managing everyone else’s deadlines, etc. Also at my reviews I was frequently called “pushy” and “bossy”, which are adjectives that I have never, ever heard applied to a man. Of course, my managers were telling me all this for my own good, so that I could adjust my personality to be less off-putting (read: threatening) to my male colleagues.

    • Reply Kat August 18, 2022 at 7:09 pm

      There’s a talk/article that’s been shared more and more in tech called Being Glue

      It walks through how doing important but not promotable work, especially before you’re really senior, often has a really negative effect.

      It’s on the long side, but had amazing illustrations for visual learners, and suggests some ways forward/around this issue.

  • Reply CBS August 18, 2022 at 4:01 pm

    This is fascinating. I see it in academia – I get students coming in with questions that my male colleagues would NEVER get. I walked back to my office one day and said “Gosh, I hate it when students cry…” and my male colleague (at the same level) was stunned that I had students crying, telling me about their personal problems etc. And my male colleagues get much better reviews – no one comments on their voice, accent, dress, smiles…

    • Reply Amy August 18, 2022 at 9:05 pm

      Lol now I feel the need to apologize for my college self, crying to my professors about my personal problems 😂😂

  • Reply Irene August 18, 2022 at 10:34 pm

    I’m a little self conscious about it but my PCP is a male concierge doctor who caps his number if patients so we can all feel free to message him as much as necessary. And I do! So I guess that’s another way that some people try to deal with the ever increasing demands of modern health care.

    I adore and respect my neurologist but I have never been able to get an appointment with less than a month wait and there is no nurse line or anything so for something like scary side effects from a new medication I really do need to message. They have a little disclaimer saying they may charge you for their time (which would be fine!) but I have never seen them actually do it.

    • Reply Sarah Hart-Unger August 19, 2022 at 5:37 am

      you should not be afraid to message 🙂 The point of this is not to villainize patients who do – it’s just to point out an interesting inequity and how it leads to more work on female shoulders.
      You should message away 🙂 ESP if your doctor is male. (JK, either way!)

      • Reply Irene August 19, 2022 at 8:23 am

        Ha! No I didn’t think you were implying that. I mostly was reflecting on how the two had structured things in such a way to make messaging possible/inevitable but one is putting boundaries on his time with his model! I have literally never messaged our pediatrician because they have an excellent nurses line and you can almost always get in same day for an urgent appointment. I don’t think they get compensated per call but for the nurse on duty that is all she’s doing, so it’s not invisible labor at least! We are very lucky with our pediatrician I think.

        • Reply Irene August 19, 2022 at 8:26 am

          Actually as I am thinking more about my neurologist I am pretty sure she has some one else triaging her inbox. I frequently get responses from a nurse/MA on her behalf. Especially for things like refills. It’s interesting there are so many different ways to structure this.

  • Reply Ali August 18, 2022 at 11:22 pm

    Could this be at all how your office staff and handling things? Could maybe they be sending too many patients to you via message vs making an appointment?

    I was sick this past spring and called my pcp’s office to make an appointment. Instead, the front desk took my # and said the Dr would call me—which surprised me. A few hours later, my pcp called and probably spent 10 minutes on the phone with me before deciding I probably didn’t need to be seen and offering advice. As a patient, this was much more convenient (and also free vs a likely $200 charge due to our high deductible insurance), but gosh…it just struck me at the time as not a great deal for my super kind Dr. I would gladly pay as a patient for that. But who knows?? Maybe she would’ve preferred I come in (despite the front desk giving me this as a solution)!”?

    I say all that to say—could it be a front desk thing?

    • Reply Kari August 18, 2022 at 11:50 pm

      I think that’s part of the point of the article – staff and patients alike make different requests of the female vs male physicians.

    • Reply Sarah Hart-Unger August 19, 2022 at 5:37 am

      yep, could be part of it – whoever is triaging!
      i suspect it’s some of both.

  • Reply Helen Thomas August 18, 2022 at 11:48 pm

    Those comments are fascinating! I would use MyChart a LOT with my kids’ male pediatrician. I figured it was easier that way much like I’d prefer a text over a phone call. He would answer very quickly. And it was mostly him, not nurses. Now he’s left and we have a female and I don’t know her well yet, but the nurses usually respond and respond a lot slower than with our other doctor (same office)! I don’t message my PCP as often but I haven’t had great nurses responses so I just don’t ask questions lol

    Anyway yes, I agree that women are treated far differently and aren’t always “allowed” to make and keep boundaries without consequences.

  • Reply Nelle August 19, 2022 at 8:15 am

    I switched into a healthcare system that uses MyChart a few years ago and as a patient it has been a GIFT—especially going through infertility where a) I have a lot of questions and b) the whole process has been quite emotionally charged.

    That said I am fairly shocked to find out that those messages are being added to already-overfull workloads. I hope that the medical system I’m in is taking that into account! And taking the gender differential into account too! I will say it doesn’t bother me when nurses answer but that’s sort of the same issue given that nurses are disproportionately women.

    It’s interesting because I’m in a whole different industry (nonprofit comms) and there is also no question that I am being judged on my prompt and polite emails to clients. We don’t do billable time so that’s all-in but some are more free with the Send key than others. In this small sense I can relate! (And unlike your inbox SHU, what I’m dealing with is NEVER a matter of life and death, no matter how much the sender may think it is…)

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