Work, life, and the gender effect: Perspectives of ACVIM Diplomates in 2017. Part 2—The intersection of personal life and professional career

Abstract Background In the field of veterinary surgery, women neither marry nor have children at the same rate as men, and those who do may experience more career disruption as a result. The American College of Veterinary Internal Medicine (ACVIM) is 1 of the few areas of specialized medicine that is predominantly female; it is unknown if such a demographic shift would produce a different environment for individuals cultivating their personal life. Hypothesis/Objectives To report data regarding subjective and objective aspects of the intersection of the personal and professional lives of Diplomates of the ACVIM. Sample Eight hundred ninety‐six surveys (781 completed) of ACVIM Diplomates, including cardiology, large and small animal internal medicine, neurology, and oncology. Methods An 82‐item online survey was distributed to ACVIM Diplomates via Diplomate college listservs. Participation was voluntary. Results Men were more likely to be married and have children than were women. Women had or adopted their first child at a later career stage compared with men, and agreed more strongly that career stage was an influential factor in family planning. Those with children worked fewer hours compared with those without, and this effect was greater among women. Women were more likely to require external childcare, but most men and women shared childcare responsibilities equally outside of working hours. Conclusions and Clinical Importance The intersection of personal and professional life differs between men and women in the ACVIM, which may create different needs, preferences, or barriers to work‐life balance in the workforce.


| INTRODUCTION
Veterinary medicine has evolved over the past 40 years as rapidly as any other high-level profession of note. This evolution includes the use of modern science and technology, increasing specialization within fields, as well as improving management and organization of hospitals and practices. It has become increasingly common for specialty practitioners to gravitate toward private practice rather than academia-a choice based on a variety of factors, including professional, economic, and personal reasons. In a time when more and more choices are available, Diplomates may have more flexibility in prioritizing the needs of their personal lives over their professional ones.
Both veterinary and human medical programs currently report a female majority in their graduate training programs. 1,2 However, veterinary medicine has changed more dramatically than human medicine. In 2019, 50.5% of matriculants to United States medical schools were women, compared with 80.5% of those enrolling at US veterinary medical colleges. 1,2 In this way, veterinary medicine can serve as a model for other high-level professional groups, providing an example of what happens when a field requiring multiple years of graduate and postgraduate training shifts to a predominantly female demographic.
The American College of Veterinary Internal Medicine (ACVIM) could serve as a particularly good model for considering the features of a feminized medical profession because it is a large field, comprised of many specialties, each of which reports a female majority membership. 3 The professional lives of male and female veterinarians differ substantially, and practice setting is a major component of this difference. 3,4 Furthermore, the personal and professional lives of veterinary surgeons intersect, and those experiences may differ between men and women. 5 In contrast to the ACVIM, the American College of Veterinary Surgeons (ACVS) is a predominantly male specialty college.
The culture of practice of specialties within the ACVIM may foster an environment more attractive to women in the profession. Conversely, the culture of practice may have adapted to a feminized workforce, and that similar assessment of the intersection of professional and personal lives of ACVIM Diplomates may differ. Although differences between personality traits and professional interests play a considerable but unmeasurable role in determining career path, contrasting the experience of ACVIM Diplomates with that of ACVS Diplomates will broaden the knowledge base for what life as a veterinary specialist entails.
Our objectives were to collect and consider data regarding the reciprocal effects of a career and a personal life for ACVIM Diplomates. Topics including personal relationships, family planning and balance, and the subjective experience of how these elements integrate were explored using a survey questionnaire. Our aims include providing relevant, objective, and statistically appropriate information to those in the field to inform decision making and guide practice management.

| Study population
The study group comprised ACVIM Diplomates in good standing as of February 2017 who were subscribed to ≥1 listservs serving the specialties of large animal internal medicine (LAIM), small animal internal medicine (SAIM), cardiology, oncology, and neurology. The size and gender demographic for each college specialty are reported elsewhere, 3

| The survey
An 82-item questionnaire (Supplementary Item 1) collected objective and subjective data about the professional and personal lives of Diplomates, and was administered using an online platform (Qualtrics©, Provo, Utah). Broad details regarding the surveyed areas are reported elsewhere. 3 This manuscript addresses responses to questions directed toward the respondents' personal life and family (marital status, children, childcare arrangements, age at first child), the interdependent effects of career and family, and any perceived effect of gender on these topics. All data collected was anonymous and automatically entered into a computerized database for analysis. Responses were collected over the course of 1 month, with 3 email prompts for participation. For personal income, which was subject to right censoring at $400 K, regression models with adjustments for covariates were fit using parametric survival analysis under a Weibull distribution assumption. Although such analysis is most commonly used for survival data, it is also appropri-ate for other types of data subject to right censoring. All statistical analysis was performed using R version 3.6.3 (R Core Team, R Foundation of Statistical Computing, Vienna, Austria, 2020) 3 | RESULTS

| Marital status and spousal information
Overall, 76.9% (n = 598) of Diplomates indicated they were married or in a domestic partnership. At the time of survey, 5.3% (n = 41) were separated or divorced, 0.1% (n = 1) were widowed, and 17.7% (n = 138) were single (and never married). Significant differences were found in relationship status between men and women after adjusting for age (P = .002); men were more likely to be married or in a domestic partnership (n = 169, 86.2% versus n = 426, 73.6% of women), and women were more likely to be single and never previously married (n = 117, 20.2% versus n = 21, 10.7% of men). Men were more likely to be with a partner who was also a veterinarian compared with women (n = 86, 48.0% versus n = 130, 27.4%, P < .001). No differences were found in the proportions of those who were ever married or partnered versus single by specialty (P = .89) or practice type (academia versus private practice, P = .64).

| Number and timing of children
Overall, 51.7% (n = 402) of respondents reported that they had at least 1 child; this proportion was significantly higher among men (n = 133, 67.9%) than women (n = 267, 46.2%; P < .001) and the difference remained significant after adjusting for age (P < .001, Figure 1). Even within the subset of respondents >35 years of age who identified themselves as "not single," women were still less likely to report having children as compared with men (n = 234, 62.6% versus n = 126, 80.8%; P < .001). No difference was found in the proportion of those with children between those in academia versus private practice. Among respondents reporting having children, the mean number of children was 1.9.
Respondents reported having or adopting their first child at an average age of 34.3 years (n = 393), with no difference by gender.
However, a significant difference was found between male and female Diplomates in the timing, relative to career stage, of having or adopting their first child. Women respondents had their first child later in their career than did men (P < .001; Figure 2). In particular, among those having children, 31.7% of men (n = 40) versus 12.0% of women (n = 31) had their first child during or before completing their residency program. More women (n = 212, 47.2%) than men (n = 47, 28.7%) strongly agreed that their stage of career (in training versus employment, or number of years practicing) played or would play an important role in family planning (P < .001).

| Interrelationship of children and professional demographics
The ACVIM Diplomates worked an average of 40 to 49 h/wk and hours worked varied by practice setting and, to a lesser extent, by specialty and by gender. 3 A difference was observed in the number of hours worked between those with children and those without (median, 40-49 versus 50-59 h/wk; P < .001). In particular, 20.2% of respondents with children (n = 81) indicated that they worked <40 h/ wk compared with 9.3% of those without children (n = 35), and this difference was higher for women than men (n = 62, 23.4% versus n = 29, 9.3% for women with and without children, respectively, and n = 19, 14.3% versus n = 6, 9.5% for men with and without children, We assessed the association between having children and measures of professional success. Although respondents with children were more likely to be more advanced in their careers, these differences disappeared after adjusting for age and relationship status. Similarly, although respondents with children reported higher incomes than those without, the difference was not significant after adjusting for key covariates, including gender age, Diplomate year, practice type, and employment status. there was no evidence of differences in these proportions by gender. Those employed in an academic setting were far more likely to report that parental leave was fully compensated compared with those working in private practice (n = 141, 58% versus n = 50, 12%, P < .001).
The average number of fully or partially paid weeks of parental leave was 4.9 weeks and 7.5 weeks, respectively. For those receiving compensation for parental leave, the most common coverage category was "compensation specifically designated for parental leave,"

| Subjective measures of personal life and career balance
Diplomates were asked about the effects that their career may or may not have had on their personal relationships. Overall, 15.4% (n = 117) felt that their career had positively impacted their relationships, whereas 48.0% (n = 364) reported a negative effect. Women were somewhat less likely than men to report a positive effect (n = 77, 13.6% versus n = 39, 20.5%, P = .05).
Diplomates were asked to subjectively assess the impact of family on career. Among Diplomates with children, women were significantly more likely than men to perceive a negative impact of having a family on their professional career (n = 149, 55.8% versus n = 35, 26.7%) and were less likely to perceive a positive impact (n = 33, 12.4% versus n = 48, 36.6%; P < .001; Figure 3)

| DISCUSSION
The current professional demographics of the different specialty groups within the ACVIM, and some objective and subjective measures of professional success and climate among men and women, and in different age groups are described elsewhere. 3 Here, we consider the same population to summarize elements of life outside of the work environment, and assess the conflicting effects of personal life and a demanding professional career. Although fewer differences appear to exist among the various specialties in this regard, it is clear that male and female Diplomates experience distinct differences within these spheres. Outlining those discrepancies and considering where barriers and benefits might exist will be useful to current and future ACVIM Diplomates, as well as to those seeking to hire and retain them.
Among ACVIM Diplomates, men were more likely to be married than were women, and women were more likely to report being single and not previously married. These findings were significant even after accounting for the age difference between those populations, and were consistent with observations among Diplomates of the ACVS.
Men were nearly twice as likely as women to be married to another veterinarian; this finding suggests the possible presence of an imbalanced "marriage market" created by current demographics in  1 Although no difference was found in divorce between the genders, an accurate rate could not be calculated because it is assumed that some proportion of those who had been divorced were remarried, and responded to the survey in the latter category. Only 5.3% of Diplomates responded that they were separated or divorced, which is in contrast to a finding among US medical physicians, where overall divorce prevalence was 24.3% and the number divorced at the time of survey was 7.7%. 6 This same study showed a higher prevalence of divorce associated with longer weekly work hours among female physicians, and also among other professions such as dentists, pharmacists, lawyers, and health-care executives. The supposition is that the stress and demands of the medical profession contribute to high divorce rates. 7 Although the dataset provided in our study cannot be compared to that presented previously, the relatively small Fewer women had children than did men, regardless of the constraints of age or relationship status. This finding did not vary between practice types or specialties. This gender discrepancy is consistent with data observed among ACVS Diplomates, including the average age at which women had children (approximately 34 years of age). 5 The decision of whether or not to have children is complex and personal, and largely outside the scope of our analysis. However, the smaller number of women having children coincides with a lower marriage rate compared with men and an average age of 34.3 years for women having their first child. This finding is especially important, because it estimates that almost half of female ACVIM Diplomates will have their children after 35 years of age, which is considered advanced maternal age, and associated with decreased fertility and increased risk of birth defects and other pregnancy-related complications. 8 Other observations made regarding family planning include the finding that women had children later in their career compared with men. Specifically, almost 33% of men had their first child before they completed residency training, as compared with only 12% of women.
Women also were more likely to indicate that career stage had influenced family planning; the competing requirements of medical training and beginning a family may be more challenging for women.
Anecdotally, it has become more common for female veterinary students, interns, and residents to combine these endeavors and, although institutional policies on pregnancy and lactation are rare, 9 increasing attention has been paid toward amending this issue.
Instead, women with children more often took time out during the early stages (first 5 years and beyond) of their careers to have children and also reported substantially more parental leave time than did men shared this responsibility equally. The economic effect of women having children during their early professional years is described as the "motherhood penalty," wherein women have been shown to suffer a 4% decrease in income associated with each child. 11 Although children, as a specific covariate, did not appear to be associated with an income discrepancy, Diplomates with children reported working fewer hours per week, and this reduction was more frequent among women than men (23% versus 14% Development of policies in professional programs, as well as increased opportunities for positive and supportive discussion and dialogue within the workplace, would help combat any negative perception that may be associated with having children and a successful career.
Although we identified differences between male and female Diplomates who had children and those who did not, our study had some important limitations to consider in how some results are interpreted.
Alterations in work schedules and personal responsibilities are, at least in part, a choice. Differences identified are often the result of those individual choices, albeit at times they may be difficult ones. The conscious prioritization of work versus family was not investigated, and it is likely that most people prioritize family. Also, in our study, children were the only dependents investigated. A more accurate scope of family would have included aging parents or other relatives who cannot care for themselves. In failing to account for such individuals, our results may present some bias against those definitions of family. It was also noted in the first part of our study that 776 individuals reported their gender. 3 This data was solicited at the end of the study in an attempt to minimize response bias by avoiding sensitizing participants to the effect of gender. However, due to the nature of many of our questions, doing so was likely an impossibility. The overall completion rate was 87% and questions could be left unanswered at will by participants at any time. Therefore, determining a gender-based participation bias, or other participation bias, is difficult and since not all questions represented identical datasets of respondents, response numbers should be considered in addition to percentages when interpreting our findings. Additional limitations relevant to the nature of our study design, such as the existence of response bias, and to the sample population, such as the paucity of racial diversity, are addressed elsewhere, but are critical to consider in the overall interpretation of our results. 3 The ways in which personal life and career intersect for Diplomates of the ACVIM overall were strikingly similar to observations for Diplomates of the ACVS. 4,5 Beyond the technical occupational differences between the 2 colleges, the requirements and climates of training programs and employment environments are likely similar, because Diplomates of both colleges often work together. Although the majority of ACVIM Diplomates are women, and the majority of ACVS Diplomates are men, we did not identify differences in their experienced work environment. We suggest that a paradigm shift in workplace management and culture, structured more specifically around the needs of a female workforce, is critical in order to address the barriers and gender gaps that have been reported across various disciplines of veterinary medicine. [3][4][5]9 ACKNOWLEDGMENT Statistical analysis was supported by the Clinical and Translational Science Award program, through the NIH National Center for Advancing Translational Sciences (grant No. UL1TR002373).