Here Come the Couples

Thirteen years ago, Arnold Relman, in an editorial in The New England Journal of Medicine, announced Here come the women [1]. And so they have. The proportion of women entering U.S. medical schools increased from 5% in 1949 (and just 9% in 1970) to 42% in 1992 [2]. The wave of women entering the profession is moving into practice but has not yet reached senior ranks; 27% of physicians younger than 35 years are women, compared with only 8% of those 55 to 66 years [3]. Nevertheless, it is only a matter of time before what was once nearly an all-male profession, with all that implies, includes women and men in similar proportions.

Now the profession has entered the next era. The couples are coming. In the past, about half of the relatively few women in medicine married male physicians [4]. Because the numbers of women were small, physician couples were rare. As the number of women increased more recently, the tendency for about half to marry physicians has persisted [5]. If this pattern continues, soon nearly half of all young physicians will be married to each other. Sixty percent of female academic physicians are already married to other physicians [6]. It only stands to reason that this would happen. As a colleague in Mexico City said of his marriage to a physician, We were so busy during training, who else would we meet? Most female physicians who do not marry physicians marry other professionals [7]. Male physicians are also following this trend. So, most future physicians who opt to marry will do so either to another doctor or to another professional, many in careers as demanding as medicine. Physicians choosing other relationships are likely to follow a similar pattern. This relatively new phenomenon demands attention but to date has largely been unrecognized by the profession.

Attitudes about medical marriages are burdened by baggage from the past. Powerful traditions have stereotyped how doctors and their spouses should behave. William Osler, who with Flexner set much of the tone for American medicine in this century, wrote What about the wife and babies if you have them? Leave them! Heavy are the responsibilities to yourself, to the profession and to the public. Your wife will be glad to bear her share of the sacrifices you make [8]. Our own early experience with others' opinions of two-doctor marriages was far from encouraging. When Robert proudly introduced his new wife, after their first year of medical school, an old friend of the family said, Of course you are going to make her stop. Another commented, Even if she never practices a day, medical school will have been so much fun. Our medical school advisor for internship applications was openly skeptical that the two of us could fit into the same field, much less the same program. Why don't you, Robert, become a surgeon or Suzanne a pediatrician? he advised. Times have changed, but medical couples still face special challenges.

The knowledge base about two-physician marriages is limited. Although there is a growing literature about women in medicine and medical marriages in general, few articles are about physicians married to each other. Most articles describe experiences and opinions; far fewer report the results of careful research. The few data that are available suggest two-physician marriages survive as well as or better than average [5]. Moreover, medical marriages are a moving target. What is true today is far different from what was true a generation or even a decade ago, and so today's situation may not predict the future.

How does marriage to another physician affect the physicians themselves? Swan touched on this when he wrote of his daughter and her husband: After work they would sit together on the deck with a glass of wine, or ice tea, like newlyweds . A goodly proportion of her BI housestaff were women and several, as did Kath, married or were married to their contemporaries. This unique groupcombining full professional career with an equally important family lifebonded together in a spirit of total commitment to one another [9].

No doubt two full professional careersin medicine or other demanding workis a challenge to both members' energy, ingenuity, flexibility, and good humor. Because so much time and effort is already committed, there is just not as much reserve capacity in case something goes wrong, such as a sick child, a broken home appliance, or failed transportation. It is more difficult for two family members than for one to live close to the edge of the impossible from day to day. Career opportunities for each may be in different places, so one or both members of the marriage must keep options open. A pediatric endocrinologist and a neuroradiologist are less likely than a general internist and general surgeon to find the work they want in the same place. The two careers may follow disparate courses; a time of great opportunity and intensity for one may occur at a time of winding down for the other. One may meet unexpected successes and the other, unfair reverses. All of these are stressors on professional marriages and require adjustments.

However, having a spouse in the same profession can be an asset too. Sharing professional as well as family work and overcoming challenges together provide an opportunity for adding special strength to the marriage. A respected colleague is close at hand for consultation, sometimes even for joint professional ventures. Then too, a physician spouse can more fully understand the demands of the other's professional life. As Michael LaCombe wrote of his marriage to an orthopedic surgeon, He could never say he hadn't been warned And being a doctor himself, he might have known what it was like to live with one. But when have we ever counted ourselves as anything but a blessing? [10].

How will two-physician marriages affect the profession? Medicine will have to change its institutions. It will need to implement coordinated schedules, leave policies for childbearing and childrearing, day care in the workplace, flexible approaches to the time course for promotion and tenure, ways of taking two careers into account during recruiting, and special rates with medical organizations. These changes are beginning to be considered because of the growing number of women in medicine, but now they are even more urgent because of physician and professional couples. They need to be put in place for both men and women. Society can still expect physicians to be unusually responsible, educated, and hard-working. But the old way of demanding single-minded dedication to the profession needs to be recast because it depended on a full-time backup for the rest of life's activities.

Unlike many changes now taking place in the environment of medicine, such as the explosion of technology or health system reform, two-physician and two-profession marriages have been increasing so gradually that they have received little attention. It seems likely that these new kinds of marriages will have powerful effects on the profession, just as they will throughout society. We hope medicine begins to study the effects and to adjust itself so as to find ways to maximize the good and minimize the harmboth to the couples and to the profession. The first step is recognizing the phenomenon.

• Copyright 2004 by the American College of Physicians