The “fourth shift” is a term that is often used in manufacturing, and I am uniquely applying it here to describe a new phenomenon for women in medicine at this time in history.

When I tweeted about the four shifts that women in medicine are doing during the COVID-19 pandemic, so many people responded that I knew it resonated. A lot of men are doing extra work too, but there are distinct gender differences.

Since I study workforce (and patient care) disparities, it is interesting to consider how the work for each shift, depending on gender, differs at this crucial time in history. In this blog, I am writing about gender primarily in its binary form (i.e., women versus men), which is the research construct typically used.

Of course, it is critically important to consider the gender spectrum and intersectional identities such as race, ethnicity, sexual orientation, and disability.

The First Shift

The first shift is our regular job. I am an Associate Professor and an Associate Chair of the Department of Physical Medicine and Rehabilitation (PM&R) at Harvard Medical School. Much of my work has been focused on cancer rehabilitation and prehabilitation.

For example, I recently led a technical work group convened by the World Health Organization that focused on a systematic review of cancer rehabilitation guidelines that was published in the high-impact journal CA: A Cancer Journal for Clinicians.

In this review, we found that cancer rehabilitation is often part of clinical guidelines, but many patients are not referred for these critical services.

I have also been working with a great team of physicians at Mass General on prehabilitation prior to surgery. For example, in research led by Motaz Qadan, MD, PhD, and Naomi Sell, MD, MHS, we published a report in the Annals of Surgery about how we virtually supported patients enrolled in a pancreatic cancer prehabilitation clinical trial during the early phases of the pandemic.

There are many gender-related differences in first shift work for women in medicine. For example, a recent systematic review on pay gaps found that in nearly every study, women physicians earned significantly less than men, often tens of thousands of dollars less per year, despite similar demographic and work-related profiles.

In the BMJ, my colleagues and I wrote about how the pandemic is making pay disparities worse for women physicians and scientists. A study in the New England Journal of Medicine was profoundly discouraging for women in academic medicine and reported that there is little to no progress in promotion to higher ranks (associate and full professor) over a 35-year period.

As the director of the Harvard women’s leadership CME course, part of my own effort to address the findings in this deeply troubling study is to add a new full day workshop focused on accelerating academic publishing and promotion.

Indeed, for first shift work among men and women, the workload may be similar, but an abundance of solid science demonstrates that the rewards are not.

The Second Shift

The second shift is what we do at home to take care of our loved ones and ourselves. I have a lot of new second duty responsibilities.

For example, nearly every evening after work I connect with my mom over Zoom and listen to an Audible book. Although I started this during the pandemic to alleviate some of her social isolation (mindful of how toxic this can be for elderly people), it has been a real blessing for both of us.

Many studies demonstrate that women do a disproportionately high amount of childcare, eldercare, and household chores. The high second shift load has been implicated in burnout symptoms.

My colleagues and I recently studied women runners and found increased burnout was significantly associated with greater domestic responsibility and hours working, but exercise alone did not appear to control these symptoms.

Bottom line: women are not able to outrun burnout. This research was led by Monica Verduzco-Gutierrez, MD, Chair of the Department of PM&R at University of Texas Health San Antonio. She is one of the few Latina professors and chairs in the U.S.

The Third Shift

The third shift is the work that women are doing to lift other women up. Gender equity work—which is usually unpaid. This was recently described in an article titled “The Third Shift: A Path Forward to Recognizing and Funding Gender Equity Efforts” that was co-authored by a leading gender equity advocate, Dr. Shikha Jain.

To demonstrate how this works, and why it is so problematic that women in medicine are doing the majority of the work to achieve equity, my colleagues and I analyzed published studies on physician compensation.

In research I co-led with Dr. Allison Larson, Boston University Dermatology Residency Program Director and Vice Chair for Medical Education, we found that despite the fact that men make most of the compensation decisions (because they are in the majority of top leadership roles and therefore control the finances) there were disproportionately more women authors of compensation studies.

We also found women did most of the dissemination of the results (via citing them in other reports and discussing them on social media), and most of the studies were not funded—suggesting women are doing this research on compensation disparities without financial support.

There are many opportunities for men to be active allies in third shift work. Some of the men in the Department of PM&R at Harvard Medical School—Drs. Ross Zafonte, Adam Tenforde, and Jeff Schneider—have participated in publishing workforce gender equity studies with my colleagues and me. So have others across states and countries.

Some of the #HeForShe colleagues who have worked with me on unfunded gender equity research include:

• Dr. Howard Liu, Chair of the Department of Psychiatry at University of Nebraska Medical Center
• Dr. Gianni Lorello, Chief Diversity Officer in the Department of Anesthesiology and Pain Medicine at the University of Toronto
• Dr. Miguel Escalon, Vice Chair of the Department of Rehabilitation and Human Performance at the Icahn School of Medicine at Mount Sinai.

Dr. Madhukar Pai, Canada Research Chair in Epidemiology & Global Health at McGill University, reached out to me when he cited my report “Where are the Women? The Underrepresentation of Women Physicians Among Recognition Award Recipients from Medical Specialty Societies” for a study he led on awards for women involved in global tuberculosis work.

Following this, he invited me to be interviewed in his column for Forbes —amplifying the research my colleagues and I are doing on gender equity.

The Fourth Shift

The fourth shift involves the work that people are doing during the pandemic which is not part of their usual job. Examples include conducting unfunded research on COVID-19, getting the word out about the benefits and risks associated with the new vaccines, volunteering at testing or vaccination sites, providing additional mentoring and support to a greater proportion of medical students or other trainees who are struggling with mental health issues or pandemic-related concerns (e.g., becoming infected themselves, dealing with a COVID-related death in their family).

This shift is new and therefore not widely described or recognized. However, because women tend to have less (or no) paid administrative time, in this fourth shift there are important gender differences.

For example, women often do this work late at night and on weekends without any compensation. Some of these issues have been recently described in a report by the National Academies of Sciences, Engineering, and Medicine titled “The Impact of COVID-19 on the Careers of Women in Academic Sciences, Engineering, and Medicine.”

My fourth shift work has involved publishing reports on how to do a telemedicine physical examination, developing a post-COVID-19 clinical rehabilitation program, identifying gaps in vaccine trial inclusion for people who identify with racial and ethnic minority groups (this research was led by one of my mentees, MD/PhD candidate Laura Flores from the University of Nebraska Medical Center), and implementing surgical prehabilitation for patients who have had delays in their surgeries due to the pandemic. The number of additional hours I have spent volunteering for pandemic-related duties and providing additional mentoring and support to trainees and faculty is incalculable.

When women in medicine work three shifts, it is arduous. Working four shifts undeniably demonstrates the incredible strength, intellectual capital, and commitment of women in medicine.

However, this is not a sustainable model for the medical and scientific workforce. Thus, healthcare leaders at the highest levels, most of whom are men, need to urgently address the issue of women working four shifts.