Working to bridge medicine's stubborn gender wage gap

Women now outnumber men in U.S. medical schools, but after training, they can expect to earn significantly less than their male counterparts, regardless of their specialty choice, productivity, or level of seniority.

Though the dollar amounts vary by year and by setting, a gender wage gap has stubbornly persisted in medicine over decades of study.

“No matter how the field of medicine has sliced the data, in academic medicine, in medical practice, we see a gender wage gap and we see that regardless of the internal medicine subspecialty, men are paid more than women,” said Nosheen Reza, MD, assistant professor of medicine at the University of Pennsylvania in Philadelphia, who has studied gender pay equity.

In 2021, the Association of American Medical Colleges (AAMC) issued a report exploring faculty salary equity at U.S. medical schools by gender and race/ethnicity. This was the AAMC's first report on salary by race/ethnicity and its second report breaking down the data by gender.

It found that women physicians, across races and ethnicities, were paid between 67 and 77 cents on the dollar compared with White men. Men of all other races and ethnicities were paid between 83 cents and $1.01 per dollar compared to White male counterparts. The report noted that gender was the “primary factor” driving inequities in compensation, with men consistently making more than women of the same race or ethnicity.

Similarly, an analysis by Dr. Reza and colleagues that looked at compensation data by internal medicine subspecialty showed a gender gap in compensation across the board, though in 10 of 13 subspecialties women's salaries were at least 90% of men's salaries. The exceptions where the gaps were larger included procedural subspecialties like cardiology, gastroenterology, and critical care medicine, according to the results published by JAMA Internal Medicine in 2021.

Another recent study, published in December 2021 by Health Affairs, focused specifically on community-based physicians, using data from more than 80,000 full time U.S. physicians to calculate that female physicians would earn about $2 million less during their careers than male physicians.

“There's been so much research on the gender pay gap for women physicians, and a lot of the research points to a similar magnitude of the gap,” said Vineet Arora, MD, MAPP, MACP, an author of that analysis and the Herbert T. Abelson Professor of Medicine and dean for medical education at the University of Chicago Pritzker School of Medicine.

Dr. Arora and her colleagues wanted to break through the oft-quoted statistic of an average $20,000 a year gender wage gap in medicine to see how the lost earnings compounded over time. “There is actually real money on the table, and it's generational wealth,” she said.

Understanding the problem

A challenge of research into the gender wage gap are the many factors that could potentially create uneven work and lead to different levels of compensation. Analyses have controlled for a variety of factors such as work hours, specialty, practice setting, productivity, and other potential variables.

The fact that they consistently show a pay gap may be explained in part by explicit bias, but experts said bias that is baked into the payment system is the major issue. For instance, compensation in academic medicine is often based on a variety of factors including clinical and academic productivity. However, productivity calculations may depend on research publications and grants, negatively affecting women who are often disproportionately asked to serve on committees and perform other institutional service, taking time away from research activities, explained Dr. Arora.

“A lot of places have reformed their promotions to value these other things, but they still aren't valued the same way as publication and grants,” she said. “At the end of the day, even though you can have a rule that says that this is valued, if the person who is doing the evaluation still harbors some bias about that activity, you're only as good as the people evaluating you.”

Women are also underrepresented in leadership roles in academic medicine, which has implications for their own compensation and the promotion of other women. Dr. Reza's study found that in 2018 to 2019, women made up almost half of medical faculty at the instructor and assistant professor rank, but only 24% at the full professor level.

“We see that women's representation along the pipeline—assistant professor, associate professor, full professor, department chair, and then the dean's suite—is a funnel, with fewer and fewer women the higher one goes in seniority and leadership. That has tremendous impact on compensation,” said Amy S. Gottlieb, MD, FACP, a general internist at Baystate Health and associate dean for faculty affairs at the University of Massachusetts Medical School-Baystate in Springfield.

In community practice, compensation packages tend to be heavily based on revenue generation, but even there the system seems to favor the practice patterns of male physicians, explained Ishani Ganguli, MD, MPH, an assistant professor of medicine at Harvard Medical School and an internal medicine physician at Brigham and Women's Hospital in Boston who was also a coauthor on the Health Affairs study.

Dr. Ganguli recently analyzed how women primary care physicians fared under four different types of payment systems—productivity-based fee-for-service, panel size-based capitation with and without risk adjustment, and hybrid payment models—compared with their male colleagues. The analysis, published by Annals of Internal Medicine on July 19, revealed that all four payment models favored male physicians and resulted in a gap in payments. However, capitation that was risk adjusted for both age and sex of patients produced the smallest gap, which was statistically nonsignificant in the analysis.

The study highlights that the typical practice patterns of women physicians, such as spending more time with each patient (a finding her team previously described in the New England Journal of Medicine) and more time responding to patient emails, are not valued in current payment systems, according to Dr. Ganguli.

“Our results caution policymakers and clinic leaders to think carefully about repercussions and to look at different approaches that are more relevant in primary care,” she said.

Greater awareness, attention

Though the gender wage gap has been stagnant for many years, attention to it is starting to change, experts said. “Certainly, over the last five to 10 years, along with the larger societal focus on gender disparities across various industries, there has also been a higher awareness of gender disparities in medicine,” Dr. Reza said. “I'm hopeful that these efforts will push all of us forward into thinking about how to reconcile these disparities.”

Increasingly, professional medical societies have begun to highlight gender compensation inequity and pushed to close the gaps. In May 2018, ACP issued a position paper affirming the need for equitable physician compensation that is not based on characteristics of personal identity, including gender. The policy states that compensation should be based on comparable work at each stage of a physician's career and that physicians should not be penalized for working less than full time. It also supports routine assessments of the equity of compensation arrangements by all organizations that employ physicians.

“The medical profession and our patients benefit greatly from a diverse physician workforce,” ACP stated in the position paper. “A concerted effort must be made to eliminate the imbalance in compensation and career advancement opportunities and provide a more inclusive environment to realize the full potential of all physicians in the workforce.”

Transparency and benchmarks

Potential first steps to address gender pay equity include pay transparency, sponsorship to bring women into leadership roles, redefinition of productivity, and regular and recurring implicit bias training, experts said.

It is also critical to recognize that this is a systems issue. “The burden of salary equity lies beyond the control of an individual woman. Organizations must explore factors that drive their compensation calculations and develop frameworks that account for gender inequities when assessing experience, performance, and responsibilities. … The gender pay gap is a crucible in which all the forces that diminish women's professional value within our medical institutions converge,” Dr. Gottlieb said.

Organizations can also create a women's committee to address gender equity issues and promote mentoring and networking for women physicians. These committees, which are being established at some academic medical centers, are one way to ensure that the problem is being examined critically, with leaders creating processes aimed at leveling the playing field, said Dr. Arora.

Employers, whether in academic medicine or community practice, can also help promote equity by eliminating salary negotiation practices that are prone to bias, said Dr. Reza. Regular performance reviews should trigger a set increase in salary based on clear and transparent milestones. “Everything boils down to taking these kinds of subjective interactions and decisions and making them as objective as possible,” she said.

Identifying salary benchmark ranges and consistent metrics for placement within those ranges that are not subject to negotiation is another way to level the playing field for women physicians, said Dr. Gottlieb, who serves as chair-elect for the AAMC's Group on Women in Medicine and Science and has published a book to guide organizations seeking to close their gender pay gap.

“One of the most disheartening elements of the gender pay gap is that women have been consistently shown to earn less than men right out of training,” Dr. Gottlieb said. “There is robust evidence demonstrating that even small gender pay gaps at the beginning of one's career can amount to a loss of hundreds of thousands of dollars, if not millions of dollars, over a professional lifetime.”

There needs to be greater accountability about correcting these issues, said Anupam B. Jena, MD, PhD, the Ruth L. Newhouse Professor of Health Care Policy at Harvard Medical School in Boston.

A public scorecard highlighting gender differences in pay and rank could help force action by large hospital and academic medical centers. Folding pay equity into hospital or graduate medical education requirements could also force institutions to begin addressing the underlying problems. “You can't rely on organizational altruism,” he said. “You need accountability.”