Female physicians make less money than male doctors, here’s why

Female doctors make less than male physicians.

That conclusion gained major media traction recently.  A recent post on KevinMD.com by medical student Emily Lu had some great conversation discussing some reasons why women make less money in medicine.

To recap, the study from Health Affairs concluded that,

newly trained physicians who are women are being paid significantly lower salaries than their male counterparts according to a new study. The authors identify an unexplained gender gap in starting salaries for physicians that has been growing steadily since 1999, increasing from a difference of $3,600 in 1999 to $16,819 in 2008. This gap exists even after accounting for gender differences in determinants of salary including medical specialty, hours worked, and practice type, say the authors.

Everyone hypothesized all sorts of reasons.  Female doctors prefer more family-friendly hours and less call, which may impact their salary.  Women are simply worse negotiators than men.  Blatant sexism exists when hiring new physicians.  Money isn’t as important to women as it is to men.

All of which may, or may not, be true.

Of course, the reasons probably are multi-factorial.  But there’s one that I haven’t seen discussed much.

Women, in general, spend more time with patients — up to 10% more.  Pauline Chen, in a New York Times column last year, noted stark differences in how men and women practice medicine, and whether, in fact, women make better doctors by spending more time in the exam room.

So, even though women may work the same number of hours as their male counterparts, they’re likely to see less patients during that time.  And since physician compensation is still mostly based on fee for service or productivity-based incentives, women doctors are going to come up short on compensation scale.

As I commented to CBS News, “By spending more time with patients, female physicians are financially penalized by seeing less patients during the day.  It’s another reason why we need to change the way doctors are paid, and reward them for spending time with patients, instead of penalizing them.”

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Harry

    Like it or not, physicians, male or female, are all part of the same third party payer volume-driven payment system (unless of course you don’t participate in the madness of insurance, ie. Concierge/direct/cash-only practices…which, by the way, are gaining steam).

    Until the system changes how docs are paid (not reimbursed), there is no financial incentive to spend more time with patients. I would venture a guess and say that by spending additional time with complicated patients, overall patient care would improve, along with phisician job satisfaction. However, especially for private practice docs, doing so means either extending an already long work day or seeing fewer patients per day, thus cutting into the bottom line. I almost hate mentioning that term, but the reality, like it or not, is that medicine is a business and a rather expensive one at that, in relation to the revenues generated. And with tremendous student loan debts, it really puts those docs who choose to spend more time with patients, in that much more of a financial bind…..male or female alike. By far, primary care docs are hit the hardest and are the docs that really need to spend the most time with patients, especially with an ever-aging population, and the inherent problems that undeniably arise with age.

    It would be nice to get paid based, at least in part, off the quality of care that you provide, and not just simple by the quantity of care, necessarily. Many payers do have quality incentive programs, but an additional 3-5% bonus hardly touches the tip of the iceburg for most docs.

  • Vox Rusticus

    “As I commented to CBS News, “By spending more time with patients, female physicians are financially penalized by seeing less patients during the day. It’s another reason why we need to change the way doctors are paid, and reward them for spending time with patients, instead of penalizing them.””

    Evidence of benefit, please. Show that the extra time you say women physicians supposedly spend with patients has any benefit in morbidity outcomes or costs.

    And let me put a backspin on this: patients of male doctors wait less for appointments and are treated sooner than patients of female doctors. Discuss.

    • Kevin

      No hard evidence of benefit in terms of mortality or cost, but increased patient satisfaction. From the NY Times piece by Pauline Chen:

      In one study, for example, Swiss and American researchers found that patients, depending on their gender, evaluated their male and female physicians’ displays of concern for their patients differently. While male patients tended to be content regardless of physician gender and communication style, female patients were much more specific when it came to assessing their doctors. The female patients were most satisfied with their women doctors if those doctors expressed great concern and empathy and were extremely reassuring. But if the doctors were male, the female patients were dissatisfied with overt displays of caring and actually preferred less empathy and reassurance from the doctors.

      Of course, not everyone wants a doctor who spends more time with them. But I hypothesize that a majority of patients do.

      Kevin

  • Dr Chris

    I suspect part of why women spend more time is that the look at a patient’s health as part of a system.
    Example-a 94 you pt has avascular necrosis. He is irritable at baseline, and more so now.His wife, 12 years younger, but not in the best health looks completely worn out.
    To make this surgery work, if it will, we need not only VNA / OT now-it turns out that Mr W. is climbing into the bathtub rather than using the shower, but a HHA, just to keep him together until his surgery date.
    The kids are called-reminded that their stepmother is no longer 70.
    Explaining that it doesn’t matter when he last did his lab work, etc, her needs it again takes a bit (and he’s not wearing his hearing aid), as he rails against the cost to Medicare.
    He then complains about his teeth, and we discover his bridge has broken. We talk about the need for good nutrition to get him though this surgery.
    Aside from the 45 minute emergency visit, stemming from a 40 minute visit last week, followed by an emergency call because they got to the xray facility without the script,I now have several calls to his cardiologist, pulmonologist to make ,the paperwork for the VNA, and I will need to dictate hi pre-op. I already made calls to get him into the orthopedist the same day as his xray.I will probably get paid for the 45 minute visit., but all the rest in probably unreimbursable. I have tried the management codes-they never seem to fly.

  • http://www.sharayurkiewicz.com/ Shara Yurkiewicz

    This is a great point, and even better because it’s actually supported by evidence and not just pie-in-the-sky conjecture (i.e., women purposely negotiate for family-friendly hours).

    Since I was young, I have been fairly attuned to signs of blatant and not-so-blatant sexism (thankfully, I only experienced the latter). To the credit of my medical school, where I am a first year, I have not experienced even a hint of subtle sexism.

    I hope this will last, but getting out the classroom after second year and going on to the wards is a whole other story.

    My take on the study is that it’s not (necessarily) not sexism, and we should be careful before we dismiss discrimination entirely: http://tinyurl.com/6zoej5z

  • Finn

    Seems to me that the only way to determine how much of the salary difference may be attributable to sexism or less aggressive negotiation, and how much to spending more time per patient, would be to separately analyze the salaried physicians & those paid by third parties. Bigger discrepancy among those paid by third parties would suggest that they see fewer patients; bigger discrepancy among the salaried would suggest sexism, salary negotiations, or choice of shorter hours.

    • http://www.chrisjohnsonmd.com Chris Johnson

      I agree — this would be key data to have. I work in pediatric critical care as a salaried physician, and I think my specialty has more salaried physicians than not. I know the salary and benefit packages we offer to new full-time hires are the same for everybody. There is still the issue of if women are more likely then men to take part-time salaried positions. Those data must be out there somewhere.

  • Productive MD

    I find this story very irritating,with a current primary care shortage patients have to wait days to make appointments, they spend hours in the waiting room all for relatively minor things, to now propose a system that actually rewards lack of productivity is absurd, if men made less than women in the field no one would say a word. I see 45 people a day, and no i don’t spend 45 minutes with each one, i don’t need to as a primary doc, as most visits are routine rx refills and upper respiratory infections, those who are truly sick in my office will recieve as much time as they need. I may step out of the room to attend to another patient simultaneously but I make sure I address every single issue a patient has no matter how many they have before they leave my office. My patients do not wait long and I do not work extremely long hours either. It’s all about being efficient with your time, there are many women who are like this and they make a TON of money and there are many men who waste a lot of time complaining, chitchatting with patients and office staff and don’t really look at the bottom line and thus they don’t make as much. The point is that increased efficiency leads to higher productivity it does in every aspect of life. In this day and age gender bias is rarely seen, women are wired differently from men and so there will be a tendency for men to have higher incomes than women but in the end men have much higher pressure on them to make more money as male physicians are more likely to be the main bread winner in their family than women who may be married to someone who is already successful. There is no “better” doctor it is up to the patient to decide what their priorities in picking their doctor, if they feel like waiting weeks for an appointment just so they have an MD spend 30minutes explaining their UTI to them or do they want to get a same day appointment and be in and out. If you don’t want to be productive and work hard you do not deserve to compensated the same way and that’s the truth regardless of the profession, or gender. If you forget about ethics for a moment and look at it from a pure financial perspective it would behoove me to do an excellent job on every patient because better outcomes for the patient will lead a better reputation which will lead to more patients and less people leaving the practice, also better outcomes will lead to less malpractice. All these things help boost the bottom line, not just stuffing as many patients into your schedule as possible because if you are doing the wrong thing with these people you will eventually lose them as patients. I”ve been trained by some amazing women physicians and they have every right to be paid as well as men for the same work.

  • JustADoc

    Actually, my comments were all about the point you make here. Women spend more time per patient. Doctors get paid for seeing patients and not time spent with them.

  • ninguem

    If, for the sake of argument, women are spending more time per patient visit than men, then they are by definition less productive than men if working the same hours. That’s not sexism, that’s math.

    Though if they really are spending more time, they should be mitigating that difference by billing based on time rather than complexity.

    So, again, the study is really comparing apples and oranges, because, in fact, the women are not doing “the same work”……..if it is accurate that they are spending more time per patient visit.

    The author took pains to point out the possibility of this bias in the study.

    Yet everybody wants to attribute this to sexism.

    • Kevin

      “Though if they really are spending more time, they should be mitigating that difference by billing based on time rather than complexity.”

      Even so, a 25-minute office visit billing a 99214 is less than two 99213′s that could be seen during that same time.

      Kevin

  • jsmith

    In my clinic most of the male docs treat ‘em and street ‘em, and the female docs spend more time, especially with female pts. We male docs make more money and see more of the acute serious cases.

  • Dr Chris

    I I was doing at least three other things while this patient was being evaluated-I got an asthmatic going on a nebulizer, a call about altered mental status in a hospital patient at the same time. Was I non productive because I averted a longer hospitalization? His wife is my patient too-she looked awful, I was actually caring for both of them at the same time-the two patients and the system that will keep him out of a nursing home, save medicare money, and prepare him for a rocky surgery.
    If you spend 10 minutes with a patient it will work ok for a URI, not at all for a chronic migraines,not for dementia evaluation, depression, subtle onset of AS, atypical angina. I was brought up short by the PIM for ABIM-it seems I talk nonstop about diabetes treatment. I said” you have to see an eye doctor every year”Perhaps I did not say clearly enough, “you can get retinopathy” , or what it was.
    And there is less sexism, but it is there. It is subtle, and it applies to women as patients and doctors. I ignore it, and do my work.

  • Smart Doc

    My own experience (N=1) is that female physicians just don’t work as many hours as males. I have seen absolutely no evidence that they see patients for one second longer than male doctors.

    The females work part time much, much more frequently as males. They take time off, use flex time, and take per diem and salaried positions all at a much higher rate than the males.

    Again N=1, but that is what I see.

    • stitch

      However, if you look at the report, the factor of working fewer hours is accounted for, and still women make less money.

      As a female doc, I have chosen to work part time in order to spend more time with my family. I have also chosen to be in salaried positions but that is because I know where my strengths and weaknesses lie. I would actually have more flexibility over my time and mode of practice if I chose to run my own practice, but it’s a choice I have made.

      Working part time, I accept that I will make less money, but on an RVU contract I should not expect to make less per RVU than a male doc. Therein lies the question, are women making less for equal work? I think we need more information on that.

      • Kevin

        It’s doubtful that women are paid less per RVU than men. A 99213 and 99214 gets paid the same, whether care is given by a male or female. Although the study accounted for the number of hours worked, it did not mention productivity. With women spending 10% more time per patient, they’ll garner less RVUs than men — even when billing for time (two 99213s >> one 99214) — in the same time period.

        Kevin

        • jsmith

          Kevin, It might be that Stitch is paid by her employer, so although the employer gets paid the same per RVU, she does not. Stitch?

      • jsmith

        I am a doc married to a doc. She works less than I do and earns less money. She spends more time with our kids than I do and even has the time to volunteer at their school from time to time. It works for us.
        The idea that women and men will make the same choices in life is entertained only by people who have no understanding of women and men. We’re different, and that’s ok with me.

  • Dr Chris

    Both of bove are good comments. I also think women don’t know how to negotiate salary and job benefits well.
    I also suspect they may not know how to code their work. I worked for a large group- and their billing management audited our coding-I was consistently under-coding by at least one, and frequently two levels. When I brought that skill to private practice, I got one or two letters saying my coding was above average level. I sent in the notes, and never got another letter.
    To Productive MD-a very significant number of my patients have lupus, interstitial lung disease, CAD, etc. Because I am good at this, other specialists referred their patients for primary care, and it became a huge part of the practice. A fever in a patient on immune suppressants is not a 10 minute affair -even if the face time is relatively short, the follow up that has to happen THAT day, and the next few days is not.”Chit Chat” with someone who had a silent MI becomes what t I jokingly call “Is it bigger than a breadbox” history “Are you short of breath on stairs?” “I don’t climb stairs. ” DId you ever?” “I live in a one story”What were you doing a year ago? and so it goes.
    It means you have the history down so well that you don’t believe the nuclear stress test.

  • Mt Doc

    The bottom line is, that if you see fewer patients and bill less you will make less money, whether you are male or female. The most efficient person in my group is female – so is the least efficient.

    It may be true that doctors should be able to bill for the time spent with patients, but the reason for this should not be to equalize the wage scale between male and female physicians (as suggested by CBS news) . It should occur only if the extra time spent with patients correlates with better care, regardless of the sex, age, ethnic group etc of the doctor.

  • http://www.picumd.com PICU MD

    Here’s another n=1, anecdotal, observational opinion so take it for what it’s worth.

    I’ve noticed the following among women vs. men pediatric residents:
    1. I’ve found that of the married female residents, the VAST majority are married to folks who make (or will make) more than the typical pediatrician (often they are married to other residents in more lucrative subspecialities).

    2. The married male residents are often married to folks who make less than them (or are at home with the kids).

    These 2 facts in mind I’ve found that the women residents don’t place as high a value on salaries as the male ones do. I think a lot of the women residents just want a job that makes them happy and in many cases allow them flexibility to be with their kids. The male residents are more focused on the dollars since they have to provide. I think it would be an interesting drill down to see if the difference holds true for married vs. single male or female residents.

    Anyways, my point in all this is that women residents will tend to take jobs that satisfy them (since they don’t need to worry as much about the $$) hence they may take lower paying jobs. Meanwhile men go for the $$$.

    • jsmith

      Great point. I see that a lot too. A local female pediatrician is married to a surgeon. The peds stopped working. Another local FP is married to a hardscrabble farmer. She works a lot and wants more hours.

  • Dr Chris

    My observation, is that male subspecialists have a wife to get them through residency.That wife usually handles the household. He may help, but she is organizing the circus. (Reality check-who finds daycare, arranges the birthday party, knows the kids immunizations. )
    Most women don’t have a wife. Most residents can’t afford a nanny. Women end up delaying having kids until they are older, or they have family very close by, or can afford a nanny. It is frequently the case that women are younger and the last through school. Subspecialty gets put on hold as the money runs out.Or they are faced with kids or career.Few men are faced with that option. When younger(female) physicians ask me what they should do ,I half seriously tell them to move next door to their mother or mother-in-law.Or vice versa.It doesn’t mean they aren’t working as hard-they have two jobs, and most husbands can’t step up to the plate, either they don’t understand how big that other job the wife is carrying is, or a residency program doesn’t have the give to allow it. I was really fortunate that my husband could do his work anywhere while my kid was little. My friends and younger colleagues don’t have that option.My trade-off was a ridiculous commute for really good daycare.

  • http://seattlemamadoc.seattlechildrens.org Wendy Sue Swanson, MD

    I make more, per FTE, than many of my male counterparts. That’s because my schedule is always booked. But my practice style is reflected in the study Dr Chen and Dr Pho mention. I do appointments every 20 minutes, while my male partner does them at 15 min intervals. I’m never at my desk, he often is. I’m always in the exam room. I don’t think this is an “efficiency” issue. I simply enjoy getting to know my patients, hearing about their worries and doing more than is asked of the visit. I tried the faster model (15 min check ups and appointments) and didn’t like it. I had to shed all of the bonding time and sterilize how we discussed things.

    This hurts my bottom line, of course. But I couldn’t care less. I want to enjoy time with my patients and get to know more about them than the numbers.

    This is not because I don’t want to make money. I do. I’d love to make more money. But creating “longer” appointment times was a decision I made in balance. Yes, I deserve to be paid well for what I do. But I also owe it to myself, and to my profession, to practice in a way that is compassionate. For me, to get the whole story from families, and both empathize and provide compassionate care, I need a little more time.

  • http://mommyblawg.blogspot.com The Mommy Blawger

    Kevin, they see fewer patients, not less patients.

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