Why is there a gender gap in physician salaries?

Some research studies just contain too many revelations to not share with the world. The Health Affairs study on the pay gap between newly-trained male and female physicians is just such a study, demonstrating conclusively that:

1. The gender gap in physician salaries is not related to specialty choice or work hours. No matter where women are choosing to work (solo practice vs. hospital, city vs. rural), which specialty they choose to work in or how many patient care hours per week they sign up for, women physicians earn less than their male counterparts.  According to the lead author, the authors of this study “honestly tried everything we could to make [the trend] go away, but it wouldn’t.”

 

2. The gender gap has grown nearly five times from 1999 to 2008 from a $3,600 difference to a $16,819 difference. According to the authors, that $3600 difference (which takes into account all the confounding factors noted above) is not statistically significant (p=0.08), but the $16,819 difference is highly statistically significant (p < 0.001). This trend places doctors as the worst profession for women in terms of disparities in pay. Without these adjustments and just looking at a Population Survey from 2007, the New York Times reported that women doctors earn a whopping 40% less than their male colleagues. That is worse than every other profession the Times looked at. Yes, even lawyers. The only professions that come close are finance managers and clinical researchers.

 

3. Women choosing lower-paying primary care specialties have nothing to do with this trend because women have increasingly not been going into primary care specialties. In 1999 (when, remember, women did not have a statistically significant difference in wages from men), women were joining primary care fields at much higher rates than men (49% vs. 33%). In 2008, both women and men are joining primary care specialties at a rate of about 33%. Disregard the problem that this poses for the nation’s primary care shortage for a moment – this demonstrates that our nation’s women, who are becoming an increasingly large part of the health care workforce, are ambitiously seeking higher paying, more demanding specialties and still, are seeing an increased rather than a decreased gap in wages.

The authors claim that they cannot point to discrimination as a reason for this wage gap because:

  • the increase in wage gap from 1999-2008 occurred in primary care specialties (i.e. internal medicine, pediatrics and family medicine) and non-primary-care specialties.
  • they find it unlikely that discrimination could have increased so drastically in the ten years studied.
  • they lack sufficient information about the non-financial incentives that may be driving women to lower-paying positions.

That all may be true and clearly, this subject merits more careful and thorough study. However, for all those lady physicians and physicians-to-be out there wondering what to do about this trend, I invite them to watch the TED talk by Sheryl Sandberg on why we have so few women leaders and to think about how many of the factors she names applies to a female physicians.

Emily Lu is a medical student who blogs at Medicine for Change.

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  • Megan Fox

    I dont understand. You wrote:

    “Without these adjustments and just looking at a Population Survey from 2007, the New York Times reported that women doctors earn a whopping 40% less than their male colleagues.”

    If there is a disparity of $17,000 on average and that is equivalent to 40% less than a male physician’s salary, that would mean that male physicians on average make approx. $42,000 – while female physicians on average make approx. $25,000. That is a 40% difference equal to 17,000.

    Something is obviously wrong here.

    • http://www.medicineforchange.com/ Emily Lu

      No, the explanation is very simple. The New York Times used a different data set which included physicians at all levels of training, while the study only talked about physicians that were just out of residency (thus eliminating the disparities due to there being more older male doctors in medicine who naturally make more money due to being of higher rank).

      Furthermore, the New York Times did not do the regression analysis that the study authors did to adjust for the confounding factors of specialty choice, work hours, etc. Without making that adjustment, the actual difference in salary is $28,658, meaning male doctors just out of residency make 18% more than female doctors.

      You’re right though, the New York Times article is not quite an apples-to-apples comparison of the research study. I’d love to see a similar study done on recent law school graduates to see whether similar gender gap occurs!

  • Dave Miller

    So, Emily Lu, since you mentioned the confounders, let’s discuss them for a moment.

    1) Job sharing – it’s pretty common practice, even in residency, to have two working moms “share” a 40-hour job, thus each taking home 1/2 the salary of their male and female colleagues who are working a “whole” job.

    2) Choice of specialty – women tend, more than men, to choose lower paying specialties like Pediatrics. If enough of them do so, then you have a “perceived” gender gap when it reality it is more a gap in pay of specialties.

    IMHO, it’s more than a bit irresponsible for the NYT to put out a story like this. This would never be acceptable in any scientific journal. Indeed, it’s a pretty classic case of finding the right data set to prove one’s point, regardless of the truthfulness of the point. Let’s see a comparison of the hourly rates WITHIN SPECIALTIES for men and women and then we can talk.

    • http://futureoffamilymedicine.blogspot.com mdstudent31

      You bring up very good points worth discussing.

      Your request for comparison of rates within specialties has had limited research within family medicine and brought to attention on a similar post (segment below) from Future of Family Medicine Blog about same topic re: gender disparities:

      “The vague concept of “productivity” has been another rationale for the discrepancy, often as measured by patient visits over time, rather than on the more clinically relevant measures of quality or outcomes. Results presented at the WONCA 2010 Conference (http://bit.ly/fwQFxq) show that among Canadian family physicians, women spend more time with patients (17.8 minutes vs. 13.3 minutes), are more emotionally engaged, and allow more time for discussion and questions. Unfortunately, these women also report more signs of burnout and physical stress. Ultimately, studies regarding productivity have been mixed.”

      Take those results with a grain of salt… Obviously we need to study this more but there is data out there. Would love to see similar data from other specialties, especially sub-specialties.

      Disparity in pay between primary care and specialty is a whole different can of worms that needs to be addressed and was addressed most recently in COGME’s 20th Report “Advancing Primary Care.”

  • http://www.medicineforchange.com/ Emily Lu

    Dear David Miller,

    Thank you for pointing out some really great reasons for why I didn’t use the New York Times article as the main focus for the piece, but instead focused on the Health Affairs article that did take into account of all of the factors that you mentioned (the p-values I cited in point #2 are from a multivariate regression they did using those variables) and in fact, did some comparison of the hourly rates within specialties.

    If you would be so kind as to follow the link to the original article you would find the following bulletpointed list of examples:
    - Female heart surgeons were paid $27,103 less on average than males.
    - Female otolaryngologists made $32,207 less than males.
    - Women specializing in pulmonary disease made $44,320 less than men.
    - etc.

    The tables in the full article break things down by every specialty, practice type, hours per week worked reported. In all of these categories, women are paid less than men. If you’d like the tables, I’d gladly email them to you.

    Regards,
    Emily

    PS: women’s tendency to go into primary care has nothing to do with it since as the number of women going into primary care specialties has DECREASED from about 50% to about 33% (similar to the levels seen in men in this sample) while the wage gap has INCREASED about 5x.

  • Dave Miller

    Emily,

    I don’t have a subscription to that particular journal so, if you wouldn’t mind, I’d like to have a copy of the article, pretty please. :-)

    Thanks

  • Anon

    Last time I checked, a level 1 through 5 office visit payed the same amount regardless of the gender of the physician. If you run your own practice, your “salary” is based on how much you work and how well you manage your overhead. Just sayin.

    • http://www.medicineforchange.com/ Emily Lu

      It’s worth noting then that only 12.3% of the men and 8.7% of the women in this study were “running their own practice.” So, though an interesting point, I’m not sure how much it applies in the grand scheme of things.

      • Fam Med Doc

        Dear Ms Lu,

        Could it be women are more often self selecting for straight salaried positions and men more often to productivity based salaries? Was their any data on this?

        • http://www.medicineforchange.com/ Emily Lu

          Not that I know of, but that would be a really interesting thing to look at: what doctors tend more to go for straight salaried positions vs. productivity-based salaries .. and furthermore, the implications that would have on patient care!

      • Anon

        If you “run your own practice” you are not depending on an employer to set how much you can make or how much you work. If someone employs you as a physician, you have probably willingly signed a contract agreeing to the terms of your employment.

  • JustADoc

    Doctors get paid for seeing patients. If women spend 17 minutes and men spend 13 minutes then men will see more patients per unit time and make more. End of story. No gender discrimination. It really is that simple.

  • Fam Med Doc

    A gender gap in pay is obviously unacceptable & if it is truly a fact, it needs to be addressed. As a male physician I for one am all for equality in all arenas.

    But could there be hidden causes of gender pay inequality that have to do more with female physician job preferences than true pay discrimination? When new physician grads are looking for & interviewing for positions, I hypothesize some women self select practices that are more reasonable in their approach to work/personal life balance. A female physician having just completed med school & then residency is often in her 30′s & knows that maternity goals are real & time quickly passing. She may intentionally select that physician group that better reflects that goal. I speculate if physician groups that tend to be less …alpha … and more reasonable with work hours might make less money as a aggregate physician group, therefore offering lower salaries to new grads, who might trend to female.

    I have seen that men tend to be more aggressive in their seeking of the highest paying position for the converse reason from the preceding paragraph: many men know they will be the sole bread winner, at least for a period of time, while their partner is on maternity leave/raising infants & working in the home. Yes, there is a pressure on men to… provide, & provide as much as possible.

    But that same pressure is slightly blunted in some female physicians who I suspect tend to be married to higher male earners. It’s exactly this blunted pressure that could be the impetus for women in lower paying jobs.

    Somehow I am unconvinced the research took this into consideration.

    • http://www.medicineforchange.com/ Emily Lu

      The study was not able to take that into account because of the surveys that they took the data from. However, the researchers do consider this and concluded that the difference in pay gap could be a result of some employers offering more nonfinancial incentives for women that provide better work-life balance, which could not be adequately measured in their study.

      • Fam Med Doc

        Here is a paragraph that I copied from the article that is linked from “Healthy Affairs”

        But Lo Lasso (one of the authors of the study) believes that the divergence in starting salaries may have more to do with the fact that women physicians are seeking greater flexibility and family-friendly benefits, such as not being on call after certain hours. He suggests that women may be negotiating these conditions of employment at the same time that they are negotiating their starting salaries.
        “It may be that lifestyle factors may be increasingly important to newer physicians,” says Lo Sasso. “It could be that women in particular want to have more of a lifestyle balance in their medical careers.”

        So, you see im I’m not the only one that suggests that women are actively seeking out better quality of life jobs but with the consequential exchange for diminished income. There is nothing wrong with this exchange, but without having research that investigates this hypothesized cause of gender pay differences with physicians, I am hopeful people do not jump to the conclusion of inherent gender pay bias is Medicine. More research is needed. Thank you for bringing up this important topic Ms Lu & best of luck in med school & beyond.

        • http://www.medicineforchange.com/ Emily Lu

          Right. That’s precisely the section I was thinking about when I said the authors included such thoughts in their discussion. It’s always good to hear your own theories are also entertained by others, right?

          My own opinion is that, well, this needs to be looked into more. It shouldn’t be taken for granted that it’s all women looking for better work-life balance or primary care positions, but by the same token, the salary numbers and work hours clearly don’t tell the whole story either. I also will be very interested to see how this direction of research goes…

  • charlie dickens

    Gender discrepancies in pay for the same work are not acceptable…!

    But physicians working in different types of practices do get paid differently…For example, my wife is a physician and works for a large city in the Northeast. Her colleagues are about 70 percent female…As a city employee, her pay, and that of her male colleagues is less than mine (I also am a doc.) BUT, she works less in a full day with less stress, has better benefits , such as more vacation,(unionized too) and a little more job security. She has great health care benefits, 403b, matched 401 k, and free basic health and drug plan! I prefer cash, she prefers benefits… Was the value of benefits taken into account in overall compensation? Employers position their jobs in terms of overall compensation.

    Was the type of employment structure taken into account? With most docs being employed by third parties at somewhat fixed salaries I am not sure how there could be this disparity…

    Good luck, def. needs more research. Very interested in seeing more follow up.

    • Fam Med Doc

      Hey Charlie!

      You prove my point well.

      I see this all the time in my city too.

      • ninguem

        Undesirable work hours, undesirable locations, undesirable conditions, the unbalanced work-life balance, taking the entrepreneurial risk of running your own practice rather than a straight salary and security, on and on….

        I can think of a whole number of reasons why the pay may be different, and the author admits same in the report.

  • http://drpullen.com medical blog

    In our practice we have nearly equal numbers of male and female providers, and earnings don’t seem to reflect gender as much as they reflect style of practice and “need” to generate income vs. “need” for better lifestyle. I agree with most of the comments that women at least in family medicine can make choices between income and lifestyle, but neither men nor women can maximize both.

  • ErnieG

    I echo the skepticism regarding the sex inequality. Most physicians (non-academics) get paid one of two ways- 1) direct business owner/partners with incomes based on productivity from revenues from E&M or ancillary services. Neither of these streams of revenues are based on gender differences as these are set by third party payers. 2) employees of medical practices with set salaries and some combination of bonus pay. These practices are very aware of gender discrimination, and I would be surprised if salaries differed by sex. In general, direct owners/partners have higher paychecks, but longer hours, higher risks, and lower benefits, and salaried physicians have lower paychecks but lower risk, shorter hours/better “lifestyles” and greater benefits. I am pretty darn sure that woman physicians tend to self select away from direct owners/partner models to salaried models- that’s what my woman colleagues and physician fiancee tell me.

    There is also a tendency when comparing direct owner physicians paychecks and salaried physician paychecks to ignore those benefits to salaried physicians and not see them as a compensation package eg 401K contributions, college tuition for children, malpractice insurance, life/disability/health insurance.

  • Vox Rusticus

    Let’s see, did we adjust for practice payer mix? If I work in a practice with lots of Medicaid, my revenue per RVU will be lower than if I worked somewhere with a balance toward private payers. And of course, if the salaried employee vs private practice business owner at-risk is not equal, then can we say anything more meaningful than the fact it would appear one gender prefers a lower-risk lower paid salary-based compensation to the higher-risk, possibly better paying business-owner model?

  • Vox Rusticus

    Perhaps a more scientific sample or comparison, maybe gender differences among Kaiser-employed physicians, adjusting for work hours and specialty, or possibly the same for VA doctors, or even a mix of employers, as long as confounders like private vs. institutional employment, owner profits and equity, work hours, specialty and payer mix are all adjusted-for. Short of that level of analysis, gender comparisons vis a vis professional compensation are meaningless.

  • Amy S

    If the difference could be explained by work-life balance choices alone it would be likely that the pay gap between men and women would mirror the pay gap in other industries as it is unlikely that women physicians have more of a penchant to choose these jobs as any other women. Additionally more men doctors are also making choice to take lower paying jobs based on work-life balance.

    I think its interesting that all of the comments want to try to explain away the difference instead of accepting that there is a real difference. In fact I think the difference may get worse as more females become physicians. Male doctors will be seen as more valuable– and yes for the same reasons that you are all arguing– “they work harder”.

    Clearly there are some valid reasons for the pay differential gap, but likely one of the reasons is still good old fashioned sexism.

    • JustADoc

      No sexism in insurance contracts. Maybe there is an academic medicine, but in private practice there isn’t. Money in -money out =money made.
      As I stated above, if women spend more time with patients but don’t bill more for spending more time than they will be paid less for the same amount of time worked. It is that simple. There is nothing else there.

  • ninguem

    “……….I think its interesting that all of the comments want to try to explain away the difference instead of accepting that there is a real difference……….”

    Sigh………..no one denies the difference. If the researcher found a difference, the researcher found a difference. The question is what explains the difference. “Equal work for equal pay” is fine. Was this actually “equal work”? He may be comparing apples and oranges. Even the author admits that.

    “…….but likely one of the reasons is still good old fashioned sexism……”

    Prove it, before you make inflammatory charges like that.

  • LynnB

    ITHINK JUST OUT OF RESIDENCY I WORKED ON GURANATEE AND MOST NEW HIRES (WHETHER JOINNING AND INDEPENDENT PRACTICE OR A BEHEMOTH) DO ALSO. IN THE SAME SPECILATIES , FULL TIME IN OUR AREA WOMEN SEEM TO BE PAID LESS, THOUGH WE ARE NOT SUPPOSED TO DISCUSS IT. I WOULD ASSUME THE MANAGERS CAN PAY THEM LESS (RIP THEM OFF), BECAUSE THEY ARE LESS SAVVY, SO THEY DO.

    SORRY FORE ALL CAPS , IN MEDIWRECK TONGHT

    • JustADoc

      When I was interviewing after residency I reviewed the contract at one place. The guarantee for 2 year offer was identical to what someone received 2 years earlier. Inflation had of course occurred during that time. She was female. I am not. She was, in effect, paid more than I was being offered. Of course, plural of anecdote is…

      Another place I liked and was offered same as someone from 2 years prior(male in this case). I countered for an extra $10K and received it. Had he been a she would it be sexism that I made more than her. Or would it just be that I bothered to ask for more and she didn’t?

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    These are all valid points, on both sides.
    But if we want to talk about gender issues in medicine, let’s open up the discussion.
    — Why are there so few male nurses in the system?
    — What are nursing schools and associations doing to recruit more males into nursing?
    — Why are their so few male cna’s, or med assistants or patient techs? Is it only due to the pay scales?
    — How does the preference patients have for the gender of their caregiver affect the quality of patient care. i.e. to what extent do gender differences affect open communication, and to what extent does thatt affect the quality of care?
    — Why are there women’s clinics all over the country and very few if any men’s clinics?
    — When you go to a bookstore, and look at the health section, why are there shelves and shelves under the title of “Women’s Health,” and very often no shelves titled “Men’s Health”? There are books on men’s health issues, but they just seem to be grouped under general categories.
    — To what extent do people really believe that most men are not interested in their health? If it’s true, where’s the data to support that assertion?
    — What seems to be the fact that many men just don’t go to the doctor or to hospitals, are often coerced there by their spouses — to what extent does the gender imbalance in nursing and other assistants have to do with this — or does it have anything to do with this?
    The answers to these questions are not simple. They’re complex and have economic, historical, sociological and psychological aspects. There is some research into this area, but not much. The general philosophy in medicine seems to be the “gender neutral” one. Many studies don’t even mention gender — doctors are just doctors, and nurses are just nurses. They seem to imply that gender isn’t an issue in medicine. If that’s true, where’s the data?
    I think these questions are as important as the one raised by the poster of this thread.