Diagnosing Medicine’s Intractable Gender Pay Gap

In recent news, some scenes in the movie All the Money in the World needed to be reshot when the actor Kevin Spacey was replaced by Christopher Plummer. Co-stars Michelle Williams and Mark Wahlberg, both represented by the same talent agency, received vastly different compensation for the reshoot: Michelle Williams received a per diem of $80 for about 10 days of work, which included Thanksgiving, while Mark Wahlberg received $1.5 million. There was some outrage when this 1000-fold gender pay gap became public, and Wahlberg and William Morris Endeavor donated $2 million to the Time’s Up organization before it was all over.

So: in medicine we are not alone.

While female doctors and surgeons earn 71% of their male colleagues’ salaries, female financial specialists are paid 66% as much as comparable men, women one year out of college earn 6.6% less than men after controlling for occupation and hours, and female MBA graduates earn $4600 less than their male classmates.

A small difference in first salary is, furthermore, compounded over a 3-decade career, as raises and pension contributions are made on top of smaller bases, debts are paid off more slowly, and less is invested. Estimates are that a $10,000 difference in starting salary will result in a 1 million–dollar lower worth by retirement. Yet evidence suggests that women are superior providers of medical care, often yielding better outcomes including lower mortality and readmission rates in US and Canadian studies.¹

Throughout medicine and the biomedical sciences, women continue to receive lower salaries and less funding, have fewer publications and first author publications — including in clinical cancer research, where they are relatively well-represented in the workforce — and be promoted at slower and lower rates. Facile explanations for these differences include differential household and child-rearing responsibilities, and different preferences on work-life balance.

These facts may contribute to sex differences in salary and promotion by reducing research productivity, but should have little independent effect on faculty rank once measures of productivity are accounted for. When, however, Jena et al controlled for age, years since residency, specialty, authored publications, National Institutes of Health (NIH) funding, and clinical trial investigation, women remained significantly less likely to attain the rank of full professor than men.²

Faced with the evidence that these stereotypical explanations cannot fully account for the existing gender pay gap in medicine, the sources of the pay gap remain to be fully identified.

Certainly, access to the best-paying positions in medicine and academic medicine is restricted for women. In academia, Association of American Medical Colleges (AAMC) data from 2014 demonstrate that women are poorly represented among leadership positions, occupying only 15% of department chairs and 16% of deanships. Jagsi et al documented that female cardiologists are significantly less likely to practice interventional cardiology than their male peers, and are commensurately less well compensated.³

The quality of experience junior physicians have in early positions may, furthermore, influence success and compensation. Women in academics may be saddled with greater amounts of the less rewarding tasks. Guarino and Borden investigated the amount of academic service performed by female or male faculty.⁴ Using 2 large databases, they found that female faculty perform significantly more internal service than men, controlling for rank, race/ethnicity, and department.

Survey data demonstrate that research faculty who report having been the beneficiary of strong sponsorship by a faculty mentor are more likely to achieve academic success, and that such mentorship is reported more often by men than women.⁵ Indeed, discrepancies in the value placed on the work of women in academic medicine may begin even before graduation.

A review of 1120 senior theses submitted to fulfill the requirements for graduation from the Yale School of Medicine documented disparity in the rates at which women received a coveted designation of “highest honors.” Women authored 51% of submitted theses, but earned only 31% of highest honors awards (odds ratio [OR], 0.41, 95% CI, 0.23-0.74). Men were more likely to work with a mentor with a history of multiple thesis honorees, take an additional year of study, secure competitive research funding, undertake a Master’s degree, and conduct laboratory research. Yet even after adjustment for these factors, women were still less likely to receive highest honors.⁶

Salary discrepancies are documented even within seemingly homogenous groups of physicians. In a survey of recent recipients of NIH mentored career development (ie, K08 or K23) awards, the mean salary was $141,325 for women and $172,164 for men. Male gender remained an independent, significant predictor of salary (+ $10,921, P < .001) even after adjusting for specialty, academic rank, work hours, research time, and other factors. Ten to 17% of the gender disparity was unexplained by of the variables the investigators examined.⁷

Unconscious or implicit bias continues to drive decisions made about hiring, compensation, promotion, access to internal resources, and the climate in which women physicians work.

In a famous demonstration that scientists are susceptible to subtle gender bias, Moss-Racusin and colleagues designed faux applications for a laboratory manager position.⁸ These were identical with the exception of the names of the application, some of which were male and some of which were female. When these were submitted to 127 male and female professors, male candidates were rated significantly better and were offered higher salaries than female applicants.

Successful strategies to increase fairness and diversity in hiring in medicine include more metric-based, conscious decision-making rather than following a “gut feeling” about a candidate. Establishing a job description and list of qualifications prior to launching a search, allowing time for review of CVs and publications, and use of structured questions can all allow fuller evaluation of women or candidates from underrepresented groups.

The #MeToo movement has inspired many women to relate stories of harassment, and again medicine is no exception. The power differentials in hospitals, the scale of the investment of money and effort required of students to get into medical school or a competitive training program, and even the geography of the hospital and the call room may render women in medicine particularly vulnerable to harassment and particularly unwilling to complain when harassed. Harassment intimidates and marginalizes women, and can lead women to drop out of a program or leave a good position. The ways in which these effects contribute to unhappiness and burnout, and interfere with success, strong negotiating, and competitiveness for leadership positions are just starting to be explored.

A large body of evidence now exists to demonstrate that the gender pay gap is pervasive in medicine, that it cannot be fully explained by the personal choices of individual women who are not fairly paid, and that a lower valuation continues to be placed on work when it comes from a woman. This is the case despite the fact that women now represent over half of new medical school enrollees, provide medical care that leads to superior outcomes, and that these attainments come in spite of a climate that is consistently less supportive to women than to men.

Yet each of our trainees, each young doctor who brings the gifts and the years of study and service that are the price of entering our field, deserves an equal chance to succeed and an equal chance to be valued for that success. It is past time for some models to narrow these pay gaps, rather than a further series of papers demonstrating that they exist.

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References

1. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875
2. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex differences in academic rank in US medical schools in 2014. JAMA. 2015;314(11):1149-58. doi: 10.1001/jama.2015.10680
3. Jagsi R1, Biga C2, Poppas A, et al. Work activities and compensation of male and female cardiologists. J Am Coll Cardiol. 2016;67(5):529-41. doi: 10.1016/j.jacc.2015.10.038
4. Guarino CM, Borden VM. Faculty service loads and gender: are women taking care of the academic family? Res High Educ. 2017;58(6):672-94. doi: 10.1007/s11162-017-9454-2
5. Patton EW, Griffith KA, Jones RD, Stewart A, Ubel PA, Jagsi R. Differences in mentor-mentee sponsorship in male vs female recipients of National Institutes of health grants. JAMA Intern Med. 2017;177(4):580-2. doi: 10.1001/jamainternmed.2016.9391
6. King JT Jr, Angoff NR, Forrest JN Jr, Justice AC. Gender disparities in medical student research awards: a thirteen-year study from the Yale School of Medicine. Acad Med. 2017 Nov 14. doi: 10.1097/ACM.0000000000002052 [Epub ahead of print]
7. Jagsi R, Griffith KA, Stewart A, Sambuco D, DeCastro R, Ubel PA. Gender differences in salary in a recent cohort of early-career physician-researchers. Acad Med. 2013;88(11):1689-99. doi: 10.1097/ACM.0b013e3182a71519
8. Moss-Racusin CA, Dovidio JF, Brescoll VL, Graham MJ, Handelsman J. Science faculty’s subtle gender biases favor male students. Proc Natl Acad Sci U S A. 2012;109(41):16474-9. doi: 10.1073/pnas.1211286109

This article originally appeared on Cancer Therapy Advisor