A little while ago, LoOG chum and husband-of-doctor Will posted a link in one of the comments to a report of a new study about gender inequality in physician salaries. (Much obliged, Will. I can always use blog fodder.) From the article referenced in the report above:
Newly trained physicians who are women are being paid significantly lower salaries than their male counterparts, according to a new study published in the February issue of Health Affairs, released today. 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.
The authors based their conclusions on survey data from physicians exiting training programs in New York State, which is home to more residency programs and resident physicians than any other state in the country (1,073 programs, according to data assembled by the Association of American Medical Colleges). The number of physicians in the survey sample included 4,918 men and 3,315 women.
The study findings are especially significant since women represent nearly half of all US medical students and are projected to make up about one-third of all practicing physicians at the beginning of this coming decade. Women had lower starting salaries than men in nearly all specialties, according to Anthony Lo Sasso, a professor and senior research scientist at the School of Public Health of the University of Illinois at Chicago, and his coauthors. The gap grew steadily from 1999 to 2008. In 1999, new women physicians earned $151,600 on average compared to $173,400 for men—a 12.5 percent salary difference. That difference grew to nearly 17 percent by 2008, with women starting out at $174,000 compared to $209,300 for men.
I need to stipulate a couple of things before going any further. First of all, this is only one study. While the findings are certainly noteworthy, it’s appropriate to be somewhat skeptical at this stage until more data emerge to support what’s been found. And the actual study is behind a subscription wall, so it’s impossible for me to evaluate its methods and conclusions with much authority. (I’m interested in the results, but not enough to subscribe to Health Affairs.) Take the following musings as nothing more than that.
I’m going to take it as a given that the results are valid. Assuming that, there are a few explanations I can think of for why men and women in the same specialty are being paid different amounts. We can exclude work experience, which is one of the first things that sprang to mind, as the survey was take of physicians exiting training, in which case all of them would presumably be naive to the healthcare workforce.
The simplest explanation for the pay gap is outright bias. I’m having a difficult time finding good information about the proportion of women holding administrative or executive positions in American hospitals and healthcare systems. (As always, anyone with reliable data is welcome to share in the comments.) However, it’s been my perception that more and more women are entering administrative positions (since residency, I’ve had women as bosses at two of my three jobs), so frank bias seems less plausible to me as an explanation for an increasing pay gap. But perhaps it’s me who is naive to think so.
Another explanation that struck me as a possible contributor to the gap is the possibility that men might seek additional training before entering practice. The report only says that the survey was done on physicians exiting training programs, it’s not clear to me if that would include those leaving residencies only, or also subspecialty fellowships. Fellows are still physicians in training, and are often classified as residents since they’re still paid along the same lines and supervised in a similar manner. It seems at least somewhat plausible that men are getting additional training, which improves their bargaining position when looking for employment. A person with training in rheumatology, for example, might join an internal medicine practice and work the same hours as a colleague without the additional training, but get paid significantly more. For my own part, I sought additional subspecialty certification in part to improve my prospects in the job market, even though I work in a primary care office. It’s possible that this study does not account for this kind of situation.
However, this explanation seems the most straightforward to me:
But [study author] Lo Sasso 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. [emphasis added]
If the study did not account for a discrepancy in the amount of call or after-hours shifts worked, then that’s a pretty serious weakness. (I suspect the authors would be willing to concede as much.) In my experience, on-call coverage comprises a significant chunk of a physician’s pay, but isn’t lumped in with the hours that a provider works. There’s a lot of variability from shift to shift in how much time is spent on patient care during call, making it complicated to calculate during salary negotiations. When you break down a physician’s pay, there’s usually a lump amount per year that’s compensation for taking call.
If women are more often negotiating to take less or no call, that would easily account for the discrepancy in pay. Around $16,000 per year is a totally reasonable amount for a physician to be paid to be part of call coverage, which is the gap the study found. It is regrettable that apparently the authors did not find a way of teasing out that information, because it makes a huge difference. Physicians who opt out of taking call (women or men) are working fewer hours, even if on paper the amount of time they’re spending at the office appears the same. If female providers are more often negotiating less or no call, then it makes sense that they would be paid less.
Before concluding that there really is a gender-based discrepancy in physician pay, more information is clearly needed. As I’ve said before, women entering the medical field may have changed it for the better with regard to its willingness to accommodate the balance between work and home life. However, for those who opt to put more of an emphasis on the latter and negotiate to do less of certain kinds of work than their collegues, it would make sense for there to be less pay as a result. Gender may be associated with this decision, but it’s too soon to say that it is the cause of lower salaries outright.