The gender gap in physician pay

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.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


    • I was going to offer this as well, though without any actual citation!
      The idea that bias would be lessened by the presence of members of the group biased against presumes that all acts of bias are conscious. A vast majority are not, which is why it is so hard to properly identify bias.

      For instance, assertive women are much more likely to be seen as “bitchy” than assertive men are. If an assertive man applies for the job, he is more likely to be described as a leader, or a go getter, or a strong personality. A woman is more likely to be perceived (though not necessarily explicitly described) as bitchy or controlling or unbecoming. Most people who fall victim to this particular form of bias don’t do so consciously, but do it nonetheless. Well, which of those two folks is the hiring person going to go after more aggressively? The go-getter man with leadership potential? Or the bitch? Who are they going to make a stronger offer to?
      Most acts of bias are inherently irrational. Most of us who react differently to a black guy approaching us on a dark street than a white guy aren’t thinking, “This guy is X% more likely to harm me and the appropriate response is to tense up.” No. They’re emoting. They’re reacting. Which is why black folk do that just as much as white folk. They’re conditioned by most of the same media and socialization as white folks and thus are just as likely to develop the emotional response that leads to bias. Same thing for women…

          • I think the preferred usage on these here Interubes is “You’ve got teh ghey.” That second “h” is very important or people won’t know what you’re talking about.

          • See, that is completely different from how I see the gay thing.

            “How was your day?”
            “Euh. How was yours?”
            “I’ll be in the den, playing my games.”
            “I’ll be in the other den, arguing with strangers on the internet.”

            The next time they talk is Thursday.

          • Do they have two dens because they’re both men? Or neither would cede decorating rights?

          • “How was your day?”
            “Euh. How was yours?”
            “I’ll be in the den, playing my games watching horrible television.”
            “I’ll be in the other den, arguing with strangers on the internet.”


          • I kind of think like gay people have a responsibility to the rest of the community to have more exotic lives than the rest of us. Like, letting us live vicariously through them as a price for ruining the sanctity of our marriages and stuff. If Hollywood has taught me anything, it’s that you should be spending your evenings going to swank dance clubs, or brushing shoulders with avant garde artists in a tony cocktail bar, or helping your female best friend out with her guy problems.

            This really feels like you guys are slacking.

          • Oh. I’m sorry. Did I neglect to mention that I have a small child?

            Once upon a time, I lived a life not so different from that Hollywood concoction you describe. Now? Now I can barely manage to stay awake until 10 PM.

            You want to know what I’m looking forward to most in Vegas? You know, the epicenter of sinful indulgence? Huh? Sleeping as late as I want. That, right there, is the most luscious fantasy I can dream of.

          • And alas, you do help your female best friend with problems, but they are usually child problems.

            Our lives have changed.

          • I have heard of this mystical place you speak of, Sleepinglate. I have come to fear it is a myth.

          • I have heard of this mystical place you speak of, Sleepinglate. I have come to fear it is a myth.

            No it is no myth. I am here to bring you the Good News. Sleepinglate exists! And I go there regularly!

  1. Great post, however I can’t help but notice that the theory “It’s Because Men Are Wicked Awesome!” seems a little underrepresented.

  2. Two thousand a month to have your sleep and free time subject to interruption and potentially subject to stressful professional decisions at any time. Hmm.

    I too might prefer to forego the additional income.

    • The degree to which it is negotiable likely varies from job to job. Given that nobody particularly loves to take call, certain practices or positions might not be open to those who aren’t willing to spread out the call pool. It would affect my hiring decisions if an applicant indicated an unwillingness to share the call burden.

  3. I was going to say what Rose did. There seems to be a lot of tension among women in the medical community. I could go on, but I think I’ll refrain for now. However, howevermuch that discrimination is to blame, there’s no reason to believe it’s gotten worse in recent years. Not by leaps and bounds. Especially as more women are entering the profession.

    I had one idea that wasn’t mentioned here: there are numerous kinds of work environments, and “family-friendly scheduling” is only a part of it. My wife took a job that pays $x/yr. There were other jobs being offered $2.5x/yr. I don’t know how many hours the latter works or what kind of call schedule they’re looking at, but it isn’t mathematically possible that they’re working 2.5x more and they’d have to be on call virtually every day to be taking on that much more call.

    Our theory is that they’re profit-maximizing outfits. They probably don’t get to spend the time with their patients that Clancy does. They may work the same 10-hour day, but work it in a different way that makes a lot of money but doesn’t provide much else. I would be amazed if these outfits were overwhelmingly male (and not because of sexist hiring). I think these sorts of jobs repel women and likely have a significant effect on the financial numbers.

    • Our theory is that they’re profit-maximizing outfits.

      Oh, quite likely. There are lots of ways of maximizing profits, which involve lots of different strategies.

      And the one very profit-oriented practice I remember best of all had at least one very affluent woman pediatrician. I’ll never forget her fur coat, which she draped across a chair as she sauntered in to see the patients she kept in the hospital for rea$on$ that had little to do with their clinical needs.

      • Speaking of which, I had come across this article, and wanted to call it to your attention.
        Thanks for giving me the clever lead-in.*

        * Clever lead-ins are covered under my insurance plan; no co-pay.

  4. Relocation may be another factor. Exceptions like the Trumans not withstanding, a female doctor, I suspect, is much more likely to have a spouse with a job paying a similar or higher salary. This makes relocating for the sake of salary optimization considerably more difficult, since you have to find good jobs for both spouses.

    • For the record, I know that “notwithstanding” is one word. Not sure how that happened.

      • Or is that “notsurehow that happened?”

    • Relocation could not be a factor because we are talking about fresh medial graduates. Unless women are more likely to get married while they are in college than men, they are not likely to have any more problems moving than men. (Similarly a married guy who has just graduated from medical school will also have trouble moving if his wife cannot get a well-paying job)

      Of course, if the inability for one’s wife to get a well-paying job counts less than the inability of a husband to get a well-paying job, then there is another kind of sexism going on.

      • A lot of docs are married fresh out of residency. A majority of my wife’s colleagues were. The proportion doesn’t matter, though, if the men are more likely to have wives that are flexible about the move than women’s husbands.

        Granted, among my wife’s colleagues, most of the female doctors had marriages like mine. However, that’s rural family medicine. It may be different as far as the specialties go.

        On the other hand, a married female resident is not unlikely to have a man that is flexible enough to put up with residency itself. I suspect that most female doctors who do marry laterally or up do so after they get out of residency. Maybe during, but dating and residency are hard to pull off together.

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