Unmeasured factors: Revisiting the gender gap in physician salaries

The evidence of a gender salary gap for physicians is solid. The reasons, however, are elusive due to “unmeasured factors,” according to authors of a study published recently in Health Affairs.1

The research — using data from graduating medical residents and fellows in New York State — showed that male physician average starting compensation was $235,044 from 1999 to 2017, while female physicians’ average starting compensation was $198,426 during that same period — creating a $36,618 gender salary gap.2

Evidence of a compensation gap between male and female physicians is nothing new:

• A 2015 study pointed to female hospitalists earning about $15,000 less than male hospitalists.3
• A 2016 study published in the Journal of the American Medical Association (JAMA) found a difference of more than $51,000 between the unadjusted salaries of male and female academic physicians.4
• A 2018 survey found that male physicians in Maryland reported an average annual compensation of $335,000 —almost 50% higher than the female physician average ($224,000).5
• A 2019 review of physician compensation data from 2017 and 2018 noted that male physicians earn an average of $1.25 for every $1 earned by female physicians.6

 
These differentials are not simply an outcome of unequal pay — they also stem from a gap in expectations. In 2019, a study noted that female post-residency surgeons reported an average “ideal salary” of $334,709, while their male colleagues responded with an average ideal salary about $30,000 higher.7

As the authors noted, that $30,000 salary differential, extrapolated across a 30-year career, could lead to a $900,000 lifetime earnings gap between a male and female surgeon.8

Known factors

When assessing the reasons for these disparities, there are some known factors.

MGMA’s Physician Compensation and Production Survey has highlighted that a pay gap exists, but that factors such as age and experience influence the gender pay disparity. In 2017 survey data, male doctors reported higher average compensation in family medicine and general pediatrics, but those male doctors also had an average of seven years more experience.9

The same MGMA survey also showed how productivity plays a role in the disparity. Males in invasive-interventional cardiology made more than 25% more than their female counterparts but showed 42% greater median work RVUs (wRVUs). Meanwhile, male general orthopedic surgeons made almost 50% more than their female counterparts with more than 80% greater median wRVUs. The large difference in the data may be due to the number of women in these specialty areas and the experience they have.10

The gap in explaining the gap

There remain those “unmeasured factors,” however, as productivity and specialty do not explain the full gender pay gap. In the Maryland example, when compared on a specialty-by-specialty basis, male physicians still earned more. In family medicine, the gender compensation gap resulted in male physicians earning 48% more than their female colleagues.11

In the new Health Affairs study, about 60% of the gap was explained by specialty differences and the amount of time spent in patient care.12 For the final four years of the data collected, the survey of the new doctors instituted new questions on work-life balance, which found that female respondents were more likely than male respondents to rate control of work-life balance issues as very important.13 This, after reviewing respondents’ preferences for control over hours worked, length of work day and other work-life issues, left the authors convinced that something else was responsible for the salary gap:

While it is apparent that women say they place a greater premium on control over work-life balance factors, this difference does not appear to explain the observed starting salary difference, conditional on other factors. There may nevertheless exist workplace biases, whether intentional or unintentional, that differentially affect women irrespective of their individual stated preferences for work-life balance.14

Reshma Jagsi, MD, DPhil, director, Center for Bioethics and Social Sciences in Medicine, University of Michigan, notes that her own studies find it “impossible to explain away the whole difference” solely on specialty, productivity and hours worked.15

Fixing the unmeasured factors

Writing for Harvard Business Review, Lisa S. Rotenstein, MD, MBA, resident physician at Brigham and Women’s Hospital, and Jessica Dudley, MD, chief medical officer, Brigham and Women’s Physicians Organization, recommended a series of ways to acknowledge and mitigate gender pay gaps for physicians:

• Better accounting of uncompensated work, such as unpaid committee or office improvement projects
• Improved auditing of the patient complexity of patients seeing female physicians compared to the patients of their male colleagues
• Increased salary transparency.16

 
Maryam M. Asgari, MD, MPH, associate professor, dermatology, Harvard Medical School, has pointed to the amount of support provided to female physicians compared to male physicians, resulting in the best operating schedules being given to men, which then results in more visits and higher productivity and revenue.17

That is one of many examples of how implicit or subconscious bias can influence a healthcare organization. In a 2019 MGMA Stat poll, almost half (49%) of practice leaders said their organizations do not address implicit bias, and another 26% responded that they did not know what implicit bias is.18

Mitigating the potential for unintentional or implicit biases requires recognition that all of us can be prone to such biases.19

Lastly, even in organizations in which a robust, structured compensation model is in place to provide fair pay regardless of physician gender, there are still noticeable gender discrepancies in how many women attain leadership roles. A recent analysis of the Mayo Clinic’s structured compensation plan found pay equity was achieved in nearly every setting of the 2,845 physicians studied, yet men were twice as likely as women to hold or have held a compensable leadership position.20

While specialty, experience and productivity remain the likely culprits for much of gender pay gaps among physicians in the United States, other “unmeasured factors” still have a measurable effect in sustaining the difference between what men and women are paid for the same work, as well as the uneven potential for advancement into leadership roles in healthcare.

Notes:

1. Lo Sasso AT, Armstrong D, Forte G, Gerber SE. “Differences in Starting Pay for Male and Female Physicians Persist; Explanations for the Gender Gap Remain Elusive.” Health Affairs, 39(2), Jan. 22, 2020. Available from: bit.ly/2Sbwdqi.
2. Ibid.
3. Weaver AC, Wetterneck TB, Whelan CT, Hinami K. “Priorities and Gender Pay Gap.” J. Hosp. Med 2015;8; 486-490. doi:10.1002/jhm.2400.
4. Jena AB, Olenski AR, Blumenthal DM. “Sex Differences in Physician Salary in US Public Medical Schools.” JAMA Intern Med. 2016;176(9):1294–1304. doi:10.1001/jamainternmed.2016.3284.
5. Merritt Hawkins and The Maryland State Medical Society. “Survey shows wide earnings gap between male and female physicians in Maryland.” July 30, 2018. Available from: bit.ly/2tGRb75.
6. Doximity. 2019 Physician Compensation Report. March 2019. Available from: go.aws/3boQXTm.
7. Gray K, Neville A, Kaji AH, et al. “Career Goals, Salary Expectations, and Salary Negotiation Among Male and Female General Surgery Residents.” JAMA Surg. 2019;154(11): 1023–1029. doi:10.1001/jamasurg.2019.2879.
8. Ibid.
9. MGMA. 2017 MGMA DataDive Provider Compensation.
10. Ibid.
11. Merritt Hawkins.
12. Lo Sasso, et al.
13. Ibid.
14. Ibid.
15. The Advisory Board. “Female physicians make $37k less in their first job (and it’s not just because of specialty choice.” Daily Briefing. Jan. 30, 2020. Available from: bit.ly/39oM76O.
16. Rotenstein LS, Dudley J. “How to Close the Gender Pay Gap in U.S. Medicine.” Harvard Business Review, Nov. 4, 2019. Available from: bit.ly/2vggqO4.
17. Ducharme J. “The gender pay gap for doctors is getting worse. Here’s what women make compared to men.” Time. April 10, 2019. Available from: bit.ly/38eSqtf.
18. MGMA. “Implicit bias: the importance of self-awareness for patient care and in the workplace.” Jan. 10, 2019. Available from: mgma.com/stat-implicit-bias19.
19. Green C. “A feeling of belonging: An inclusive culture is the foundation for addressing unintentional bias.” MGMA Connection. January 2020. Available from: mgma.com/inclusive-culture.
20. Hayes SN, Noseworth JH, Farrugia G. “A Structured Compensation Plan Results in Equitable Physician Compensation.” Mayo Clinic Proceedings, January 2020, 35-43. Available from: mayocl.in/37gEQnL.