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Feature: In Pursuit of Equity: Examining Compensation Systems for U.S. Medical Faculty

I. A Case Study: “Every dollar adds up, Julia”
II. Salary Equity Studies: Experiences of Four Medical Schools
III. Pearls from Salary Equity Discussions at the 2004 Annual AAMC Meeting

A Case Study:

The names in this case study are fictional, but the situation is very common. Could it occur in your medical school? Does it occur? Do you have systems to discover whether such occurrences are common? Does your school have processes in place to decipher whether the disparities are discriminatory or rational?

“Every dollar adds up, Julia.”

Dr. Julia Sanders re-read the message from the financial officer of the Department of Medicine. The memo was a response to her request to add her colleague, Dr. Todd Jenkins, to the federal grant she was renewing. Both she and Dr. Jenkins were division chiefs in the Department of Internal Medicine. They had met during an orientation session for the hospital and faculty practice staff 7 years ago. Their families had celebrated together when first Julia and then Todd were named Division Chiefs last year. Todd’s career led him to national distinction through his specialty society and this year he had been voted President of that society. The Department Chair granted him a modest reduction in clinical time to accommodate his busy national schedule. Julia’s career successfully blended clinical research with practice. She was pleased to be able to bring Todd onto her grant to compare different types of team-approaches to caring for patients with chronic disease. The grant would continue support of 60% of her salary and she had offered Todd a 15% position to assist with recruitment of patients and consultation from his division. But now, after reading the memo, she realizes she will have to adjust Todd’s percent effort for the grant. She initially had estimated Todd’s salary based upon her own, but his was $25,000 greater than hers. How could that be?

Good friends that they are, Julia asks Todd to share his career and salary history with her. His response leads her to develop a comparison, which she prepares to share with the Chair:

Julia SandersSalaryTodd JenkinsSalary
First AppointmentAssistant Professor$130,000Assistant Professor$135,000
Clinical Duties:

5 clinical sessions/week
Hospital attending 6 weeks/year

5 clinical sessions/week
Hospital attending 6 weeks/year

TeachingMedical student clinical preceptor;
2 resident lectures/ year

6 resident lectures/year;
3 Medical student lectures/year

ResearchMember of collaborative research team with 2 other med schoolsDrug trials, office based
AdministrativeDepartment Quality Improvement CommitteePharmacy and Therapeutics Committee for Hospital
Promotion after 5 yearsAssociate Professor$156,000Associate Professor$169,000
Leadership Appointment after 7 yearsDivision Chief$175,000Division Chief$199,000

Clinical

4 clinical sessions/week
Hospital attending 6 weeks/year

4 clinical sessions/week
Hospital attending 3 weeks/year

Teaching

Medical student clinical preceptor;
Skills Instructor, first year students;
3 Graduate Student seminars /year;
2 Resident lectures/year

6 resident lectures per year;
1 Clinical Correlation in first year anatomy course;
3 medical student lectures/year;
Supervision, 4 SubInterns/year

Research

P.I. of international collaborative research team of 20 med schools;
Co-PI, 2 clinical intervention trials

Co-PI, 3 different clinical drug trials
Administrative

Chair, Institutional Review Board;
Reviewer, NIH subcommittee;
Member, Course co-director, first year clinical skills (1 semester)

Vice President, Medical Staff;
President, National Specialty Society;
Co-Director, Residency Program

How could it be that two full professors with significant administrative positions and healthy academic careers could be compensated so differently? How does it happen that each advances without the knowledge of compensation policies and salary distributions within the same organization?

Julia and Todd figured it out by comparing annual salary increases. Each had received 3% per year increases over their 7 years. Each had received increases as salary adjustments at the time of promotion and with the appointment as Division Chief. However, Julia had accepted her initial offers of $5000 with the promotion and $10,000 additional for the responsibility of Division Chief. Todd had pretty easily negotiated $7000 at the time of his promotion and $15,000 for the Division Chief position. The previous year, he received an additional $5000 for accepting a position as co-director of the residency program. Todd was surprised that Julia accepted so many new responsibilities without re-negotiating her time allocations and salary. “Every dollar adds up, Julia. You need to negotiate better.”

“You’re right, Todd.” Julia replied, “But my institution needs to monitor salaries and work assignments better, also.”

Salary Equity Studies: Experiences of Four Medical Schools

Recent publications on inequities in salary and resource distribution and panel discussions during the 2004 Association of American Medical Colleges Annual Meeting have drawn attention to institutional practices to monitor faculty compensation patterns. The Council of Deans Administrative Board, has encouraged all medical schools to entertain conducting such studies. In a March 2003 memo, the Chair of the Council of Deans, Dr. Darrell Kirch wrote, “Salary equity is an exceptionally important issue deserving of national attention… A proper analysis can be conducted only at an institutional level because relevant factors…cannot be assessed on the basis of nationally available information. “ The challenge is not an easy one.

The scenario with Drs. Sanders and Jenkins highlights the impact of unequal negotiation practices between two faculty with similar initial resources and job assignments. However, most salary studies of medical schools find significant variations due to differences in reimbursement of clinical activities, work assignments, and other measures of productivity.

Salary models used in regression analyses of studies of equitable awards generally include consideration of academic position, years in rank of appointment, department and division, responsibilities for teaching and administration, and honors. Justifiable salary variations are likely to include measures of productivity such as RVU-based clinical activities or metrics of reimbursement of clinical services and financial support from grants and contracts. Speakers at the 2004 AAMC Annual meeting highlighted these metrics.

Drs. Jeffrey Houpt (former Dean, University of North Carolina School of Medicine and former CEO, UNC Health Care System), Claudia Adkison (Executive Associate Dean for Administration and Faculty Affairs, Emory University School of Medicine), Kevin Grigsby (Vice Dean for Faculty and Administrative Affairs, Pennsylvania State University College of Medicine), and Ms. Patricia St. Germain (Associate Dean for Administrative and Financial Affairs, University of Arizona College of Medicine) spoke to the initiation, methodology, and outcomes of salary equity studies at their institutions. On several occasions, the in-depth look at salaries in their medical schools arose after publication of university-wide studies that failed to compare the myriad differences in job descriptions of medical faculty, and consequently revealed more substantial disparities than the final medical-school based studies. For example, the University of North Carolina study in 2003 published an average discrepancy between male and female faculty salaries of between $7000 and $9000 dollars. Then Dean Jeffrey Houpt immediately commissioned a study within the medical school, one that used the factors described above to compare populations of faculty with similar time in rank and work assignments. In the final analysis, the salaries of 13 (1.9%) of men and 10 (3%) of women were identified for in depth review and considered for salary increases. Most of the disparity was attributed to a “loyalty tax”, i.e. salary compression of long-term faculty members rather than any systematic discriminatory actions.

The University of Arizona, GRACE (Generating Respect for All in a Climate of academic Excellence) project targeted the full University campus in a hypothesis-driven study that included quantitative salary studies and qualitative information from faculty. The results showed significant differences in perception of treatment at the College of Medicine by men and women. Analysis of variance of salary data showed 28 women faculty who were apparently under compensated and who subsequently benefited from salary increases.

Dr. Claudia Adkison has been monitoring initial salaries, annual raises, and outliers for several years. In the course of routine monitoring, salary adjustments are made in consultation with chairs. When Emory University recently initiated a cross-campus study of salary equity, Dr. Adkison took on the challenge of educating the university committee about medical faculty responsibility and compensation while simultaneously responding to their inquiry. As a result of ongoing review and adjustments, few changes have been deemed necessary to respond to the University mandate. In contrast, a very recent study at Pennsylvania State/ Hershey used an average of the results of three different regression models to compare salaries of similar groups of men and women faculty; subsequently, salaries were adjusted for almost 240 Penn State Medical School faculty members.

Dr. Lois Haignere, author of the book, Paychecks, a Guide to Conducting Salary-Equity Studies for Higher Education Faculty, and consultant for the Penn State School of Medicine study, writes of the strength of multiple regression analysis to compare populations of faculty with similar responsibilities and status. In her 2004 Annual Meeting presentation, she was clear that, “multiple regression conceptually compares faculty with the same education, years of experience, discipline or specialty, and rank while measuring the impact of race and gender.” It uses analysis of data to address the “yes, but” response to salary inequities. This response goes something like this: “yes, BUT women are paid less because the tend to have less education, or have fewer years of experience, or be in lower ranks or lower paid specialties, or be less productive.” Good studies turn these hypotheses into measurable outcomes of compensation systems.

Pearls/ Take Home Messages from AAMC Annual Meeting Discussions

Houpt: Salary equity studies should be viewed as an OPPORTUNITY, not a burden for the Dean. The process demonstrates moral leadership in addressing what is essentially an issue of justice, it engenders trust that can undo generations of “deals”, it engages Chairs in examining reward systems for the institution, and it moves the medical school towards performance based compensation without endless committee resistance.

Adkison: Consider carefully the culture of your institution. Confidentiality of salary information and transparence of compensations policies are both important but can clash and fuel concerns about equity in the process of discussion of studies.

St. Germain: Many of the myths of gender based salary or advancement inequities between men and women can be dispelled by hypothesis-driven institutional research. It is clear that the dearth of women in leadership positions, however, is not due to an inadequate “pipeline”, differences in commitment or ambition or differences in productivity.

Grigsby: Equity studies using validated data; open discussion of results, recommendations and conflicts; and alignment of resources with values demonstrate organizational commitment to actions that are consistent with stated organizational values.

Haignere: Good studies of salary equity require careful construction of a clinical science database; this may involve allocation of extra time and personnel resources to ensure data accuracy. Work on specialty definitions that reflect overlapping medical expertise and work content; maintain at least five people in each category being analyzed.

For further references on Studies of Resource Equity, consult the References section in this issue.

Selected References from Recent Literature on Compensation and Resource Equity

Do women receive similar rewards for similar achievement in the current environment of academic medicine? The authors address the question by analyzing 1814 (60% response rate) responses to a mailed survey of full time faculty from 24 randomly selected medical schools in the United States in 1995. Outcomes were salary, pretax academic year compensation including clinical payments, and promotion to full professor.

The authors constructed models to compare male and female faculty data for deviations from expected rates of promotion based upon equal career seniority (number of years from first appointment), comparable numbers of publications and academic responsibilities (teaching, administrative, research, clinical); in addition to the factors already listed, they analyzed expected ranges of salary based upon type of department (primary care, medical specialty, surgical specialty, and basic science.

Results of their analysis showed that for all levels of productivity measured, women are less likely to be full professors and to be less well compensated than their male peers. For each year of seniority, women were less likely than men to be promoted to full professor. Women were more likely to be full professor if they were in a basic science department, had more career publications, were chair or chief of an academic division, and worked more hours. For both men and women, salaries were higher for faculty with more seniority, more than 40 publications, physicians in a medical or surgical specialty, chairs and chiefs of divisions, and working more hours per week. Time spent in research or teaching was associated with a reduction in compensation. Independent of profession, female physicians received almost $12000 less than male physicians, and almost $5000 less additional salary than men for each 10 years of seniority.

The accompanying editorial by Laine and Turner, Unequal pay for equal work: the gender gap in academic medicine, lays out strong challenges to men and women in academic medicine to address the profession in which the gap between male and female wages reported in 2000 by the U.S. Census Bureau is greater than any other profession listed. The Census Bureau clearly states that it has not considered differences of work load or reimbursement patterns within the profession. While this difference may be due more to the wide variation in practice patterns and specialties than to discriminatory behavior on the part of employers, it is still an important difference. The challenge requires women to learn to negotiate effectively and to advocate for themselves and for each other and for leaders of good conscience to increase transparency in the promotion and compensation practices of academic medical institutions.

Fang D, Moy E, Colburn L, Hurley J. Racial and ethnic disparities in faculty promotion in academic medicine. JAMA 2000;284: 1085-1092.

Analysis of data from the AAMC Faculty Roster system compared promotion rates of 50,145 full time U.S. faculty who became assistant or associate professors between 1980 and 1989. Racial/ethnic disparities in promotion were evident for all underrepresented minorities, even after adjusting for cohort, sex, tenure status, degree, department, medical school type (public or private) and receipt of NIH awards. After 17 years of follow-up, only half of the minority faculty who had become assistant or associate professors in 1980-81 had been promoted. Receipt of NIH awards is one of the strongest predictors of promotion. However, minority faculty members are less likely to receive NIH awards or be on tenure tracks. They are more likely to be affiliated with departments and medical schools with lower promotion rates and more likely to be women.

Fister E, Gordon MA, Hoersch M, McAlpine L, Morrissey C editors, Beyond Parity Workbook for Action, The University of Illinois at Chicago Center for Research on Women and Gender 2004.

The Beyond Parity Workbook for Action was developed to assist with activism to promote positive gender climates at academic medical institutions, to increase diversity within leadership positions and to reframe academic excellence to reflect the contributions of women faculty. The Workbook includes 1)a summary of the Beyond Parity conference held in 2002; 2) a summary of 20 models of medical academic women’s leadership programs; and 3) an outline of implementations steps for transforming the academic work environment to increase the diversity of leadership. Background points highlight the challenges in this proposed transformation:

1. The norm that assumes unlimited time for professional endeavors differentially disadvantages women, since they are more likely to have their career interrupted or decelerated by family obligations. As dual career families increase, this obstacle will have more of an impact upon men as well.

2. System norms facilitate ongoing discrimination against women and minorities, however inadvertent or subtle.

3. Given that leadership in academic medicine continues to be largely represented by majority males, women and minorities are often underrepresented on high-level committees, and other decision-making bodies, rendering them voiceless on important procedural issues and policy decisions.

Wright A, Schwindt L, Bassford T, Reyna V, Shisslak C, St. Germain P, Reed K. Gender differences in academic advancement: patterns, causes, and potential solutions in one U.S. college of medicine. Acad Med 2003;78:500-508.

The author’s report the results of information from the personnel database and 198 responses to an on-line survey of 418 faculty at the University of Arizona College of Medicine. The results of this analysis of faculty salaries, ranks, tracks, leadership positions, resources and perceptions of academic climate showed significant gender differences, even after adjusting for rank, track, degree, specialty, clinical revenues, years in rank and administrative positions. Men and women gave similar importance to career advancement, leadership ability and aspirations, work-personal life conflict. However, women were less likely to have been asked to serve as section or department heads, to have decision-making authority over promotion of colleagues or non-grant related resources, and to feel that they effectively influenced departmental decisions. They were more likely than men to share research space.

The results of this study describe an academic environment that is significantly more challenging for female than for male faculty in their institution. Solutions proposed to improve the academic climate for all faculty include: regular monitoring of salary and resource distribution, mentoring and advising junior faculty, increased flexibility in tenure track positions and definition of scholarly contributions, and education about subtle forms of discrimination.

Faculty Vitae

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