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    Closing the gender pay gap in medicine

    Leaders in academic medicine have been working to address salary inequities. A new AAMC report highlights the progress made to date — and the challenges yet to come.


    In 1999, when Janis Orlowski, MD, was executive dean and associate vice president at Rush University Medical Center in Chicago, Illinois, one of her responsibilities was to ensure faculty salary equity. “I recall sitting in my office, shocked and distressed over the dramatic pay differences between men and women,” says Orlowski.

    Orlowski and her team leveled the field, but when they assessed salary equity again three years later, they noticed another split forming within certain divisions. Many institutions have that same issue today. Even in 2019, women at academic medical institutions across the country are still receiving less pay than their male counterparts.

    A 2013 study published in JAMA Internal Medicine reported an absolute annual pay gap of $51,315 between men and women physicians at U.S. public medical schools. After adjusting for potential confounding factors such as age, years in rank, and specialty, the annual disparity was $19,878. More recently, the 2018 AAMC Faculty Salary Survey uncovered a difference in median compensation between men and women at every rank across a majority of specialties and departments — and the gaps are bigger at higher levels of leadership. The report found that across the basic science disciplines, women earned 90 cents per $1 earned by men, and 77 cents per dollar across clinical science disciplines.

    “Unequal pay for women often begins with their first job and persists for the duration of their careers,” says Sareh Parangi, MD, professor of surgery at Harvard Medical School and president of the Association of Women Surgeons. Indeed, a recent study published in Annals of Internal Medicine reported that the mean starting salary for newly graduated male residents was nearly $17,000 higher than the starting salary for newly graduated female residents.

    “Achieving salary equity in academic medicine is the right thing to do and the smart thing to do.”

    John Prescott, MD

    The good news: With women entering medical school in record numbers, academic medicine is perfectly positioned to lead the way in salary equity. “There’s a huge pool of women who are extremely knowledgeable, well trained, and highly qualified,” says Julie Silver, MD, associate professor and associate chair in the department of physical medicine and rehabilitation at Harvard Medical School.

    What’s more, a growing number of leaders in academic medicine are committed to closing the salary gap, with some schools forming comprehensive review boards to explain compensation differences and others paying outside firms to conduct in-depth research studies. Many of these efforts are outlined in a new AAMC report, Promising Practices for Understanding and Addressing Salary Equity at U.S. Medical Schools.

    “Achieving salary equity in academic medicine is the right thing to do and the smart thing to do,” says John Prescott, MD, AAMC chief academic officer. “Yet it is a challenging task, requiring an institutional commitment to transparency, cross-campus collaboration, ongoing communication, dedicated resources, and enlightened leadership.”

    Pay gap explained

    Myriad factors contribute to pay inequity in medicine. While some of these are broader issues of gender inequity, other factors may also play a role.

    Women often find more career opportunities in lower-paying specialties. According to AAMC specialty data, 63% of pediatricians are women, whereas 95% of orthopedic surgeons are men.

    Women are also more likely to prioritize flexible schedules over higher pay. In a study of 776 hospitalists, men listed substantial pay as their number two priority (after optimal workload). Women, on the other hand, ranked optimal collegiality and control of personal time above pay.

    Many women also cut down on work hours once they have children. According to a JAMA Internal Medicine study, women with children work 11 hours less each week, on average, than those who don’t have kids.

    And women tend not to self-promote or negotiate salary. “They often accept the first offer they get, no questions asked,” says Katherine M. Sharkey, MD, PhD, assistant dean for women in medicine and science at the Warren Alpert Medical School of Brown University. “There are so many of us, myself included, that look back to our first positions and think ‘I should have negotiated better.’”

    “More women are choosing to become pediatricians than are choosing to become neurosurgeons, that’s true. But the gap persists within specialty, too.”

    Sareh Parangi, MD
    Harvard Medical School

    But disparities in pay extend well beyond negotiation prowess or specialty. “More women are choosing to become pediatricians than are choosing to become neurosurgeons, that’s true,” says Parangi. “But the gap persists within specialty, too, especially in male-dominated specialties like neurosurgery where women aren’t just a minority, they’re almost an anomaly.”

    This spills over into relative value units (RVUs), which are used by hospitals and insurers to compensate physicians for the work they do. “The perception is that women generate fewer RVUs because they’re lazy,” says Parangi. “In reality, if you look at the specialties where there are a high percentage of women, such as obstetrics and gynecology, which is 54% women, and compare it to urology, which is about 8% women, you see dramatic disparities in RVUs for analogous procedures.”

    In a paper published in 2017 in Gynecologic Oncology, researchers compared gynecologic and urologic procedures and found that 72% of male procedures were weighted more for work and total RVUs, and 84% of procedures were compensated at a higher rate for male-specific procedures. For instance, a biopsy of the prostate is worth 4.61 RVUs while a biopsy of the endometrium is 1.53 RVUs. Even the same procedure — a total urethrectomy — has different RVUs for men and women. For men, it’s 16.85; for women, 13.72. The differences may not be nefarious, but Parangi suspects they reflect a male-dominated culture in medicine. “The committee that establishes RVUs has 30 voting members. Only two are female,” she says.

    Changing the tide

    A growing number of academic medical institutions across the country are developing policies and procedures that ensure pay equity right from the start, according to the AAMC report. In the Department of Medicine (DOM) at the University of Colorado School of Medicine at Anschutz Medical Campus (CU School of Medicine), for example, administrators ensure every new hire starts on equal ground by using AAMC benchmark data to determine starting salary.

    “We encourage division heads to share benchmark data with new recruits during the hiring process, or I share them myself. That’s part of the transparency process,” says David A. Schwartz, MD, professor and chair of the DOM at CU School of Medicine.

    In 2011, the DOM began evaluating salary equity, and discovered that compensation was below AAMC benchmarks (adjusted for year-in-rank) for nearly 40% of men and women, with the largest disparity striking women at the assistant and associate professor ranks.

    “We met with each of the division heads and asked them to further consider and justify any disparities compared to the benchmark,” says Schwartz. “If they weren’t able to tie the deficiency in pay to a deficiency in accomplishments in annual evaluations, we asked them to adjust compensation accordingly.”

    The approach has paid off for both men and women. “Only 15% of faculty currently fall below their year-in-rank AAMC benchmark — an equal number of men and women,” says Schwartz. The next priority: Identifying faculty that are above the 90th percentile and asking, “Can we justify the higher pay for these individuals, and is there a differential between men and women?”

    “The idea is to help women navigate the system and advance to senior leadership roles.”

    Allison R. Larson, MD
    Boston University School of Medicine

    Many schools have formed task forces to assess institutional practices that impact gender equity, examine best practices that lead to improved equity, and determine how to measure accountability. The University of Texas Southwestern Medical School (UT Southwestern), for example, has been studying salary equity for decades. Since 1999, the school has relied on the same in-house biostatistician, Joan Reisch, PhD, to drill down the numbers using a complex methodology.

    Similar to the process at the CU School of Medicine, UT Southwestern delivers the study results and comparable AAMC data to the department chairs, so they can adjust salaries when appropriate.

    “Gathering all of the data required to do a comprehensive survey is not easy,” says Sharon Reimold, MD, professor of medicine and vice chair of medicine for ambulatory operations and faculty development at UT Southwestern. “In most centers, the data reside in different databases. It’s more time intensive, but often better, to gather data from the different sources and make sure it’s clean.”

    That’s one reason many schools hire outside experts to analyze compensation data. The Washington University School of Medicine in St. Louis, for example, uses an outside firm to conduct pay equity studies every five years. They’ve recently completed their sixth study; their third using an outside firm.

    “We built our central administrative database to include more than 30 variables that impact compensation, such as age, highest degree, years in rank, and years prefaculty at Washington University School of Medicine,” says Diana Gray, MD, professor of medicine in the departments of obstetrics and gynecology and radiology and associate dean for faculty affairs at Washington University School of Medicine. “The consulting group tested each variable and narrowed it down to 19 that helped predict salary.”

    In the most recent study, the Washington University School of Medicine reported a 1.5% differential between men and women for base pay. For total compensation, including bonuses and additional income earned, the gap was 2.9%. “It’s time-consuming, costly, and complicated to do it this way, but I think it provides a truer reflection of compensation and there are fewer conflicts of interest,” says Gray, who presents the results to interest groups across the institution, highlighting disparities in mean compensation both before and after it’s run through regression analysis.

    Advancing women

    Of course, that’s where some controversy enters the picture. If some of the variables are biased to begin with, entering them into a regression equation may unfairly wash out some of the differences in compensation. “We know that far fewer women than men are in leadership positions, and far fewer women than men are full professors or endowed chairs,” says Gray. “But to look at equity scientifically, we can’t just exclude factors that affect pay.”

    What institutions can do, though, is recognize that balancing the scales between men and women extends beyond number crunching and adjusting for deficits, to devoting resources toward advancing the careers of women in medicine. UT Southwestern, for example, has a “stop the clock” allowance to extend promotion and tenure processes for faculty who take parental leave. At Boston University Medical Center and School of Medicine, the CEO and academic dean, both women, are committed to providing women with the tools they need to advance. “The idea is to help women navigate the system and advance to senior leadership roles,” says Allison R. Larson, MD, assistant professor in the department of dermatology and assistant dean for medical education at Boston University School of Medicine.

    Add it all together and for the first time in history, financial compensation for men stood still while compensation for women grew 2%, according to Doximity’s 2019 Physician Compensation Report. While male physicians still make an average of 10% to 25% more than female physicians, the Doximity report seems to suggest the pay gap in medicine is beginning to narrow.

    One medical specialty, radiology, has already made significant headway. As recently as 2013, female radiologists made nearly 20% less than their male colleagues, according to a report in Academic Medicine. Beginning in 2016, these differences evened out. Perhaps not surprisingly, radiology has more female professors and women in leadership positions than most other medical specialties.

    “Sometimes it starts with the spark of one leader — someone who has the power and the money to make waves that ripple,” says Sharkey. “I think we’re going to make strides in ways we’ve never made strides before, in part because of brave institutions who are willing to take a stand and be transparent.”