Women in medicine earn about 20 percent less than men. That is a problem for multiple reasons. It is, of course, not fair to the women who go through the same training and have the same skills as their male counterparts. Worse still, if well-qualified women are discouraged from entering the profession because of this inequity, it is bad for patients.
The reasons for this pay disparity are complex. Because medicine is still largely a fee-for-service reimbursement system, the explanation cannot simply be that women with identical qualifications receive lower salaries for doing the same exact work as their male colleagues—although this does happen. A more complete explanation must take into account pay differences between specialties and differing reimbursement patterns within a specialty.
Specifically, there are three important drivers of this pay gap, all of which can and should be addressed: (1) The best-paid specialties are often unfriendly to women trainees; (2) The relative value unit (RVU) reimbursement system used in the United States favors specialties that attract more men; and (3) Men in procedural or surgical specialties receive more referrals for lucrative procedures than do women.
There are vast differences in payment between different specialties, and in most cases the top-paying specialties have historically been—and continue to be—dominated by men. Overall, while 65 percent of practicing doctors are men, according to the Association of American Medical Colleges, in the top 10 remunerated specialties, 80 percent are men. Aside from dermatology, which is composed of 49 percent women, the other top-paying specialties are heavily weighted to men, ranging from 74 percent for radiology to 95 percent for the top-paying profession, orthopedics. According to Medscape, the average US orthopedist gets paid $482,000 per year, while the average pediatrician, a specialty that is 62 percent women, makes $225,000—less than half as much.
A recent article in Stat News by Dr. Qaali Hussein illustrates one reason why this discrepancy exists. Many of the best-paid specialties are surgical or heavily procedural, which tend to be dominated by men. Dr Hussein describes a culture in her specialty, trauma surgery, vehemently resistant to motherhood. She quotes one of her senior residents saying, “anyone who chooses to get pregnant in a surgery residency is selfish.” Far from an isolated occurrence, this opposition to motherhood is prevalent in surgical specialties. Several of my friends in surgical specialties have faced similar reactions from their peers and supervisors.
If the medical profession is serious about promoting gender equality, all specialty boards and accrediting bodies should require hospitals to offer appropriate parental leave for all physicians. While this is already in place in many of the more gender-balanced specialties, the male-dominated specialties tend to be the furthest behind. Many departments don’t have parental leave policies at all. This is self-defeating, if leaders in these specialties truly want to encourage women to enter their field.
Second, the medical profession needs to reconsider how value is attributed to the work of physicians. The current reimbursement system heavily favors procedural specialties, which tend to be dominated by men. While some may argue that women “choose” to enter less well-paying specialties, this fails to consider the outright discrimination against women, as described by Dr. Hussein, particularly prevalent in surgical specialties. It also does not recognize that for complex cultural reasons, women may prefer non-procedural specialties, which historically have been considered more “feminine.” Just as traditionally male industrial jobs tend to pay better wages than traditionally female jobs in clerical professions, the “male” medical specialties receive better compensation than the more “female” specialties.
Whatever the reason that fewer women enter procedural specialties, women in medicine should not feel obligated to enter those specialties in order to receive the best pay. The current reimbursement system should be restructured to reimburse non-procedural work more equitably with procedural work. After all, successfully counseling a patient to quit smoking is just as valuable to society as cutting out a tumor from a lung, even though the difference in reimbursement for the two activities is drastically different.
Last, an article published in JAMA Surgery this month by Dr. Fahima Dossa and her colleagues showed that, in Ontario, women surgeons in the same subspecialty earn less money than men surgeons, even after adjusting for the amount of time they spend in the operating room and how efficiently they work. Women tend to spend their time doing less lucrative types of surgery, performing only 6 percent of the best-reimbursed common surgeries, compared with 27 percent of the worst-paid surgeries (25 percent of the surgeons in the study were women). Why? It’s probably not that women don’t care about how much they’re paid. The best explanation for this difference is that women surgeons receive fewer referrals for the most lucrative surgeries than do men.
Of all the sources of pay discrepancy between men and women, this may be the most difficult to address because it would be hard to mandate gender balance in referrals from the top down. One plausible approach would be to have all elective surgical referrals distributed evenly among physicians who are qualified to perform the surgery. This approach, however, will frustrate doctors who have a good working relationship with a specific surgeon and prefer to refer cases to that person. This change will need to be instituted gradually and thoughtfully.
We know what to do to start addressing this problem of pay imbalance in medicine. The reimbursement system should be rebalanced toward non-procedural specialties, all medical specialties should offer fair parental leave, and referring physicians must not preferentially refer to male doctors for the more remunerative procedures. It won’t be a simple fix, but these three changes would be a good start.