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Julie Miller was the former Managed Healthcare Executive Editor in Chief until May of 2014.
Why female physicians make less, and how to fix it.
In Texas, a primary care physician working in a Denton County clinic discovered she was being paid $34,000 less per year than a male physician who performed the same duties. She questioned the matter and was later fired by administrators, who cited poor job performance.
The Equal Employment Opportunity Commission (EEOC) brought the doctor’s claim to federal court. In a resolution reached late in 2018, a judge ordered the county to pay the female doctor $115,000 in damages and to correct its compensation policies.
In spite of numerous equal-pay regulations and ongoing EEOC enforcement, female physicians are chronically underpaid compared to their male counterparts.
“For every specialty and every geography, there is a significant gap,” says Christopher Whaley, Ph.D., an adjunct assistant professor at the University of California, Berkeley School of Public Health, who has studied the gender pay gap.
Medical Economics found in its survey of primary care physicians that female physicians reported a median annual income of $175,000, while male physicians reported an income of $275,000. In other words, the women surveyed earn 63 cents for every $1 that men earn. At the highest end of the pay scale, 10 percent of male respondents say they earn $500,000 or more compared with only 3 percent of female respondents.
These results are similar to other industry studies, including one conducted in 2017 by Doximity, a social network of medical professionals. In its study of more than 65,000 physicians, the organization discovered that industrywide, women earned 27.7 percent less than men. When examined by specialty, data provided to Medical Economics show women family medicine doctors earn $212,535 annually, or about 83 cents per $1 that their male counterparts earn.
Based on the dollar figures reported in the surveys, it’s clear the lost lifetime earnings for a female physician can add up to $1 million or more. Whaley, who was the lead author on the Doximity study, says it’s surprising that medicine-with its intensive education requirements and high standards applied uniformly to all professionals-would demonstrate such wide discrepancies in compensation between men and women.
“It’s not as if a woman in the study sample had inadequate training,” he says.
Reasons behind the gap
The Equal Pay Act of 1963 was the first law making it illegal for employers to pay women less than men for doing the same job. Subsequent state and federal rules have aimed to reinforce pay equality, but the regulatory stick hasn’t been enough to level out earnings. Census Bureau data from 2016 show America’s working women are earning just 80 cents for every $1 that men earn.
Implicit bias is often to blame for the historic pattern of discrimination, experts say. For example, women are less likely to be perceived as family breadwinners or as loyal workers willing to put in long hours, says Theresa Rohr-Kirchgraber, MD, FACP, executive director of the Indiana University National Center of Excellence in Women’s Health and a chief physician executive at Eskenazi Health. Rohr-Kirchgraber has studied gender pay gaps for years.
She advises female physicians-many of whom are in fact the breadwinners in their households-to avoid talking about personal issues at work. If a woman declines a meeting invitation because of childcare concerns, for example, it’s in her own best interest to skip the explanation. Talking about outside demands can give the impression that professional duties aren’t a priority.
“It set us up to look as if we’re not as enthusiastic about our jobs,” Rohr-Kirchgraber says.
Yet she doesn’t believe men in medicine are deliberately acting with a gender bias, or worse, encouraging it to gain their own financial advantage. “There is plenty of work to go around,” she says. “Guys are just as confused as women as to why this is happening.”
Lack of transparency
Another reason for pay gap's persistence is that organizations often keep workers’ salaries and bonuses confidential. Without that data, women can’t quantify discrimination, making it extremely difficult to address.
Sharona Hoffman, JD, LLM, professor of law and bioethics at Case Western Reserve University School of Law in Cleveland, says women in medicine need to start asking questions and advocating for transparency. “It might seem impolite, but if women are serious about closing the pay gap, they need the data,” Hoffman says.
Ana MarÃa LÃ³pez, MD, FACP, president of the American College of Physicians (ACP), says even if an organization won’t reveal comparative compensation data, physicians have a responsibility to do their own research. Other factors determine pay, such as regional market differences, years of experience, or hours of clinical time in proportion to other professional duties. Such data can build a case for negotiating higher pay.
“At my first job as an assistant professor, I remember being told my starting salary,” LÃ³pez says. “I just said 'thank you,' and I had no idea that I could have done research and negotiated anything.”
She recommends that physicians explore data from the American Association of Medical Colleges to get a general idea of salary ranges. Additionally, academic medical centers tend to have some safeguards in place to ensure equal pay, so they can be a source of benchmark data, she says.
In May 2018, the American College of Physicians published a position statement in the Annals of Internal Medicine addressing equal pay. The statement supports a number of solutions, including increased transparency in compensation data, training to reduce implicit bias, and requirements that women be included on boards and committees.
“We need more inclusive decision-making bodies to come up with better solutions, including moving equity from a lofty goal to something that we practice,” LÃ³pez says.
Let’s talk about paychecks
Conversations about pay don’t have to be confrontational. It makes sense during annual reviews or contract renewals for female physicians to ask whether the organization is at least aware of any gender pay gaps, Hoffman says.
“They might not tell you the truth, and they might squirm a little bit,” she says. “But you have shown that you’re sensitive to the issue.”
Women who suspect gender discrimination can file a complaint with the EEOC, but it’s difficult to prove without supporting data, according to Hoffman, who worked for the EEOC from 1992 to 1998 as a senior trial attorney.
“I don’t remember a single case that was purely pay discrimination, and that’s because it’s very difficult to get that information,” she says. “It’s hard for an employee to show evidence that she is earning ‘X’ while her male counterpart is earning more.”
If a female physician suspects unfair pay, she can speak directly with an EEOC investigator to determine whether an actionable case of discrimination has occurred. The commission has contact information on its website (https://www.eeoc.gov/).
“No ‘proof’ is required at this stage, although of course, the more supporting evidence she has, the better,” James Ryan, spokesperson for EEOC, tells Medical Economics in an email.
Billing plays a role
In medicine, compensation can be tied to how much revenue a physician brings into the practice. And revenue is a direct function of billing. For example, CPT code 99215 for established patients brings higher reimbursement than CPT 99213, and women might be less inclined to code at the higher level, according to Whaley.
Rohr-Kirchgraber agrees, and adds that pay gaps are further amplified when women are less assertive than men in their billing practices. “We might feel sorry for the patient and may be tempted to bill a bit lower,” she says. “And we don’t appreciate ourselves enough either. We tend not to expect to practice at a higher level.”
But physicians do like to benchmark, so practices might consider sharing productivity numbers in an anonymous way, she says. At the very least, the less-productive clinicians should have an opportunity to ask about improving their productivity from those who bill more.
Female physicians are also held to different standards by patients. In soon-to-be-published research, Rohr-Kirchgraber found that female physicians and those from under-represented minority groups tend to score lower in patient satisfaction scores.
Although the study didn’t survey the patients, the reason female doctors score lower, Rohr-Kirchgraber believes, is because patients have higher baseline expectations for women, thus making it harder for them to earn exceptional scores. And lower satisfaction scores translate into lower compensation in today’s value-based environment.
For example, patients assume male physicians will have a straightforward bedside manner but are less tolerant of pragmatic female physicians.
“The patients expect [female doctors] to be warm and fuzzy,” she says. “And if you’re not as warm and fuzzy as they expect, you score lower.”
Patients also believe female doctors will spend more time with them-and perceive that women always have more time available because they’re not as busy as male doctors. Rohr-Kirchgraber says many female doctors do invest extra time with patients, but the result is they get behind schedule, which can cause dissatisfaction among patients in the waiting room.
“Even if they’re doing the most they can do, the patient anticipates more,” she says.
She says the solution for female physicians is to ask questions, seek out comparative compensation data and negotiate assertively for equal pay. For those in leadership, she recommends they ensure all employees are being paid fairly, not just to reduce liability risk but also to maintain professional harmony.
“You want the people in your group to be happy and satisfied in their jobs because if a doctor leaves your practice, it can be devastating,” she says.