“Equal pay for equal work,” is an expression that has resonated in our society since the early 20th century, evolving as the watchword for the women’s movement in post-war, industrial America. Women who were doing “men’s work” in the wartime workforce were devalued at war’s end. Confident in their abilities and empowered by the possibilities, this generation of brave women fought for equality. Since the Equal Pay Act of 1963, it has been illegal to pay men and women different salaries for similar work. In recent decades, women have entered male dominated fields, including medicine, in record numbers. Indeed, over 50 percent of today’s medical school students are female.1 Women are well-represented in all specialties, even those traditionally male-dominated surgical and procedural fields. In addition, exceptionally talented women have gained national recognition and have achieved top positions in our professional societies. Those of us, male and female, who believe in diversity in medicine and in life, are thrilled that in academic medicine, women are joining their male colleagues in the highest leadership roles. We are Fans of Diversity.
In gastroenterology, women hold 34 percent of the GI fellowship positions2 and are increasingly represented at the faculty level at academic medical centers and as practitioners in medical practices. Women represent an increasing proportion of our national societies; AGA is currently 24 percent women. Women hold a record number of leadership positions in AGA and have increasing representation in the annual AGA awards portfolio (AGA internal data). In this amazing and historic year, the presidents of national societies including AGA, AASLD, ASGE, Society of University Surgeons (SUS) and the Association for Academic Surgery (AAS) are all women (apologies if I missed any women society leaders!). The Fans of Diversity are applauding.
Evidence suggests, however, that women do not progress in their academic careers as effectively as their male peers. With decades of nearly equal enrollment in medical schools, and plenty of time for women to reach the top, 44 percent of assistant professors but only 22 percent of full professors are women.3 AGA notes that women fall off the radar of organizations like AGA more readily than male GIs, with the most rapid fall off in membership observed in women just out of fellowship (AGA internal data). Scientifically, while women obtain an equal percentage of training and early career grants, and even comparable numbers of first-time NIH RO1s, a PI renewing an RO1 or having multiple RO1s is much more likely to be male.4 The reasons for the failure to progress and sustain advancement are likely multifactorial. It is no coincidence that these early career transitions correspond with the timing of childbearing and heightened young family responsibilities. However, to attribute pay inequity to family responsibilities alone is not consistent with the data, and in doing so, reinforces gender stereotypes.5,6,7 It is time to step back and appreciate what women bring to medicine and science, address relevant factors, optimize their value to the institution, and equalize their compensation.
Gender-based pay inequity in medical practice has been demonstrated in several studies. However, methodologic concerns such as the reliance on data collected by survey and the lack of control for important factors such as effort and productivity have decreased the impact of the message. Recent studies that use claims data and physician registries — and adjust for confounding factors such as hours worked, productivity and level of experience — have improved the reliability of the analyses. Two recent rigorous studies provide highly compelling data. Using Medicare and other publicly available data, female health care providers received significantly lower reimbursements than their male counterparts. Despite adjusting for confounding factors, female providers received lower reimbursements in 11 of 13 medical specialties, including gastroenterology.6 In the most rigorous study to date controlling for age, rank, work and scholarly productivity, and other factors, male physicians in academic programs earned nearly $20,000 more annually than female physicians. The gap grew with rank and was highest in surgery and surgical subspecialties.7
Why, when women achieve the same rank as men, would they make a lower salary? Explicit bias? Implicit bias? The answer again is multifactorial. Women perform more underpaid and unpaid roles in medical education and committee work. Men take on more lucrative long-distance or off-hours assignments than women. They are more mobile and “look” at other jobs more than women. Consequently, they are more likely to leverage an offer letter to secure a retention package. Men network more effectively with other men on the lecture circuit, at national meetings and socially. They are more likely to do career-enhancing consulting and to hold editorial board positions. At national meetings, including DDW, they are more likely to chair sessions, give state-of-the-art talks, and be faculty for satellite symposia. Lessons learned from organizational and systems research tell us that the dominant members of the organization will have easier access to opportunity, money, prestige, favorable decisions, preferential treatment and access to decision makers.8 While we are focusing in this article on the pay gap, there are other important aspects of professional life that women GIs are finding harder to access. Now the Fans of Diversity are silent.
Psychologists tell us that men are more self-promoting and more likely to negotiate to their benefit. One highly effective woman chair said that when negotiating salary packages with women faculty she is frequently frustrated by their seeming reluctance to “ask,” so she physically takes off her invisible chair’s hat and sets it aside to advise the faculty about the possibilities. What if every leader, whether in practice or in academics, took off their hard ball negotiating hat to think more globally about what might be best for an individual faculty? Not just a nice gesture, this has practical and economical implications because of the high institutional cost of faculty loss through burnout, failed retention efforts or faculty leaving the field of medicine.9 The Fans of Diversity are restless.
Whatever the reason for gender pay inequality, it is in all of our best interests to help women break through their personal and institutional ceilings. The approach, like the problems, should be multifactorial. Let’s list some strategies institutions could employ to address the issue of pay equity.
•Know your local data: Perform an institutional analysis to assess equity gap and man/womanpower at all ranks. When done at my home institution, the University of Florida, we were relieved to have no serious pay gap but were alerted to a major drop off in the number of women faculty at the full professor rank. This allowed our leadership to examine contributing factors including the promotion process and set about designing career development programs for our junior women aimed at helping “at risk” faculty stay on track for promotion. The University of Florida’s recommendation is to pattern the analysis after the rigorous recent national study7 with a few modifications. When analyzed institutionally, we used the percentile of The American Association of Medical Colleges (AAMC) salary per specialty and rank rather than the dollar amount, and the actual full-time equivalent (FTE) rather than a surrogate for FTE. The data was highly relevant at the institutional level with the ability to monitor the metrics over time.
• Be transparent: Institutions should be transparent with regard to their compensation plans. They should analyze and publish their pay equity data and gender distribution by rank. This can ignite internal initiatives that enhance recruitment and retention. Further, local data can quickly evolve into national metrics, and transparency fuels a national conversation with sharing of best practices. National organizations like AGA hear from our membership and are highly invested in keeping women gastroenterologists thriving, but have limited data and minimal impact at the local levels. AAMC keeps a close eye on this issue with serious investment by several AAMC sections including the Group on Faculty Affairs (GFA) and the Group on Diversity and Inclusion (GDI), both groups having valuable resources for institutions (https://www.aamc.org/members).
• Be creative and supportive: Don’t let women jump ship or be too quick to take a slow boat. Both male and female faculty need strong support and creative methods to sustain faculty vitality. Arthur J. DeCross, MD, AGAF, reported the results of the AGA Institute Education and Training Committee survey of gastroenterologists demonstrating the enormous burden of burnout, and found that women are more likely to experience symptoms of burnout, a common cause for leaving the practice of medicine.10 An increasingly common “solution” for women is to “go part time.” Decreasing effort to a fractional FTE solves many issues, and seems like a good idea to everyone, but can create unforeseen negative consequences. Women at partial FTE are taken less seriously in their careers and are offered fewer leadership opportunities. They often do uncompensated work beyond their FTE on their “off days” to catch up on administrative and patient care issues. Their accomplishments for promotion are scrutinized with partial FTE faculty staying much longer at the assistant professor level.11 Whether partial FTE status is right for a particular faculty should be individualized and alternatives should be carefully considered. Maximizing creativity, flexibility and support, while helping the faculty continue scholarly activities and maintaining an eye on a long-term career plan can help to keep their academic ships right.
• Take off your hat: Finally, leadership should not hesitate to take off their dean/chair/chief hats and advise women about what is possible. This modern movement from a declarative to an interactive negotiating style could be a winning long-term strategy.
A gender pay gap exists in medicine and science as in many other fields. Its roots are complex and implications far-reaching. The cumulative financial and social effects have life-long consequences. Further, there are equity concerns in practice beyond pay, affecting women with families and those without, and especially impacting faculty in the LGBT community. Though less well-publicized, and hopefully less common in medicine than in politics or Hollywood, sexual harassment also exists in our field. The ideas presented here are low hanging fruit to address a small part of the complicated subject of pay equity, with suggestions for realistic institutional strategies that will enhance faculty vitality. What we do for women in this regard elevates us all. To our institutional leadership, the Fans of Diversity are watching!
Dr. Zimmermann has received a research grant from AbbVie.
1. The American Association of Medical Colleges. More Women Than Men Enrolled in U.S. Medical Schools in 2017. December 2017. https://news.aamc.org/pressreleases/article/applicant-enrollment-2017
2. The American Association of Medical Colleges data: https://www.aamc.org/download/280338/data/tablef3.pdf
3. The American Association of Medical Colleges data: https://www.aamc.org/download/475558/data/16table9.pdf
4. Pohlhaus, J.R., Jiang, H., Wagner, R.M., Schaffer, W.T., Pinn, V.W. Sex Differences in Application, Success, and Funding Rates for NIH Extramural Programs. Acad Med. 2011; 86: 759-767.
5. Greenberg, C.C. Association for Academic Surgery Presidential Address: Sticky Floors and Glass Ceilings. Journal of Surgical Research. 2017; 219: IX-XVIII.
6. Desai, T., Ali, S., Fang, X., Thompson, W., Jawa, P., Vachharajani, T. Equal work for unequal pay: the gender reimbursement gap for healthcare providers in the United States. Postgrad Med J. 2016; 92: 571–575.
7. Anupam, J.B., Olenski, A.R., Blumenthal, D.M. Sex Differences in Physician Salary in US Public Medical Schools. JAMA Internal Medicine. 2016;176:E1-10.
8. Oshry, B. Seeing Systems: Unlocking the Mysteries of Organizational Life. 2nd Ed. Berrett-Koehler Publishers. 2007.
9. Shah, D.T., Williams, V.N., Thorndyke, L.E. et al. Restoring Faculty Vitality in Academic Medicine When Burnout Threatens. Acad Med. Publish Ahead of Print; Nov 2017.
10. DeCross A. The Current State of Professional Burnout in Gastroenterology. AGA Perspectives. 2017; 13(4):22-24.
11. Darbar, M., Emans, S.J., Harris, L., Brown, N.J., Scott, T.A., Cooper, W.O. Part-Time Physician Faculty in a Pediatrics Department: A Study of Equity in Compensation and Academic Advancement. Acad Med. 2011;86:968–973.