The details were new, but the story was not. Women neurologists earned less — 89 cents on the dollar — than men with comparable credentials and experience for the same work, after controlling for race, region, years of practice, practice setting, call status, leadership role, and subspecialty.
The analysis of the American Academy of Neurology’s 2019 compensation survey, published in the Neurology journal earlier this year, confirmed that the gender pay gap in medicine is alive and well.
Women in leadership positions, on average, had a salary of $269,000, while male leaders made $315,000. Women in high-compensation subspecialties like interventional neurology brought home nearly $84,000 less than their male counterparts — and even less than men working in pediatric neurology and other low-compensation subspecialties. Women neurologists with 11–20 years of practice had a lower mean hourly wage than all men neurologists except those in practice for five or fewer years.
There’s nothing special about neurology. For decades, articles have documented the pay gap in various ways and for individual medical specialties.
“Despite all of the hand-wringing over the years and the fact that we’ve known about this gap for a long time, very little has changed,” Elizabeth Loder, MD, MPH, head of research for the BMJ and vice-chair for academic affairs for the Department of Neurology at Brigham & Women’s Hospital in Boston, said in a Neurology podcast interview. “Maybe the gap is narrowing, but the gap is still there.”
But one thing is new. In 2019, women, for the first time, made up the majority of students in U.S. medical schools, according to the Association of American Medical Colleges. During the next application cycle, 53.7% of students admitted to MD-granting medical schools were female.
“The reality is that women are soon going to be the majority of doctors in the United States,” Loder says. “And intelligent and ambitious people can vote with their feet and leave academic medicine or medical practice for other endeavors — to work in industry, to work in public health or administration.”
She adds, “Equal pay is one of the ways, one of the most important ways, that we can ensure the future of our field.”
Women Rising
The gender gap in medicine — not just in pay, but in many other facets of professional life as well — sits uncomfortably against the story of women physicians’ contributions to healthcare.
Their increasing number is just one measure. When the American College of Physician Executives (forerunner to the AAPL) asked Deborah Shlian, MD, MBA, to compile a monograph in 1995, Women in Medicine and Management: A Mentoring Guide, about 19% of American physicians were women. By the time she updated that work in 2012, women accounted for more than 30% of practicing physicians. The new edition, Lessons Learned: Stories from Women Physician Leaders, was published earlier this year, and now more than 36% of practicing physicians are female.
In the new volume, 33 women physician leaders tell their professional stories; many of them are updates of their accounts in the two earlier publications. The leaders are top administrators, entrepreneurs, inventors, policymakers, researchers, managed-care executives, and more.
“My hope is that everyone who reads this book is going to find someone whose story they can identify with, someone who will not only inspire them to become physicians, but also to strive to obtain leadership roles within the profession,” Shlian says.
None of the leaders complain about unfair pay in clinical medicine, but many describe difficult working conditions, often coupled with responsibilities for childrearing and other caregiving. It is noteworthy, however, that as they matured in their careers, many of the women have completely or mostly moved away from a practice environment.
Eliza Lo Chin, MD, an internist by training, is one of them. She serves as medical director for a retirement community and, for the past decade, as executive director of the American Medical Women’s Association (AMWA).
The organization’s vision — a healthier world where women physicians achieve equity in the medical profession and realize their full potential — shows that work is still needed more than a century after AMWA was founded.
Its three-fold mission starts with advancing women in medicine through training, coaching, mentoring, and leadership opportunities to close the gender gap in organizational leadership. Chin points out that women make at least 75% of the healthcare decisions in their households, and at least 75% of the healthcare workforce is female, but fewer than 30% of healthcare leaders are women.
In academic medicine, women account for nearly 50% of medical students, and about 50% of instructor-level positions are filled by women. “But as you keep going up — assistant, associate, full professor, department chair, dean — there are fewer and fewer women,” she says. “Again, there’s this dichotomy.”
That’s why advocacy is AMWA’s second area of focus. “Our focus is on changing the culture of medicine to be more equitable so there can be pay equity, opportunities for advancement for both men and women, and more importantly, more women leaders in the senior positions,” Chin says.
AMWA’s long advocacy agenda also includes working against racism that drives healthcare disparities and working to support physicians’ mental wellbeing, including making it safe for physicians to seek mental health services.
The organization also works to improve women’s healthcare by, among other things, increasing awareness of sex- and gender-specific health issues. Example: Women may suffer potentially lethal arrhythmias when they take some of the medications that effectively stabilize cardiac rhythm in men.
Transparency and Accountability
AMWA President-Elect Theresa Rohr-Kirchgraber, MD, professor of medicine at the Medical College of Georgia, has seen men in leadership positions handle pay inequities well and handle them poorly.
Earlier in her career, she was working at another academic institution when her department leaders conducted a salary review of the faculty members. Rohr-Kirchgraber did not know the salary of other faculty members, and the person who did know wasn’t telling.
“When I had a meeting with the head of the medical group, it was very obvious that he knew I had been significantly underpaid for years and years compared to other people at my same level, but he didn’t say anything,” she says. “When you see that specific kind of abnormality, you should bring it up to the person and say what’s going on.”
On the other hand, she once interviewed an academic dean who told her that when he took the job, part of his mission was to review salaries and make them fair. “And he did, without anybody asking,” Rohr-Kirchgraber says.
In another incident, a chief medical officer told her that he hired four new physicians — two men and two women — all just out of residency and all at the same salary because salary negotiation was not allowed. Shortly thereafter, he realized the men had received signing bonuses, and the women had not. “And so he made up that difference and gave [the women] the signing bonuses without them asking,” she says.
In the latter two examples, those leaders were simply meeting their obligations. Julie Silver, MD, associate chair in the Department of Physical Medicine and Rehabilitation at Harvard Medical School, points to the Accreditation Council for Graduate Medical Education core competency of professionalism. One of its tenets is: All business practices should be handled ethically.
“We have an obligation in healthcare to embrace professionalism,” she says. “Also, it’s illegal to pay people unfairly.” Federal law requires equal pay for equal work, and some states, such as Massachusetts, have recently passed laws prohibiting wage discrimination based on gender.
Expecting individual women to negotiate for higher salaries or to demand more money is not appropriate, Loder says in the Neurology podcast. While a man might be perceived as a strong negotiator, a woman using the same tactic may be seen as an angry problem-maker.
“Those sorts of strategies can actually backfire,” she says. “When women ask for more money, they may meet with a very different, sometimes hostile response, compared with men. We cannot put the onus on individual women to fix what is a systemic problem.”
Beyond that, physicians often do not have access to the information needed for salary negotiations. Loder advocates that salary information at academic institutions should be made public, and accountability should be enforced.
“The leaders, the people who make salary decisions, need to be held accountable for this in some way,” she says. “Perhaps funding bodies, like the National Institutes of Health, could say that a demonstration of measures taken to ensure gender salary equity is necessary in order to receive public research funds.”
Give Her a Reason to Stay
Silver directs a continuing education course, Career Advancement and Leadership Skills for Women in Healthcare, that launched the “Give Her a Reason to Stay in Healthcare” campaign last year. The campaign is a call to action for healthcare institutions and individuals, as well as businesses and other organizations, to find and act in specific ways to support women in medicine. For example:
Compensate for extra work. Silver’s survey at a national conference for women physicians documented that nearly half of respondents reported spending more time on committees, task forces, and the like, than did their male peers.
The question “Will someone here take minutes?” seems like a simple request until you think about not only taking the minutes, but also writing them up, circulating them, and fielding complaints. “Someone will look around the room, their eyes will land on a woman, and they will ask her to take notes during the meeting,” Loder says. “These kinds of uncompensated activities take time away from paid work.”
Committee service is of concern to many women physicians because it can be significant to career growth, Rohr-Kirchgraber says. Serving on certain committees is an opportunity to build a professional network and demonstrate leadership skills that can lead to promotions.
“But if you go on a committee, that takes away from your clinical time, which impacts your salary. Or, if the committees meet before or after work, it impacts your home time,” she says. “Let’s make committee work be reimbursed somehow.”
Loder questions whether compensation for citizenship activities is uniform. “I have experienced in my career many uncompensated activities that I’ve done or my female colleagues have done, which, once they’re taken over by a man, suddenly are paid,” she says. “These things aren’t always done consciously. I think men often will feel entitled to ask for compensation or assistance in carrying out those tasks so that it doesn’t take so much time away from their paid work.”
Open doors. A relatively small investment can make a big difference in a person’s career. When Rohr-Kirchgraber started a new academic position, her supervisor encouraged her to participate in a leadership program for new physicians at the university.
“It was a great program that got me to understand the workings of the institution, but I wouldn’t have known to find that if he hadn’t said, ‘Theresa, this is a good one for you — it is every Monday, and I’m giving you that time and covering the salary for it,’ ” she says.
Stand back when appropriate. A male pediatric intern told Rohr-Kirchgraber that he noticed how patients routinely deferred to him rather than his female colleagues. For example, when his team conducted rounds, patients would often look to him for confirmation of points being discussed simply because he was the only male on the team. Recognizing the dynamic, he intentionally stood in the back of the group unless he was responsible for the specific patient they were visiting so that the patient would interact with the appropriate female team member.
“Now that is an ally — somebody who recognizes a power dynamic and says, ‘I didn’t have anything to do with it, but here’s how I can help fix it,’ ” she says. “That kind of thing is really powerful.”
Fix the pay gap. In a 2019 article in Neurology, Silver pointed out the significance of even a small differential in pay. A woman physician who receives an additional $30,482 in salary each year, after 40 years of investing and adjusting for inflation, would have a net return of more than $2.5 million.
“We often read at the end of research papers that more research is needed,” Loder says. “I would say in this case, we don’t need more research, but what we actually need is some action … show us the money, hold the people in power accountable, and don’t expect individual women to fix what is a systemic problem.”