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Gender-based pay inequity in gastroenterology
In 2017, the number of women students entering medical school surpassed that of men.1 However, the future generation of women doctors is unlikely to be paid the same as their male colleagues for equal work unless something changes in health care. About 34% of gastroenterology fellows are women,2 and there are increasing proportions of women in all academic and community practices, as well as in leadership positions.
Despite this progress, equity in pay between male and female physicians has been unequal in many areas of the country, despite the same level of training.3 Doximity, a social network for physicians, surveyed 65,000 doctors in the United States and found a difference in pay between male and female physicians who worked full time.4 This is an issue that the medical field has been aware of for many years, and articles have been published on this topic in several medical journals.5-11 Doximity found that women physicians are paid less than men, although the extent of the difference varies among regions.
In 2017, per the Doximity report, the field of gastroenterology was one of the top five specialties with the biggest pay gap: Women gastroenterologists earn 19% less (or $86,447) than men gastroenterologists. This study did not differentiate among practice types (academic, private practice, hospital, or multispecialty), but it did break down the data for all physicians into general groups of owner/partner, independent contractor, and employee – it found a gender-based gap in pay among all three of these groups. For owner/partners, the gap was a $114,590 (27.2%) difference.4 According to Doximity survey data from 2018, gastroenterology is no longer in the top five specialties with the largest gender pay gap, indicating the gap is shrinking but still exists.12
A questionnaire sent to gastroenterologists 3, 5, or 10 years after they completed their fellowships (in 1993 or 1995) revealed that after 3 years women earned 23% less per hour than men, and at 5 years, the gap had decreased to 19% less per hour.6-7 The statistical data showed that the mean annual gross income of males was significantly higher at 3 years and 5 years.7 Unfortunately, at 10 years the income gap increased up to 22%.6 The researchers found that female gastroenterologists at academic centers earned 39% less than male gastroenterologists at academic centers, whereas women at nonacademic centers earned 24% less than men, despite similar work hours and call schedules.6-7
Desai and colleauges analyzed health care provider reimbursement data for various medical specialties using the 2014 Medicare Fee-for-Service Provider Utilization and Payment Data Physician and Other Supplier Public Use File, and they found a disparity in reimbursements of female versus male physicians.11 Female physicians received significantly lower Medicare reimbursements in 11 of 13 medical specialties,4 despite adjustments for productivity, work hours, and years of experience. Factors that might affect Medicare reimbursement include variations in payment among different locations, types of service provided, location of procedures performed (hospital vs. clinic), and missing data because of privacy concerns.
Among medical specialties, the gender-based payment gap is highest among vascular surgeons, followed by occupational medicine physicians, gastroenterologists, pediatric endocrinologists, and rheumatologists. In these specialties, men earn approximately 20% more than women (approximately $89,000 more for a male vascular surgeon or about $45,000 more for a male pediatric rheumatologist).4
Gender-based gaps in pay, leadership opportunities, and other opportunities exist in the health care field regardless of whether physicians are employed at academic institutions, community-based private practices, or large health care systems. Women physicians occupy fewer leadership positions, and female physician leaders have greater disparities in pay, compared with men than women who are not in leadership positions.6,10 A 2016 survey of the 50 medical schools with the largest amounts of funding from the National Institutes of Health revealed that only 13% of the department leaders were women.
The Fair Pay Act of 2013 and the Paycheck Fairness Act of 2014 aimed to close the salary gap between men and women.13 So why are women paid less than men for the same work? Some researchers have proposed “gender differences in negotiation skills, lack of opportunities to join networks of influence within organizations, and implicit or explicit bias and discrimination.”8,10
The fee for service model based on relative value units can result in lower pay for female physicians, who spend more time with patients, compared with male physicians, because of fewer billable RVUs per hour and per day.15
What should be done?
The American Medical Women’s Association leadership stated that the key to pay equity is transparency, which has been a struggle. Some states, such as New York, require state contractors, including providers that work with the state health department, to disclose salary information. Because of the persistent gender gap in pay in all medical specialties (even after adjustments for age, experience, faculty rank, and measures of research productivity and clinical revenue), the American Medical Association House of Delegates announced a plan to balance salaries within the AMA, and in medicine overall, by promoting research, action, and advocacy.14 In the American College of Physicians, 37% of the members are women. This organization published a position paper in 2018 on gender disparity in pay, and proposed solutions included reviewing and addressing recruitment and advancement of women and other underrepresented groups.15
The executive director of Indiana University’s National Center of Excellence in Women’s Health in Indianapolis, Theresa Rohr-Kirchgraber, MD, who is a professor of clinical care and pediatrics, said that women physicians should bill and code in ways that better reflect the services they provide. Women should also demand more transparency in salaries and push to remove patient satisfaction scores from being a factor in salary determination.16
It is also important to note that there are medical groups and hospitals at which disparities in gender pay might not be an issue, because of physician compensation models. These include but are not limited to Kaiser Permanente and large private practice groups (such as MNGI Digestive Health). For example, with MNGI Digestive Health, shareholder track, ambulatory surgical center distributions are based on full-time equivalent status and not on production. Shareholder compensation is transparent and communicated to all. For Kaiser Permanente, salary is based on specialty and years of service. We will have the opportunity to evaluate the effects of different compensation models as health care delivery moves toward value-based care.
There is a limitation in data presented, as we were unable to obtain specialty salary data from the Association of American Medical Colleges or Medical Group Management Association to confirm findings from the Doximity survey, etc.
Conclusions
It is important to acknowledge that we have made great strides in ensuring gender diversity in the field of gastroenterology. All professional medical and gastroenterological societies are working to address gender disparities in compensation and leadership opportunities. Medical schools and fellowship programs have incorporated training on negotiation skills into their curriculums. The medical profession and overall society will benefit from providing thriving workplaces to female physicians, allowing them to achieve their full potential by ensuring gender equity in compensation and opportunities.
Dr. Perera is a gastroenterologist at Advocate Aurora Health, Grafton, Wisc. Dr. Toriz is a gastroenterologist, treasurer, and board member, MNGI Digestive Health, Bloomington, Minn. They disclosed having no relevant conflicts of interest.
References
1. The American Association of Medical Colleges. “More Women Than Men Enrolled in U.S. Medical schools in 2017.” 2017 Dec 17. http://news.aamc.org/press-releases/article/applicants-enrollment
2. The American Association of Medical Colleges data. https://aamc.org/downlaod/280338/data/tablel3.pdf
3. CBS Business. “The gender pay gap for women doctors is big – and getting worse.” 2018 Mar 14. https://money.CNN.com/2018/03/14/news/economy/gender-pay-gap-doctors/index.html4. Doximity. “Doxmity 2018 Physician Compensation Report.” 2018 Mar 27. https://blog.doximity.com/articles/doximity-2018-physician-compensation-report
5. Tomer G et al. Gastroenterology. 2015;60: 481-5.
6. Singh A et al. Am J Gastroenterol. 2008 Jul;103(7):1589-95.
7. Burke CA et al. Am J Gastroenterol. 2005 Feb;100(2):259-64.
8. Achkar E. Am J Gastroenterol. 2008 Jul;103(7):1587-8.
9. Hoff TJ. Inquiry. 2004;41(3):301-15.
10. Weaver AC et al. J Hosp Med. 2015 Aug;10(8):486-90.
11. Desai T et al. Postgrad Med J. 2016 Oct;92(1092):571-5.
12. Doximity. “Women in Medicine: The Gender Pay Gap” 2018 Oct 2. https://blog.finder.doximity.info/women-in-medicine-the-gender-pay-gap
13. H.R.438. Fair Pay Act of 2013. 113th Congress (2013-2014)
14. O’Reilly KB. American Medical Association. “Physicians adopt plan to combat pay gap in medicine.” 2018 Jun 13. https://www.ama-assn.org/delivering-care/health-equity/physicians-adopt-plan-combat-pay-gap-medicine
15. Butkus R et al. Ann Intern Med. 2018 May 15;168(10):721-3.
16. Commins J. “5 Reasons Women Doctors Earn Less Than Men.” Health Leaders. 2018 Aug 6. https://www.healthleadersmedia.com/clinical-care /5-reasons-women-doctors-earn-less-men
In 2017, the number of women students entering medical school surpassed that of men.1 However, the future generation of women doctors is unlikely to be paid the same as their male colleagues for equal work unless something changes in health care. About 34% of gastroenterology fellows are women,2 and there are increasing proportions of women in all academic and community practices, as well as in leadership positions.
Despite this progress, equity in pay between male and female physicians has been unequal in many areas of the country, despite the same level of training.3 Doximity, a social network for physicians, surveyed 65,000 doctors in the United States and found a difference in pay between male and female physicians who worked full time.4 This is an issue that the medical field has been aware of for many years, and articles have been published on this topic in several medical journals.5-11 Doximity found that women physicians are paid less than men, although the extent of the difference varies among regions.
In 2017, per the Doximity report, the field of gastroenterology was one of the top five specialties with the biggest pay gap: Women gastroenterologists earn 19% less (or $86,447) than men gastroenterologists. This study did not differentiate among practice types (academic, private practice, hospital, or multispecialty), but it did break down the data for all physicians into general groups of owner/partner, independent contractor, and employee – it found a gender-based gap in pay among all three of these groups. For owner/partners, the gap was a $114,590 (27.2%) difference.4 According to Doximity survey data from 2018, gastroenterology is no longer in the top five specialties with the largest gender pay gap, indicating the gap is shrinking but still exists.12
A questionnaire sent to gastroenterologists 3, 5, or 10 years after they completed their fellowships (in 1993 or 1995) revealed that after 3 years women earned 23% less per hour than men, and at 5 years, the gap had decreased to 19% less per hour.6-7 The statistical data showed that the mean annual gross income of males was significantly higher at 3 years and 5 years.7 Unfortunately, at 10 years the income gap increased up to 22%.6 The researchers found that female gastroenterologists at academic centers earned 39% less than male gastroenterologists at academic centers, whereas women at nonacademic centers earned 24% less than men, despite similar work hours and call schedules.6-7
Desai and colleauges analyzed health care provider reimbursement data for various medical specialties using the 2014 Medicare Fee-for-Service Provider Utilization and Payment Data Physician and Other Supplier Public Use File, and they found a disparity in reimbursements of female versus male physicians.11 Female physicians received significantly lower Medicare reimbursements in 11 of 13 medical specialties,4 despite adjustments for productivity, work hours, and years of experience. Factors that might affect Medicare reimbursement include variations in payment among different locations, types of service provided, location of procedures performed (hospital vs. clinic), and missing data because of privacy concerns.
Among medical specialties, the gender-based payment gap is highest among vascular surgeons, followed by occupational medicine physicians, gastroenterologists, pediatric endocrinologists, and rheumatologists. In these specialties, men earn approximately 20% more than women (approximately $89,000 more for a male vascular surgeon or about $45,000 more for a male pediatric rheumatologist).4
Gender-based gaps in pay, leadership opportunities, and other opportunities exist in the health care field regardless of whether physicians are employed at academic institutions, community-based private practices, or large health care systems. Women physicians occupy fewer leadership positions, and female physician leaders have greater disparities in pay, compared with men than women who are not in leadership positions.6,10 A 2016 survey of the 50 medical schools with the largest amounts of funding from the National Institutes of Health revealed that only 13% of the department leaders were women.
The Fair Pay Act of 2013 and the Paycheck Fairness Act of 2014 aimed to close the salary gap between men and women.13 So why are women paid less than men for the same work? Some researchers have proposed “gender differences in negotiation skills, lack of opportunities to join networks of influence within organizations, and implicit or explicit bias and discrimination.”8,10
The fee for service model based on relative value units can result in lower pay for female physicians, who spend more time with patients, compared with male physicians, because of fewer billable RVUs per hour and per day.15
What should be done?
The American Medical Women’s Association leadership stated that the key to pay equity is transparency, which has been a struggle. Some states, such as New York, require state contractors, including providers that work with the state health department, to disclose salary information. Because of the persistent gender gap in pay in all medical specialties (even after adjustments for age, experience, faculty rank, and measures of research productivity and clinical revenue), the American Medical Association House of Delegates announced a plan to balance salaries within the AMA, and in medicine overall, by promoting research, action, and advocacy.14 In the American College of Physicians, 37% of the members are women. This organization published a position paper in 2018 on gender disparity in pay, and proposed solutions included reviewing and addressing recruitment and advancement of women and other underrepresented groups.15
The executive director of Indiana University’s National Center of Excellence in Women’s Health in Indianapolis, Theresa Rohr-Kirchgraber, MD, who is a professor of clinical care and pediatrics, said that women physicians should bill and code in ways that better reflect the services they provide. Women should also demand more transparency in salaries and push to remove patient satisfaction scores from being a factor in salary determination.16
It is also important to note that there are medical groups and hospitals at which disparities in gender pay might not be an issue, because of physician compensation models. These include but are not limited to Kaiser Permanente and large private practice groups (such as MNGI Digestive Health). For example, with MNGI Digestive Health, shareholder track, ambulatory surgical center distributions are based on full-time equivalent status and not on production. Shareholder compensation is transparent and communicated to all. For Kaiser Permanente, salary is based on specialty and years of service. We will have the opportunity to evaluate the effects of different compensation models as health care delivery moves toward value-based care.
There is a limitation in data presented, as we were unable to obtain specialty salary data from the Association of American Medical Colleges or Medical Group Management Association to confirm findings from the Doximity survey, etc.
Conclusions
It is important to acknowledge that we have made great strides in ensuring gender diversity in the field of gastroenterology. All professional medical and gastroenterological societies are working to address gender disparities in compensation and leadership opportunities. Medical schools and fellowship programs have incorporated training on negotiation skills into their curriculums. The medical profession and overall society will benefit from providing thriving workplaces to female physicians, allowing them to achieve their full potential by ensuring gender equity in compensation and opportunities.
Dr. Perera is a gastroenterologist at Advocate Aurora Health, Grafton, Wisc. Dr. Toriz is a gastroenterologist, treasurer, and board member, MNGI Digestive Health, Bloomington, Minn. They disclosed having no relevant conflicts of interest.
References
1. The American Association of Medical Colleges. “More Women Than Men Enrolled in U.S. Medical schools in 2017.” 2017 Dec 17. http://news.aamc.org/press-releases/article/applicants-enrollment
2. The American Association of Medical Colleges data. https://aamc.org/downlaod/280338/data/tablel3.pdf
3. CBS Business. “The gender pay gap for women doctors is big – and getting worse.” 2018 Mar 14. https://money.CNN.com/2018/03/14/news/economy/gender-pay-gap-doctors/index.html4. Doximity. “Doxmity 2018 Physician Compensation Report.” 2018 Mar 27. https://blog.doximity.com/articles/doximity-2018-physician-compensation-report
5. Tomer G et al. Gastroenterology. 2015;60: 481-5.
6. Singh A et al. Am J Gastroenterol. 2008 Jul;103(7):1589-95.
7. Burke CA et al. Am J Gastroenterol. 2005 Feb;100(2):259-64.
8. Achkar E. Am J Gastroenterol. 2008 Jul;103(7):1587-8.
9. Hoff TJ. Inquiry. 2004;41(3):301-15.
10. Weaver AC et al. J Hosp Med. 2015 Aug;10(8):486-90.
11. Desai T et al. Postgrad Med J. 2016 Oct;92(1092):571-5.
12. Doximity. “Women in Medicine: The Gender Pay Gap” 2018 Oct 2. https://blog.finder.doximity.info/women-in-medicine-the-gender-pay-gap
13. H.R.438. Fair Pay Act of 2013. 113th Congress (2013-2014)
14. O’Reilly KB. American Medical Association. “Physicians adopt plan to combat pay gap in medicine.” 2018 Jun 13. https://www.ama-assn.org/delivering-care/health-equity/physicians-adopt-plan-combat-pay-gap-medicine
15. Butkus R et al. Ann Intern Med. 2018 May 15;168(10):721-3.
16. Commins J. “5 Reasons Women Doctors Earn Less Than Men.” Health Leaders. 2018 Aug 6. https://www.healthleadersmedia.com/clinical-care /5-reasons-women-doctors-earn-less-men
In 2017, the number of women students entering medical school surpassed that of men.1 However, the future generation of women doctors is unlikely to be paid the same as their male colleagues for equal work unless something changes in health care. About 34% of gastroenterology fellows are women,2 and there are increasing proportions of women in all academic and community practices, as well as in leadership positions.
Despite this progress, equity in pay between male and female physicians has been unequal in many areas of the country, despite the same level of training.3 Doximity, a social network for physicians, surveyed 65,000 doctors in the United States and found a difference in pay between male and female physicians who worked full time.4 This is an issue that the medical field has been aware of for many years, and articles have been published on this topic in several medical journals.5-11 Doximity found that women physicians are paid less than men, although the extent of the difference varies among regions.
In 2017, per the Doximity report, the field of gastroenterology was one of the top five specialties with the biggest pay gap: Women gastroenterologists earn 19% less (or $86,447) than men gastroenterologists. This study did not differentiate among practice types (academic, private practice, hospital, or multispecialty), but it did break down the data for all physicians into general groups of owner/partner, independent contractor, and employee – it found a gender-based gap in pay among all three of these groups. For owner/partners, the gap was a $114,590 (27.2%) difference.4 According to Doximity survey data from 2018, gastroenterology is no longer in the top five specialties with the largest gender pay gap, indicating the gap is shrinking but still exists.12
A questionnaire sent to gastroenterologists 3, 5, or 10 years after they completed their fellowships (in 1993 or 1995) revealed that after 3 years women earned 23% less per hour than men, and at 5 years, the gap had decreased to 19% less per hour.6-7 The statistical data showed that the mean annual gross income of males was significantly higher at 3 years and 5 years.7 Unfortunately, at 10 years the income gap increased up to 22%.6 The researchers found that female gastroenterologists at academic centers earned 39% less than male gastroenterologists at academic centers, whereas women at nonacademic centers earned 24% less than men, despite similar work hours and call schedules.6-7
Desai and colleauges analyzed health care provider reimbursement data for various medical specialties using the 2014 Medicare Fee-for-Service Provider Utilization and Payment Data Physician and Other Supplier Public Use File, and they found a disparity in reimbursements of female versus male physicians.11 Female physicians received significantly lower Medicare reimbursements in 11 of 13 medical specialties,4 despite adjustments for productivity, work hours, and years of experience. Factors that might affect Medicare reimbursement include variations in payment among different locations, types of service provided, location of procedures performed (hospital vs. clinic), and missing data because of privacy concerns.
Among medical specialties, the gender-based payment gap is highest among vascular surgeons, followed by occupational medicine physicians, gastroenterologists, pediatric endocrinologists, and rheumatologists. In these specialties, men earn approximately 20% more than women (approximately $89,000 more for a male vascular surgeon or about $45,000 more for a male pediatric rheumatologist).4
Gender-based gaps in pay, leadership opportunities, and other opportunities exist in the health care field regardless of whether physicians are employed at academic institutions, community-based private practices, or large health care systems. Women physicians occupy fewer leadership positions, and female physician leaders have greater disparities in pay, compared with men than women who are not in leadership positions.6,10 A 2016 survey of the 50 medical schools with the largest amounts of funding from the National Institutes of Health revealed that only 13% of the department leaders were women.
The Fair Pay Act of 2013 and the Paycheck Fairness Act of 2014 aimed to close the salary gap between men and women.13 So why are women paid less than men for the same work? Some researchers have proposed “gender differences in negotiation skills, lack of opportunities to join networks of influence within organizations, and implicit or explicit bias and discrimination.”8,10
The fee for service model based on relative value units can result in lower pay for female physicians, who spend more time with patients, compared with male physicians, because of fewer billable RVUs per hour and per day.15
What should be done?
The American Medical Women’s Association leadership stated that the key to pay equity is transparency, which has been a struggle. Some states, such as New York, require state contractors, including providers that work with the state health department, to disclose salary information. Because of the persistent gender gap in pay in all medical specialties (even after adjustments for age, experience, faculty rank, and measures of research productivity and clinical revenue), the American Medical Association House of Delegates announced a plan to balance salaries within the AMA, and in medicine overall, by promoting research, action, and advocacy.14 In the American College of Physicians, 37% of the members are women. This organization published a position paper in 2018 on gender disparity in pay, and proposed solutions included reviewing and addressing recruitment and advancement of women and other underrepresented groups.15
The executive director of Indiana University’s National Center of Excellence in Women’s Health in Indianapolis, Theresa Rohr-Kirchgraber, MD, who is a professor of clinical care and pediatrics, said that women physicians should bill and code in ways that better reflect the services they provide. Women should also demand more transparency in salaries and push to remove patient satisfaction scores from being a factor in salary determination.16
It is also important to note that there are medical groups and hospitals at which disparities in gender pay might not be an issue, because of physician compensation models. These include but are not limited to Kaiser Permanente and large private practice groups (such as MNGI Digestive Health). For example, with MNGI Digestive Health, shareholder track, ambulatory surgical center distributions are based on full-time equivalent status and not on production. Shareholder compensation is transparent and communicated to all. For Kaiser Permanente, salary is based on specialty and years of service. We will have the opportunity to evaluate the effects of different compensation models as health care delivery moves toward value-based care.
There is a limitation in data presented, as we were unable to obtain specialty salary data from the Association of American Medical Colleges or Medical Group Management Association to confirm findings from the Doximity survey, etc.
Conclusions
It is important to acknowledge that we have made great strides in ensuring gender diversity in the field of gastroenterology. All professional medical and gastroenterological societies are working to address gender disparities in compensation and leadership opportunities. Medical schools and fellowship programs have incorporated training on negotiation skills into their curriculums. The medical profession and overall society will benefit from providing thriving workplaces to female physicians, allowing them to achieve their full potential by ensuring gender equity in compensation and opportunities.
Dr. Perera is a gastroenterologist at Advocate Aurora Health, Grafton, Wisc. Dr. Toriz is a gastroenterologist, treasurer, and board member, MNGI Digestive Health, Bloomington, Minn. They disclosed having no relevant conflicts of interest.
References
1. The American Association of Medical Colleges. “More Women Than Men Enrolled in U.S. Medical schools in 2017.” 2017 Dec 17. http://news.aamc.org/press-releases/article/applicants-enrollment
2. The American Association of Medical Colleges data. https://aamc.org/downlaod/280338/data/tablel3.pdf
3. CBS Business. “The gender pay gap for women doctors is big – and getting worse.” 2018 Mar 14. https://money.CNN.com/2018/03/14/news/economy/gender-pay-gap-doctors/index.html4. Doximity. “Doxmity 2018 Physician Compensation Report.” 2018 Mar 27. https://blog.doximity.com/articles/doximity-2018-physician-compensation-report
5. Tomer G et al. Gastroenterology. 2015;60: 481-5.
6. Singh A et al. Am J Gastroenterol. 2008 Jul;103(7):1589-95.
7. Burke CA et al. Am J Gastroenterol. 2005 Feb;100(2):259-64.
8. Achkar E. Am J Gastroenterol. 2008 Jul;103(7):1587-8.
9. Hoff TJ. Inquiry. 2004;41(3):301-15.
10. Weaver AC et al. J Hosp Med. 2015 Aug;10(8):486-90.
11. Desai T et al. Postgrad Med J. 2016 Oct;92(1092):571-5.
12. Doximity. “Women in Medicine: The Gender Pay Gap” 2018 Oct 2. https://blog.finder.doximity.info/women-in-medicine-the-gender-pay-gap
13. H.R.438. Fair Pay Act of 2013. 113th Congress (2013-2014)
14. O’Reilly KB. American Medical Association. “Physicians adopt plan to combat pay gap in medicine.” 2018 Jun 13. https://www.ama-assn.org/delivering-care/health-equity/physicians-adopt-plan-combat-pay-gap-medicine
15. Butkus R et al. Ann Intern Med. 2018 May 15;168(10):721-3.
16. Commins J. “5 Reasons Women Doctors Earn Less Than Men.” Health Leaders. 2018 Aug 6. https://www.healthleadersmedia.com/clinical-care /5-reasons-women-doctors-earn-less-men