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Invited Commentary
September 2016

It Is Time for Equal Pay for Equal Work for Physicians—Paging Dr Ledbetter

Author Affiliations
  • 1Department of Medicine, University of Chicago, Chicago, Illinois
JAMA Intern Med. 2016;176(9):1305-1306. doi:10.1001/jamainternmed.2016.3289

“No one should get paid less for doing the same job because she is a woman.”

Lilly Ledbetter

In a Supreme Court case, Lilly Ledbetter sued Goodyear Tire and Rubber Company for unequal pay.1 Although her salary was initially on par with those of male peers, over the years her pay was, on average, 20% lower than that of men working the same job. She lost her case because of the statute of limitations; however, she has been a stalwart advocate of equal pay for equal work for women.

Although the profession of medicine achieved gender equity with equal representation in medical schools’ admissions, we are faced with one of the largest pay gaps between sexes among professionals. It is particularly alarming that the gender pay gap among physicians appears to be widening. One study2 showed that newly trained male physicians in New York State in 2008 made, on average, $16 819 more than newly trained female physicians, compared with a $3600 difference 10 years earlier.

In this issue of JAMA Internal Medicine, Jena and colleagues3 further characterize the gender gap in earnings between male and female academic physicians by using a large administrative database of publicly reported salaries from 12 state institutions and linking it to the Doximity database to control for various physician characteristics that could influence income. The investigators found that, after controlling for specialty, age, faculty rank, and metrics of clinical and research productivity, male physicians earned nearly $20 000 yearly more than female physicians. One of the most interesting findings is the significant variation by site and specialty. In 2 academic centers, there were no differences in physician income by sex. Likewise, women in radiology did not experience a pay gap. These findings, although still sobering, emphasize the importance of understanding these positive deviants. What policies, procedures, leadership, or culture at these sites helps to counteract a gender pay gap? Recognizing these factors could help to create a potential remedy that could be adopted and tested in the sites that experience the greatest disparity in income by sex.

To develop solutions, it is equally important to fully understand the mechanism of disparity in income between male and female academic physicians. A bevy of literature from other industries4 suggests that women are not as effective at negotiating salaries, highlighting the importance of building this skill for academic women physicians in this area. One reason for this weakness is the well-described higher social cost for women who engage in negotiating their jobs compared with men. Another is stereotype threat, which highlights that women may be less likely to negotiate because they do not perceive that behavior as a characteristic of women.5 In this case, educational and empowerment interventions to address stereotype threat could be helpful. Regardless of a woman’s ability or desire to negotiate, there could be a bias against women, such that supervisors do not offer as much when hiring because they know women will be less likely to negotiate. In this case, employer training and policies that promote salary transparency would be helpful. Although this bias could be implicit or explicit, a harsher economic view from Nobel Laureate Edmund Phelps6 highlights that these inequalities are related to “statistical discrimination” or bias against all women based on the stereotype that women are less productive during childbearing years. This phenomenon would explain why women who are entering academic medical careers would earn less initially; however, Jena et al3 show that the pay discrepancy persists even when accounting for rank and age, highlighting that women are at a disadvantage throughout the course of their professional career. Certainly, a key point is that academic salaries are often negotiated at entry, which could explain the difference. However, academic salaries can be periodically renegotiated throughout one’s career, particularly if an academic physician is being recruited to another institution. It is likely that men are more aggressive than women in seeking offers and counteroffers that result in higher salaries. Because women physicians tend to be married to other professionals, it may be much harder for these women to assume the leading role in relocating their family, which is a necessary prerequisite to obtaining a lucrative offer or counteroffer. In these cases, periodic assessments of gender equity in pay coupled with performance reviews for faculty are critical to ensuring that women who are loyal to their institution are not penalized despite high levels of performance. In this case, instituting a “loyalty bonus” for women and men with high performance who are not threatening to leave may be important.

Although the findings of Jena et al3 validate what many women physicians have thought or known, it is worth also exploring the counterargument that maybe the “job” in the study by Jena and colleagues is not equal between male and female physicians, even after the authors’ great efforts to control for all observable characteristics. For example, men may be more likely, for a variety of reasons, to assume job responsibilities that come with higher income (eg, undesirable call shifts, administrative commitments, or leadership roles) and salary stipends or bonuses but do not alter clinical or research productivity. In that case, the gap would be explained by the unequal work that men and women are assuming in the workplace. However, although some may be quick to conclude that women may be less likely to aspire to leadership positions or assume roles that come with higher pay, this assumption may be playing into a stereotype as well. In a recent study7 of gender pay gap among hospitalists, women were more likely to be working night shifts despite having lower salaries. Women in that study prioritized substantial pay lower than did men for job satisfaction. Meanwhile, internal data from the University of Arizona at Tucson’s GRACE (Generating Respect for All in a Climate of Academic Excellence) Project8 concluded that, although there was no difference in leadership aspirations between women and men, women were significantly less likely to have been asked to serve as leaders. Lessons from the industry highlight that transparency in salaries between men and women is not enough. Concerted efforts to promote women into senior leadership positions are also necessary.

Fixing the pay gap between male and female physicians in academic medicine requires more than just studies showing that it exists; concerted efforts are needed to understand and eliminate the gap. Fixing the gap will also require the courage and leadership of women academic physicians—the “Dr Lilly Ledbetters” out there—to advocate to eliminate it. It is time that the “woman card” be worth the same amount as the “man card.”

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Article Information

Corresponding Author: Vineet M. Arora, MD, MAPP, Department of Medicine, University of Chicago, 5841 S Maryland Ave, MC 2007 AMB W216, Chicago IL 60637 (varora@uchicago.edu).

Published Online: July 11, 2016. doi:10.1001/jamainternmed.2016.3289.

Conflict of Interest Disclosures: Dr Arora is a member of the board of directors of the American Board of Internal Medicine and is a founding member of Women of Impact for Healthcare, a 501c3 organization. No other disclosures were reported.

Additional Contributions: Jeanne Farnan, MD, MHPE, and David Meltzer, MD, PhD (University of Chicago Section of Hospital Medicine) provided valuable feedback on this commentary. There was no financial compensation.

References
1.
Ledbetter vs Goodyear Tire & Rubber Co. 550 US 618 (2007).
2.
Lo Sasso  AT, Richards  MR, Chou  CF, Gerber  SE.  The $16,819 pay gap for newly trained physicians: the unexplained trend of men earning more than women.  Health Aff (Millwood). 2011;30(2):193-201.PubMedGoogle ScholarCrossref
3.
Jena  AB, Olenski  AR, Blumenthal  DM.  Sex differences in physician salary in US public medical schools [published online July 11, 2016].  JAMA Intern Med. doi:10.1001/jamainternmed.2016.3284.Google Scholar
4.
Bowles  HR. Why women don’t negotiate their job offers. Harvard Business Review. https://hbr.org/2014/06/why-women-dont-negotiate-their-job-offers/. Published June 19, 2014. Accessed April 16, 2016.
5.
Burgess  DJ, Joseph  A, van Ryn  M, Carnes  M.  Does stereotype threat affect women in academic medicine?  Acad Med. 2012;87(4):506-512.PubMedGoogle ScholarCrossref
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Phelps  ES.  The statistical theory of racism and sexism.  Am Econ Rev. 1972;62:659-661.Google Scholar
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8.
GRACE Project. Generating Respect for All in a Climate of Academic Excellence. http://graceproject.medicine.arizona.edu/final-report.pdf. Accessed May 3, 2016.
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