Career Goals, Salary Expectations, and Salary Negotiation Among Male and Female General Surgery Residents

Key Points

Question  What are the similarities and differences between male and female general surgery residents in terms of future salary expectations, career goals, and views on salary negotiation?

Findings  In this survey-based study of 606 male and female surgery residents, overall career goals were similar for men and women; however, women had lower future salary expectations and a significantly more negative view of salary negotiation.

Meaning  These findings may aid in identifying strategies to help narrow the gender gap in general surgery.

Importance  In general surgery, women earn less money and hold fewer leadership positions compared with their male counterparts.

Objective  To assess whether differences exist between the perspectives of male and female general surgery residents on future career goals, salary expectations, and salary negotiation that may contribute to disparity later in their careers.

Design, Setting, and Participants  This study was based on an anonymous and voluntary survey sent to 19 US general surgery programs. A total of 606 categorical residents at general surgery programs across the United States received the survey. Data were collected from August through September 2017 and analyzed from September through December 2017.

Main Outcomes and Measures  Comparison of responses between men and women to detect any differences in career goals, salary expectation, and perspectives toward salary negotiation at a resident level.

Results  A total of 427 residents (70.3%) responded, and 407 responses (230 male [58.5%]; mean age, 30.0 years [95% CI, 29.8-30.4 years]) were complete. When asked about salary expectation, female residents had lower expectations compared with men in minimum starting salary ($249 502 [95% CI, $236 815-$262 190] vs $267 700 [95% CI, $258 964-$276 437]; P = .003) and in ideal starting salary ($334 709 [95% CI, $318 431-$350 987] vs $364 663 [95% CI, $351 612-$377 715]; P < .001). Women also had less favorable opinions about salary negotiation. They were less likely to believe they had the tools to negotiate (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03) and were less likely to pursue other job offers as an aid in negotiating a higher salary (124 of 177 [70.1%] vs 190 of 230 [82.6%]; P = .01). Female residents were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), were less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and believed they would have more responsibility at home than their significant other (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001). Men and women anticipated working the same number of hours, expected to retire at the same age, and had similar interest in holding leadership positions, having academic careers, and pursuing research.

Conclusions and Relevance  This study found no difference in overall career goals between male and female residents; however, female residents’ salary expectations were lower, and they viewed salary negotiation less favorably. Given the current gender disparities in salary and leadership within surgery, strategies are needed to help remedy this inequity.

Women account for 47% of the current US labor force and earn approximately 20% less than their male counterparts doing the same work. This gender gap is also reflected in the number of women holding leadership positions, with female members of the S&P 500 labor force accounting for only 25% of executive and senior level officials, holding only 20% of board seats, and representing only 6% of chief executive officers.¹

This inequality holds true for women in medicine, including surgery. In 2017, women constituted just above 50% of medical school matriculants for the first time in history and currently hold about 40% of general surgery resident positions.² However, despite this increasing number of women entering medicine, a disproportionately lower number of women hold leadership positions. In 2017, only 16% of all medical school deans and department chairs across all medical specialties were women, and only 10% were senior authors in medical journals.³ In terms of salary differences, female physicians earned on average $105 000 less than their male counterparts, and this gap has been increasing.⁴ In surgery, women represent only 20% of assistant professors, 11% of full professors, and 10% of department or division chairs nationally.⁵ Women in surgery also earn significantly less than their male counterparts who hold the same positions, with women making on average $32 000 less than their male general surgery colleagues annually.⁶

The reason for these disparities is likely multifactorial. The purpose of this study was to survey surgical residents about their overall career goals, future salary expectations, views on salary negotiation, and family and lifestyle goals to determine whether a difference exists between genders.

This study was approved by the Human Subjects Committee of the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, which determined the study to be exempt from informed consent due to the anonymous and voluntary nature of the survey. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline.

The survey consisted of 74 questions (eAppendix 1 in the Supplement). The present study analyzes the survey questions related to the residents’ career goals, attitudes toward salary negotiation, expected future work hours, and lifestyle perspectives. Additional questions asked as a part of the survey are not reported herein. Survey questions were constructed as a 4-point Likert scale, yes or no, true or false, or fill in the blank. Survey respondents had the option of choosing not to respond to any question. Career goals questions asked about the types of leadership positions the resident aspired to hold, future plans for practice type and location, fellowship plans, research goals, anticipated work hours, anticipated retirement age, and other future career plans. Ideal starting salary and minimum acceptable starting salary were collected by having respondents write in a value. Questions about salary negotiation asked about overall perspectives toward negotiation and whether residents believed they had the skills to successfully negotiate. Although the goal of the survey was to compare men’s and women’s responses, the residents were not informed of this purpose. Demographic information was collected at the end of the survey, including sex, marital status, whether they had or planned to have children, what responsibilities they had at home, and whether they were the primary income earner.

A second survey was sent to each program director (eAppendix 2 in the Supplement). This survey focused on information about the residency program, including the program type and size, the size of faculty, and the distribution of leadership positions by sex.

Twenty-three residency programs across the country were invited to participate in the study, and 19 chose to participate. Programs were invited through email correspondence sent to program directors from institutions that had collaborated in prior studies or had expressed interest in this particular study. Programs represented various regions throughout the United States (West, Midwest, South, and Northeast) and varied by program type (university, university affiliated, and independent). The anonymous survey was sent to all 606 categorical general surgery residents at these 19 residency programs. The survey was administered using SurveyMonkey, an online survey software program. Separate survey links were generated for each program and sent to the program director, who distributed it to categorical general surgery residents. All responses were collected anonymously.

Data were collected from August through September 2017 and analyzed from September through December 2017. The primary end points of this study were overall career goals, salary expectations, and perspectives on salary negotiation as they differed by sex. The secondary end points were the residents’ perspectives on lifestyle and family expectations. Statistical analysis of resident and program responses were exported into a native SAS format using a computer program (DBMS-Copy, version 9.4; DataFlux Corporation). Analysis was conducted using SAS version 9.3 (SAS Institute Inc). All responses were compared by sex and were controlled for by program type, postgraduate year level, and clustering within programs using generalized estimating equations. A 2-sided t test was used to calculate P values, and P < .05 indicated significance.

Overall, 427 residents submitted responses for a response rate of 70.3%, with 20 declining to complete the demographics portion of the survey. Of the remaining 407 respondents, mean age was 30.0 years (95% CI, 29.8-30.4 years); 177 (43.5%) were female and 230 (56.5%) were male; and sex distribution across postgraduate years was even. Three hundred six respondents (75.2%) identified their program as university; 61 (15.0%), as independent; and 40 (9.8%), as university affiliated (Table 1). When comparing men and women, the men were slightly older, with no difference between the 2 groups in terms of race or ethnicity and postgraduate year (Table 2).

The program director survey demonstrated that the programs had a mean of 32 categorical residents with a mean of 14 (43.8%) female residents. In terms of faculty and leadership positions, women represented a mean of 14 of 55 (25.5%) full-time faculty members, 5 of 19 (26.3%) program directors, 3 of 16 (18.8%) full professors, 2 of 19 (10.5%) department chairs, and 0.5 of 6 (8.3%) division chiefs.

There was no difference between male and female general surgery residents when comparing overall career goals (Table 3). There was no difference between men and women in their desire to hold leadership positions such as department chair (72 of 230 [31.3%] vs 48 of 177 [27.1%]; P = .20), division chief (115 of 230 [50.0%] vs 74 of 177 [41.8%]; P = .06), or program director (61 of 230 [26.5%] vs 49 of 177 [27.7%]; P = .40). There was no difference between sexes in their desire to contribute to their field through research (137 of 230 [59.6%] vs 118 of 177 [66.7%] P = .10), interest in an academic career (141 of 230 [61.3%] vs 121 of 177 [68.4%]; P = .20), or desire to become a leader in their field (154 of 230 [67.0%] vs 134 of 177 [75.7%]; P = .10). There was also no difference between sexes in desire to teach medical students and residents (194 of 230 [84.3%] vs 151 of 177 [85.3%]; P = .50) or to become an active member of a surgical society (189 of 230 [82.2%] vs 158 of 177 [89.3%]; P = .20). However, women were more likely to agree or strongly agree with the statement, “It is important to me to work in a setting that provides medical care to an underserved patient population” (141 of 177 [79.7%] vs 157 of 230 [68.3%]; P = .03). Men were more likely to agree or strongly agree with the statement, “It is important to me to be involved with medical innovation and/or device development” (123 of 230 [53.5%] vs 71 of 177 [40.1%]; P = .002).

There was no statistically significant difference in the minimum hours expected to work (women, 56.5 [95% CI, 55.0-58.0] hours; men, 56.9 [95% CI, 55.5-58.3] hours; P = .30) or the maximum hours expected to work each week (women, 76.4 [95% CI, 74.5-78.3] hours; men, 77.6 [95% CI, 75.8-79.4] hours; P = .20). There was also no difference in projected retirement age (women, 67 [95% CI, 66-68] years; men, 67 [95% CI, 66-68] years; P = .30) (Table 4). There was also no difference between men and women in their desire to pursue fellowship (207 of 230 [90.0%] vs 165 of 177 [93.2%]; P = .20) (Table 2).

There was a statistically significant difference between male and female residents in terms of their mean anticipated minimum future starting salary (women, $249 502 [95% CI, $236 815-$262 190]; men, $267 700 [95% CI, $258 964-$276 437]; P = .003) and their mean anticipated ideal starting salary (women, $334 709 [95% CI, $318 431-$350 987]; men, $364 663 [95% CI, $351 612-$377 715]; P < .001) (Table 4). The mean minimal future starting salary was $18 198 less for women, and the mean ideal future starting salary was $29 954 less.

Overall, 256 residents (62.9%) disagreed or strongly disagreed with the statement, “I believe I will be offered a fair salary without needing to negotiate”; 301 (74.0%) disagreed or strongly disagreed with the statement, “I believe that I have the tools to successfully negotiate an appropriate salary”; and 314 (77.1%) agreed or strongly agreed with the statement, “I envision seeking other job offers to help negotiate a higher salary” (Table 5). When comparing answers by sex, women were less likely to agree or strongly agree with the statement, “I believe that I have the tools to successfully negotiate an appropriate salary” (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03). They were also less likely to strongly agree or agree with the statement, “The thought of negotiating for my salary is appealing to me” (38 of 177 [21.5%] vs 79 of 230 [34.3%]; P = .02) and less likely to agree or strongly agree with the statement “I envision seeking other job offers to help negotiate a higher salary” (124 of 177 70.1%] vs 190 of 230 [82.6%]; P = .01) (Table 5).

When analyzing perspectives about family and lifestyle, women were more likely to agree or strongly agree with the statement, “I anticipate that I will have a greater responsibility at home than my significant other” (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001) (Table 3). Women were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and less likely to desire having children in the future (106 of 177 [59.9%] vs 149 of 230 [64.8%]; P = .003) (Table 2). Women were also less likely to say that they would be the primary income earner for their household (85 of 177 [48.0%] vs 172 of 230 [74.8%]; P < .001) (Table 2).

This multi-institutional survey of 427 general surgery residents at 19 general surgery programs across the United States explored similarities and differences between male and female residents in terms of future salary expectations, career goals, and views on salary negotiation. There was no difference in terms of overall career goals; however, women had lower salary expectations and a significantly more negative view of salary negotiation. Furthermore, women were less likely to be married, less likely to have children, and more likely to anticipate having increased responsibility at home compared with their significant other.

Male and female trainees in the present study reported similar career goals. Both planned to enter fellowship at the same rate, work the same hours, and retire at the same age. They also had the same future interest in research, becoming a program director or a department chair, and being recognized as a leader in their field. This similarity between women and men in their desire to be successful in their careers is represented outside medicine as well. A combined 2010-2011 study from the Pew Research Center surveyed members of the workforce aged 18 to 34 years and found that 66% of women rated their career high on their list of priorities, compared with 59% of men. In addition, more women than men rated being successful in a high-paying career as being important.⁷ This desire to be successful, however, has not yet translated to equality in leadership positions for women in surgery. In the present study, women represented only 26.3% of general surgery residency program directors, 18.8% of full professors, 10.5% of department chairs, and 8.3% of division chiefs. Time will tell if these aspirations lead to a change in the demographics of leadership in surgery.

Female residents in this study had lower salary expectations than men in minimum acceptable starting salary ($249 502 vs $267 700) and ideal starting salary ($334 709 vs $364 663). These overall salary expectations are reasonable when compared with current salary statistics. The 2016-2017 data from the Association of American Medical Colleges indicates that the 25th percentile, median, and 75th percentile salaries for general surgeons at the assistant professor level are $279 000, $334 000, and $415 000, respectively.⁵ Interestingly, this Association of American Medical Colleges interquartile range ($279 000-$415 000) falls within the minimum and ideal salary expectations reported by men and women in our study. However, female residents, on average, anticipate an ideal staring salary that was $30 000 less than male residents and well below the 75th percentile salary mark represented in the Association of American Medical Colleges salary statistics. Given that the women in our study anticipate working similar hours and retiring at the same age as their male counterparts, this $30 000 difference, multiplied during a 30-year career, would amount to a $900 000 potential difference in lost wages over a lifetime. This pay disparity between men and women in the medical profession has been well established, with studies showing that women earn less independent of rank, clinical hours, research productivity, or training.^6,8,9

Our study also found that female trainees are less likely to be married, have children, or desire children in the future. This finding correlates with previously published data showing that women across all specialties entering medical training are less likely to be married or have children.¹⁰ Women in medicine face unique challenges having children during residency and beyond. In a recent study of female general surgeons who had 1 or more children during residency,¹¹ 39% had seriously considered leaving residency and nearly one-third reported they would advise a female medical student against pursuing a career in surgery because of the difficulties of balancing pregnancy and motherhood with training. In a 2014 study of physicians with active academic affiliations and recipients of National Institutes of Health grants,¹² women spent 8.5 more hours per week on domestic activities than men and were more likely to take time off during disruptions of their usual child-care arrangements. This reality is echoed in the perception of current trainees that they anticipate having a greater responsibility at home than their significant other.

Male and female residents both viewed salary negotiation unfavorably; however, women had a more negative view of salary negotiation, were less likely to believe that they had the tools to negotiate successfully, and were less likely to seek out other job offers as a negotiating tool. A recent study^13,14 demonstrated that only about 30% of women compared with 46% of men in the overall workforce negotiate for their salary. These gender differences in approach to salary negotiation can also contribute to a gender pay gap, given that an individual who negotiates for their salary can earn significantly more during the course of their career. Similarly, research looking at women in nonmedical careers has demonstrated that they view salary negotiation less favorably than men and are less likely to ask for what they want.¹⁵ Adding negotiation skills training to residency curriculum may help all residents become more comfortable with negotiation tactics. In addition to teaching negotiation skills, an education program should also include examples of successful negotiations, demonstrations of what can be achieved through negotiation, and practical sessions that allow residents time to practice these skills.

There are several ways to potentially address gender disparities in surgery. One is to increase the number of women in surgical leadership. The number of women in surgery chair positions is rising, and these leaders will serve as role models to junior faculty and residents. In addition, some surgery departments have made all faculty salaries transparent. This approach provides faculty with accurate salary goals and highlights potential existing disparities that can then be addressed. In recent examples of this, Morris et al¹⁶ (2018) demonstrated that an objective and structured compensation plan improved the gender pay gap. Before the plan, women were paid significantly less, whereas after implementation of the plan, male and female faculty compensation was similar, as was rate of promotion. Hoops et al¹⁷ (2018) found that there was significant improvement in the salaries for female surgery faculty after standardizing a compensation plan. They also demonstrated that no change in the salaries of male surgeons occurred. However, despite the fact that women’s salaries increased significantly, they were still earning less than their male counterparts.¹⁷

The major limitation to our study is that these findings are based on resident perspectives about their future career. Because our results represent future expectations, there is no way to determine whether these expectations will come to fruition, and there is always a chance that an individual’s perspective may shift once they graduate. However, many of our findings are supported by the results of other studies analyzing gender differences in the workplace in medical and nonmedical fields. Furthermore, given that most residency programs currently lack any formal training in salary expectation and negotiation, these perceived differences will likely persist beyond residency. Another potential limitation is that this study may lack sufficient sample size to detect a difference between men and women in terms of career goals. The 427 total responses constitute a large group; however, if a larger sample were pooled, differences may be identified.

This study demonstrated no difference between male and female general surgery residents in terms of their overall career goals; however, female general surgery residents had significantly lower salary expectations than their male counterparts and viewed salary negotiation less favorably. In terms of lifestyle, women were less likely to be married, less likely to have children, and more likely to have increased responsibility at home compared with their significant other. These findings are the result of a survey and in some instances may not accurately predict the future of the respondents. However, this survey provides insight into the perspectives held by the next wave of physicians entering the general surgery workforce and provides some insight into potential areas in which resident education may help to address some of the gender disparities that exist in general surgery.

Accepted for Publication: June 9, 2019.

Corresponding Author: Christian de Virgilio, MD, Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson St, PO Box 461, Torrance, CA 90502 (cdevirgilio@labiomed.org).

Published Online: August 28, 2019. doi:10.1001/jamasurg.2019.2879

Author Contributions: Drs Gray and de Virgilio had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gray, Neville, Kaji, Donahue, Jarman, Morris, de Virgilio.

Acquisition, analysis, or interpretation of data: Gray, Neville, Kaji, Wolfe, Calhoun, Amersi, Donahue, Arnell, Inaba, Melcher, Smith, Reeves, Gauvin, Salcedo, Sidwell, Murayama, Damewood, Poola, Dent, de Virgilio.

Drafting of the manuscript: Gray, Neville, Kaji, de Virgilio.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gray, Kaji, de Virgilio.

Administrative, technical, or material support: Donahue, Smith, Reeves, Dent, de Virgilio.

Supervision: Neville, Kaji, Calhoun, Amersi, Donahue, Arnell, Morris, Murayama, Damewood, Poola, de Virgilio.

Conflict of Interest Disclosures: Dr Smith reported receiving personal fees from Stryker Endoscopy outside the submitted work. No other disclosures were reported.