The 63% question: Why are female physicians lagging behind?

Jennifer Rubin Grandis, MD, an otolaryngologist at the University of Pittsburgh, wasn't looking to stir up controversy when she started gathering statistics on salaries as part of an overall study on how women were faring in her field. Her goal was to become better equipped to offer career advice to the growing number of women medical students considering specializing in otolaryngology -- head and neck surgery.

"I don't have an ax to grind," she said. "I've been the only female faculty member for such a long time, and students were asking for help. I wanted to get a sense of the playing field, to find out what was going on."

Women physicians are catching up with men in terms of sheer numbers, but they aren't keeping pace on the pay scale, according to Dr. Grandis and others who recently have published studies on the matter. Specifics of these studies vary, but they share a common theme: The gender divide in income has yet to disappear.

Dr. Grandis was surprised by what she found.

"I thought the other studies didn't have the robust control groups [that I did]," she said. "If you really equalized everybody ... then maybe there was a chance income would not be so discrepant."

The fact that so many women physicians work part time has been offered up as a key reason they make less, but Dr. Grandis found that this was not necessarily the case in her specialty.

"I was shocked that so few of the people in the study worked part time," she said, especially since most women, like herself, manage careers while handling the majority of household and family tasks.

Within academic otolaryngology, Dr. Grandis found that female physicians made 15% to 20% less a year than male peers, after taking into account professional practice hours, hours spent in surgery, type of practice and years since residency.

"We do the same work and we make less money, and that's not OK," Dr. Grandis said.

The results of her work were published in the June Archives of Otolaryngology -- Head & Neck Surgery.

Medicine is certainly not the only profession facing this issue. Women have run into pay and promotion barriers often enough that the term "glass ceiling" emerged to describe the situation. But in medicine, where salary is tied to productivity, many doctors find it hard to believe that gender could have an impact on income. Several studies conducted over the past several years indicate that it might.

Roberta Ness, PhD, MPH, chair of epidemiology at the University of Pittsburgh, surveyed internists in all practice settings in Pennsylvania in 1998. After adjusting for age, training, practice characteristics and family characteristics, women earned 14% less per hour than men.

"We adjusted for everything that could be imagined and still found a 14% discrepancy," Dr. Ness said. "Given the same job, the same circumstances and the same training, women are making less."

According to the U.S. Census Bureau, the gender gap in medicine is bigger than in any other profession. Women physicians make 63 cents for every dollar male physicians earn, according to a recent report using 1999 census data.

The gap may have more to do with specialty choice than with discrimination, according to Daniel Weinberg, PhD, the author of the report and chief of the bureau's division for housing and household economic statistics.

"Women might be picking lower-paying specialties or organizational arrangements [HMO positions] that end up giving them less salary for more control of their time," Dr. Weinberg said.

But other studies looked at salaries within specialties.

Lack of awareness a factor

The most recent and perhaps most comprehensive study on salaries comes from the August Annals of Internal Medicine. Here, a national study on promotion and pay among women in academic medicine found that female academic physicians make nearly $12,000 less than their male counterparts.

Phyllis Carr, MD, co-author of the study, said the depth of the data gathered gives this study particular weight. Surveys from 1995 and 1996 gathered data on physician faculty by gender, seniority, number of publications, rank, department chair or chief status, race, department and percentage of time in research, administration and teaching, among other criteria.

"We had a very rich data base," Dr. Carr said. "We were really able to look at equality, the same jobs, same number of papers, comparing females with similarly accomplished males."

The study's authors also found that women were not promoted at the same rate as men and that even women who began practice in the 1990s were behind male counterparts in terms of pay and professional advancement.

Why?

Dr. Grandis said a lack of awareness regarding pay inequalities could be a contributing factor.

"We don't talk about these things. Women are not in settings where salary discussions are shared. ... Women get no mentoring on salary negotiations. Generally, this offer is being made by a man, and we trust he'll do the right thing. We're doing the same work. We're just as qualified. It doesn't occur to us that we're underpaid. It's startling," Dr. Grandis said.

Reactions to Dr. Grandis' findings have been mixed.

"When I present the data, it's very uncomfortable," she said. "All the [department] chairs are male. They don't like to look in the mirror and figure it out."

Dr. Ness, who handles performance reviews as a department chair, said cultural reasons could be partly to blame.

"I would speculate that it has to do with women's expectations. I also think it may have to do with women's knowledge that they're juggling both home and work considerations," she said. "They tend to feel guilty about anything they ask for. 'I'm working hard, but I'm going to have to take time for my child's appendectomy, so how much more can I ask for?' "

Dr. Ness said women faculty tend to be less demanding on income.

"I know who comes into my office at the point of their annual review and says, 'It's time for me to make "x" amount of dollars,' and it's more likely to be a man than a woman," she said.

Christine Laine, MD, MPH, senior deputy editor for the Annals of Internal Medicine, said she found the results of Dr. Carr and her co-authors' work particularly distressing.

"The argument was that this problem existed because there were not many women in medicine ... [The contention was] things are different and women make as much as men," she said.

Dr. Laine is referring in part to research by Laurence Baker, PhD, suggesting that the rising number of women in medicine had begun to equalize pay. He based this conclusion on survey data from 1987 and 1991 which were published in the April 1996 New England Journal of Medicine. Other studies have not duplicated these findings.

Dr. Carr and her co-authors of "Compensation and Advancement of Women in Academic Medicine: Is There Equity?" looked at surveys from more than 1,800 faculty members from all departments in 24 randomly selected U.S. medical schools. She found that women's salaries were lower than men's.

Male model of success

Dr. Carr said one factor could be a difference in culture. "Our model of success has tended to be a male one in academic medicine," she said. Men have a more independent approach to research and teaching, and individual achievement is a common benchmark for success.

"Women are more collaborative, so it's harder to determine the unique contribution of each," she said "We haven't known how to reward that."

To change how success is measured, the culture needs to change, she said. "It will take a real commitment from leaders in academic medicine to improve this. No institution is above having some of these issues."

Dr. Laine said greater transparency on salaries is needed, including having schools make salary formulas public.

In addition, Dr. Laine said women should find out what compensation they ought to expect before negotiating their salary.

"There's interesting data on women professionals in general," she said. "They tend to not haggle about salaries, while men's knee-jerk reaction is to haggle for more."