There is no form of human excellence before which we bow with profounder deference than that which appears in a delicate woman … and there is no deformity in human character from which we turn with deeper loathing than from a woman forgetful of her nature, and clamorous for the vocation and right of men.1
—Albert Taylor Bledsoe, 1856
In the corporate world, Hollywood, and medicine, women earn less than men2; are less likely than men to reach top-level leadership positions3; and are more likely to leave an academic career.4 Women are also less likely than men to initiate negotiations. Although there are numerous barriers to advancement, the lack of strong negotiation skills and the reaction to women negotiating for their interests impairs the professional success of women.
Negotiation is often thought of in the context of salary, but pertinent negotiation topics can be much broader when navigating a career in medicine. Asking for work resources—including physician extenders and laboratory space—flexible schedules, protected administrative time, and other benefits can greatly improve the work environment. However, not asking for these benefits and resources may create frustration and career dissatisfaction. The problem is, women do not ask, and when they do, they are perceived negatively, perpetuating a vicious cycle of abstaining from negotiation and placing them at a disadvantage. Even if women keep pace with other advancements in their careers, they still lag behind men because of this initial disadvantage.5 To achieve equality in the workplace, women must start negotiating, and we must accept that women should negotiate.
DATA: WOMEN DO NOT ASK
Social psychologists have been interested in gender differences in negotiation for decades. In 1994, Watson argued that women are less competitive negotiators than men and therefore are less effective negotiators.6 More recently, Babcock et al. provided data that women initiate a negotiation less frequently than men.7 They sampled 227 working adults and asked how recently they had initiated a negotiation. Men initiated a negotiation two to four times as frequently as women. A separate study of graduating Master of Business Administration students found that 51.9 percent of men negotiated their job offer, whereas only 12.5 percent of women did, and the remaining women accepted their offer without negotiating.8
Small et al. reproduced the findings that women initiated a negotiation less frequently than men.9 Providing cues about the negotiability of payment in the study did increase women’s rates of asking for more payment; however, it did not eliminate the gender differences. The majority of women did not negotiate, even when they were told directly that payment for the assigned task was negotiable. In another study, Babcock was able to show that men were seven times more likely than women to ask for more money.10
Women in plastic surgery are not immune to this phenomenon. Recently, the Women Plastic Surgeons Steering Committee conducted an informal survey of female members of the American Society of Plastic Surgeons. Forty percent of survey respondents felt that their “lack of aggressiveness hurt their ability to negotiate.”11 In their book, Women Don’t Ask, Linda Babcock and Sara Laschever say that “More men ask. The women just don’t ask.”5
DATA: WHY WOMEN DO NOT ASK
Women may not negotiate for a variety of reasons. Some of these reasons include the following: women do not know that they can ask and are more likely to view negotiations as something to be avoided; women only ask for what they need, and if they do not need it, they do not ask; women may not believe that they deserve more than they receive and are more likely to believe that they will be rewarded for hard work (without asking); and women fear they may be perceived negatively for asking, and do not want to jeopardize relationships with others by asking.
Women Do Not Like It
Women may not ask because of how negotiations are traditionally framed. A recent blog post on the popular Web site KevinMD.com discussed this issue regarding female physicians and negotiations. Men view negotiations as a sport or competition to be won, whereas women tended to view them as something to be avoided, like “going to the dentist.”12
In addition, women may not realize that certain things are available to them if only they ask. A recent report on National Public Radio discussed the lack of female authors in either the first or last authorship position in medical journals because authorship position is an important component of academic advancement and prestige. A physician who was interviewed described how she initially never thought to ask that she be the first author on an article; however, when she did, her colleagues agreed to place her name first.13 Babcock and Laschever emphasize that no amount of negotiation advice will help if one is not willing to engage in the process.5
Women Do Not Need It
Many women will not engage in negotiation because they ask only for what they absolutely need. For example, when asked about her negotiations with Sony after discovering that she made less than her male counterparts, Jennifer Lawrence said, “I failed as a negotiator because I gave up early. I didn’t want to keep fighting over millions of dollars that, frankly, due to two franchises, I don’t need.”14 Although male counterparts in Hollywood do not “need” additional money either, they are paid more than women for the same work, in part, because they ask for it. Stereotypically, women are supposed to be “team players,” and as team players, women will ask only for what they absolutely need, not what they believe they deserve.15
Women Do Not Deserve It
Women may not initiate a negotiation because they believe that they do not deserve more money or other benefits that they may obtain through a negotiation. Claire Shipman and Katy Kay have explored this issue in their book The Confidence Code16 and article “The Confidence Gap.”17 Their research indicates that women tend to undersell themselves, whereas men tend to oversell themselves—an issue of confidence.
Shipman and Kay state, “In studies, men overestimate their abilities and performance, and women underestimate both. Their performances do not differ in quality.”17 Furthermore, “Underqualified and underprepared men don’t think twice about leaning in. Overqualified and over prepared, too many women still hold back. Women feel confident only when they are perfect. Or practically perfect.”17 Echoing this sentiment, one of the respondents in the informal Women Plastic Surgeons survey stated, “I feel as a whole females appear less confident than their male counterparts in plastic surgery.”11 Under these circumstances, women may be less likely to negotiate because they do not believe that they deserve more than they receive.
Once a woman chooses not to negotiate because of a lack of confidence, a self-perpetuating cycle can develop. A report by McKinsey & Co, Women in the Workplace, discusses this effect of performance attribution bias. “Because women receive less credit—and give themselves less credit—their confidence often erodes and they are less likely to put themselves forward for promotions and stretch assignments.”18
Furthermore, women are more likely to believe that hard work will be rewarded. Unlike men, who are more likely to self-promote, women are more likely to wait to be noticed and rewarded. Sheryl Sandberg, Chief Operating Officer of Facebook and author of Lean In, makes reference to the “tiara syndrome” in which women are more likely to believe that if “they do their job well someone will notice” and reward them.19 Unfortunately, although hard work should be recognized and rewarded, this assumption is not always the case. In their book, Babcock and Laschever recount numerous anecdotes in which the hard work and stellar performance of women was not recognized because women assumed that they would get what they deserved.5
Women Who Ask Are Not Nice
During the negotiation process, women are also perceived differently. Bowles et al. conducted a series of experiments to evaluate gender differences in the propensity to initiate a negotiation. In two experiments, participants evaluated written accounts of men and women who did or did not attempt to negotiate higher compensation. In both experiments, male and female evaluators penalized women more than men for initiating negotiation. Women who initiated the negotiation were perceived as not nice and overly demanding. In addition, evaluators were less inclined to hire female candidates who initiated a negotiation. Interestingly, in this study, both male and female evaluators penalized the women for negotiating.20
A third experiment determined that women incurred a higher social cost for initiating compensation negotiations than men, but only with male evaluators; the female evaluators penalized both the men and women equally. The final experiment in their series demonstrated that women were less likely than men to attempt negotiation for higher compensation when negotiating with a man.20 These experiments indicate that a significant barrier to initiating a negotiation is the way women are perceived during the process. If women are constantly penalized for their requests, the learned behavior is to not ask.
Amanatullah and Morris conducted a computer simulation experiment to better understand gender differences in negotiation. They noted that self-advocating female negotiators made larger concessions than self-advocating male negotiators, conceding away 20 percent of the total value in the first round of negotiation. Women strategically balance economic and social costs. They concede economically when they foresee backlash for violating gender stereotypes. Interestingly, when social costs are eliminated during the process of other-advocacy, women were found to demonstrate the same assertive behavior and successful outcomes as men.21
DATA: FINANCIAL REPERCUSSIONS OF NOT ASKING
Although the repercussions for not asking can be varied and can help explain the lack of women in leadership positions, the financial repercussions are the most well-studied. Since the inception of the Equal Pay Act in 1963, the wage gap has been closing, although at a very slow rate. In 2010, women earned 77 cents for every dollar earned by a man. Economist Evelyn Murphy, president of The Wage Project, estimates a loss of approximately $2 million for a professional school graduate over a lifetime (47 years of full-time work).22
The wage gap is a reality for physicians. A recent article in JAMA Internal Medicine found that male physicians earn nearly $20,000 more per year than female physicians.23 In addition, a study performed by Jagsi et al. surveyed recent recipients of National Institutes of Health mentored career development (i.e., K08 or K23) awards.24 One thousand twelve of the 1275 survey respondents reported salary information. Mean salary for women was $141,325 and $172,164 for men. After adjusting for specialty, academic rank, work hours, research time, spousal employment, and other factors, male gender remained an independent statistically significant predictor of higher salary. Interestingly, the gender differences in salary were more pronounced in the highest paying specialties, such as neurosurgery and radiology. The Committee on Maximizing the Potential of Women in Academic Science and Engineering found that gender differences are not limited to salary. Female faculty members are paid less, promoted more slowly, receive fewer honors, and hold fewer leadership positions than male faculty members.25
The lower salary that women receive compared to male colleagues starts at the beginning of their careers, continues throughout their careers, and has been shown to widen over time.26 Babcock and Laschever explain that if a woman fails to negotiate her starting salary, she will never be able to catch up to the salary of a man who did negotiate for the same job. They state, “The impact of neglecting to negotiate in this one instance—when starting a new job—is so substantial and difficult to overcome that some researchers who study the persistence of the wage gap between men and women speculate that much of the disparity can be traced to differences in entering salaries rather than differences in raises.”5
Concerning for female plastic surgeons is the fact that this discrepancy is even more significant in higher paying specialties such as plastic surgery. A 2015 Compensation Report issued by Medscape indicated that the average compensation for full-time, self-employed male plastic surgeons is $383,000, compared with $247,000 for female plastic surgeons (36 percent difference). For employed plastic surgeons, the compensation is $365,000 for male plastic surgeons, and $296,000 for female plastic surgeons (19 percent difference).2 The wage gap is a complex, multifactorial issue, but negotiation plays a central role.
Let us never negotiate out of fear. But let us never fear to negotiate.27
—John Fitzgerald Kennedy
Women must start negotiating to have successful careers. To better understand barriers to negotiation and develop strategies for a successful negotiation, Sarfaty et al. conducted telephone interviews of 20 academic medical faculty.28 Men and women were asked closed-ended questions about common concerns including salary, position, and support staff. Four key strategies for effective negotiation were identified. These included preparing for the negotiation process, obtaining information regarding what is negotiable, understanding the negotiation process, and viewing negotiation as a process, not a single meeting.
Tips for a Successful Negotiation
Preparing for the negotiation process involves examining priorities, ranking their importance, and knowing your leverage. When asked to rank the importance of salary, promotion, position, work responsibilities, space, support staff, authorship, time flexibility, work schedule, and equipment, Sarfaty et al. found that men ranked salary and position first; however, women ranked space first, followed by support staff and salary (second). Women must spend time thinking about what is most important to them so they do not concede on the “absolute musts” during the negotiation process. In addition, women must understand their value in comparison to everyone else before initiating negotiation. Sarfaty et al. found that preparing in advance for negotiation was associated with greater comfort in being more assertive in the negotiation process and greater self-confidence after the negotiation process.28
Obtaining information about what is negotiable can assist with knowing what one can ask. Women traditionally do not negotiate as much as men because they believe that many things are nonnegotiable. When applying for a position, one typically negotiates a salary; however, as time goes on, what is negotiable becomes less clear. Women must know what is negotiable and should use this information throughout their careers to prevent a stagnant work environment.
An anonymous Women Plastic Surgeons respondent recalls her experience of a successful negotiation: “I also called a local recruiter... and spoke to another surgeon who joined a group in my community. I managed to negotiate up 25K (but not to the level of the other surgeon, a MAN) from what I was offered. Best negotiation I did because I knew my market.”11 This case example highlights the importance of preparation for a successful negotiation in plastic surgery.
Understanding the negotiation process involves understanding your personal negotiation style and the style of the person with whom you are negotiating. Anticipate how the person you are negotiating with might respond to your requests. Role-play the situation with a trusted mentor to help you clarify your thought process and find your voice.
Change the way you look at the negotiation process. When the topic of negotiation arises, many people think of an adversarial zero-sum process—someone wins and someone loses. This describes a negotiation style termed “positional bargaining.” Each side takes a position, often extreme, and a negotiation ensues until concessions are made and someone “wins.” Fisher et al. shifted the paradigm by developing a new method called “principled negotiation.”29 In this approach, involved parties focus on “basic interests, mutually satisfying options, and fair standards” to arrive at outcomes that are beneficial to both parties. In positional bargaining, two parties who are fighting over an orange come to an agreement by dividing the orange in half. In principled negotiation, the two parties recognize that one party wants only the juice, whereas the other wants only the rind for baking.30
In her book, Babcock argues that women may find this type of negotiation more comfortable because it is about building relationships rather than a “winner” or a “loser.”5 Negotiations are processes, not single events. Establish rapport with the person with whom you are negotiating during the initial meeting. At the conclusion of each secondary meeting, send a summary e-mail to this individual to ensure you are on the same page, and to document what was discussed.
During his course on negotiation at the Wharton School, Professor G. Richard Shell advises people to refrain from negotiating until they are prepared. He recognizes that most physicians have limited time and encourages them to think of five short/simple questions before negotiating31:
1. What is my goal?
2. What are the other party’s main interests?
3. What standards may help us solve the problem?
4. What are some options?
5. What will happen to us if we walk away?
Many academic centers recognize that training in negotiation is lacking. Workshops and seminars on negotiation for female faculty are becoming increasingly common. These workshops should include female medical students, residents, and fellows to ensure proper negotiation skills before starting one’s professional career. The American Society of Plastic Surgeons has tried to address some of these issues through its course entitled “Essentials of Leadership.” However, more training sessions—at national meetings and by means of the Plastic Surgery Education Network—are needed.
The Need for a Paradigm Shift
Although women must start negotiating, a paradigm shift also needs to occur. This shift requires that we become aware of our own biases and change our reactions to women who initiate a negotiation. Instead of “fixing the women” by asking them to start negotiating like men, we must change the way we think of negotiation at the organizational level. Studies have shown that the primary reasons employees do not voice their concerns are fear of being labeled (i.e., as a troublemaker or complainer), fear of damaging relationships, a sense of futility, and fear of retribution.32,33 These are similar to the reasons women shy away from negotiation. Leaders of health organizations, from division chairs to chief executive officers, need to create a supportive environment in which it is safe to speak up, share one’s perspective, and talk openly about problems.34
Historically, women have had both extrinsic and intrinsic barriers to initiating a negotiation that limit their propensity to negotiate. The repercussions of failing to negotiate for salary and other benefits are detrimental for both women and men. We have outlined tips for a successful negotiation and a list of potential resources for women (and men) to assist with the negotiation process (Tables 1 and 2). Nevertheless, for true change to occur, we must become aware of our own biases as women and men who are on either side of the negotiation table.
1. Bledsoe ATAn Essay on Liberty and Slavery1856PhiladelphiaLippincott
3. Silva AK, Preminger A, Slezak S, Phillips LG, Johnson DJMelting the plastic ceiling: Overcoming obstacles to foster leadership in women plastic surgeons.Plast Reconstr Surg2016138721–729
4. Waljee JF, Chang KW, Kim HM, et alGender disparities in academic practice.Plast Reconstr Surg2015136380e–387e
5. Babcock L, Laschever SWomen Don’t Ask2007New YorkBantam
6. Watson CGender versus power as a predictor of negotiation behavior and outcomes.Negotiation J199410117–127
7. Babcock L, Gelfand M, Small D, Stayn HDe Cremer D, Zeelenberg M, Murnighan JKGender differences in the propensity to initiate negotiations.In: Social Psychology and Economics2006Mahwah, NJLawrence Erlbaum Associates Publishers239–259
8. Gerhart B, Rynes SDeterminants and consequences of salary negotiations by male and female MBA graduates.J Appl Psychol199176256–262
9. Small DA, Gelfand M, Babcock L, Gettman HWho goes to the bargaining table? The influence of gender and framing on the initiation of negotiation.J Pers Soc Psychol200793600–613
11. Women Plastic Surgeons (WPS) Steering Committee Informal Survey.ASPS2015
16. Shipman C, Kay KThe Confidence Code: The Science and Art of Self Assurance—What Women Should Know2014New YorkHarper Business
19. Sandberg SLean In: Women, Work, and the Will to Lead2013New YorkKnopf
20. Bowles HR, Babcock L, Lai LSocial incentives for gender differences in the propensity to initiate negotiations: Sometimes it does hurt to ask.Organ Behav Hum Decis Process200710384–103
21. Amanatullah ET, Morris MWNegotiating gender roles: Gender differences in assertive negotiating are mediated by women’s fear of backlash and attenuated when negotiating on behalf of others.J Pers Soc Psychol201098256–267
22. National Committee on Pay EquityThe wage gap over time: In real dollars, women see a continuing gap.Available at: www.pay-equity.org/info-time.html
. Accessed June 26, 2016
24. Jagsi R, Griffith KA, Stewart A, Sambuco D, DeCastro R, Ubel PAGender differences in salary in a recent cohort of early-career physician-researchers.Acad Med2013881689–1699
25. National Academy of Sciences, National Academy of Engineering, Institute of MedicineBeyond Bias and Barrier: Fulfilling the Potential of Women in Academic Science and Engineering2006Washington, DCThe National Academy Press
26. Gerhart BGender differences in current and starting salaries: The role of performance, college, and job title.Indust Labor Relat Rev199043418–433
28. Sarfaty S, Kolb D, Barnett R, et alNegotiation in academic medicine: A necessary career skill.J Womens Health (Larchmt.)200716235–244
29. Fisher RC, Ury W, Patton BGetting to Yes: Negotiating Agreement Without Giving In20113rd edNew YorkPenguin
30. Sambuco D, Dabrowska A, Decastro R, Stewart A, Ubel PA, Jagsi RNegotiation in academic medicine: Narratives of faculty researchers and their mentors.Acad Med201388505–511
31. Shell GRNegotiating effectively in academic medicine.Am J Med1996101571–573
32. Milliken FJ, Morrison EW, Hewlin PFAn exploratory study of employee silence: Issues that employees don’t communicate upward and why.J Manag Stud2003401453–1476
33. Detert JR, Burris ER, Harrison DADebunking four myths about employee silence.Harv Bus Rev20108826
©2017American Society of Plastic Surgeons
34. Dankoski ME, Bickel J, Gusic MEDiscussing the undiscussable with the powerful: Why and how faculty must learn to counteract organizational silence.Acad Med2014891610–1613