Although the phrase “79 cents on the dollar” may now be considered part of the standard American lexicon, it is a crude estimate at best of the difference in pay in the United States attributable to gender alone. The U.S. Census Bureau does the hard work of tracking annual wages for men and women who work full-time and year-round using Current Population Survey data. Although the median annual wage for an American woman who worked full-time, year-round in 2015 was $40,742 (standard error [SE] $146), or 79.6% of the median annual wage of $51,212 (SE $136) for an American man who worked full-time and year-round during the same year,1 this does not account for the myriad potential confounders, including but not limited to choice of occupation and the number of actual hours worked. The fact that significant gender differences in annual median earnings persist when the population is stratified by educational attainment, with the largest absolute difference seen between men and women with graduate or professional degrees ($55,702 [SE $209] compared with $82,215 [SE $220] in 2014),1 has been suggested as more direct evidence of systemic inequality. Although population-level data are helpful for quantifying absolute differences in earnings from a population perspective, the real question remains: Is there a statistically significant difference in the amount that a woman gets paid for doing the same job for the same number of hours when compared with a similarly qualified man?
Medicine provides interesting scaffolding against which to answer these questions given the extremely proscribed training and examination course through which female and male physicians must traverse in equal measure. In the older literature on salary equality in medicine, methodologic issues with unadjusted analyses and significant residual confounding were common. A newer cadre of studies, however, deserves our attention.
In 2012 Jagsi et al2 published the results of a survey of physicians who received prestigious National Institute of Health K08 and K23 awards in 2000–2003 and continued to work in academic institutions in 2009–2010. After controlling for physician specialty, academic rank, leadership positions, number of publications, and research time, male gender was associated independently with a significantly higher annual salary ($13,399, P=.001). Furthermore, using Peters-Belson analysis, an alternative approach to linear regression wherein expected salaries were calculated for female physicians using all of their baseline variables but with gender changed to male, expected annual salaries increased by $12,194 per female physician. Furthermore, there was no interaction between physician gender and parental status; female physicians with no children earned lower salaries than their male counterparts. Finally, as the authors note, assuming these reported differences in salaries remained static over time, male physicians in this cohort would earn at least $350,000 more than their female colleagues over a 30-year career.
In August 2016 Freund and colleagues3 published the results of their 17-year follow-up study to the National Faculty Cohort Study to measure longitudinal changes in compensation by gender in academic medicine. Their cohort included 490 physicians who had completed an original survey and continued to practice medicine full-time or retired from full-time practice in 2012–2013. In their final analysis, which was adjusted for race and ethnicity, marriage and family status, department affiliation, years since the first academic appointment, academic rank, percent effort in the standard academic domains, and any leave or part-time status, female physicians earned a mean of $16,982 less than their male counterparts (95% CI −$32,954 to +$1,010, P=.04). However, mean change in salary over time in adjusted analysis was not significantly different (+$84,212 for men, +$82,670 for women, P=.86), meaning that in this cohort, the gender disparities from earlier in one’s career propagated over time but appeared not to widen.
The nuanced work of Jena and colleagues4 is of particular interest to academic obstetrician–gynecologists (ob-gyns). In July 2016, these clinician-researchers published their analysis of more than 10,000 academic physicians at 24 public medical schools in states mandated by the Freedom of Information laws to release salary data online. After controlling for age, years of experience, faculty rank (assistant, associate, or full professor), specialty, publications (both total number as well as number of first or last author publications), National Institutes of Health funding (none compared with one or more grant), clinical trial participation (none compared with one or more where the physician was a principal or subinvestigator), and Medicare reimbursements (a proxy for clinical productivity and full- compared with part-time effort), female physicians earned on average $19,878 less than male physicians (95% CI $15,261–24,495). Gender differences in salary were present at all faculty ranks. Moreover, female full and associate professors had adjusted salaries comparable with those of male associate and assistant professors, respectively. Finally, among the 18 individual specialties analyzed, obstetrics and gynecology had the fourth largest gender salary gap with women in our field earning a mean of $36,390 less per year than men in adjusted analysis (95% CI $16,375–56,406).
As with all studies, the possibility of residual confounding must be considered. For example, the Jena study used Medicare reimbursements from 2013, obtained from publicly available data from the Centers for Medicare & Medicaid Services, as a proxy for clinical productivity, which may not accurately reflect number of patients seen nor clinical revenue in the field of obstetrics and gynecology. None of the studies quantifies the extent to which individual health care providers make personal choices that would increase their compensation (eg, extra call, more shifts, or more procedures performed). Finally, all three studies focused on a cohort of academic physicians; data measuring gender differences in salary between ob-gyns in the private sector are lacking.
That said, these newer studies urge us to at least consider the possibility that significant compensation differences exist between men and women in academic medicine after controlling for clinical and research productivity. These differences may be explained in part by less strenuous negotiating at the start of one’s career.3 However, we must also consider the possibility that unconscious or implicit bias affects the relationship between gender and salary in academic medicine, although measuring or quantifying this contribution to observed differences in compensation is, by definition, extremely challenging.
The medical literature is replete with suggestions on how to close the gender salary gap: training women in better negotiating skills; dedicated mentoring or sponsorship programs for young female faculty; training in unconscious gender bias at the leadership level; institutional transparency of starting salaries; nondepartmental oversight of compensation models and metrics; support for work–life balance; critical mass theory (waiting for women to represent greater than 30% of a given workforce); even prestigious external awards for higher education institutions who have excelled in self-assessment and best practices around gender equity.5–11 However, the question remains: what is the rational period of time beyond which we should expect these strategies to achieve gender parity if they are going to work? Our own field, for example, has been a majority-female specialty since at least 2012, the first year when more than half of the American College of Obstetricians and Gynecologists Fellows and Junior Fellows were women. Moreover, the proportion of our professional field represented by women is still increasing with 82.3% of those matching into an obstetrics and gynecology residency in 2016 being women,12 yet as outlined previously, we were fourth worst in a field of 18 specialties for adjusted salary differences by gender.
The field of academic medicine needs active leadership on salary parity, and ob-gyns are well suited for the role. As the people who have dedicated our vocational lives to the well-being of women,13 we can move swiftly to—not toward—equal pay for equal work. The American College of Obstetricians and Gynecologists could convene a task force to develop an evidence-based framework for best practices around measuring salary parity in academic medicine and could commission research around salary parity in the private practice sector as well. Academic obstetrics and gynecology departments around the country could commission equity studies around gender and compensation within the year using either internal metrics or the publically available measures of clinical and research productivity outlined at length by Jena et al. Programs that identify parity in compensation by gender within subspecialties, when controlling for clinical and research productivity, could consider sharing best practices with others in the field. Programs that identify disparities in compensation may begin the hard work of mapping out the course toward salary parity, the path to which may be unique at different institutions. Gender-neutral compensation for equivalent clinical and research productivity is an attainable goal; we can be the first in the field to make it so.
1. United States Census Bureau. Available at: https://www.census.gov/data/tables/2016/demo/income-poverty/p60-256.html
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5. Sanfey H, Crandall M, Shaughnessy E, Stein SL, Cochran A, Parangi S, et al. Strategies for identifying and closing the gender salary gap in surgery. J Am Coll Surg 2017;225:333–8.
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12. Rayburn WF. The obstetrician-gynecologist workforce in the United States: facts, figures, and implications 2017. Washington, DC: American Congress of Obstetricians and Gynecologists; 2017.
13. American Congress of Obstetricians and Gynecologists. ACOG mission, vision and core values. Available at: https://www.acog.org/About-ACOG/About-Us/ACOG-Mission-Vision-and-Core-Values
. Retrieved July 19, 2017.