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In Practice

Gender Salary Inequality Worst in Neurology

What Can Be Done to Remedy the Matter?

Avitzur, Orly, MD, MBA, FAAN

doi: 10.1097/01.NT.0000510771.20635.99
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ARTICLE IN BRIEF

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In response to reported salary disparities between men and women neurologists, women in leadership positions and management consultants provide pointers on how to negotiate better and more equitable compensation.

When Neurology Today recently published data from a JAMA Internal Medicine study that revealed that salary inequality in academic medicine was greatest in the specialty of neurology it raised widespread concern. The fact that women currently get paid less than men for the same job in the United States is a well-documented inequity across a diverse spectrum of fields including medicine.

Indeed, the 2015 AAN Compensation and Productivity survey had already shown a similar gap — $45,000 for women in academia — but the discovery that female academic neurologists could be paid the “least-of-all specialties” was a wake-up call, and it raised a number of alarming questions.

The knee-jerk response was to blame the situation on productivity, and on women assuming more part-time positions, or billing fewer hours, especially during child-raising years. But the JAMA Internal Medicine study adjusted for age, years of experience, faculty rank, scientific authorship, National Institutes of Health funding, and used Medicare reimbursement data as a proxy for clinical revenue. Even more disturbing, the results showed that the chasm — 85 cents on the dollar compared to male counterparts — was the greatest in neurology.

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Could other factors be playing a role, and could our negotiating styles and skills be contributing? To get at the heart of the matter, Neurology Today spoke to several experts on the role of salary and workplace negotiation who shared their strategies here for pay parity in the workplace.

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GET THE 411

“One of the reasons women are paid less is because they often lack good information,” said Deborah M. Kolb, PhD, author of Negotiating at Work: Turn Small Wins into Big Gains (Wiley, 2015), which highlights the barriers to success faced by women and offers advice on how women can overcome them though effective negotiation skills. When you have good information, such as salary transparency, and work structure transparency in an academic department, hospital or medical practice, the discrepancies are more likely to go away, she said, explaining that men typically network better in order to have that information prior to negotiating salaries.

“Overall transparency in departmental budgets and hospital transfers helps, including payments for medical directorships and call pay,” said Stefan M. Pulst, MD, FAAN, professor and chair of the department of neurology at the University of Utah. Dr. Pulst, who reached out to his female faculty for their perspectives before co-chairing a course on gender differences in leadership at the 2015 AAN Annual Meeting, pointed out that many public universities are now forced by the tax-paying public to disclose salaries through print newspapers or on the web. At the University of Utah, all departments internally report on salary as a percentile of the Association of American Medical Colleges (AAMC) salary survey by rank comparing male and female faculty.

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NETWORK AND SHARE

In a November 2015 Harvard Business Review article, “Managing Yourself: Be Your Own Best Advocate,” Dr. Kolb encourages women to make their value visible by starting a negotiation with their accomplishments in a currency that matters for that organization. But knowing what that currency is often requires networking. To be an effective negotiator, you also need intelligence on the parties with whom you'll be negotiating, advises Dr. Kolb. “How do they like to receive news or special requests? Do they want a lot of advance notice? Do they want you to present a solution or develop one with you?”

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While men need to make little effort to join established networks for information sharing (golf outings, drinks after work, etc.), women generally need to make a concerted effort to seek out others in order to get the same level of intel on salary, values and job structure. Without that knowledge equalizer, women are handicapped when it comes to bargaining.

It's also possible that women feel less at ease sharing that information than men. Few women doctors are comfortable discussing salary, and certainly, when Neurology Today first broke this story in the August 18th issue, the writer noted that despite many women being approached for comment on the salary gap for that article, many did not respond for requests for interviews or declined them.

Ann H. Tilton, MD, FAAN, professor of neurology and pediatrics and section chair of child neurology at Louisiana State Health Science Center in New Orleans, Louisiana, who did agree to be interviewed for that story, suggested, “The issue of salary is personal and people tend to be very closed about it, but if we cannot negotiate from knowledge, and don't know the going rate, we are placed at a distinct disadvantage.”

“Women need to advocate more for each other,” said Cynthia L. Harden, MD, system director of epilepsy services at Mount Sinai Health System. “Unfortunately, we often do not champion each other as well as we should; we need to encourage stronger networking and support among women professionals.”

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LEARN TO BE AN EFFECTIVE NEGOTIATOR

Even with the right information, negotiation is not a core competency gained in medical training, as it is in business training. The Association of American Medical Colleges, which is keenly aware of the gender salary gap due to its data collection, suggested in an August 2016 report in Academic Medicine that a lack of instruction in negotiation skills in medical school and residency may disproportionately affect women.

Negotiation experts agree that you need to negotiate a package, not one issue at a time. Robin Ryan, author of 60 Seconds and You're Hired (Penguin Books, 2016) recommends that women practice and role play with a friend or colleague so that they are comfortable during the interview.

Dr. Kolb encourages women to think about multiple issues when negotiating including resources they need, such as hours, assistants, collaborators, and research time. “Think about the good reasons your employer may say, ‘no,’” she advises. “That will allow you to connect what's good for you with what's good for your department or organization. Step behind the interests of the person with whom you are negotiating.”

“Don't fixate on a single solution that works for you,” Dr. Kolb, said. “Instead consider what matters to your counterpart and find multiple ways to satisfy both of you.”

A smart first step for women, who are sometimes perceived as greedy or demanding when they try to negotiate, is to reframe the conversation from a battle to a problem-solving collaboration, according to Margaret A. Neale and Thomas J. Lys, who co-authored another Harvard Business Review article, “More Reasons Women Need to Negotiate Their Salaries.” The goal is to negotiate a solution that benefits both you and your potential employer, or at least doesn't cost them, they advise.

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ASPIRE HIGH EARLY ON

Anthony LoSasso, PhD, a health and labor economist at the University of Illinois at Chicago School of Public Health, investigated the salary gender gap as part of a study that focused on physicians at the start of their clinical careers, thereby controlling for differences in potential productivity. The analysis, which was published in Health Affairs in 2011 and widely cited, concluded: “Relative to men, the salary gap grew between 1999 and 2008, and the trend towards diverging salaries is hard to explain.” It's difficult to reconcile, and perhaps even counterintuitive that it has only gotten worse over the years, he said.

In reality, what you earn in the early years may matter the most, and your first salary negotiation can be the most important in your career. Researchers at George Mason University and Temple University looked at the compounded cost of not negotiating for $5,000 more in salary, finding it could cost an employee $600,000 over the span of a 40-year career. “People leave anywhere from $500,000 to one million dollars on the table if they don't negotiate salary,” says Ryan.

Notably, the August 2016 Academic Medicine article pointed out that initial salary decisions for women in academic medicine are determined at the division or departmental level, and unless there is explicit institutional oversight there may be no clear process of equity comparison to ensure parity. Moreover, once a compensation level is determined, increases are often capped, making adjustments difficult to accomplish.

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Dr. Tilton believes that part of the problem is that women are often just grateful for being at the table. “Women tend to be more deferential — Southern women in particular are very deferential — and when a woman negotiates she is almost apologetic and doesn't want to offend by asking for more money,” she explained. “The ‘Imposter Syndrome’ may play a role as well,” she suggested, noting that women may express their doubts and fears more than men, worrying, “What if someone finds out I'm not really as talented as they think I am?”

“I think that women have got to internalize the idea that money is the yardstick by which our value is judged,” said Dr. Harden. She recommended that women adopt a traditionally male attitude about salary, even if they don't care about money, as it is a key metric that yields power and recognition from the administration and leadership.

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A CALL TO ACTION

There is no doubt that a multiplicity of factors may be holding women back, especially in academic settings. Women receive less funding, have less opportunities to publish, and are promoted at lower and slower rates, according to a June 2016 commentary in Academic Medicine, which calls for overall gender parity. The authors advocate for transparency in starting salaries, programs to train women to overcome social and systemic gender norms by teaching effective negotiation skills, and for the leadership to address biases in the hiring and negotiation process through undertaking implicit bias training.

The American Academy of Neurology is also concerned, and has created several programs to help women become more effective leaders including a leadership group for women, chaired by Cynthia L. Comella, MD, FAAN, professor of neurologic sciences at Rush University Medical Center: “The discrepancies between men and women in academic medicine are reflected in the reduced compensation, reduced representation of women as academic leaders (deans, chairs, professors), and the recognition that women are not adequately included as presenters in academic conferences,” Dr. Comella said, reflecting on the urgency of this situation.

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The AAN Women in Leadership program is designed to target these gaps through specific training in leadership, negotiation, and presentation techniques. “Through the acquisition of these skills, women will be equipped to effectively represent and promote themselves and other women in the competitive arena of academic medicine,” she said.

The AAN has also created a new task force, chaired by AAN Board member Elaine C. Jones, MD, FAAN, to explore issues related to the disparities between male and female neurologists, including compensation, professional advancement, leadership opportunities, and work/life balance. “We hope to find strategies to improve these disparities,” said Dr. Jones.

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LEADERSHIP AND NEGOTIATION SKILLS AT THE WORKPLACE

Neurology Today Associate Editor Orly Avitzur, MD, MBA, FAAN, is co-chairing a full-day workshop with Janice Massey, MD, and Barbara Hoese on women in leadership on Saturday, April 22, 2017, at the AAN Annual Meeting in Boston, for those interested in gaining better leadership and negotiation skills at the workplace.

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LINK UP FOR MORE INFORMATION:

•. Fallik D. Salary disparities reported between men and women academic physicians — The widest gap is in neurology http://journals.lww.com/neurotodayonline/Fulltext/2016/08180/Salary_Disparities_Reported_Between_Men_and_Women.1.aspx. Neurology Today 2016; 16(16): 1, 32-34.
    •. Kolb DM. Managing yourself: Be your own best advocate https://hbr.org/2015/11/be-your-own-best-advocate. Harvard Business Review 2015: 93(11):130–133.
      •. Neale MA, Lys TZ. More reasons women need to negotiate their salaries https://hbr.org/2015/06/more-reasons-women-need-to-negotiate-their-salaries. Harvard Business Review 2015; Epub 2015 June 29.
        © 2016 American Academy of Neurology