Article In Brief
Although the pay gap between women and men neurologists is shrinking, a new analysis of the 2019 AAN Compensation and Productivity Survey shows that women neurologists are still paid almost 11 percent less than their male colleagues for doing the same work. Women neurologists interviewed by Neurology Today said that awareness is not enough; it is time for leadership to step up efforts to address it.
Women neurologists are paid significantly less than their male colleagues doing the same work, a new analysis of the 2019 AAN Compensation and Productivity Survey shows.
That is not particularly surprising, said Melissa Yu, MD, co-director of the Alzheimer's Disease and Memory Disorders Center at Baylor College of Medicine. “It's validating more than it is surprising,” said Dr. Yu, who chairs the AAN work group that oversees the survey.
But she and others were taken aback by this finding: Women neurologists with 11 to 20 years of practice had a lower mean hourly wage than all men neurologists except those with five or fewer years of practice.
“That's a pretty alarming statistic that I think should get attention,” said Allison Brashear, MD, MBA, FAAN, vice president for health sciences and dean of the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo.
The analysis, published by Neurology ahead of print online on January 21, adds neurology-specific details to the well-documented pay disparity between women and men physicians. Among other findings:
- The estimated annual full-time-equivalent (FTE) salary for women neurologists in 2019 was 10.7 percent less than men, after controlling for race, region, years of practice, practice setting, call status, leadership role, and subspecialty.
- The average hourly wage for women neurologists, controlled for the same factors, was $119 per hour, compared with $137 for men neurologists–a deficit of 11.3 percent.
- Women neurologists in high-compensation subspecialties like interventional neurology are paid, on average, nearly $84,000 less than men in those subspecialties. In fact, they are even paid less than men working in pediatric neurology and other low-compensation subspecialties.
- Women in neurology leadership positions had a mean salary of $269,000 compared with $315,000 for male leaders.
- Male neurologists in academic and government practice had, on average, adjusted FTE compensation of $263,000 compared with $226,000 for women neurologists in those sectors.
- Women neurologists in private practice had an average compensation of $288,000, compared with $340,000 for their male colleagues.
Compensation in Context
The gender pay gap among physicians in general has been documented in dozens of studies dating back to the 1960s. More recently, a few studies have examined the pay disparity, specifically among neurologists.
In 2016, JAMA Internal Medicine published a review of public salary data that showed a gender pay gap of more than $40,000 among 449 academic physicians. Medscape Physician Compensation Report reported a pay gap between men and women neurologists of $37,000 in 2015 and $56,000 in 2019.
While the new AAN analysis showing a pay gap of about 11 percent may reflect progress in diminishing the disparity, it might also reflect different study designs, said Julie Silver, MD, associate chair in the department of physical medicine and rehabilitation at Harvard Medical School who has published widely on gender-based disparities in medical professions.
“There are big pay gaps when we don't account for other variables; in this study, they did account for a number of other variables, which is really important,” she said. “The pay gap shrinks, but it is still significant.”
Any pay gap has major financial consequences, Dr. Silver pointed out in a 2019 Neurology article: “... if a woman received an additional $30,482 in salary each year, after 40 years of investing and with adjustment for inflation, she would have a net return of $2,507,647.”
Dr. Silver pointed out that paying women less than men for the same work is unethical; in Massachusetts and several other states it is also illegal.
She uses the term “financial stress equation” to describe the combination of compensation disparities that women physicians experience and the high educational debt common among physicians.
“When she surveyed participants in a women's leadership continuing medical education course, 89 percent agreed that financial stress is related to burnout. Analysis of survey responses showed that lower compensation is associated with higher levels of burnout,” Dr. Silver said.
“We saw women making career decisions that were really financial decisions that weren't necessarily optimal for health care in general,” she said. For example, more than 50 percent of respondents said educational debt had negatively influenced or prevented their ability to pay for vacations or pay for household help such as childcare or cleaning services. Forty-three percent said it hindered their ability to join professional societies and participate in their conferences, while 39 percent said it kept them from working in a lower-compensation position, such as academia.
What Neurologists Say
Until she moved to Florida last year, neurologist Amy Hessler, DO, worked in academic medicine, where some male trainees were hired as faculty after they graduated. I helped train them and they were hired at higher starting salaries than I was making,” she said. “It felt very demoralizing and that I was undervalued.”
The gender pay gap reflects a double standard that exists throughout society, Dr. Yu said. The often-heard judgment that women physicians do not negotiate strongly enough for better pay ignores the inherent risks in doing so.
“When a woman goes in to negotiate a salary and is a little more forceful, that may backfire against her because it goes against the gender-based norms of how a woman should behave,” she said. “That candidate may not be seen as favorably in the hiring process. Once you get anchored at that lower starting salary, it's very difficult to make that up.”
In academic departments, for example, a leadership role is typically compensated as a percentage of the individual's salary. “If the woman has a lower base salary, 20 percent of her salary is going to be lower than 20 percent of a man's salary,” she said. “So, even in an equivalent leadership position, a woman may not earn as much as a man.”
Dr. Hessler and others interviewed by Neurology Today attributed the gender pay gap to women being less valued than men—in society in general and in neurology pay decisions in particular. But they identified many complexities that allow the pay gap to persist.
“I think that maybe women also rationalize that, ‘Well, I want to do all of these other things in academics,’ and we accept (lower pay),” Dr. Hessler said.
Those “other things” often wind up being unpaid contributions to the organization or profession. One of Dr. Silver's studies found that women physicians report more citizenship work—serving on committees, taking recruits out for lunch, and similar tasks—than their male colleagues. Another found that women physicians produce and disseminate the vast majority of compensation studies that examine the gender gap, and most studies are unfunded. That perpetuates a cycle in which women lose clinical revenue while conducting the research and do not receive academic credit for promotions because the research is not funded by grants, she said.
“They make less even though women are contributing just as much and sometimes more in their workplaces,” Dr. Silver said in an interview.
The gender pay gap in private practice suggests that men neurologists have more relative value units (RVUs) for billing purposes than women do. Kathrin LaFaver, MD, FAAN, a neurologist at Saratoga Hospital in upstate New York, questions whether that means they are more valuable.
Elderly hospitalized patients treated by women physicians have lower 30-day mortality rates and fewer hospital readmissions than those treated by men, according to a 2017 study published in JAMA Internal Medicine. Other research shows that women physicians spend more time with patients and that patients expect more from women physicians than men.
“It's a double-edged sword, because yes, we do obviously want to make our patients feel heard and answer all their questions, but to some extent that comes at the expense of how many patients we are going to be able to see in a day,” Dr. LaFaver said.
What Is To Be Done
Awareness of the gender-based pay gap in neurology has not eliminated it, which means leadership must step up efforts to address it, Dr. Brashear said.
“It's really incumbent on the leaders of academic institutions to adopt practices that assess whether pay is comparable, to ask those tough questions, and then ask for action plans around them,” she said. “If there are pay inequities, fix them.”
The same holds for private practices, said David Evans, MBA, CEO of Texas Neurology. “If we support equal pay for equal work, we should challenge our own organizations, regardless of size or setting, to review employment agreements and compensation at all levels to ensure equity,” said Evans, a co-author of the AAN paper.
Leaders should recognize that a neurologist who perceives she is underpaid may leave because of that—and that replacing a physician is more expensive than correcting the salary disparity, Dr. Yu said. Increased transparency can let neurologists know whether they are being paid fairly.
“I think regular salary audits need to be done, and that really should come from the leadership,” she said. “It shouldn't be the onus of the women to do all the negotiation because the (gender-based pay gap) should be something that's recognized.”
When Kathleen M. Shannon, MD, FAAN, became chair of the department of neurology at the University of Wisconsin School of Medicine and Public Health, she reduced gender disparities by appointing new division leaders, giving women neurologists increased pay and responsibility.
“I changed the leadership of several of our divisions to women who were equally talented and competent to be division leaders but had not been offered that opportunity,” she said. “Of course, you can only do that for people who are eligible—so it decreases the average disparity when you do the numbers, but there are still people who are underpaid.”
More systemically, as part of a university-wide initiative, Dr. Shannon's department is rewriting its compensation plan this year. One idea under exploration is moving away from RVU-based pay to a shift-based compensation system.
Dr. LaFaver at Saratoga Hospital thinks new payment approaches might reduce the gender pay gap by acknowledging that more time with patients—a trait that is common for women neurologists—leads to better patient outcomes.
How to Seek Fair Pay
When Amy Hessler, DO, was offered her first position after training, she was not aware that the AAN and organizations like the American Medical Group Association (AMGA) and the Association of American Medical Colleges (AAMC) publish benchmarking data for physician compensation and she did not understand how to negotiate her compensation.
“I was happy that someone was going to give me money to do what I love to do,’” she said. “I didn't really know what I was worth, so I didn't know what to ask for.”
She is no longer naïve in that department. Dr. Hessler recently moved to a new city for family reasons and, as she evaluates job opportunities, she has been reading books about negotiation and listening to contract lawyer talks about compensation and contract negotiation. Among other things, she has learned the importance of having multiple offers.
“It's important to consider multiple different practice opportunities and have more than one offer as it gives you leverage in the negotiation process,” she said.
Neurologist Allison Brashear, MD, MBA, vice president for health sciences and dean of the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, encourages women considering an academic job offer to learn what benchmarks—the AAMC Faculty Salary Report is commonly used—the institution uses.
“A lot of times you don't know what other people make but you can say you expect to be paid at the 50th percentile—or whatever percentile that you have some understanding the organization aspires to,” she said. “That's a very proactive data-driven argument when an individual is negotiating with a future employer about salary.”
Equally important: Know what the employer's expectations are for that compensation. “Whether it is that you are expected to get a certain number of grants or see a certain number of patients or hit a certain number of RVUs [relative value units], knowing the expectations is a key piece,” Dr. Brashear said.
And don't stop there. Ask whether additional work—more call duty or more RVUs, for example—mean additional pay. “Sometimes those things are not really clarified upfront, and I think that's another opportunity that women should seek,” she said.