The First Step: Pay Equity in Medicine

“Men work harder than women.”

My mother is a pediatrician, and I have two sisters—one is a dermatologist, and one is a real estate attorney. Therefore, I think understandably, this message took me by surprise. Of late, I have been particularly awed by my lawyer-sister, with whom I catch up when she is taking the 7:45 p.m. commuter train home to care for her two children. By that time, I am often already home with my feet up, drinking a beer.

The message, however, was unavoidable. My cell phone was experiencing status epilepticus, vibrating urgently with updates regarding the initial message—and then with rapid-fire commentary regarding that initial message.

The Dallas Medical Journal is the primary publication of the Dallas County Medical Society, which counts the majority of physicians practicing in the Dallas area among its members. According to its website, the Dallas Medical Journal “includes practical advice regarding the business of medicine, profiles on member physicians, legislative updates … .”¹ In September, in honor of Women in Medicine month, the editors elected to dedicate the issue to women in medicine, focusing on “cracking the glass ceiling” and “pay inequality between the sexes.”

Big mistake.

Not the topic, mind you. As with all things, however, the devil is in the details. In this case, in advance of the September issue, the Dallas County Medical Society queried its members thus: “According to a Wall Street Journal article, salaries of women physicians are about 65% of their male counterparts’ salaries. We asked our physicians if they believe a pay gap exists between male and female physicians. If so, what is the cause? What steps can physicians take as individuals and as a community to address this?”

Dr. Gary Tigges, an internist in Plano, Texas, responded: “Yes, there is a pay gap. Female physicians do not work as hard and do not see as many patients as male physicians. This is because they choose to, or they simply don’t want to be rushed, or they don’t want to work the long hours. Most of the time, their priority is something else … family, social, whatever. Nothing needs to be ‘done’ about this unless female physicians actually want to work harder and put in the hours. If not, they should be paid less. That is fair.”²

The Internet then exploded.

Perhaps in the era before the World Wide Web, these comments might have passed unnoticed: transmission would have been limited to a handful of copies. Back in the day, it took a certain energy of activation to rip the offending page from a journal, add some choice epithets and then shove it in an envelope addressed to your best friend, marked with an ancient talisman called a postage stamp.

If around one-third of practicing female rheumatologists are telling us that knowing what they know now they would not have chosen to specialize in rheumatology, then our workforce issues are even more dire than we had suspected.

The Furor

That was then. As far as I can tell, the deluge started with Aletha Allen, a pediatrician in Winchester, Va., who tweeted: “If anyone knows Dr. Gary Tigges in Plano, Tx, please tell him that he’s just pissed off a few thousand HARD WORKING women physicians. Because, you know, quotes like this tend to get shared a lot on social media.”³

Truer words were never spoken. Unfortunately, most of the online commentary cannot be shared in a family publication such as this, but it is notable that even Mad Magazine felt obligated to weigh in on the controversy, tweeting, “A male doctor is under fire after saying the pay gap exists because female physicians ‘do not work as hard,’ which is quite a claim, considering they have to do the exact same job all while fighting the urge to punch him in the face.”⁴ The prize for commentary under 140 characters, however, goes to the Huffington Post, which just tweeted a single word: “Yikes.”⁵

Some on social media have argued this story has already received enough oxygen, and that women physicians have been done two disservices: first by publishing the original account, and second by publicizing it further. I disagree. The last few years have proved to me that when ideas are allowed to hide in the darkness, they fester and grow. To kill a bad idea, you have to drag it into the light.

Christos Georghiou / shutterstock.com

Backpedaling does not appropriately capture the warp-speed with which Dr. Tigges tried to distance himself from his own comments, saying that his statement had been misconstrued.⁶ Even in this era of alternative facts, however, that explanation is hard to swallow. He had submitted the comments electronically, and with all due respect, his writing lacks a Joycean complexity that might lend to multiple interpretations.

In linguistics, the concept of the folk etymology, also known as analogical reformation, describe how a word or phrase is reanalyzed and changed by a listener who applies faulty logic that seems to make sense. The classic example is sparrowgrass, which arose from generations of Brits mishearing the word asparagus.⁷

Dr. Tigges basically created an intellectual folk etymology for himself. He made an observation, came up with an explanation, and the explanation seemed to make so much sense to him that he did not bother to double check his facts. But what are the facts?

The Facts

In 2018, Medscape surveyed 7,600 female physicians and compared their experiences to those of 12,729 male physicians across over 29 specialties. In its survey, male primary care physicians earned $33,000 more annually than women doing the same job; among specialists, that discrepancy increased to $95,000 per year.⁸

The problem with the data is that Medscape failed to take into account that almost twice as many women as men in its survey (22%) elected to work part time. The 2015 ACR Workforce Study noted that “females … are reported to work seven fewer hours each week on average and [have] fewer numbers of patient visits on average than their male counterparts. While overall females treated more patients than in 2005, females treat approximately 30% less than their male counterpart [sic].”⁹ So if more female physicians worked full time, would the discrepancy in salaries vanish?

The answer is a resounding no. In 2017, the American College of Physicians asked some of its members, “What is your estimated annual income from your professional activities before taxes?” Of the 374 full-time internists who responded to the survey, the median salary for men was $50,000 higher than the median salary for women. In other words, women who are internists earn 80 cents for every dollar earned by men, even when one takes into account professional and employment characteristics.¹⁰

Why is this the case? The American College of Physicians released a position paper in 2018 outlining some possible explanations, including the following:¹¹

• Limited opportunities for advancement: Women comprise half of all medical students, but their numbers dwindle in the higher levels of academia. Women constitute 38% of full-time medical school faculty, but only 21% of full professors, 15% of department chairs and 16% of deans. Lack of appropriate mentorship and lower rates of advancement may contribute to this.
• Workplace discrimination: Women who are physicians are five times more likely to experience obstacles to career advancement, and three times more likely to experience disrespectful or punitive actions, than their male counterparts.
• Implicit bias: Female physicians are scrutinized more critically than male physicians. Female physicians may be described as judgmental, rude and unfriendly for exhibiting the same personality characteristics seen as positive among their male counterparts.

Of these, implicit bias is the most insidious; because it is subconscious, it is difficult to address. One interesting example: At the University of Pennsylvania, 24% of the clinical faculty in 1996 were women; by 2007, the female clinical faculty had increased to 30%. During this time, however, only 10% of clinical award recipients were women. The authors of this study suggested that one possible explanation for the discrepancy might be our implicit biases in how we judge female vs. male physicians.¹²

Our patients may be suffering as a result. In the Medscape survey, if they had to do it all over again, 78% of female rheumatologists say they would train in internal medicine, but only 48% would have chosen again to train in rheumatology. This is bad. If around one-third of practicing female rheumatologists are telling us that knowing what they know now they would not have chosen to specialize in rheumatology, then our workforce issues are even more dire than we had suspected.

Our patients may suffer in less obvious ways, as well. In a study of more than 1.5 million Medicare hospitalizations, patients treated by female physicians had a lower 30-day mortality and a lower 30-day readmission rate. In this study, the number needed to treat was 233, meaning that if 233 of these patients had been treated by women rather than men, one additional life would have been saved.¹³

Our surgical colleagues fare much the same. In a cohort study of 104,630 matched patients treated by 3,314 surgeons, operations performed by women were associated with lower mortality, fewer readmissions and fewer surgical complications than operations performed by men. The authors of this study comment, “We don’t know the mechanism that underlies better outcomes for patients treated by female surgeons, although it might be related to the delivery of care that is more congruent with guidelines, more patient centered, and involves superior communication. … Other possible explanations include a willingness to collaborate by female surgeons. … Further study is required to understand how differences in medical practice, clinical acumen, technical skills, or risk taking behavior could underlie the sex based differences in mortality that we found, with a view to improving outcomes for patients treated by physicians of either sex.”¹⁴

There are obvious motivations to encourage women to enter medicine in general, and rheumatology in particular, and an important part of this may be pay equity. As you may imagine, these problems are not unique to healthcare. Many other industries are attacking this problem head-on, by working on ways first to attract women to their respective fields and then supporting their career growth and development to the highest levels.

Again, the best way to tackle the problem is to drag it into the light. Both the American College of Surgery and the American College of Physicians have called for greater transparency in setting salaries and criteria for promotion. We need to first acknowledge, however, that these issues are real, and not just the result of female physicians not wanting to “work harder and put in the hours.” As they say in Alcoholics Anonymous, admitting that we have a problem is the first step.

Philip Seo, MD, MHS, is an associate professor of medicine at the Johns Hopkins University School of Medicine, Baltimore. He is director of both the Johns Hopkins Vasculitis Center and the Johns Hopkins Rheumatology Fellowship Program.

References

1. Dallas Medical Journal.
2. Tigges G. Big and bright ideas. Dallas Medical Journal. 2018:104(9):11.
3. Allen A (AletheaAllen). If anyone knows Dr. Gary Tigges in Plano, TX, please tell him that he’s just pissed off a few thousand HARD WORKING women physicians. Because, you know, quotes like this tend to get shared a lot on social media. 2018 Aug 31, 9:59 p.m. Twitter.com.
4. MAD Magazine (MADmagazine). A male doctor is under fire after saying the pay gap exists because female physicians ‘do not work as hard,’ which is quite a claim, considering they have to do the exact same job all while fighting the urge to punch him in the face.” 2018 Sep 4, 7:02 p.m. Twitter.com.
5. Huffington Post (HuffPost). Yikes. 2018 Sep 3, 12:59 a.m. Twitter.com.
6. Ramirez M. Doctor resigns from leadership posts at Texas Health Plano after remarks about female physicians. Dallas News. 2018 Sep 5.
7. Sparrowgrass, n. Oxford English Dictionary Online. 1989.
8. Peckman C. Medscape female physician compensation report 2018. Medscape. 2018 Jul 5.
9. 2015 Workforce Study of Rheumatology Specialists in the United States. American College of Rheumatology. 2016; p. 93.
10. Read S, Butkus R, Weissman A, Moyer DV. Compensation disparities by gender in internal medicine. Ann Intern Med. 2018 Aug 7.
11. Butkus R, Serchen J, Moyer DV, et al. Achieving gender equity in physician compensation and career advancement: A position paper of the American College of Physicians. Ann Intern Med. 2018;168(10):721–723.
12. Abbuhl S, Bristol MN, Ashfaq H, et al. Examining faculty awards for gender equity and evolving values. J Gen Intern Med. 2010 Jan;25(1):57–60.
13. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017 Feb 1;177(2):206–213.
14. Wallis CJD, Bheeshma R, Coburn N, et al. Comparison of postoperative outcomes among patients treated by male and female surgeons: A population based matched cohort study BMJ. 2017 Oct;359:j4366.