As the only female contributor to this blog, it seems only appropriate that for my first post I tackle some gender issues. The February 2011 Health Affairs Table of Contents came out today and the very first article I noticed was “$16,819 Physician Gender Gap”. This sort of article occasionally appears, long enough to elicit some guilty feelings and an apathetic hope for change, then disappears quietly until the next round.
In a world where over half of entering medical students are female, and a disproportionate amount of those are pursuing careers in primary care, the gender-based income gap is a huge workforce issue that we never really address. We’ve paid a lot of attention to disparate salaries across specialties, but not within our own profession. It’s something we toss out to the free market, assuming that the gap will close under the appropriate conditions. Some of us may even silently think things are fine as they stand.
This is issue is not unique to the specialty family medicine, and it is certainly one that appears across many non-medical professions. According to this graphic from the New York Times, physicians are actually at the bottom of the barrel where the income gap is concerned – that is to say we’re doing worse than lawyers, pharmacists, medical scientists, teachers, postal workers, and pretty much everyone else.
Lest you think I’m approaching this from a purely feminist angle, I have considered the free market argument potentially justifiable. I mean, women in medicine choose primary care careers, and take time off for children, and spend more time with patients for lower total reimbursement, right?
Let me rephrase – all of those points are true. However, these classic rationalizations have been proven inconsequential by the authors of the Health Affairs article. Men simply make more money than women for the same work.
The authors used survey data from New York State to examine salary trends from 1999-2008. Their data not only shows that an income gap exists, but that it has grown almost five-fold in the last 10 years, from a gap of 12.5% to 17%. To avoid confounders of experience and rank, they only looked at starting salaries. More importantly, this study is the first to my knowledge to show that disparities exist across specialty, practice type, and work hours. Controlling for these and other factors slightly reduces the gap, but does not eliminate it entirely.
The high prevalence of women in primary care has often been cited as a reason for the income gap; however, a decreasing proportion of women are choosing primary care. As the authors point out, this argument would predict the gap to decrease, rather than increase as it has in recent years. A stratified analysis of primary care versus non-primary care specialties revealed similar results – unfortunately, the analysis lumped family medicine together with pediatrics and internal medicine, three specialties that have very different post-residency workforce dynamics.
The vague concept of “productivity” has been another rationale for the discrepancy, often as measured by patient visits over time, rather than on the more clinically relevant measures of quality or outcomes. Results presented at the WONCA 2010 Conference show that among Canadian physicians, women spend more time with patients (17.8 minutes vs. 13.3 minutes), are more emotionally engaged, and allow more time for discussion and questions. Unfortunately, these women also report more signs of burnout and physical stress. Ultimately, studies regarding productivity have been mixed.
“Quality of life” is often used as a euphemism in these discussions to reflect the part-time and re-entry options available to balance family and work obligations. The authors postulate that quality of life may be a direct cause of the discrepancy. As more practice options become available, “female physicians may be seeking out employment arrangements that compensate them in other – nonfinancial ways.” Women are the typically beneficiaries of these changes, but men are increasingly attentive to quality of life concerns as well. I remember a professor of mine, a retired physician, who recalled (with a smile) a successful presentation at rounds some fifty years ago because he chose to stay at the library all night instead of returning home to his wife and newborn. It is fair to say this is not the current day expectation. And no, he was not a family physician.
While causality data for the gap is patchy and contradictory, evidence does exist that debt load and anticipated future income affects specialty choice. The average debt for a medical senior graduating in 2007 was $145,000 for public schools and $180,000 for private schools, and over 23% of students had debt above $200,000. Less than 8% of those students are pursuing careers in family medicine, a majority of them women.
The COGME Report included a recommendation to increase primary care physician income to 70% of the median level of specialists. I propose we pay equal and special attention to the less discussed income gap in medicine that exists along gender lines. With women as a historical majority of the primary care workforce, and female graduates increasingly choosing subspecialty fields, income discrepancy may be contributing more to workforce dilemmas than we realize.
With that said, I challenge to you to think about this - what can family medicine do to lead the change?
(1) Sasso AT, Richards MR, Chou C, Gerber SE. The $16,819 Pay Gap For Newly Trained Physicians: The Unexplained Trend Of Men Earning More Than Women. Health Affairs, 30, no.2 (2011):193-201.
(2) Palmert M, Pipas C, Wadsworth E, Zubkoff M. Economic Impact of a Primary Care Career: A Harsh Reality for Medical Students and the Nation. Academic Medicine, 85, no.11 (2010):1692-1697.
(3) Sullivan MG. Women Physicians Connect Emotionally With Patients, But Are More Stressed Out. Elsevier Global Medical News. Published online on June 29, 2010. Available at http://www.medconnect.com.au/tabid/84/s22/Neurology/ct1/c337421/Women-Family-Physicians-Connect-Emotionally-With-Patients-But-Are-More-Stressed-Out/Default.aspx. Accessed February 3, 2010.
(4) Why Is Her Paycheck Smaller? New York Times. Published online May 18, 2010. Available at http://www.nytimes.com/interactive/2009/03/01/business/20090301_WageGap.html?src=tp. Accessed February 3, 2010.