For Physicians, Gender Pay Gap Starts With First Job

Female physicians earned on average nearly $37,000 less as a starting salary in their first job after completing residency or fellowship than their male counterparts, and the difference can't be entirely explained by specialty choice or other obvious factors, researchers found.

In a study of 16,000 graduating seniors who had just completed their residency training at some point during the period 1999-2017 in New York state, Anthony Lo Sasso, PhD, of DePaul University in Chicago, and colleagues found that the unconditional mean starting compensation was $235,044 for men and $198,426 for women over the entire period. Although the men and women in the study were similar in many characteristics, including sociodemographic and practice characteristics, "important differences were also evident," the team noted in the study online in Health Affairs. For instance, "women chose primary care fields more often, and surgical specialties less often, than men did."

In addition, "women less commonly reported spending very high amounts of time (50 hours or more per week) in direct patient care, relative to men," the investigators wrote. And "men reported having had six or more job offers more often, relative to women."

Looking just at the 2014-2017 subsample, "men had slightly higher rates of partnered status and having dependent children than women had," the authors wrote. "Women were consistently more likely to rate control over each measure of work-life balance preference as 'very important' in comparison to men, with the difference ranging from nine percentage points to 12 percentage points."

"Our work highlighted continued disparity and persistent unexplained gender differences in pay for new physicians," the researchers concluded. "Efforts to capture previously unmeasured job preferences related to work-life balance factors revealed clear differences between men and women, but those differences did not explain the salary differential. Research to learn more about non-monetary job characteristics will be important in the future."

Data From New York Database

Data for the study came from the New York Survey of Residents Completing Training conducted by the Center for Health Workforce Studies of the University at Albany, State University of New York, for graduating residents and fellows; New York trains more residents than any other state, the researchers noted in their introduction.

"Information about new physicians accepting their first non-training position is valuable, as it minimizes unobserved differences in productivity and work experience that may confound analyses of a wider range of physician seniority," the team continued. "In addition to starting salary and bonus information, the data also provide a wide range of information on demographic characteristics, specialty, practice setting and location, and other labor-market variables. Given these characteristics and longevity, the data offer a unique opportunity to analyze salary differences."

The study outcome was a measure of the base starting salary "plus any anticipated bonus the person was set to receive in their upcoming clinical position," the authors explained. "We combined two categorical measures of salary to construct the compensation measure."

Starting in 2014, survey questions about job characteristics regarding work-life balance were added; respondents were asked how important it was for them to have control over things like a predictable start and end to the workday, the length of each workday, the frequency of overnight call, and the frequency of weekend duty. The survey also included results for demographic information such as sex, gender, age, and citizenship status.

The investigators found that choice of specialty consistently explained 40% to 55% of the total starting salary differences, with a mean share over the entire period of 46%. "Other factors explained comparatively little of the differences," the researchers wrote. For instance, "differences in the number of job offers, which could represent the search effort made by new physicians or the demand for their skills or specialty, explained 2% to 9% of the differences, with a mean share over the entire period of 5%. Hours of time spent in patient care explained 7% of the starting salary difference over the period. No other factor that we measured explained more than 1% of the difference ... On average, the unexplained component of starting salary averaged 39% of the total salary difference."

"Unexplained" Differences Are Growing

This "unexplained" portion of the differential continued growing throughout the 2010s, the authors said. "Approximately 60% of the unadjusted gap in starting salary could be explained by observable characteristics -- primarily specialty and hours spent in patient care. However, our analysis showed that physician-stated preferences for controlling work-life balance, including having predictable hours, the length of the work day, the frequency of being on call overnight, and the frequency of weekend duty, had virtually no effect on the starting salary differential between men and women. Similarly, the inclusion of relationship and family status measures had no meaningful effect on the unexplained starting salary differential."

The study did have several limitations, the authors noted. First, it was based on data from one state. "However, it is difficult to think of reasons why physicians trained in New York would experience differential trends in the gender pay gap than physicians trained elsewhere in the U.S. would," they said.

Second, the investigators were not able to observe whether the respondent's job actually incorporated the desired level of control over hours, being on call, and weekend duty. Third, only 5% of the reported salaries in the sample were top-coded by either gender (for example, "$375,000 and over"), and the fact that more men had top-coded salaries than women did implies that the imputation approach likely understated the difference between men's and women's salaries. Finally, the data were self-reported and thus subject to potential recall bias.

Conclusions Not Surprising

Reshma Jagsi, MD, DPhil, director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan in Ann Arbor, said she wasn't surprised by the findings. "They provide important confirmation of an uncomfortable truth: men and women, even highly educated ones like physicians, are paid differently for equal work," she said in an email, noting that her own research "revealed that about half of the gender difference in pay of a different sample of physicians was attributable to specialty, just as in this study. And just as in this study, we included many other factors that are often proposed as likely causes (including work hours and many other measures of productivity and family characteristics), but it remained impossible to explain away the whole difference -- a very similar proportion of the difference remained unexplained in our study."

When she was doing her own research, Jagsi said, "some speculated that these findings might have reflected differences in behavior that were not measured in our study: perhaps the women were less willing to accept odd hours and call duties because they valued flexibility to be able to care for their children, and men were more willing to accept odd hours and call duties to try to earn more to support their families ... However, in our study, even the women without children earned less than the men."

This new study is valuable, Jagsi added, "because it confirms in a different way the same conclusions we drew years ago."

"Unfortunately, we have work to do to ensure equal pay for equal work, even after the many strides we have made together in advancing women's participation in the workforce," she concluded. "Systems-level changes to increase transparency and promote consistency in defining the criteria for advancement and compensation are essential in medicine and beyond."

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