The Gender Pay Gap in Family Medicine: Evidence and Next Steps

The gender pay gap in medicine is the disparity in income between male and female physicians. This gap has been demonstrated in multiple studies, and this difference persists despite controlling for employment characteristics such as hours worked, years in practice, and practice type and personal characteristics such as age and desire for work–life balance.^{1⇓⇓⇓⇓–7} Although the difference is more marked in surgical subspecialties, the gender pay gap is present in family medicine as well. Female physicians of all races earn less than male physicians in primary care; the earning does not vary significantly by race when controlling for other personal and practice characteristics.⁶ There is no data on the pay gap for nonbinary physicians.

The percentage of female physicians in family medicine has increased from 31.3% in 2008 to 41.3% in 2019.^7,8 The percentage of female residents in family medicine is even higher, reaching 53.7% in the latest report from the American Association of Medical Colleges.⁹ This increasing number of new female physicians makes exploring the cause of the gender pay gap and addressing gender equity a priority for our field.

Female physicians do work fewer hours than male physicians, but the salary disparity persists when controlled for hours worked or part-time status. In an attempt to further explain this difference, some studies have looked in more detail at the work of female physicians compared with male physicians. One examination of 24.4 million primary care visits found that when controlling for clinical hours, female physicians saw fewer patients but billed the same amount per patient as male physicians. This may indicate that female physicians spend longer amounts of time per patient than male physicians, agreeing with findings in studies of communication styles.^10,11 However, other studies that have controlled for the number of patient visits have continued to demonstrate a difference in physician reimbursement.⁶ Another hypothesis is the obvious but most concerning one, that the health care employment system discriminates against female physicians based on gender itself.

Physicians are not immune to gender bias in other aspects of our professional lives. Female grand rounds speakers are less likely to be introduced by their titles when compared with male speakers.¹² Resident evaluations demonstrate gender bias in their comments and assessments.¹³ In family medicine, women are less likely to be journal authors or to be on editorial boards.¹⁴ Female physicians are less likely to be in leadership positions in academic medicine and health care corporations.^15,16 While some of this limitation in leadership roles may be voluntary to preserve family time and work–life balance, these differences persist even for those women who want to move into leadership positions. Given these examples of persistent differences, it is not surprising that the gender pay gap exists and that gender bias is an underlying cause.

The study by Jabbarpour in this issue of the journal looks specifically at the data from the 2019 American Board of Family Medicine New Graduate Survey to see if experience or work hours could explain the gender pay gap for family physicians.¹⁷ The data indicated that the gap existed despite controlling for these factors. Although the work hours were self-reported, this study provides additional support for the finding that the gender pay gap is not solely due to hours worked, part-time status, or years in practice. In addition, because this salary difference was found among recent residency graduates, the difference essentially represents a lower starting salary for female family physicians in family medicine. Even a small gender pay gap for a new residency graduate represents a very large difference in pay over the course of a person's career.

Although more research is needed into the causes of the gender pay gap, several steps can be taken now to improve equity and reduce the disparity. First, there should be transparency about salaries within and across organizations. Any opportunities for bonuses should be clearly outlined, including common work–life choices such as call schedules, extended clinical times, weekend coverage, and productivity bonuses. One study of physicians in the Veterans Administration (VA) system showed no difference in salaries between male and female physicians in the surgical specialties, despite the fact that these fields usually have an even wider gender pay gap than nonsurgical fields.¹⁸ The authors attributed this to salary transparency within the VA system. Organizations can analyze their physician salaries to make sure they are equitable and also review the percentage of women in higher-paying leadership positions. A recent publication offers guidance to organizations that want to achieve gender pay equity.¹⁹

The difference in physician salaries within the first 3 years following residency graduation may also represent a difference in negotiating styles. Female job applicants also should be aware that they may unconsciously be penalized for negotiating, especially with male interviewers.²⁰ Residency training programs should strive to equip their graduates with skills to broker their starting salaries, including use of legal representation, as well as advice on negotiating salary, especially for female residents.

Finally, legislation is an important intervention to mitigate bias. Although the Federal Equal Pay Act does require an employer to pay the same salary for work with substantially equal skill, effort, and responsibility, these criteria can be difficult to prove. One more specific legislative intervention is to ensure that employers are not allowed to ask about salary histories. Since we know that gender bias exists in current salaries, the goal of this legislation is to mitigate the effect of past gender bias in salaries on future positions. Currently, 21 states and many localities prohibit asking about salary history in hiring. Several states also have laws that prohibit employers from blocking their employees from sharing salary information. Taken together, efforts by individuals, organizations, training programs, and government are needed to help close the gender pay gap and should be a priority for family medicine.