Re: The Gender Wage Gap Among Early-Career Family Physicians

To the Editor: We commend the authors of “The Gender Wage Gap Among Early-Career Family Physicians” for providing a helpful addition to the literature on the gender wage gap broadly and especially within family medicine.¹ In the article, the stark differences in pay between genders, regardless of practice type or location, are highlighted. While the primary purpose of the article was to analyze these differences, it also proposed several solutions to address this issue. In discussing potential solutions, the focus is seemingly placed external to the institutions that use physicians. This includes recommendations for educating trainees, as well as changes to care reimbursement models. Our concern is that the universality of the pay gap highlighted in the article underscores the need for structural change within these institutions.

One offered solution is to educate family medicine residents on salary differentials to ensure that well-informed decisions are made regarding postresidency employment. While education is an essential tool, we propose that it does not address the fact that, across the spectrum, female physicians still make less than their male counterparts.¹ The data in the article underscores that in the current climate, the personal choices of graduates cannot come close to eliminating the gender pay gap, and the suggestion that clinician education may help achieve equity seems to put the responsibility of finding a “higher paying” role within family medicine on the shoulders of the women pursuing employment. Putting this data in the hands of trainees does not and should not relieve pressure on institutions to put in place policies and protocols to actually create and maintain gender pay equity. Instead, the American Medical Association (AMA) recommends training individuals who are in positions of hiring power, and the Association of American Medical Colleges (AAMC) acknowledges the power differentials that may underlie some of the pay inequities noted.^2,3 We propose that by increasing opportunities for women to ascend the academic ranks and obtain leadership positions, the gender wage gap may be addressed. The responsibility of change should not be on the individual employee, but belong to the systems that use them.

Increased salary transparency is mentioned as another important part of the solution. However, this still requires applicants to advocate for themselves. However, the article references a study showing that when women use negotiation tactics, they are less likely to be hired and leave a more negative impact. Transparency must be present during the hiring process and beyond to eliminate pay gaps throughout the career course.⁴ Its importance is less in the information it provides to interviewees and more as a source of accountability for the institution.

Changes to reimbursement that would encourage rather than penalize traditionally female practice patterns were discussed as a potential solution. This will be important for moving toward a more equitable system. Even in a capitation model adjusted for age, sex, and hierarchical condition category, the pay gap was still $66,000.⁵ These changes should be viewed primarily as relieving external pressures that enforce the gender gap within institutions but not as the primary mechanism by which the gap will be closed.

Systemic change is needed to be the driving force for eliminating the gap. We propose that locally, institutions should implement mechanisms to offer standardized base salaries and routinely share salary data. They should focus on developing sustainable policies and procedures that advance equity. This includes training leaders on implicit and explicit biases that may impact salary decisions. Designing processes for routine equity review may also be meaningful. Lastly, a more global focus on systems for physician payment and reimbursement models should be evaluated as mechanisms to address the gender wage gap.⁶