Closing the Gender Pay Gap in Primary Care

Women physicians make about 77 cents on the dollar compared with their male colleagues, which translates to between $0.9 million and $2.5 million in lost career earnings over their lifetime.

Worse, women in primary care earn 19% less than their male colleagues (down from 25%), per the Medscape Physician Compensation Report 2023. In fact, women in primary care make the least of all physicians, despite the fact that some studies show that they often outperform male doctors across several metrics.

“Early on there was this cultural narrative that there is no gender pay gap; it’s just that women work part-time,” said Amy S. Gottlieb, MD, chief faculty development officer, associate dean for faculty affairs, and professor of medicine and obstetrics & gynecology at UMass Chan Medical School-Baystate.

“But it’s not true. Most studies that look at the gender pay gap now control for the number of hours worked,” said Gottlieb, chair of the Association of American Medical Colleges Group on Women in Medicine and Science Steering Committee and the author of Closing the Gender Pay Gap in Medicine: A Roadmap for Healthcare Organizations and the Women Physicians Who Work for Them.

Why Are Women Paid Less?

Gottlieb said that compensation models, typically based on RVUs (relative value units) for employed physicians, have some flaws that inadvertently lower women’s pay. Physician pay models usually involve a formula: Base salary (based on benchmark data) + monetary rewards for seniority and leadership + physicians’ productivity.

Within the compensation framework, four domains exist in which total compensation is determined: base salary, productivity, rank and seniority, and leadership. Here’s how that compensation framework can lead to a pay gap for women in primary care and across other specialties.

Base Salary

Many organizations usually have a considerable difference between their low and high base salary range. So, two physicians straight out of residency or training may be offered vastly different salaries — the woman’s salary often being less. “There is some evidence also that women are penalized for negotiating more than men are,” said Gottlieb.

Moreover, recent research from the Harvard Business School reports that women who negotiate aggressively face more backlash. Researchers think that ingrained stereotypes and subconscious notions about how women “should” act (and a likability standard that doesn’t apply to men during hiring) is responsible for the disparity. The catch-22: If women don’t negotiate, they risk not getting their value, and yet if they do, they still risk not closing the compensation deal they want.

Another factor that may contribute to the pay disparity among women physicians is called occupational gender segregation. That’s when women choose certain specialties or career paths. In medicine, for example, women may be drawn to specialties like pediatrics, ob/gyn, and primary care that may require a more nurturing personality but are lower paying when compared with specialties like surgery and orthopedics.

Gottlieb said the research shows that when many women populate a field or specialty, a decline in pay can occur. Outside of medicine, schoolteachers were vulnerable to this phenomenon. “The earning potential of an entire specialty and all the women entering it is put at risk,” Gottlieb said.

Productivity in Compensation

Research also points out that productivity-based compensation models can negatively affect a woman’s pay due to organizational service duties that don’t lead to promotions. This is when women in particular are asked to participate in multiple committees, write the staff call schedule, or perform other volunteerism. These tasks can pull women away from meeting the volume of patients that male physicians do.

Consequently, Gottlieb says that women see fewer patients, spend more time with patients, and provide services with lower reimbursement rates, which can result in better patient outcomes yet a lower overall volume of patients; this, in turn, impedes their productivity and compensation.

“The better outcomes are from spending more time, making the extra phone call, answering extra questions, and staying later and longer with the patients,” said Theresa Rohr-Kirchgraber, MD, professor of medicine at AU/UGA Medical Partnership in Athens, Georgia.  

Women also have more messages in their inboxes and need to spend longer time answering messages than male physicians, noted Rohr-Kirchgraber, who served as president of the American Medical Women’s Association for 2022-23.

“In a primary care practice or any medical practice, how many staff assigned to you matters too,” said Rohr-Kirchgraber. “If you have one MA to one physician, you can get people in and out, you can have better turnover, get to people faster, you have back up.” Men in specialties like ob/gyn have a female support person always in attendance. On the other hand, if a woman has no support staff or is always assigned the newest support employee, their productivity can falter, and their compensation can be lower.

Rank and Seniority

Both Gottlieb and Rohr-Kirchgraber said that women are also promoted less than men, offered fewer leadership positions than men, and are historically less sponsored for the C-Suite and other governance roles within an institution in both academic medicine (only 28% of women are full professors) and in primary care (with appointments for positions like department chair more elusive to women).

Leadership Premium

Moreover, women less often receive sponsorship or get the accolades for promotions and leadership roles by colleagues and supervisors as men do, so they don’t have equal opportunity to increase their compensation, said Rohr-Kirchgraber.

“The gender pay gap is a systems problem that cannot be solved on the backs of individual women,” Gottlieb says.

What You Can Do

Women need to know about salary benchmark standards and institutional target ranges and the type of compensation models used within their institution. They must negotiate salary when possible and know their worth. “You need to see what other physicians are making in your area and how are they making it,” said Rohr-Kirchgraber.

Additionally, pay transparency is another concrete solution that neutralizes pay gaps. There can be reluctance though, especially where inequities abound, but faculty can start initiatives from the bottom up. “We have to have some pay transparency at the workplace,” Rohr-Kirchgraber insists.

She also said to watch out for other pay inequity issues that pop up. For instance, if you’re new to a primary care practice and the other doctors aren’t taking new patients, you’re perhaps getting all the new patients so you’re possibly getting more of the Medicare/Medicaid patients, and thus your amount received is going to be a lot lower. “Your productivity theoretically may be the same but you’re going to be bringing home a lot less,” she said.

Likewise, be aware if your compensation model has patient satisfaction scores built in. Rohr-Kirchgraber said she noticed in one situation that women and underrepresented minorities received lower patient satisfaction scores regardless of what specialty they were in. “It was obvious that White males received the better scores, so we were able to negotiate and take patient satisfaction scores out of the reimbursement component.”

“Closing the gender pay gap will require not just physicians and organizational leaders but our HR and finance colleagues to take a good hard look at the basic assumptions underlying our institutional compensation methodologies to understand the expectations they’re generating,” says Gottlieb.

Ultimately, organizations must understand that some of the compensation framework inadvertently perpetuates inequities.

What Your Employer Can Do

Perform a Salary Audit: Organizations and practices should do a salary audit or study to determine if there are salary inequities. If there are, identify where along the career continuum the gender pay gap is most concerning. Is it at the initial hire stage or ‘promotion to mid-career,’ for instance? “Paying people equitably in the short term may seem costly, but in the long term, it’s the right business move because recruiting and retaining talent is very expensive,” said Gottlieb.

Review Compensation Methodology: Once organizations have studied how they model compensation, they should review and develop new approaches and models. Gottlieb said that alternative pay models are being investigated. However, one recent study of a primary care microsimulation of alternative pay models contained even more significant gender pay gaps and wasn’t viable. Research is ongoing.

Define Salary Benchmarks: Many institutions need well-identified or well-publicized salary benchmark standards, which they don’t yet provide. 

Minimize Salary Negotiations and set Standardized Pay for New Hires: The gender pay gap out of training needs to be eliminated, considering many physicians coming out of residency or fellowship have the same qualifications. Gottlieb said brand-new doctors should be paid the same regardless of gender, and organizations should minimize their salary negotiations for those positions since the evidence shows that women, especially in academic medicine, can lose millions of dollars due to those initial hire inequities.

Promote Sponsorship: Since women’s representation among senior faculty and organizational leadership is lower, promoting sponsorship rather than mentorship can help. Sponsorship highlights the talents and potential of other physicians. “We can narrow the pay gap by intentionally sponsoring women and underrepresented physicians for leadership opportunities,” Gottlieb says.

Think Critically about Allocating Organizational Service Demands: Women and underrepresented groups who serve on multiple committees lower their productivity levels. Evidence shows that in mixed-gender groups, women volunteer more and are expected to volunteer more, so minimizing these extracurricular duties can help women’s compensation.

Support for EHR: Implement clinical systems to support electronic health record use. Data from the primary care community notes that women receive more inbox messages than their male counterparts. Also, both patients and staff request more from female physicians, which diminishes their productivity and has implications for their well-being and burnout.

Bottom Line

Gottlieb’s hope is that institutions are starting to understand this is a recruitment and retention issue. “If their goal, and I think it is, is to recruit and retain the most talented individuals, then how institutions count work is going to be critical.”

Jennifer Nelson is Features Editor, Reports at Medscape. Her work has also appeared at WebMD, Medical Economics, MedPage Today, as well as The Washington Post, AARP, US News & World Report, The Oprah Magazine, Women’s Health and others. 

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