Surface versus Structure: The longstanding issue of the gender pay gap in medicine
By Krystal Jacques
The issue of the gender pay gap is frequently forgotten by today’s society but is still pervasive across various fields of work today. A 2019 report by StatsCan revealed that Canadian women earn 0.87 cents for every dollar earned by men.1 And the gap starts early, according to a new report that tracked the earnings of Canadian post-secondary graduates across 11 fields of study (including college, bachelors, masters, and doctoral degrees). Women earned less than men in every field, with an average gap of $5,700 (12% less than men) in the 1st year after graduation, which increased to $17,000 (25% less than men) after 5 years.2 Ontario’s gender pay gap has narrowed significantly since 1987 when the provincial government first passed the Pay Equity Act. But according to a 2019 report by Glassdoor, it will take 164 years to close the gender wage gap in Canada.3
At present, jobs that mirror traditional “women’s work” (e.g. administrative, early childhood educators) tend to be undervalued because they parallel domestic work that women were (and are) expected to perform for free. Whether the gender pay gap exists in higher paying careers, such as medicine, is a contentious issue. According to a 2020 U.S. report, a pay gap between male and female physicians at the outset of their careers not only exists, but is actually growing.4 The starting salaries of female doctors were on average $36, 618 lower than male doctors from 1999 to 2017.4 Here, we will discuss the possible reasons for the gender pay gap in medicine-a field historically dominated by men that continues to be plagued by in-built institutional gender bias.
A recently published study in JAMA Neurosurgery analyzed 1.5 million surgical procedures from the start of 2014 through 2016; it found female surgeons in Ontario earn 24% less than their male counterparts, and the proportion of women performing an operation decreased as the pay per hour for that procedure increased.5 A similar article by the Association of American Medical Colleges (AAMC) summarizing gender-based pay disparities in medicine from several resources in the Unities States (U.S.) was published a few months earlier.
These articles bring into awareness the many possible reasons for why this gender pay gap is occurring: 1) women tend to have less aggressive billing behaviours than men, 2) men tend to refuse the less lucrative medical procedures, while women tend to say yes to any opportunity they can get, 3) female physicians tend not to self-promote or negotiate salary, and 4) women tend to choose the lower paying, less lucrative specialties after their training (i.e. Gynecology).5,6 Out of all female surgeons in Ontario included in the analysis, 49% of them practiced gynecology.7 In the U.S., the percentage of female surgeons working in gynecology versus the more lucrative urology is 54% and 8% respectively.6 According to AAMC specialty data, 63% of pediatricians in the U.S. are women, whereas 95% of orthopedic surgeons are men. Also, the majority of neurosurgeons are men.5 On the surface, women tend to be less aggressive than men when it comes to self-promotion, negotiation for higher salary, getting the biggest bang for their hours, and choosing the highest paying specialties.
However, the 2020 study showing a gender gap in starting salaries for physicians found that work-life balance preferences (eg. predictable hours, length of the workday, frequency of being on-call overnight or on weekends) accounted for less than 1 percent of the pay gap, and had no effect on the differences in starting salary.4 Why are men paid more than women out of the gate? The authors say differences in specialty and the number of job offers received may explain some, but not all, of the gap.
Some believe the gender-pay gap is attributable to a difference in skill-that male surgeons are just “more capable”. However, the recent Ontario study found that in almost all cases, female and male surgeons took the same amount of time to perform identical procedures, debunking the myth that females are just “less competent” or that they work less efficiently than men. Although it may be the case that women value flexibility over lucrativeness when pursuing medicine (due to the increased demands of domestic, child and elder-care socially expected from women), the gaps also persist within speciality. Particularly in male dominated specialties. In a paper published in 2017, researchers compared Relative Value Unites (RVUs – a system of work compensation implemented primarily by U.S. medicare) between gynecologic and urologic procedures performed in the U.S. They found that 84% of procedures were compensated at a higher rate for male-specific procedures. For example, a biopsy of the prostate is worth 4.61 RVUs while a biopsy of the endometrium is 1.53 RVUs.8
Even more nefarious is the fact that the same procedure-a total urethrectomy-has different RVUs depending on whether it is performed on a man or a woman. For men, it is 16.85; for women, 13.72. Although we cannot completely rule out the possibility that the procedure is inherently more difficult when performed on men than on women (research on this is limited), Parangi, MD at Harvard Medical School, and the main interviewee of the AAMC article, suspects that the real reason for these RVU differences reflect a male-dominated structure in medicine, contending that, “The committee that establishes RVUs has 30 voting members. Only two are female.”5 Similarly, the Ontario study found that female surgeons receive fewer referrals overall.7 The reason behind this is suspected to be implicit bias.9 The authors of the Ontario study told the Globe and Mail that a possible solution to this is to pool all the referrals for each specialty and distribute them in an unbiased system.6
Besides the inherent male-bias in the structure of the medical system, research and personal experiences would suggest that differences in ambition and assertiveness is a reflection of a cultural and societal artifact. It is well documented that in childhood, girls are typically taught to be less aggressive and less confident, while boys are taught the opposite.10,11 And what seems like incompetence in female surgeons could just be lack of confidence. So how can we address this gender-pay disparity in medicine?
First, we must address institutional bias by ensuring the real-world gender ratio of medical practitioners is reflected in the governing bodies and committees who make decisions. Another solution could be putting systems into place making it impossible for surgeons to refuse lower paying procedures. But it also means we must teach all children, regardless of gender, to be confident in their skills and capabilities. Many women choose to reduce their hours to start a family, however new fathers are less likely to do so. Fathers should also be encouraged by society to share the responsibilities of childcare equitably with their partner. Perhaps this would allow women to reduce their hours by a little less or return to work more quickly after maternal leave.
Last, it is important not forget that there are many in our world that perceive women as lazy or incompetent. We see the term “lazy” also used to describe disparities in work compensation between races. Women of colour, Indigenous women, and women with disabilities are even more worse off than white woman when it comes to the gender pay gap overall.12 For example, in the U.S, black male doctors make an average of $50,000 less per annum than white male doctors, while black female doctors make almost $100,000 less than black male doctors.13 It is pivotal that we also study the intersections between race and gender to address the gender pay gap issue more thoroughly and implement solutions that ensure all women are paid fairly.
IMS writer & Executive Editor Krystal Jacques is a 2nd year IMS PhD student using human embryonic stem cells and lineage tracing mouse models to study the origins of pancreatic stem cells under the supervision of Dr. Derek van der Kooy. Outside the lab she is passionate about fine art photography, writing fiction, painting and running. Instagram: Krystaljacques_
1. Rachelle Pelletier, Martha Patterson, Melissa Moyser. The gender wage gap in Canada: 1998 to 2018. Statistics Canada. Oct 7th 2019. Available from: https://www150.statcan.gc.ca/n1/pub/75-004-m/75-004-m2019004-eng.htm.
2. Finnie, R., Miyairi, M., Dubois, M., Bonen, T. and Amery, B. (2019). How much do they make? New evidence on the early career earnings of Canadian post-secondary education graduates by credential & field of study. Ottawa, ON: Education Policy Research Initiative (EPRI) and Labour Market Information Council (LMIC). https://lmic-cimt.ca/projects/studentoutcomes/
3. Chamberlain A., Zhao D., and Stansell A. Progress on the Gender Pay Gap: 2019. (2019). Glassdoor Economic Research. https://www.glassdoor.com/research/gender-pay-gap-2019/
4. Lo Sasso AT, Armstrong D, Forte G, Gerber SE. Differences In Starting Pay For Male And Female Physicians Persist; Explanations For The Gender Gap Remain Elusive. Health Affairs. 2020 Feb 1:10-377.
5. Amy Paturel. Closing the gender pay gap in medicine. AAMC. 2019 April 16. Available from: https://www.aamc.org/news-insights/closing-gender-pay-gap-medicine
6. Wency Leung. Female surgeons in Ontario earn less than male counterparts, study finds. The Globe and Mail. 2019 October 2. Available from: https://www.theglobeandmail.com/canada/article-female-surgeons-in-ontario-paid-less-than-male-counterparts-study/?fbclid=IwAR0sm83uuBQhVZwhtXxZB90USblZ9SjRXhR0EIA_JnA_YarDWmMmFBQv4EE
7. Dossa F, Simpson AN, Sutradhar R, Urbach DR, Tomlinson G, Detsky AS, Baxter NN. Sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario, Canada. JAMA surgery. 2019 Oct 2.
8. Benoit MF, Ma JF, Upperman BA. Comparison of 2015 Medicare relative value units for gender-specific procedures: Gynecologic and gynecologic-oncologic versus urologic CPT coding. Has time healed gender-worth?. Gynecologic oncology. 2017 Feb 1;144(2):336-42.
9. Dossa F, Baxter NN. Implicit Bias in Surgery—Hiding in Plain Sight. JAMA network open. 2019 Jul 3;2(7):e196535-.
10. Cvencek D, Meltzoff AN, Greenwald AG. Math–gender stereotypes in elementary school children. Child development. 2011 May;82(3):766-79.
11. OECD. The ABC of gender equality in education: Aptitude, behaviour, confidence.
12. The facts about the gender pay gap in Canada. Available from: http://equalpaycoalition.org/myths-about-the-gap/
13. Alexa Lardieri. Report: Despite Physician Salary Increases, Wage Gaps Still Exist. 2018 April 11. Available from: https://www.usnews.com/news/health-care-news/articles/2018-04-11/report-despite-physician-salary-increases-wage-gaps-still-exist