Gender Pay Gap Most Pronounced in Procedural Specialties

Jake Remaly

July 12, 2021

Salary disparities persist in academic internal medicine specialties and are most obvious in procedural specialties, such as cardiology, in which there are fewer women, research suggests.

"Substantial salary inequities persist at the highest faculty levels and specifically in procedural-based specialties," Teresa Wang, MD, and colleagues report in a research letter published online today in JAMA Internal Medicine.

To examine the demographics and salaries of academic internal medicine physician specialists, Wang, who is with the Division of Cardiovascular Medicine at Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania, and co-authors analyzed survey results from faculty at 154 US medical schools.

They used data from the Association of American Medical Colleges Faculty Salary Report of 2018 to 2019 to assess the median annual salary, faculty rank, and gender for 21,905 faculty in 13 internal medicine specialties.

Overall, women made up less than 40% of full-time faculty across ranks. Female representation was approximately equal at the instructor and assistant ranks — 47% and 46%, respectively — but decreased to 24% at the professor level.

The authors found that women made up the majority in three specialties — general internal medicine, endocrinology, and geriatrics. In contrast, women were least represented in the procedural specialties of pulmonology, critical/intensive care, gastroenterology, and cardiology.

The greatest imbalance was in cardiology, in which only 21% were women, the researchers note.

Across faculty ranks, the median annual salary was less for women than for men. The median salary for women was within $25,000 of that for men at all ranks except chief and was at least 90% of that for men in 10 of 13 internal medicine specialties.

Cardiology, gastroenterology, and critical/intensive care were the three specialties in which women's median salary did not reach 90% of men’s. These specialties tended to be better paid overall, "but also demonstrated the largest gender disparities in both representation and salary, particularly within the higher ranks of cardiology and gastroenterology," the researchers say.

The reasons for gender disparities are unclear, though internal medicine procedural specialties "have long been male dominated in composition and leadership," the authors note. The findings indicate that workforce gender parity may be associated with salary equity, they add.

"Despite the growing awareness of workforce disparities in medicine, our findings suggest that women internal medicine specialists remain underpaid and are not promoted to senior level academic ranks when compared with career trajectories of their male counterparts," study author Nosheen Reza, MD, of the Division of Cardiovascular Medicine at the University of Pennsylvania, told Medscape Medical News.

The researchers note that they were unable to adjust at the individual level for various factors that may influence salary, such as professional service, academic productivity, clinical volume, and supplementary funding sources, and that the results might not apply to all US medical schools, in which departmental structures vary.

Procedures vs Evaluation and Management

Still, the research "provides an interesting snapshot of current salary disparities in academic internal medicine," comment Rita F. Redberg, MD, and colleagues in a related editorial. Redberg, the editor of JAMA Internal Medicine, is affiliated with the Department of Medicine at the University of California, San Francisco.

Internal medicine has 13 specialties and dozens of subspecialties, and "procedural subspecialties are more male dominated and better paid than nonprocedural subspecialties — both topics deserving of further exploration," the editorialists write.

The field needs to address various issues that drive some women to "shun male-dominated procedural-based fields — including lack of role models, macho 'cowboy' culture, unpredictable schedules, longer training periods, or cultural factors," Redberg and co-authors suggest. "Concurrently, the medical profession overall, as well as specialties, should thoughtfully and frequently reassess how to distribute pay more equitably and to remove the premium currently paid for procedures over evaluation and management services."

"Unfortunately, it is not a surprise that there continues to be a gender gap for salary in academic medicine," Redberg told Medscape Medical News. "It was interesting to see that gender pay disparities were greatest in the procedure-intensive specialties, and we do know that procedures are much more highly reimbursed than evaluation and management time, even in the IM specialties. From a patient perspective, I think what they value most highly is having their doctor talk with them and explain treatment options and risks and benefits. Sadly, our fee-for-service–based reimbursement system values procedures more highly than talking with patients. And part of the gender gap in salary is attributed to less women being proceduralists."

The Medicare Payment Advisory Commission "has made some excellent recommendations to Congress on helping to correct this imbalance," Redberg added.

In a separate viewpoint article, Leah M. Marcotte, MD, of the Department of Medicine at the University of Washington, in Seattle, Washington, and colleagues describe reasons why women physicians may have "slower promotional timelines" compared with men, such as receiving fewer and smaller grants, being underrepresented as speakers at national conferences, and receiving fewer invitations to author editorials.

"To narrow this gap, institutions should proactively nominate women, with a greater focus on those underrepresented in medicine, for internal and external awards and speaking opportunities," Marcotte and co-authors write. "Institutions should adopt policies to cover childcare, breastfeeding/pumping accommodations, and dependent travel. Academic departments should continue to offer virtual speaking opportunities even after COVID-19 pandemic travel restrictions become unnecessary."

Institutions can also assist women faculty in preparing promotion dossiers.

"Gender disparities in promotion in academic medicine have been described for decades, and yet progress to close the gap has been untenably slow," they say. "Rather than expecting faculty to adapt to existing systems, we need to change the promotion process to work better for all."

The authors have disclosed no relevant financial relationships. Redberg has received grants from Arnold Ventures, the Greenwall Foundation, and the National Heart, Lung, and Blood Institute outside the submitted work. One viewpoint co-author has received honoraria from the American Board of Internal Medicine, and another has received personal fees from F-Prime Capital, both outside the submitted work.

JAMA Intern Med. Published online July 12, 2021. Research letter, Editorial, Viewpoint article

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