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What's behind women's pay gap?
A look at negotiating styles and skills
by Tammy Worth



Published in the April 2011 issue of Today's Hospitalist

Why do female physicians make less money than their male counterparts? Over the years, data from a variety of sources have shown that female physicians in general—and female hospitalists in particular—earn less than their male colleagues.

A study published in the February issue of Health Affairs found that female physicians fresh out of training in New York state were making on average $16,819 less than males. And data from the 2010 Today's Hospitalist Compensation & Career Survey indicated that female hospitalists earn nearly 20% less than their male counterparts.
"Men are more likely to negotiate, period."

–Kimberly Bell, MD
EmCare Inpatient Services



The conventional wisdom has tried to explain these pay differences by pointing out that many women work fewer hours, typically to spend more time raising children. But in the Today's Hospitalist survey, female hospitalists said that they worked about the same number of shifts as men and had similar years of experience on the job.

So what explains the gender gap in hospitalist pay? To get an answer to that question, we talked to a number of women hospitalists, many of whom are leaders in the field. The consensus, if there is one, is that women earn less in part because some are more focused on their family life, but also because many take a less aggressive approach to negotiating.

The "mommy penalty"
Talk about the pay differences for men and women in just about any profession, and you're bound to hear the term "mommy penalty." While that term may evoke stereotypical images of women as homemakers, female hospitalists say there may be some truth there.

Hospital medicine, after all, is the fastest growing U.S. medical specialty in part because the field is so attractive to young physicians with young families. Doctors, particularly women, are sold on the idea of working more flexible hours, even if that means less money.

Susan McAllister, MD, a hospitalist at Cooper University Medical Center in Camden, N.J., thinks that the pay gap between male and female hospitalists comes down to the fact that for many women hospitalists, "money is not your first priority. Having less mommy guilt is your priority."

Dr. McAllister, who began working at Cooper in 2006 out of residency and who has four children, including two toddlers, says that because time is more important, women physicians approaching a prospective job often focus on negotiating a flexible schedule instead of brokering the best possible compensation package.

"I negotiate from the point of view of what's of value to me, which is more flexibility and personal satisfaction in the work that I'm doing," she says. "I don't negotiate over numbers."

When she was offered her job at Cooper, Dr. McAllister was well-versed in the going rates for hospitalist positions in the Philadelphia area. Because she knew that the salary she was offered was reasonable, she didn't make any counter offer. She did, however, negotiate her hours, first requesting to work primarily on weekends. She's since changed her schedule and now works a full-time schedule that combines weekdays and weekends, but spends part of that schedule on administrative work to improve hospital throughput.

Either money or time?
While her work hours were more important than money, Dr. McAllister admits that there was another reason it never occurred to her to ask for more money. The leap from her stipend as a resident to her salary as an attending looked so vast that it seemed unreasonable to ask for more money.

Katie White, MD, an internist with the VA in Madison, Wisc., who will start a job as a hospitalist for the VA Medical Center in Birmingham, Ala., in August, says that she also tends to shy away from negotiating details like salary.

Dr. White's laid-back attitude toward negotiating may be natural given her employer. Many physicians who work for the VA, she says, may not see much point in negotiating salary.

"When you're working for the government," Dr. White explains, "you tend to be somewhat nihilistic about your ability to negotiate for anything. It's a very big machine, and you get plugged into what's available."

But even outside of the VA, Dr. White admits, she's nonconfrontational. She also points out that the only time she was ever exposed to advice on negotiating job terms was at a career fair in her final year of residency. It never occurred to her to negotiate for more money either in her current job or the one she's going to later this year.

"Negotiating money doesn't fit my personality," she says, "and you can't ask for more money and a better lifestyle because you are not going to get both."

But while Dr. White may prefer to avoid negotiating salary, she had no problem negotiating her work hours. She was able to negotiate a part-time position and now works only 75% of the number of shifts of a full-time equivalent.

Negotiating trends
Can it really be that women, even when they're well educated physicians, don't like to negotiate salary? It may seem like a stereotype, but data suggest that as a group, female professionals in the U.S. are more reluctant to negotiate pay than men.

A 2003 study out of Carnegie Mellon University in Pittsburgh, for instance, looked at negotiating trends and starting salaries among men and women graduating with master's degrees.

When researchers tried to correlate the role that negotiating played in compensation, they found that only 7% of the women in the study had negotiated their compensation as opposed to 57% of the men. As a result, the average starting salaries of the men were 7.4% higher than those of the women.

If women do in fact tend to negotiate less than men, one question is whether this attitude is philosophical or pragmatic. Dr. White points out, for example, that, "I'm in a two-physician couple, so we'll be comfortable no matter what I make." She and her husband, who's an orthopedic surgeon, have decided that it will be easier for her to opt for more flexible hours with their two children than it would be for him.

That need for flexibility is going to color how she approaches negotiations throughout her career, she says. "It's much easier to rearrange your schedule if you're doing administrative work, or teaching or research," says Dr. White. "I'm always going to be negotiating around lifestyle."

Assigning value to experience
But practical considerations may not be the only factor leading female hospitalists to avoid negotiating the details of their salary. Kimberly Bell, MD, regional medical director for the Pacific Northwest Region of EmCare Inpatient Services and a hospitalist at Auburn Regional Hospital in suburban Seattle, says that in her experience, women tend to be less aggressive negotiators than men when it comes to money, particularly on issues like signing bonuses.

Dr. Bell—who's led several hospitalist programs—believes that men are more comfortable with the fact that negotiating is a normal part of the hiring process. "Men are more likely to negotiate, period," she says. Men, for example, more frequently try to negotiate the number of nights they'll work. And while men do negotiate for more flexible schedules, she notes, they're just as likely to want to buy time for other commitments, like another job or research that they want to do, as to be able to spend more time with a young family.

Rachel George, MD, MBA, chief medical officer of the West Region and chief operating officer of the West and North-Central Regions for Cogent Healthcare, a national hospitalist management company, echoes the sentiment that women typically are more reluctant to negotiate head-on.

While women candidates have no problem putting their best foot forward in a job interview and highlighting the experience they bring to a prospective job, Dr. George says, "They expect the person listening to attribute the correct value to that experience instead of saying what that dollar amount should be. They won't follow up, while men will do a better job telling you that they deserve a specific number."

It's experience, not gender
Veteran hospitalist Maria Hoertz, DO, MPH, who is now a nocturnist in Arizona, has worked in a half-dozen hospitalist jobs across the country, including working as a locum physician for four years while she cared for her mother, who had ALS. She has noted differences in the way that men and women approach negotiating.

"Men have much less compunction about saying, 'I'm not going to agree to that,' " Dr. Hoertz says. "Women will say, 'I'm going to have to think about it.' What they don't realize is that the most important factor in maintaining your ability to negotiate is being able to walk away."

But according to Dr. Hoertz, there's a bigger divide in negotiating skills in terms of physician age than gender. It's taken her many years, she points out, to realize that she needs to say "no" to bad provisions that hospitals routinely try to sneak into employment contracts. It's taken her that long not necessarily because she's a woman but because she now has enough experience to tease out the implications of different job demands.

Dr. Hoertz says that over the years, she has learned to negotiate more forcefully. She now routinely crosses out contract clauses that would, for example, tie her to working a certain number of years before she can keep a signing bonus or agree to see all her patients by noon. (The big advantage of learning to work hard to get contracts right, she points out, is that she's now very happy with the job she has.)

She also says she's walked away from many job offers— something that younger women physicians (or men, for that matter) who feel tied to one area because of family concerns may not have the luxury to do.

"A brand new crop of fresh, naive, money-hungry, student- loan-ridden residents are coming out every year, and they've never read a contract in their lives," Dr. Hoertz says. "They've never negotiated anything, and they're still in the 'I am grateful to be accepted to medical school/residency/ fellowship phase.' "

That leads young physicians to routinely sign contracts that include onerous provisions, only to realize later that the contracts are "unlivable or dangerous," she adds. "Then they quit in three years."

Practice, practice, practice
Hospitalists need to realize, Dr. George says, that most groups and companies expect physicians to negotiate around money and terms.

"We set our salary based on that," she says. "No one offers the best possible salary that they can." To help expand physicians' comfort zone with negotiations, Dr. George suggests that they try role-playing their way through a negotiating session with friends and family.

Dr. Bell agrees that the only way to get better is to practice. She recommends negotiating with all kinds of individuals, from a babysitter and plumber to someone at a flea market, until you feel more comfortable engaging in the back-and-forth.

"We just have to understand that it is a part of the process and we should expect when we have a contract offer that we should negotiate every time," says Dr. Bell. "Even if you don't get what you ask for, you are participating in the process to get what is best for yourself."

Tammy Worth is a freelance health care writer based in Kansas City, Mo.

Keeping the ball in your court

MARIA HOERTZ, DO, MPH, a nocturnist in Arizona, always likes to signal that she'll be happy to dig into negotiations any time she approaches a new job. Dr. Hoertz has worked at numerous jobs around the country and internationally, and she worked a series of locum jobs over the course of four years.

She's become very comfortable, for instance, in going through contracts even before she reviews them with an attorney, redlining provisions that simply won't do. She also has no problem walking away from job offers where she can't negotiate what she considers dealbreakers.

Dr. Hoertz even likes to take charge of the interview process before she meets with prospective employers. She's learned over the years to let companies know that she'll be paying her own expenses in terms of flying in for an interview.

"They always say, 'Oh, we'll do that,' and I say, 'If I like you, I'll let you pay for it,' " Dr. Hoertz points out. Making her own arrangements is an important negotiating strategy, she claims; she's letting companies know that she's interested in them, but that she's going to maintain control of her part of the interview process.

Dr. Hoertz says she realized the importance of keeping that control after she spent four days smiling in one small town. "I was having a meet-and-greet in the library with the community," Dr. Hoertz says, "after meeting with the fire chief."

From that experience on, she now tells all prospective employers, " 'I'll fly in and meet you all the next day, and if I think the job is a viable option, I'll spend an extra day. But if not, I'll go,' " she says. "It's important to take control of the schedule."


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