Published in the March 2016 issue of Today’s Hospitalist
FOR DECADES the gender gap for women physicians—in terms of compensation, promotions, academic appointments and speaking engagements—has been notorious. According to a federal report released this year, women in the U.S. who worked full time in 2014 earned 79¢ for every $1 earned by men, a pay gap that widens with more years of experience. But for women physicians and surgeons, those earnings are estimated to be 62¢.
How does the pay gap play out in hospital medicine? Results of the 2015 Today’s Hospitalist Compensation & Career Survey indicate that full-time women hospitalists who treat adults report earning 16% less than their male colleagues, a difference of more than $37,000 a year ($234,107 vs. $271,531). Among pediatric hospitalists, the gap narrows to 12.6%, or just under $25,000: $195,833 for women vs. $220,500 for men.
However, many women hospitalists are bullish about the specialty’s fairness in terms of gender. Across medical specialties, says Bina Desai, MD, a hospitalist for the last five years at Chicago’s Loyola University Health System, the field has a great shot at being equitable.
“Part of not having women above you is not knowing the right questions to ask.”
~ Ashley Busuttil, MD, University of California, Los Angeles
Why? “Because we are young and there are 50-50 males-to-females going into hospital medicine,” she says. “Also, we can choose shifts to fit into our lives rather than medicine being our lives,” a major factor in women’s career satisfaction.
That sentiment is echoed by Nicole Jones, DO, an associate medical director for the 60 hospitalists at John Muir Medical Group in northern California. For one, the number of male and female physicians in her group is “pretty equal.” As for group leadership, women fill 73% of those roles.
And among colleagues in such a new specialty, says Dr. Jones, “I think the bond we feel from being hospitalists—sometimes treated as super-residents by nurses and other physicians—supercedes our gender identities.”
But women hospitalists also see room to improve, both in terms of professional development and leadership opportunities. Plus, they point to several factors including transparency around compensation and schedule flexibility that would help improve the odds of fairness in the field.
While it’s certainly not universal, many women say they’re comfortable in hospital medicine, noting that they haven’t run into an entrenched old-boys’ network and they appreciate the wide variety of available jobs. In addition, young hospitalists of both genders express similar priorities in terms of work-life balance, making it likely that they will press for the same options.
“At least in my group,” says Marisha Burden, MD, chief of hospital medicine at Denver Health and associate professor of medicine at the University of Colorado School of Medicine, “men and women equally seem to want opportunity, and they care equally about their lives outside of work. I don’t see that it is just the women who care about being home with their family.”
And while there may not be an even split in terms of men and women leaders, many in the field see that as inevitable as more women physicians mature in the specialty.
Yet women hospitalists also point to subtle differences between themselves and their male colleagues. Women doctors, for instance, say they’re constantly mistaken for nurses (while male nurses are presumed to be doctors). They report being addressed by their first name more often than male colleagues and of being interrupted more frequently at meetings.
And it’s often patients who misinterpret the roles of female physicians in the hospital.
“It’s not uncommon to be on a team with a female resident, a female intern and you are a female attending, and you have a third-year medical student who is male,” says Melissa Mattison, MD, chief of the hospital medicine unit at Boston’s Massachusetts General Hospital. “The patient directs all of his or her attention to the third-year medical student—who is terrified because it’s his first clinical rotation.”
As for overt discrimination, many sources say they believe it to be rare. As Dr. Mattison puts it, “I don’t have one offer letter for women and one for men.”
Survey data also suggest some possible explanations for the pay gap. The 2015 Today’s Hospitalist survey, for instance, found that 10% of women hospitalists report working in academia compared to only 6% of men. That’s important because university-employed hospitalists report earning about $55,000 less than hospitalists overall.
Yet studies consistently show, says A. Charlotta Weaver, MD, a hospitalist and an assistant professor at Chicago’s Northwestern University Feinberg School of Medicine, that even when controlled for such factors, the wage gap persists. “That means that not only are women choosing lower-paying jobs,” says Dr. Weaver, “but they are being paid a lower salary than men in those jobs.”
Dr. Weaver was the lead author of a study published in the August 2015 issue of the Journal of Hospital Medicine. That study documented a pay gap even “after controlling for age, pediatric specialty, practice model, geography, type of clinical work and productivity measures.”
A key finding, she points out, was that women were less likely than men to prioritize “substantial pay” as important. But women hospitalists were more likely to prioritize “collegiality.”
Why? Dr. Weaver isn’t sure, but she has some ideas. “Is it because women are more often in two-income households, so they are not as dependent on their own salary to feed a family?” she asks. “Or is it because of socialization? Research shows that starting in early childhood, boys are talked to about money differently than girls, and it persists. Research also shows that girls are more likely to be urged to preserve relationships instead of negotiating for money.”
Furthermore, Dr. Weaver says, “We didn’t survey hospitalists on prioritizing equal pay. I bet most women would say they want equal pay, even if ‘substantial pay’ is not as high on their list.”
What do colleagues earn?
Sources also point out that it’s hard to gauge whether the pay gap is simply a matter of priorities or if overt compensation differences survive. That’s because transparency around pay is probably the exception, not the rule.
“A lot of places forbid you to even talk about your salaries,” says Roberta Gebhard, DO, a hospitalist who works as a nocturnist in Jamestown, N.Y., and chairs the gender equity task force of the American Medical Women’s Association (AMWA). “That’s in the contract, so you have to find out on your own.”
Dr. Gebhard believes that many institutions do pay men and women differently “because they can.” She agrees with economists and policymakers who argue that doing away with gag rules in employment contracts and forcing transparency would go a long way to closing the pay gap. The AMWA task force she chairs works to pass laws to end the use of gag orders and advocates for passage of the Paycheck Fairness Act, an act first introduced in 2013 that would close loopholes in the 2009 Fair Pay Act.
It may be no coincidence that women physicians who applaud the equitable treatment they receive in their programs also report pay transparency.
“The books are open,” says John Muir’s Dr. Jones. “The payroll is sent out. Everybody knows what shifts get paid what, what everybody else earns and how many extra points everybody gets, and points equate to dollars.”
Pay transparency is also a feature of Dr. Desai’s group at Loyola. After she presented data on the pay gap in medicine during a departmental grand rounds, Dr. Desai says her department chair announced that he intended to review salaries to see if he unintentionally “has been doing this over time.”
And Elizabeth Schulwolf, MD, Loyola’s hospitalist division director, says she regularly reviews salaries to look for gender anomalies.
“I do that,” says Dr. Schulwolf, “because I know about the gender pay gap that widens with time, and I don’t want to be complicit in that myself.” But she hasn’t unearthed any examples. “Once you get beyond five years of experience, everyone’s jobs are so different that it’s difficult to quantify.”
But for many hospitalists, the trend of don’t-ask-don’t-tell is in full force. Tracy Gulling-Leftwich, DO, a hospitalist at the Cleveland Clinic who works as a nocturnist both at the clinic’s main hospital and a couple of the system’s community hospitals, is now in her third job in six years out of residency.
Dr. Gulling-Leftwich says she has no idea what her male colleagues (or her female ones, for that matter) are paid. Further, she has run across women hospitalists who are reluctant to publicly broach the topic.
“I’ve heard women physicians say, ‘We don’t need to talk about such things as salary and a possible gender gap,’ ” she says. “The feeling is that raising ‘women’s issues’ will make others uncomfortable— and make it harder for colleagues to be willing to listen to what we have to say” in terms of clinical medicine and practice management.
Scheduling: pro and con
Survey data also reveal a gender gap in terms of career satisfaction. Among full-time hospitalists treating adults, for instance, 83% of male hospitalists reported being satisfied with their schedule, compared to only 63% of women.
For women, “the schedule,” with its emphasis on shiftwork, tops the list of both challenges and strengths in hospital medicine. On the plus side, Dr. Gulling-Leftwich says she chose hospital medicine in part because she believes its emphasis on shiftwork helps better balance work and home life.
But for Mass General’s Dr. Mattison, the specialty’s emphasis on weeklong blocks nearly drove her out of the field at the beginning of her career. At first, even trying to work part time wasn’t feasible.
“Part time initially was working one week on with three weeks off,” Dr. Mattison explains, a schedule not any more conducive to arranging day care than full-time work. If she hadn’t successfully negotiated with her program director to work three days a week for more weeks each month instead of a week-long block, “I would not have been able to go into hospital medicine.”
According to Ashley Busuttil, MD, associate section chief of hospital medicine and the hospital medicine medical director for clinical operations at the University of California, Los Angeles (UCLA), “full-time clinical hospital medicine is very inflexible. The career decisions I’ve made have focused on my own interests, but also on what is sustainable for a family. I want flexibility so I can be there with my kids.”
Having more flexibility, women hospitalists say, is part of the appeal of working in academic medicine. In addition, Dr. Busuttil’s strategy has included taking on leadership roles, with her nonclinical FTE compensation now approximately 0.5. She may work more hours, she notes, but those are not as rigid.
At John Muir in northern California, hospitalists can choose how many days in a row they want to work, says Dr. Jones. And if they need shorter shifts, they can sign up for the eight-hour shifts at any of the three skilled nursing facilities the group covers, rather than at either of two hospital campuses.
And at Denver Health, Dr. Burden says her group has “intentionally stayed away from seven-on/seven-off scheduling because it is very rigid. We work to ensure great patient continuity—but we also ensure that the schedule is feasible for our faculty for the long term.”
The leadership gap
In reviewing Denver Health’s Web site, it appears that more than 60% of the 50 hospitalists are women, while women fill six of the 11 major leadership positions.
“We make sure that opportunities are presented to the group as a whole,” Dr. Burden says. “Otherwise, you don’t know who might be the best fit, and both men and women are interested.”
Furthermore, says Dr. Burden, “I have had a great amount of exposure to very successful women,” noting that she’s worked under a variety of female leaders in her nine years at Denver Health, including a female CEO. She also reports having excellent mentorship throughout her career.
It was only when she began attending local and national hospitalist conferences that she started noticing that hospital medicine might not be so universally equitable. “It was very apparent at those meetings that there weren’t as many female speakers.”
That led to her study, published in the August 2015 issue of the Journal of Hospital Medicine, which quantified the gender gap in academic hospital medicine. The key findings: While there was equal gender representation among hospitalists in university hospitals, women led hospital medicine divisions or sections in only 16% of the groups studied. Further, women hospitalists were listed as speakers in only 26% of presentations at national meetings.
“The thought that these inequities will fix themselves over time as demographics shift may not ring true,” Dr. Burden says. “In fact, without some active efforts, we will likely not get to where we need to be.”
To offset the lack of female mentors, UCLA’s Dr. Busuttil relies on an informal group of female colleagues who regularly “bounce things off each other,” such as negotiation strategies and compensation.
“Part of not having women above you is not knowing the right questions to ask, and women don’t ask for the right things,” she points out. “We have a hard time asking for compensation, let alone a title to go along with it.”
That group has been very valuable, Dr. Busuttil notes, in encouraging its members to “not tiptoe” around issues like compensation and promotion. “Every time I have asked for compensation for something, I have ultimately gotten it. But if women talk only to women, they don’t know what the men are getting.”
At Loyola, Dr. Desai has dodged that grievance about leadership, saying that her division chief advocated for her, for instance, when the position of associate chief medical information officer became available. As a new mother, Dr. Desai was wary of taking on the responsibility, but Dr. Schulwolf negotiated on Dr. Desai’s behalf for some carved-out time.
If her division chief hadn’t done so, “I would have had to do the job in my free time, so I probably would have turned it down.” Instead Dr. Desai has now held that leadership post for nearly two years. At the same time, she points out, “I never would have thought of negotiating for myself”—and Dr. Schulwolf admits that it’s easier to advocate for the hospitalists in her group than on her own behalf. “My take-away was: We need to go in and ask.”
Northwestern’s Dr. Weaver has heard anecdotes about men hospitalists who—much more aggressively than women—press group leaders to find ways to offer them more compensation, perhaps counting their third year of residency as a year of experience to bump up their starting salary.
In addition, Dr. Weaver has noticed that “both men and women do a lot of work that is not compensated, but I see men setting limits.” Among academic faculty, she notes, women are more likely to just say yes to an extra teaching or committee assignment.
Men, on the other hand, “will say, ‘I don’t have that much time bought out. This is my limit. You are going to have to give me a bit more time.’ ”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.