This year’s AAMC review of faculty salaries recognized, once again, the persistent salary gap of >20% between men and women faculty in academic medicine. Recently, Gottlieb and Jagsi published a thoughtful NEJM piece (“Closing the Gender Pay Gap” NEJM 2021; 385: 2501-2504) delineating the multiple potential reasons that might lead to such gaps, ranging from differences in initial salary to the known occupational segregation among our specialties, to the extra burdens in lower or uncompensated service at work and at home borne by women. These authors carefully delineate the structural and non-structural biases that produce this effect, apparent now after decades of attempting to eliminate this differential or to explain its multiple causes in any one faculty, department, or role. Women faculty, now for generations, have experienced this gap; and, the years of these differences are clearly reflected in the retirement benefits of those who have persevered in the work they have loved!
I would like to lend some additional thoughts about practices that hiring officials might consider when setting salaries. Assuring equal salaries at first hire, especially as this can be the basis for an enduring differential, requires institutional guidelines. Bands for hiring are problematic when there is room for differences that are not easily described; rather, specifics for hiring rates should be based on some metric that can be applied to all. While initial academic rank might be a clear metric (or time from training, etc.), the recent AAMC report notes that 60% of instructors are women; IF these women are physicians, they will fall behind their colleagues who are hired as assistant professors. While in the past, women were appointed to this rank with the thought that they needed “extra time” to tenure (as they might have a family), this practice is not appropriate. Additionally, regardless of rank, women physicians just out of training earn less than their male counterparts. Since laws now may prevent employers from asking current salary when offering a new position, those who stay at the same institution suffer enduring effects of a lower starting salary over a long career (Rao AD, Nicholas AE, Kachniarz B et al. JAMA Network Open 2018;1(8):e186054).
I began medical school before Title IX, and on occasion, experienced explicit biases; by the time I was interviewing for department chairs (often for institutions in search of Title IX compliance), I understood that biases were often implicit and complicated by my own lack of knowledge. When I was eventually offered a position, I became forever grateful to one hiring official who “educated” me about what I should consider. I have subsequently used this practice to “pay it forward”, as I have hired faculty and deans over the years. This individual requested that I send along a rough draft of a letter of what I would need to take the position, including my own requirements and those necessary to build the department. He called and very politely asked if I minded if he helped me with this letter (which was to be addressed to him!). He subsequently included a much higher salary, along with more space, benefits, personal support than I would have considered, while assuring my academic appointment was appropriate. This was much different from two previous experiences: one, where I would be paid less because I had a husband; and another, where I was paid significantly less than a male with lesser credentials and fewer accomplishments who reported to me. Recently, I was asked, why, in this capitalistic society, would I ever pay someone more than they asked for? My answer: because ensuring equity and equality is the role of an institutional leader, not the individual.
Another important consideration is the recognition that the work necessary to sustain a department or a medical school is more than the work we measure by practice revenue generation. It includes the poorly re-imbursed work of teaching, un-rewarded administration, lower-paid governmental research, or the patient-intensive effort that funds the rest of the enterprise through downstream revenues, specialty referrals, or decreased resource utilization. After all, it takes a village to grow a physician or to care for a patient! It behooves the leader to create some equivalence among these roles, such that those (more frequently women) who engage in these are not adversely impacted, and to make clear that there is valued interdependence among these roles. This practice would go a long way toward creating equity for those who either choose or are relegated those tasks and roles that are not accompanied by huge monetary reimbursements but required for the overall institutional success. One wonders about salary inequity in institutions where the salary is equivalent for all – i.e., rewards the outcomes of the faculty’s specific institutional role, rather than primarily the outcomes of their specific billing practices.
Gottlieb and Jagsi, who are better schooled than most, in the data demonstrating the impact of explicit and implicit bias surrounding gender in the profession of medicine, exhort us to think innovatively, transparently, and systematically about how to tackle pay inequity. Salary gaps today represent the most tangible, easily documented evidence of the ongoing inequity in our gendered career journeys.
Jeanette Mladenovic, MD, MBA, MACP
President/CEO, Center for Women in Academic Medicine and Science