The "Unexplained" Portion of the Gender Pay Gap in Anesthesiology.

Abstract

Despite the passing of the Equal Pay Act over 50 years ago, the pay gap between men and women in the United States persists, even when accounting for individual factors such as hours worked and seniority. Although it is illegal in the United States for employers to pay women lower wages than men for equal work on jobs requiring equivalent skill, effort, and responsibility, Pew Research1 estimates that US women earn 84% of what men earn, the equivalent of 42 extra workdays in a year. Based on 2020 US Census data, the American Association of University Women has calculated that Asian women’s median annual earnings will not reach parity with White men’s until 2041, and Hispanic women’s not until 2451.2 To combat this discrepancy, the US federal government has reintroduced legislation reexamining the pay gap between men and women, including the Executive Order establishing the White House Gender Policy Council and the US House of Representatives’ Paycheck Fairness Act, HR 7. States have also been active in addressing the gap: recently, California enacted SB 973, legislation requiring employers to submit pay data based on gender,3 and Colorado has enacted a bill requiring employers to publicize all opportunities for promotion to their employees. For physicians, the current pay gap is estimated to be about 29%, or $19 billion.2 A recent self-reported survey of over 44,000 physicians showed that the wage gap between men and women widened to over $116,000 during the coronavirus disease 2019 (COVID-19) pandemic, an increase of 2.8% within just 1 year. There were no specialties where women earned the same or more than men,4 despite controlling for hours worked, specialty, years in practice, and Metropolitan Statistical Area. As women have comprised at least 40% of medical students since the 1990s, one would expect women to have equivalent or higher average compensation in at least some specialties.4 This phenomenon suggests the legal concept of “inexorable zero,” when zero representation of certain groups within a workplace, despite significant representation within the labor pool, suggests a “nonrandom factor such as discrimination contributed to the disparity.”5 The wage gap in anesthesiology has been documented since the 1990s. At that time, the estimated wage gap between White men and women anesthesiologists was 20%, or $60,000 after adjustment for work hours and provider and practice characteristics.6 More recently, a survey of American Society of Anesthesiologists (ASA) members in 2012 showed that the wage gap between men and women was 29%, or $90,000. After adjusting for experience, region, nonrural location, parenthood and marriage status, total hours worked, types of cases, types of payment models, and group employment type, the unexplained gap remained at 7%.7 Women theoretically working fewer call shifts only accounted for 0.5% of the gap. Published data from the American Association of Medical Colleges (AAMC) in 2019–2020 confirm a pay gap at every level in academic anesthesiology except department chair8 (Figure). The unadjusted average difference in salary for men versus women anesthesiologists ranged from −11.9% to −67.0% for instructor to chief positions. Interestingly, for department chairs, the gap was 20.8% in favor of women.8Figure.: Salary differences among academic anesthesiologists by gender, adapted from published data from the American Association of Medical Colleges, 2019–2020.8 AAMC indicates American Association of Medical Colleges.In an article that was published in the October 2021 issue of Anesthesia & Analgesia, Hertzberg et al9 illustrate that the unexplained pay gap between women and men anesthesiologists persists. This survey of all 28,000 active and eligible members of the ASA built on the previous 2012 study noted above. Additional items were included, such as age; race; academic rank; whether the anesthesiologist negotiated and/or considered salary important, trained locally, took call, completed fellowship, had paid family leave and time off; and whether the anesthesiologist had a mentor, lawyer, or a personal connection to the practice. Despite the comprehensive consideration of confounders, a significant unexplained difference remained of 8.3% to 8.9%, or $32,617. This was surprisingly larger than the 2012 ASA survey, and the equivalent of roughly 21.6 workdays. Of note, this survey was collected before the COVID-19 pandemic, which has already exacerbated preexisting gender inequities in teaching, service, and research. COVID-19 also adds additional strain on women facing the “double bind” of racial, socioeconomic, and health inequities. The findings of the article by Hertzberg et al9 are highly significant and were featured as a press release by the ASAa. Although this study’s finding were enlightening, there were several limitations. The response rate was low (7.2%), and the gender/age skew toward younger, women anesthesiologists could reflect a nonresponse bias of men and more senior anesthesiologists. The authors also collected gender as a binary variable, which may have excluded or misallocated the results for transgender, queer, and nonbinary individuals. Potential demographic confounders such as race, ethnicity, gender identity, and sexual orientation had a relatively small sample size, and yet these variables are known to also be important independent factors in wage inequity. Particularly notable in all studies of the wage gap in anesthesiology is the absence of data from anesthesiologists who have left the ASA or the practice of anesthesiology. The attrition of midcareer women is well documented in medicine and academics and is often attributed to lack of professional advancement, child- and elder-care needs, chair/leadership issues, harassment, and low salary. While the authors collected robust data on demographics and job characteristics, the influence of institutional culture and leadership on the pay gap was not assessed. It is possible that these factors may influence the unexplained portion of the pay gap10 (Table). Table. - Considerations for Mitigating the Unexplained Gender Pay Gap3,10,11 Regularly collect and review salary data by demographic factors and adjust accordingly Account for overlapping identities (intersectionality) when reviewing data, eg, women of color may have unique barriers compared to White women Equitably distribute citizenship tasks among men, women, and nonbinary individuals Reward extra duties that further the mission of the organization and patient care Include physician stakeholders in compensation planning, such as an elected physician finance committee Critically review incidences of exceptions to standard pay scales Recognize that correction of an inequity in 1 metric may introduce new inequities in other metrics Formally announce and provide access to leadership opportunities to all qualified staff Promote equity and transparency in nonmonetary forms of faculty support, including administrative and academic time and research support Comply with federal, state, local, ACGME, and institutional requirements for equity in pay and time Recognize that presenting an organization as meritocratic can be associated with increased gender bias Standardize recruitment processes and measures of job performance and promotion Organizational leaders may not recognize the extent of their workers’ participation in citizenship tasks or the degree of compensation gap without intentional and comprehensive review.Abbreviation: ACGME, Accreditation Council for Graduate Medical Education. Research in the fields of sociology and organizational psychology may be able to shed some light as to causes of the wage gap between men and women. A large study of US federal agencies, published in the American Journal of Sociology, investigated within- and between-group differences in the gender pay gap by job category. The authors discovered that while formal federal pay grades exist for most job titles and are heavily scrutinized for pay equity, federal agencies only selectively used this pay grade system, with men accounting for 74% of higher “off grade” salaries.11 In addition, the scientific occupations that tended to favor individual genius or brilliance over collective effort also tended to have a more hierarchical conceptualization of success and subsequently a higher wage gap between men and women. The authors highlighted this paradox: “when organizations are explicitly presented as meritocratic, individuals in managerial positions favor a man over an equally qualified woman with higher remuneration… To the extent that managers believe the standardized federal personnel system prevents bias, the paradox of meritocracy may be contributing to the within-job disparities…”. How might “off-grade” pay, hierarchical organization, and the meritocracy paradox manifest within the field of anesthesiology? While many academic departments, employers, and partnerships utilize standardized pay scales, there is often discretion on the part of the chief or chair to adjust compensation for recruitment or incentives. Relative value unit (RVU)–only reimbursement models also may not account for subtleties in access to high-RVU assignments and do not account for “citizenship tasks,” that is, uncompensated duties that further the organization’s goals, but do not contribute to the advancement of the individual performing them.12 Examples include holding interim directorships and other uncompensated leadership duties, mentoring and sponsoring junior physicians, performing administrative duties (eg, taking notes and organizing meetings), and serving on hospital committees. This could also include more time spent per patient interaction and more total tasks completed within the same work period. Organizations that tend to be more hierarchical and individualistic (which also tend to have the highest gender disparities in pay) may not adequately recognize and remunerate these necessary efforts that boost patient care, organizational effectiveness, and group reputation, which are not accounted for in fee-for-service structures.11,12 Despite these institutionalized behaviors, change is feasible and desirable (Table). Unlike gaps in leadership which require more long-term investment in career development to rectify, pay gaps could potentially be remedied more rapidly. When the University of Alabama–Birmingham surgery department compared men’s and women’s salaries to the AAMC median according to specialty, region, and academic rank,13 they noted that despite similar RVU production, men’s salaries were 30 percentiles higher. In response, compensation was restructured based on faculty input. Physicians were subsequently paid based on their previous years’ work RVUs (wRVU), with 12.5% withheld (10% paid back for meeting wRVU incentives and 2.5% for academic productivity). Within 1 year of the change, women’s salaries increased from 46% of their male colleagues’ salaries to 72%. The remaining pay gap was attributed to women having fewer appointed leadership positions and endowed professorships or chairs. At the Mayo Clinic, a unique compensation model has existed for the last 40 years. There is a fixed 6-step salary-only compensation plan. After the fifth year on the plan, all physicians in the same specialty are paid the same rate based on national benchmarks, without adjustment in compensation for incentives, academic rank, external recognitions, or benefits. Among their nearly 3000 physicians, 96% were within the 95% predicted confidence interval for salary. Factors associated with the remaining pay gap were more men in compensable leadership positions and more men in higher-paying specialties.14 Professional societies have also provided recommendations for addressing the gender pay gap. The AAMC outlines the approaches of 11 different medical schools in addressing the pay gap among their faculty.10 The ASA’s recent Statement on Compensation Equity Among Anesthesiologists as well as the American College of Physicians Position Paper recommend that compensation should be equitable, including nonmonetary supports such as clinician scheduling, research support, and institutional responsibilities. They additionally call for transparency in salary reporting and standardization of measures of job performance. Transparent policies including organization-level analysis and managerial and legal accountability are supported by data11(although empty policies are not). It should be noted that physicians who perceive pay fairness reported greater work satisfaction, lower turnover intention, and better health.10,15 Pay fairness was more strongly associated with these variables than the compensation itself.15 As women represent 26% of practicing anesthesiologists, perhaps our profession is also reaching a “tipping point” in which the proportion of women in our field can be expected to rapidly increase. This could represent better access of our field to the full talent pool of medical students. Group intelligence, innovation, creativity, and problem solving within perioperative teams could be enhanced. Clearly, increasing gender equity at all levels is the right thing to do, and sends a clear message that women’s expertise is welcome and valued in anesthesiology. In conclusion, while recognizing the limitations of the Hertzberg et al9 study, it is clear that a gap in salaries still exists between women and men in the specialty of anesthesiology. While some of the action steps that can be taken are in the hands of the institutions, department leaderships could and should address the issue. For example, publishing all salaries in a department will by itself drive higher level of accountability with regards to potential “unexplained” salary gaps. Published department compensation plans that are highly structured and account for variables such as interim leadership positions and participation in hospital committees no doubt will decrease potential gaps. Finally, the creation of “elected” finance committees that review and approve the department budget as well as individual compensation will drive higher accountability and fewer “special deals.” Here, the emphasis is on “elected finance committee,” these kinds of committees can drive “shared governance.” Structured, transparent compensation plans will no doubt reduce multiple salary gaps that currently exist. ACKNOWLEDGMENTS Amy C. S. Pearson acknowledge Tristan Pearson for his helpful feedback. DISCLOSURES Name: Amy C. S. Pearson, MD. Contribution: This author helped with the concept and design of the study, drafting and critical revision, and approval of the final version to be published. Conflicts of Interest: A. C. S. Pearson is the immediate past president of Women in Anesthesiology (unpaid). Name: Lisa R. Leffert, MD. Contribution: This author helped with the concept and design of the study, drafting and critical revision, and approval of the final version to be published. Conflicts of Interest: None. Name: Zeev N. Kain, MD, MBA. Contribution: This author helped with the concept and design of the study, drafting and critical revision, and approval of the final version to be published. Conflicts of Interest: None. This manuscript was handled by: Jean-Francois Pittet, MD.