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 “Do male physicians get preferential treatment in the ED?” EPM asked this among other questions in this year’s workforce survey. Think you know the answers? You might be surprised to hear what you colleagues had to say.

We frequently expect physicians to be exempt from the unpalatable social inconsistencies that plague society. In the words of Greg Henry, “We see everyone without fear or favor.” Yet we are sometimes reminded that physicians are people, and are prone to all the same social biases that exist outside the ambulance bay doors. And that includes gender inequality.
Are men and women equal in the emergency department? It depends on the context. Biochemically? Intellectually? Physically? The list of comparison points is endless. The fact is, men and women are different in a great many ways, and those differences are of great value to society. Unfortunately, gender bias often intrudes where it is neither welcome or appropriate. When gender, in and of itself, results in differences that should be independent of your x and y chromosomes, this creates inequity and social unrest.

Although much data has been published regarding gender-related differences in the business world, primarily salary gaps, very little has been reported in medicine and even less in emergency medicine. Although some annual emergency medicine salary surveys are published and/or sold, this data is not focused on the kind of issues we are considering here. Emergency Physicians Monthly conducted a survey in which approximately 650 respondents answered 30 questions about gender-related employment issues. While we recognize the limitations to our methodology, this data does help us draw some reasonable conclusions, regarding where similarities exist and where gender differences may be noted amongst EPs. Do you think women EPs are treated the same as male EPs? Read on. You may be surprised.

With respect to employment situation, most EPs – men and women – are employed full time with full benefits (see graph). But who makes more money? You probably guessed it. It appears that the same salary bias seen outside of medicine exists within emergency medicine. When asked their salary range, 47.5 percent of men working full time (FT) reported a salary (clinical hours only) from $240,000 to over $400,000, while only 23.5 percent of FT women reported the same range.

Those reporting a clinical income range of less than $100,000 to $240,000 was 51.5% for males and 76.2% for women.
Is this income difference driven by hours worked? Male respondents who reported full-time status worked more hours than their full-time, female counterparts. However, when comparing the income of male and female EPs working the same number of hours, males routinely earn more (see figure ).

More men reported being partners of their group (40%), with women reporting partnership status only 29% of the time. 52% of male EPs reported working more than 140 hours per month, whereas only 32% of female EPs reported the same. Interestingly, 36% of both female and male respondents reported working less than 140 clinical hours a month.
Women work part-time more often then men, 29% versus 15%. When asked if their part-time status negatively impacted their professional reputation with their colleagues, 23% of women felt it did, compared to only 14% of men. None of the male respondents felt that their part-time status would impact their ability to attain professional goals. However, 20% of women felt that it would limit their opportunities.

What does it all mean?
Our survey covered a lot of the nuts and bolts and gender-based perceptions about our EM workplace. After analysis, three general themes seemed to stand out and merit further comment: salary, part-time scheduling and professional development.

Compensation surveys, especially in fields like emergency medicine where there are several different compensation models, are fraught with confusion. For example, Roberziek (Modern Health Care July 2010) reviewed the data on 15 different physician salary surveys from 2009 and showed that the average reported EP salary ranged from $239,000 to $316,000. So, there are some technical difficulties comparing the salaries of an independent contractor living in Arizona with an academician teaching in New England, but when you look at all of the data, some consistent trends slowly emerge. You are probably going to make more money in emergency medicine if you practice in Texas versus Maine and if you are a man and not a woman.

In the April issue of EPM we discussed Lo Sasso’s study that showed that male EM residents graduating from New York state residency programs were likely to make $12,000 more in their first job out of residency compared to their female counterparts. But, what happens to salary for men and women EPs after they have worked for a few years? Daniel Sterns and Associates 2010 salary report shows that a full-time female director getting paid the 50th percentile made $288,000 versus $325,000 for a male and that a full time female staffer making 50th percentile brought in $240,000 versus a male’s $289,000. A similar Medscape 2010 survey found a $45,000 salary difference between male and female EPs. Our data is consistent with these studies and reinforces that there are real and tangible differences here.

Could this all be legitimate? Let’s say a guy picks up a few extra moonlighting shifts or a woman chooses a lower volume department? Perhaps. In our survey men were more likely than women to place salary in the top three considerations of employment (69% vs 41%), while woman seemed more interested in schedule (54% for women, 49% for men) and collegiality (45% women, 39% men). It would be a bit simplistic, however, to believe that this is the entire story. The American Medical Women’s Association (AMWA) is quick to point out that even if women pick jobs based on different qualities, their adjusted salaries at those jobs are frequently lower than their male colleagues. Women may be lulled into the belief that a better work environment is worth a few less dollars in their paycheck and may forgo contract negotiation because they don’t want to risk appearing “difficult and demanding” with their new employers. In our study, men appeared somewhat more comfortable negotiating than women (42% of men attempted negotiations versus 36% of women). When either gender negotiated they were successful over 80% of the time. However, when asked if the negotiation was successful in negotiating a better package, men were more likely to rate their negotiation as very successful (24% vs. 14%).

Salary transparency is also worth comment. Clem, in a study published in 2008 in the Annals of Emergency Medicine, noted that high salary alone was not a huge factor in job satisfaction for women EPs, but that receiving a salary equivalent to their male peers was. As Title 9, the Equal Opportunity Education Act of 1972, and the first big wave of women hit medical schools decades ago, many younger female physicians have grown up in a culture where equality is almost assumed. Realistically, it may not even occur to many of them to seriously consider that they wouldn’t be paid the same as their male colleagues for the same job. So, maybe they don’t ask or they consider their coworkers’ salaries off limits. Either way, the door is open for subtle discrepancies to creep in.

Now is a great time for all the bookkeepers in emergency medicine to do a quick review. Are there gender-based salary discrepancies in your group? If yes, are they objectively accounted for by hours worked, RVUs, etc? Most importantly, are there opportunities for future adjustments to make them more equitable?

How does gender affect professional advancement? When respondents were asked if they felt they had missed opportunities for professional advancement based on their gender, 13% of men answered yes compared to 41% of women. Abbuhl, at University of Pennsylvania, did a nice study looking at the gender breakdown of their university’s academic awards. (J Gen Intern Med 2009) They found that in areas where recipients were awarded for more objective and measurable parameters (i.e. publications or grant money) that the gender distributions were appropriately proportionate to any departments male/female ratio. They found, however, in areas where awards were based on more loosely subjective criteria that men disproportionately prevailed. They surmised that subconscious bias or stereotyping contributed to this and that given the lack of specific objective criteria, individuals were more likely to acknowledge and promote individuals more like themselves. If bonuses are awarded by individual discretion, based on loose subjective criteria, this could also contribute to some of the above mentioned salary differences.

A similar review by Carnes (Acad Med 2007), looked at the effect of subconscious bias in leadership promotion. They concluded that men and women will, when given equal applicant qualifications, preferentially select a man over a woman for a leadership position. This occurs even though multiple studies have shown that women are objectively as effective leaders as men and that when looking at a “transformational” style of leadership (one that inspires and empowers employees), that women may even have a slight edge. Again, the authors conclude that the preferential advancement of men is based on subconscious stereotypical assumptions of intrinsic gender traits.

Barbara Annis, author of Leadership and the Sexes, comments on two gender-specific traits that may influence opportunities and advancement. First, men are usually more comfortable with self-promotion and often make their intentions public. Women on the other hand, often expect their qualifications to be first validated by their bosses and may sit back and wait to be “asked” to put their name in the hat. Second, women are often promoted after they have already achieved the anticipated skill set for a new position, while men are often promoted for their potential. Case in point, according to an advancement committee member at Tufts University, female physicians generally tend to hold back their promotion material an extra two years compared to their male peers.

So how do we combat subconscious bias? First, consciously acknowledge that it truly exists. Other considerations include: publicly advertising opportunities within your group, directly asking qualified women to apply, making awards, bonuses and promotions as objectively based as possible and encouraging the participation of women on key committees. On this last point, per Carnes research, it is important to realize the addition of a single female to an all male group is unlikely to have a significant impact. It usually takes 1/3 of the group to be women to change its culture and avert subconscious bias.
As mentioned previously, women were much more likely than men to feel that going part-time was likely to have long term negative ramifications on their professional development. These findings are concerning because according to Clem’s Annals study women are more likely to have better job satisfaction if they are positively validated by their peers and have opportunity for job advancement.

Is gender bias real? Is the lofty profession of emergency medicine beyond such claims? Clearly not. It’s time to recognize that inappropriate gender differences do exist in emergency medicine and that tolerance of such bias only serves to validate and perpetuate their existence.

Click here to download pdf of figures 
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Comments   

# HDoc 2011-07-09 07:18
Don't think so.
My wife is a physician and I know another husband/wife ER doc couple as well, so I can ponit out my own observations on the matter.
Women usually do not want the trauma and hard cases, which of course means higher RVU's. They tend to work more in the fast track/non urgent sides. When confronted with trauma, they are more likely to leave the procedures, like chest tubes, up to the surgeons. Female doctors also tend to work fewer hours due to child care concerns then men do. This is not a bash on female doctors, this actually comes from my wife who admits it.
Both sexes have different priorities. Please don't call this gender "bias"
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