What’s driving the gender pay gap in medicine?

More women than ever are qualifying as doctors, yet in Canada and around the world, they’re consistently paid less than their male peers. Recent studies suggest the reasons for these pay gaps are complex, transcending differences in health systems and payment models.

In a recent international survey conducted by Medscape, primary care physicians in the United States, United Kingdom, Germany, France, Brazil and Mexico reported similar gender pay gaps, with female doctors in those countries making 20%–29% less than their male colleagues. The gap was greatest in Brazil, where female primary care physicians make US$38 000 annually while males make US$49 000, and smallest in Germany, where women and men make US$157 000 and US$189 000, respectively. Specialists reported even wider gaps in pay by gender, ranging from 19% in Spain to 47% in Germany.

Dr. Clover Hemans, president of the Federation of Medical Women of Canada, says Canada’s primary care pay gap is somewhere between Germany’s (20%) and the UK’s (26%). She notes that studies also show that female doctors have lower career satisfaction and less control over their work, in addition to being paid less and shouldering more responsibilities at home. “Internationally, the value of women’s work has always been less,” Hemans says.

Some have attributed these disparities to women working less than men, while others have questioned how a pay gap is even possible in a country like Canada, where most physicians are paid set fees for their services. However, a Canadian study published in JAMA Surgery in October found that female surgeons in Ontario earned 24% less than their male peers, despite the province’s fee-for-service payment model.

From the United Kingdom to the United States, female physicians across the Western world are making less than men in the same roles.

Image courtesy of iStock.com/AJ_Watt

Dr. Nancy Baxter, a colorectal surgeon in Toronto and coauthor of the study, traces the problem to women receiving more referrals for lower-paid procedures. Baxter saw this in her own practice, where male colleagues received more referrals for complex surgeries, earning them a reputation as “the best,” while she and other female surgeons received referrals for simpler procedures, such as removing anal warts.

Baxter has also heard referring doctors say they send challenging patients to certain specialists “because they have a better bedside manner,” and those specialists tend to be women. The extra time these cases involve isn’t compensated, she explains. “You’re not paid by the hour, you’re paid by the patient, so you’re actually harming the physician financially by doing that.”

The bias in referrals reflects the broader trend of women being concentrated in roles and specialties that pay less, such as gynecology and psychiatry. “The only way you’ll have equity is either you stop occupational segregation or, probably better than that, you actually ensure all the specialties and family [physicians] are paid appropriately,” Baxter says.

A cross-sectional study published in 2018 exposed a similar divide in Brazil, where 80% of female doctors held jobs in the three lowest wage categories, while 51% of male physicians had jobs in the three highest wage categories. Even after adjusting for differences in workload and experience, researchers found women earned less than men working the same hours. This pay gap has held, even as the profession has become increasingly female, says the study’s lead author, Dr. Giulia Mainardi. Within the next decade, women will outnumber men in medicine. “This is something we need to discuss now,” she says.

Many of the solutions proposed to close the pay gap in medicine could work in most Western nations. Writing for the Harvard Business Review, Dr. Lisa Rotenstein and Dr. Jessica Dudley suggest improving the collection and transparency of salary data, so that everyone can see who is being paid what. They also argue that coaching and sponsorship of female physicians should go beyond the same-gender mentorship and peer groups that have long been the norm.

Hemans says men are crucial allies in the bid for wage fairness. “We need them to encourage and promote us, to take parental leave, to stop interrupting us, to be active bystanders, call out sexism when they see it and stop taking [all the] credit.”

Baxter says a centralized referral system could ensure doctors don’t fall victim to biases when sending patients for procedures. It can be difficult for doctors to acknowledge their part in the problem, she says. “Because we have strong faith in our objectivity, our scientific methods, and believe we got here on merit, it’s really challenging for us to say ‘Maybe that’s not how it works. Maybe there is discrimination in our system.’”