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Date: March 8th, 2019

Reference: Wiler et al. Continuation of Gender Disparities in Pay Among Academic Emergency Medicine Physicians. AEM March 2019.

Guest Skeptic: Dr. Esther Choo. She is an emergency physician and researcher who studies health disparities, substance use disorders, and gender bias. Esther is an Associate Professor at Oregon Health and Sciences University and also is a founding member of the non-profit TIME’S UP Healthcare.

This SGEMHOP was recorded on International Women’s Day. It was the SGEM’s part in the Time’s Up in Healthcare initiative.

The clock has run out on sexual assault, harassment and inequity in the healthcare workplace. It’s time to do something about it.

Here is some more information on Time’s Up in Healthcare:

Case: A women colleague is being hired for an emergency department attending job wants to know why her pay is less than that of a man at the same hospital with the same years of training and the same accomplishments?

Background: Salary disparity between men and women has existed forever, and despite efforts such as the Equal Pay Act of 1963, this disparity continues to exist. This gap is seen across numerous professions, including law, marketing, administration and medicine. In the United States, women working full time are typically paid just 80 percent of what men are paid (1-4).

According to one 2010 analysis, the disparity in medicine is one of the highest for any professional industry, trailing only dentistry (5). Women now represent half of medical school graduates and 38% of faculty members in U.S. medical schools (6). After controlling for multiple factors, including specialty, age, faculty rank and metrics of productivity, male physicians earned nearly $20,000 more per year than their female counterparts (7,8). Within emergency medicine, studies have shown female faculty are paid 10% to 13% less than males (9,10).

In Canada, this gender disparity also exists and occurs across specialties and within academia.

Clinical Question: Is there a difference in compensation for men and women emergency physicians practicing in the United States?

Reference: Wiler et al. Continuation of Gender Disparities in Pay Among Academic Emergency Medicine Physicians. AEM March 2019.

  • Population: Academic emergency medicine physicians in the United States
  • Intervention: No intervention, this was a cross-sectional observational study of academic emergency physician salaries across the United States. It was done over 4 years from 2013-2017 (excluding 2014).
  • Comparison: Women vs. men emergency physicians
  • Outcome: Adjusted median annual base salary for physicians

Dr. Jennifer Wiler

This is an SGEMHOP episode which means we have the lead author on the show. Dr. Jennifer Wiler is a Professor and Executive Vice Chair, Department of Emergency Medicine, CU School of Medicine; and Professor, CU School of Business. She has served in numerous state and national leadership positions including Chair of the American Medical Association Women Physicians Congress.

Authors’ Conclusions: “Despite previously published data showing an inappropriate gender salary gap in emergency medicine, this gap has remained essentially unchanged over the past four years.”

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? No
  7. Was the follow up of subjects complete enough? Unsure
  8. How precise are the results? Precise with narrow confidence intervals.
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure
  11. Do the results of this study fit with other available evidence? Yes

Key Results: There were 7,102 respondents over all time periods (2013, 2015-17) from 81 emergency departments, representing four geographic regions of the US. Most were from the Northeast (38%) and male (65%) and reported they worked at pure academic emergency departments (94%)

Women EM physicians’ pay was significantly less per year than men EM physicians.

  • Median salary increase for men was higher ($226,746 in 2013 to $252,000 in 2017) than women ($217,000 in 2013 to $240,000 in 2017)
  • Overall salaries increased across all four years studied with an overall increase of 10.8% (95% CI 9.6% to 12%)
  • Women 10.6% (95% CI 9.4% to11.8%) vs. men 11.1% (95% CI 10.2% to 12%).
  • The overall difference in salary for males was higher and this was significant at all four time points (Z=6.33, P<0.001)
  • This pay difference persisted in the predictive model controlling for co-variates (Table 4).
  • Between 2016 and 2017, women’s salaries increased at a rate of 6.56% compared to 3.82% for men.
  • At all time points, the proportion of respondents at higher academic ranks and higher salaries was always greater for men than women.

Listen to the podcast on iTunes or Google Play to hear Jennifer’s responses to our ten nerdy questions.

1. Response Rate: This was not reported in the study. Can you comment on what the response rate was to your survey?

2. Selection Bias: These surveys were sent to listservs for AAAEM and AACEM. These are academic emergency departments. How do we know this sample represents all US emergency department physician groups?

3. Administrators: Most of the surveys were completed by department administrators and not the individual physicians. Do you think this is an accurate way to determine physicians’ salaries?

4. Exclusion of 2014: Why was the year 2014 excluded from the study?

5. Confounder: Is there any reason you can think of that pay differences would be discrepant besides gender? Some examples from a Canadian article of gender pay differences were things like more breast disease patients and rectal prolapse being referred to female general surgeons. These are both lower compensation visits/procedures and thus contributes to lower compensation for women surgeons. Is there anything like this that could account for disparity in this study?

6. Payment Scheme: What do you think of a fee for service system or hourly contracted rate of pay system to eliminate these pay discrepancies?

7. Rise is Pay Rate: In 2016 and 2017, the rise in pay rate was greater for women (7%) compared to men (4%). Is this continuing and is it an active intervention to eliminate this gender pay gap?

 8. Future Research: What future research questions are you planning to explore on the issue of gender pay inequity?

 9. Fixing the Problem: How do you think the problem of the gender pay gap can be fixed?

10. Anything Else: Is there anything else you want to say about your study, or the issue of gender pay gap?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors conclusion.

SGEM Bottom Line: There continues to be an unexplained pay gap between men and women academic emergency physicians in the United States.

Case Resolution: The objective information is taken to the proper leadership and a salary audit is request across the entire faculty.

Dr. Esther Choo

Clinical Application: We all need to be more aware of this persistent pay gap and how it continues despite our best intentions. We also need to try to employ means of being more objective and consistent in the way that we allocate pay compensation.  Every few years a review should be performed to look at salaries and other forms of compensation are distributed across a group of physicians. This is to ensure we correct any unexplained differences to make sure we have a save and equitable environment.

What Do I Tell the Colleague? Do not sit on this issue. I think it can be really tough to feel like you are not being treated equally, say nothing and slowly get disenchanted with your work place. You feel like you are not valued. Because these things are due to unconscious bias, I think often the people that you are attributing devaluing you as devaluing you are doing it and not realizing it. We need to make the implicit things explicit. I would encourage the colleague to talk about it with the leadership, express concerns and allow them to take corrective action.

Keener Kontest: Last weeks’ winner was Cody Martin. They knew the first prototype laryngeal mask was used on a person in 1981 (van Zundert et al. Anesthesia 2012).

Listen to the podcast to hear this weeks’ trivia question. If you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on the gender pay gap? Tweet your comments using #SGEMHOP. What questions do you have for Jennifer and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. We will put the process on the SGEM blog:

  • Go to the Wiley Health Learning website
  • Register and create a log in
  • Search for Academic Emergency Medicine – “March”
  • Complete the five questions and submit your answers
  • Please email Corey (coreyheitzmd@gmail.com) with any questions or difficulties.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

  1. Weichselbaumer D, Winter-Ebmer R. A meta-analysis of the international gender wage gap. J Econ Surv 2005;19:479–511.
  2. Ross AH. The Equal Pay Act of 1963: A Decade of Enforcement. Boston College Law Review Nov 1974; 16(1):1. Available at: https://lawdigitalcommons.bc.edu/ cgi/viewcontent.cgi?article=1460&context=bclr. Accessed October 28, 2018.
  3. Proctor BD, Semega JL, Kollar MA. Income and poverty in the United States: 2015. Washington, DC: U.S. Government Printing Office. U.S. Census Bureau, Current Population Reports, 2016. https://www.census.gov/ content/dam/Census/library/publications/2016/demo/p60– 256.pdf Accessed October 28, 2018.
  4. U.S. Bureau of Labor Statistics 2016, TED The Economics Daily. Women’s Median Earnings 82 Percent of Men’s in 2016. Available at: https://www.bls.gov/opub/ ted/2017/womens-median-earnings-82-percent-of-mens-in- 2016.htm. Accessed October 28, 2018.
  5. Nguyen Le TA, Lo Sasso AT, Vujicic M. Trends in the earnings gender gap among dentists, physicians, and lawyers. J Am Dent Assoc 2017;148:257–62.e2.
  6. Lautenberger DM, Dandar VM, Raezer CL, Sloane RA. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership. Association of American Medical Colleges. 2014. Available at: https://members.aa mc.org/eweb/upload/The%20State%20of%20Women%20 in%20Academic%20Medicine%202013-2014%20FINAL. pdf. Accessed October 28, 2018.
  7. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med 2016;176:1294–304.
  8. Freund KM, Raj A, Kaplan SE, et al. Inequities in academic compensation by gender: a follow-up to the national faculty survey cohort study. Acad Med 2016;91:1068–73.
  9. Watts SH, Promes SB, Hockberger R. The Society for Academic Emergency Medicine and Association of Academic Chairs in Emergency Medicine 2009–2010 emergency medicine faculty salary and benefits survey. Acad Emerg Med 2012;19:852–60.
  10. Madsen TE, Linden JA, Rounds K, et al. Current status of gender and racial/ethnic disparities among academic emergency medicine physicians. Acad Emerg Med 2017;24:1182–92.