I have to admit that I missed this article by Linda Hertzberg et al. when it was first published in Anesthesia and Analgesia last October. Interestingly, an editorial commenting on this paper was published in the January issue of the journal and it was the editorial that alerted me to this paper. I’ve asked my good friend and colleague, Lynne Ferrari MD, the Associate Chief Medical Officer and Vice Chair Department of Anesthesiology, Boston Children’s Hospital, to review the editorial for the PAAD which has a different spin on the conclusions of today’s article. In today’s PAAD, Lynne Maxwell and I will review the paper by Hertzberg et al. Myron Yaster MD
Original article
Hertzberg LB, Miller TR, Byerly S, Rebello E, Flood P, Malinzak EB, Doyle CA, Pease S, Rock-Klotz JA, Kraus MB, Pai SL. Gender Differences in Compensation in Anesthesiology in the United States: Results of a National Survey of Anesthesiologists. Anesth Analg. 2021 Oct 1;133(4):1009-1018. PMID: 34375316
This survey study was sponsored and conducted by the American Society of Anesthesiologists’ Ad Hoc Committee on Women in Anesthesia and confirmed a gender compensation gap among physician anesthesiologists that is comparable with other medical specialties in the United States. “The difference in salaries between men and women physicians has been persistent, even after accounting for factors such as age, experience, specialty, work hours, productivity, and academic rank.” These differences “typically widen and persist over the entire course of a physician’s career”. The implications are obvious, particularly as the percentage of women in medicine and anesthesiology increases. Do these findings surprise any of you? By now most of you know I (Myron) love the 1942 movie Casablanca and I often use quotes from the movie in the PAAD, particularly, “I’m shocked just shocked that there is gambling going on here!”
when the findings of a study like this one are not shocking or surprising at all. (And if you haven’t seen the movie, take a break from the NFL playoffs and see it and celebrate its 80th anniversary this weekend!)
There are several interesting points of the article we’d like to highlight. First, the survey was only sent to ASA members and the response rate was low, really low (7%). Although the number of responses received represented 10.5% of those surveyed, two-thirds of those were excluded because respondents were not practicing in the US, or the answers were not complete. In addition, women were over-represented in the respondents compared to the ASA membership (population surveyed). So whatever the findings, the results must be taken with a grain of salt. Indeed, in SPA survey studies that I (Myron) have been involved in, response rates below 20-30% are difficult to get past the reviewers and published. Indeed, we don’t think a 7% response rate would ever get past peer review. Nevertheless, the results are consistent with other studies in other specialties, some of which we’d like to highlight. “A recent study of US physician income (2014–2018) showed that although practices and specialties with higher proportions of women physicians had a lower income gap, a gap still existed and was exaggerated in both the surgical specialties and in practices with >90% men.(1) Another study noted that as the proportion of women rose in a medical specialty, overall compensation in that specialty fell, with persistence of the gender pay gap.(2) Why this occurs is unclear but clearly has important implications as the number of women in anesthesiology increases. This observation is not limited to medicine and has been reported over decades by social science researchers for occupations from janitors/housekeepers to computer programmers as well as physicians.(3) These studies found that as the proportion of women increases in a profession, the compensation declines. These finding were highlighted in a 2016 article by Claire Cain Miller in the New York Times.(4) In a 1994 book (Moving Beyond Words), Gloria Steinem wrote “The truth was (and still is) that in the United States, as in almost every country, categories of work are less likely to be paid by the expertise they require — or even by importance to the community or to the often mythical free market — than by the sex, race and class of most of their workers.” Ms. Steinem summarized these issues in a 2012 article.(5) Finally, although the average compensation of anesthesiologists was found to be higher than the average of physicians in all specialties, the gender-based compensation gap remained.
As will be further discussed by Lynne Ferrari in an upcoming PAAD, “women medical school faculty neither advance as rapidly nor are paid at the same level as professionally equivalent men colleagues”. “Academic women physicians have midcareer research productivity rates that are equivalent to or greater than those of men physicians, with women often showing increased productivity after childbearing age and surpassing publication rates of men.(3) However, because men often have greater research productivity earlier in their careers, they are more likely to be placed earlier in the “advancement track” by academic promotion committees.(6) Finally, this lower compensation was found in private practices as well. The authors “hypothesize that leadership and partnership positions may not be automatically given when a physician reaches milestones such as number of years in practice, cases performed, revenue generated, or administrative activities performed. A partnership offer may be based on subjective rather than objective factors. Skills such as self-promotion and negotiation, which are perceived as strengths for men, are historically perceived negatively for women”.
We think that this study can and should be repeated among SPA members. Would the results be duplicated, or would they be different because the number of women in pediatric anesthesiology is higher than in anesthesiology overall, or would the higher percentage of women in pediatric anesthesia result in lower compensation across the board? We don’t know but we should. Let us know what you think, and we’ll post in a reader response PAAD. Myron Yaster MD and Lynne G. Maxwell MD
References
1. Whaley CM, Arnold DR, Gross N, Jena AB. Practice composition and sex differences in physician income: observational study. BMJ 2020;370:m2588.
2. Pelley E, Carnes M. When a Specialty Becomes "Women's Work": Trends in and Implications of Specialty Gender Segregation in Medicine. Acad Med 2020;95:1499-506.
3. Ramakrishnan A, Sambuco D, Jagsi R. Women's participation in the medical profession: insights from experiences in Japan, Scandanavia, Russia and Easter Europe. J Women's Health 2014; 23: 927-34.
4. Miller CC. As women take over a male-dominated field, the pay drops. New York Times 2016; https://www.nytimes.com/2016/03/20/upshot/as-women-take-over-a-male-dominated-field-the-pay-drops.html
5. Steinem G. Valuing women's work. 2012; https://billmoyers.com/content/valuing-womens-work/
6. Pashkova AA, Svider PF, Chang CY, Diaz L, Eloy JA, Eloy JD. Gender disparity among US anaesthesiologists: are women underrepresented in academic ranks and scholarly productivity? Acta Anaesthesiol Scand 2013;57:1058-64.
Thank you very much for discussing and highlighting our committee's survey and study. You are correct about the limitations of the work; these were noted in our discussion as well. Having said that, I believe we adjusted for as many confounding factors as we could in our analysis and still saw a difference in compensation after adjustments. We were unable to obtain results by subspecialties in anesthesia due to inadequate numbers, even though we did ask about subspecialties in the survey. I would be very interested in having the study repeated among SPA members and seeing the whether the SPA results are similar.
Linda B Hertzberg, MD, FASA
Lynne and Myron, Thank you for this post. I would love to see this study repeated among SPA members and would be delighted to be part of the group who helps make that happen!