Closing the gender pay gap in emergency medicine: Paradigms to consider for leaders, faculty, and trainees

Abstract

The gender pay gap among physicians is a well documented and persistent problem and has a profound impact on earnings over a career lifetime. This paper describes examples of concrete initiatives three institutions took to identify and address gender pay gaps. Salary audits at two academic emergency departments highlight the importance of not only ensuring equity in salary among physicians of the same rank but also monitoring whether women are achieving equal representation at higher academic ranks and leadership, elements that typically contribute to compensation. These audits reveal how senior rank and formal leadership roles are significantly associated with salary disparities. A third school of medicine–wide initiative entailed conducting comprehensive salary audits followed by review and adjustment of faculty compensation to achieve pay equity. Graduating residents and fellows seeking first jobs out of training and faculty looking to be compensated equitably would benefit from understanding the elements that drive their compensation and advocating for frameworks that are understandable and transparent.

INTRODUCTION

The gender pay gap among physicians in the United States is well documented. In this country, women physicians earn 72 cents on the dollar compared with their male counterparts. ¹ In academic medicine, women earn less than men in every specialty and at every academic rank. ² Moreover, women physician faculty, regardless of race or ethnicity, earn less than men of every race and ethnicity. ³ Emergency medicine is no exception: women faculty physicians earn 84–94 cents on the dollar compared with white men. Most concerning, research has consistently shown that these gender‐based salary inequities begin with the first job after graduation. ⁴ , ⁵

Departmental processes that could identify and rectify drivers of the gender pay gap are not widely understood. While some root causes of salary disparities reflect deeply embedded cultural stereotypes and unconscious biases about gender role expectations, ⁶ others are the result of organizational practices at the institutional and departmental level that inadvertently impact access to professional opportunities and academic advancement, with considerable consequences for compensation. ⁷ In particular, women's representation declines steadily as one progresses up the ladder of faculty ranks: Women account for only 28% of full professors across all specialties nationwide and 21% of full professors in emergency medicine. ⁸ This disparity has improved very little over time. ⁹

Even small pay gaps at the beginning of one's career have tremendous consequences overtime. ⁵ , ¹⁰ , ¹¹ Thus, to narrow the pay gap, the next generation of faculty need to be educated during their training about compensation and taught negotiating skills to support equity for all upon entry into our professional community. ¹²

We describe novel initiatives that three of our institutions utilized to close their gender pay gaps among physician faculty. In particular, we detail three specific efforts to facilitate salary equity: two in emergency departments (EDs) and one in a large, research‐intensive school of medicine.

METHODS

This paper is based on a presentation at the 2022 Society for Academic Emergency Medicine (SAEM) annual meeting in New Orleans, LA, in May 2022. In both the presentation and this article, we describe how two academic EDs identified and compared salaries of men and women, followed salary progression over time, and shared results with the faculty for transparency. The third effort reflects the approach a large school of medicine adopted to improve salary transparency and pay equity accountability.

DISCUSSION

Departmental analysis

Two of the authors (TE and ET) independently conducted salary audits within their respective EDs: Baystate Health (BH), a large, diversified health system in western Massachusetts affiliated with UMass Chan Medical School, and Massachusetts General Hospital (MGH), a Harvard‐affiliated hospital in Boston. Both institutions utilize a four‐tier salary structure with either academic rank or a combination of academic rank and leadership positions as drivers of advancement into higher compensation tiers (Figure 1).

FIGURE 1.

Trends in women faculty by tier over time. MGH, Massachusetts General Hospital; UMMS, UMass Chan Medical School.

Salary audits focused on identifying the following elements: Were salaries equitable within each salary tier, and were men and women advancing at similar rates from lower to higher tiers? Authors conducted analyses at 1‐ to 3‐year intervals with plans for repeat analysis to assess progression. At both institutions, salaries within each tier were equitable between men and women (Figure 2). However, the rate of advancement differed by gender: women's representation in each salary tier progressively decreased in the higher tiers when compared with men.

FIGURE 2.

Comparison of male and female faculty over time.

In the first year, the analysis at Baystate Health included 27 faculty, 10 women and 17 men, and excluded chair, vice‐chair, and pediatric emergency medicine (PEM) faculty. Women accounted for 50% of the first and second salary tiers. There were no women in the third tier, and only 20% of the fourth tier were women. MGH observed a similar lack of representation in women at the highest levels of academic rank and among formal departmental leadership. Initially, the analysis included a total of 28 men and 12 women faculty (excluding chair, executive vice‐chair, nonclinical faculty, and PEM faculty). First‐, second‐, and third‐tier salaries had 17%, 47%, and 21% women, respectively, and there were no women in the fourth tier. On repeat audit these numbers progressed to 60%, 38%, 38%, and 20% at Year 2 at Baystate Health and 11%, 37%, 31%, and 0% at Year 3 at MGH respectively (Figure 1).

At Baystate Health, the salary audit examined the relationship of years of practice to salary tier progression. At the time of the first analysis in 2019, women in the overall department had an average of 7 years of practice as opposed to 13 years for men. The discrepancy in years of practice was likely a reflection of the shifting gender demographics within the department over the past 10 years during which the department had experienced a significant increase in women faculty hires, with seven of the 10 female faculty having been hired within the previous 8 years. Typical progression from the third to second tier occurred when a physician had between Years 8–11 years of practice. Repeat analysis in 2020 showed some advancement had occurred: The percentage of women in the third tier increased from 0% to 38% (Figure 1). It is unclear if this increase may have been aided by an increased scrutiny on salary progression as a result of the ongoing audits.

Instead of years of practice, MGH assessed departmental leadership roles as they related to salary advancement. Primary leadership roles were defined as chair, vice‐chair, and program director; secondary leadership roles included division chiefs, medical directors, and quality and safety chair. On initial assessment, there were six and 10 men in primary and secondary leadership roles and zero and three women, respectively. At Year 3, these numbers increased to seven and 11 for men and two and four for women (Figure 3). During the 3‐year period, promotions and leadership roles stayed fairly steady between male and female faculty with one man promoted to full professor and one to associate professor, compared to zero and two for women. Women increased their primary and secondary leadership roles from zero to two and three to four, respectively, while men increased from six to seven and 10 to 11. However, more men were hired during this time frame than women, seven versus one.

FIGURE 3.

Representation men and women in leadership roles at MGH.

Both institutions found leadership roles and academic rank to be associated with salary disparities. While salaries in each tier were equitable between men and women, women's diminished tier progression compared with men was associated with decreased academic promotion and attainment of formal leadership roles. Notably, salary audits in both departments were restricted to rank‐and‐file faculty and particular leadership roles and excluded the highest level of leadership (i.e., chair and vice‐chairs at UMass Chan Medical School–Baystate and chair and executive vice‐chair at MGH). Salaries of the high‐level leadership structures fell outside of the tiered salary structure of other faculty. Additionally, at the time of analysis at both institutions, men held all of these senior‐most positions and so no comparison was possible.

Institutional approach

In 2016, Yale School of Medicine undertook a comprehensive review of compensation. Historically, Yale's model relied on four elements to determine faculty salaries, which were benchmarked to the median of the American Association of Medical Colleges’ Faculty Salary Survey for institutions residing in the northeast: (1) education and years since graduation; (2) productivity based on collections, relative value units, and publications; (3) position and years in rank; and (4) major roles and responsibilities. Despite these seemingly objective metrics, medical school leadership observed a persistent and unexplained gender pay disparity of approximately 3% across the institution.

To help address its gender pay gap, the medical school dean developed a new annual compensation review process that utilized a multivariate regression model to analyze salaries of all faculty. Since inception, the model has undergone significant revisions to incorporate market variables, productivity measures that account for clinical full‐time equivalents (cFTEs), research versus nonresearch status, type of clinical track (clinician, clinician educator, or clinician scientist), and administrative tier. Methodology is reviewed every year and improvements are made as appropriate. An internal team that is supported by Yale School of Medicine's Academic Analytics Office proposes these changes.

Additionally, in 2016, the dean met with each department chair individually to review all 1900 clinical and research faculty member salaries. Medical school leadership in attendance at these initial chair meetings included the deputy deans of diversity, education, and finance as well as representatives from the general counsel's office and the university provost's office. The chairs presented each faculty member and discussed their approach to compensation determination. Salaries that deviated from expected parameters were addressed at the meeting and adjustments made. Aggregate results of the adjustments were presented at a compensation town hall for faculty (Figure 4). This process was repeated annually from 2016 until 2020. Since 2020, the dean presents the results of the salary equity analysis as part of her “state of the school” address (in lieu of the town hall). The individual chair meetings were thought to be too time‐intensive and were discontinued, but the dean's office continues to review each faculty member's compensation annually. In 2022, departments with large, persistent gaps underwent extended review. The criteria for determining this cohort were not promulgated.

FIGURE 4.

Yale annual salary pools and adjustments. MGH, Massachusetts General Hospital. Primary = chair, vice‐chair, program director; secondary = division chief, medical director, quality and safety chair.

During the annual dean–chair meetings that occurred 2016–2020, leaders also revised departmental compensation methodology to capture contributions deemed valuable by the medical school, such as citizenship, as well as recommended salary, projected variable compensation, clinical and research performance metrics, and leadership roles. Since 2020, the dean's office requires departments to submit their compensation determination plans to the dean's office annually. The departments must also provide these plans to their faculty.

The above steps (Table 1) represent an overview of one institution's approach to achieving salary equity. More detailed roadmaps for health care organizations to utilize are also available. ⁷ At the end of the academic year, each faculty member receives a “report card” or compensation benchmarking report. The report likely provides both an external and an internal check on equity and reinforces accountability at both the departmental and the university levels (Figure 5).

TABLE 1.

Stepwise institutional strategy to address salary equity adopted by Yale University.

Salary benchmarks determined using AAMC data, education and years since graduation, productivity, position and years in rank, and major roles and responsibilities

Developed regression model for clinical and nonclinical faculty

Salary audit conducted

Regression model adjusted yearly to account for unaccounted for factors

Dean and each departmental chair met to discuss each individual faculty member

Faculty salaries adjusted with compensation that deviates from expected parameters

Aggregate data from salary analysis presented at schoolwide town hall for discussion and to promote accountability

Abbreviation: AAMC, Association of American Medical Colleges.

FIGURE 5.

Yale sample compensation benchmarking statement.

In sum, Yale's process relies on transparency, systematic review, and institutional accountability to minimize gender inequality in pay. The Veterans Affairs system has been reported to use a similar approach with positive effect on salary equity. ¹³

LIMITATIONS

Our observations are limited to two departments and one institution. However, our experiences and results highlight important elements to consider when seeking to close the gender pay gap among academic physicians. Another significant limitation is that our initiatives and analyses assessed only disparities in total cash compensation.

There are other forms of currency in emergency medicine that potentially differ by gender. For example, the Mayo Clinic compensates physicians according to a transparent progression model over a 5‐year period with the maximum target compensation based on specialty and the number of years postresidency (i.e., a salary‐only model). The Mayo Clinic has affirmed gender pay equity among physicians who are the same number of years postresidency. ¹⁴ In emergency medicine, salary progression caps at 5 years postresidency, after which time there is an annual equitable increase in salary across the specialty. Such an approach allows for analysis of discordance in nonfinancial compensation. In a study published in 2014, one of the authors analyzed the distribution of leadership positions, academic rank, and protected time in the ED over a 3‐year period and found no significant gender difference in titled leadership positions or academic rank. ¹⁵ However, men were more likely to have protected time in the first 1.5 years and women caught up with men in both the proportion of protected time and the probability of having any protected time at about 7 years of tenure. Thus, work expectation for a particular salary is potentially another dimension to consider when assessing compensation inequity. Indeed, evidence reveals that women in the workplace are asked to do more uncompensated tasks, raising the question are equal salaries actually for equal work. ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ More research will need to be undertaken in this area.

CONCLUSIONS/IMPLICATIONS

All members of our profession, men and women as well as trainees and faculty, could benefit from transparency around how salaries are determined, especially regarding equity of opportunity for academic advancement and the organizational leadership roles that drive compensation levels. Salary audits are critical to highlighting disparities in opportunity and representation that impact compensation and can provide the impetus for leadership to reevaluate salary structures, access to leadership roles, the nature of those roles (compensated or not), and support for academic promotions. These audits should be complemented with assessments by gender of leadership representation, academic rank progression, and protected time.

By encouraging ongoing salary audits that focus on both equity within rank, as well as advancement and representation of women in higher ranks, incremental steps can be taken to address the gender pay gap from a departmental level. At the same time, broader scrutiny, transparency, and action at the institutional level is also key to ensuring accountability.

AUTHOR CONTRIBUTIONS

Tala Elia—concept and design, acquisition of the data, analysis and interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Elizabeth Temin—concept and design, acquisition of the data, analysis and interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Sharon Chekijian—concept and design, acquisition of the data, analysis and interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Neha Raukar—concept and design, analysis and interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Amy Gottlieb—concept and design, analysis and interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Elia T, Temin E, Chekijian S, Raukar N, Gottlieb A. Closing the gender pay gap in emergency medicine: Paradigms to consider for leaders, faculty, and trainees. AEM Educ Train. 2023;7(Suppl. 1):S41–S47. doi: 10.1002/aet2.10875