‘Charge what you think you're worth’: a qualitative study exploring the gender pay gap in medicine and the role of price transparency

Abstract

Background

The gender pay gap in medicine is entrenched and has a negative impact on economic growth, institutional reputation and financial success, recruitment, retention and job satisfaction of female specialists and patient care. It also discourages women from entering specialist fields of medicine. In the Australian unregulated market setting, female specialists are not simply getting paid less, they are choosing to set lower fees than their male counterparts.

Aims

We examine how implicit and explicit gender biases affect how fees are set and the potential role of price transparency in addressing the gender pay gap.

Methods

We conducted 27 semi‐structured interviews with medical specialists recruited via social media and medical society newsletters between June 2021 and March 2022. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis. Twenty surgeons and seven anaesthetists, 15 of whom identified as male and 12 as female, participated in this study. The primary outcomes and measures focused on the perspectives of surgeons and anaesthetists regarding fee‐setting practices.

Results

A combination of contextual and market‐ and gender‐related factors was the source of the biases that determine fee setting. Further, information asymmetry in medicine in Australia underlies current fee‐setting practices, exacerbating and entrenching false perceptions about women's skills as surgeons and anaesthetists. Women tend to internalise these biases, self‐regulating their behaviours and how they set their fees.

Conclusion

The gender pay gap is pervasive. Greater transparency on fees and quality could be explored as a potential solution to reduce pay inequality.

Introduction

The existence of the gender pay gap in medicine has been well established in Australia and internationally. ¹ , ² , ³ Female surgeons earned 44% less than their male counterparts in 2019–2020. Female anaesthetists fared slightly better, with earnings 27% lower than those of males. ⁴ This is well above the average pay gap of 23% across other industries. ⁵ The gender pay gap in medicine persists even after adjusting for age, family responsibilities, specialty choice, ⁶ hours worked ¹ , ² and public–private sector employment choice. ⁷ The gender pay gap is inherently problematic as it is shown to have a negative impact on economic growth, institutional reputation and financial success, recruitment, retention and job satisfaction of female specialists and patient care, as well as serving as a disincentive for women to enter into specialist fields of medicine. ⁸ , ⁹ Raising awareness of and understanding the complex reasons that contribute to the discrepancy in remuneration are a first step in trying to close the gender pay gap.

Not only do female specialists earn less, but they charge less. A study from Canada, where specialists are paid on a fee‐for‐service basis, found that patients treated by female surgeons had approximately 10% lower healthcare costs compared to patients treated by male surgeons. ¹⁰ A longitudinal survey of doctors ¹¹ working in the Australian private healthcare sector,^a where fees are unregulated and doctors are free to charge ‘what the market will bear’ show a gender pay gap in fees charged after accounting for hours worked (Fig. 1). This suggests that female specialists are choosing to set lower fees than their male counterparts. They do so despite the fact that their skill level, educational attainment and patient outcomes are on par with and in some instances exceed those of their male colleagues. ¹² The underlying reasons for setting lower fees are unknown.

Figure 1.

Difference in average fee charged by male versus female surgeons.

To address the gender pay gap in medicine, several solutions have been proposed. For salaried positions this includes salary transparency – auditing, reporting and correcting wage disparities between men and women performing equivalent work. The rationale is that the gender pay gap persists because of secrecy, and with transparency it would be difficult to sustain. ¹³ The American Medical Association has advocated for greater transparency in physician compensation, ¹⁴ and the Association of American Medical Colleges reports the salary gaps for various medical and surgical fields, the annual salary medians by region, professor rank and gender. ⁸ , ¹⁵ Publicly reporting salary data enable women to advocate for equal pay when they believe they have been paid less than their male peers, and organisations are expected take actions to reduce the gap as a response to public attention. ² , ¹⁶ Evidence from Canada, Denmark and the United Kingdom suggests that this mechanism is proving effective. ¹⁶ , ¹⁷ , ¹⁸ However, there is some evidence suggesting such initiatives may have unintended consequences, such as a shift in bargaining power from employees to employers, reducing wages overall. ¹⁹

While research regarding gender pay gaps in salaried positions exists, there is a paucity of work focused on women working in private practice. ²⁰ There is a gap in understanding why women and men charge differently and whether this impacts quality of care or practice style. ²¹ In this study, we explore how implicit and explicit gender biases – that is, the unconscious and conscious ‘associations and judgments that influence social behaviour’, ²² might influence the rationale behind fee setting. We consider whether transparency of healthcare costs and performance initiatives geared towards making healthcare more affordable by empowering consumers to choose lower‐cost and better‐performing healthcare providers, may serve to close the gender pay gap in a similar way that banning pay secrecy clauses is paving the way forward in salaried positions. ²³

Methods

Study design

This qualitative study was part of a multiphase mixed‐methods program investigating the sources of variation in fees and out‐of‐pocket costs in specialists' services. Semi‐structured interviews were conducted using a pilot‐tested interview guide designed to understand what factors influence fee setting and specialists' views on participation in price transparency initiatives. Notes were taken after each interview, and the researchers engaged in reflexive practice meetings to ensure academic rigour. The study is reported in line with the Consolidated Criteria for Reporting Qualitative Research. ²⁴

Participant recruitment

Purposive sampling was used to recruit participants between June 2021 and March 2022 via social media and medical society newsletters, and email invitations were sent to 200 randomly selected surgeons whose emails were publicly available on the Royal Australian College of Surgeons website. Recruitment ceased when researchers were confident sufficient data had been collected for thematic saturation. ²⁵ Specialists were offered an AU$80 digital gift card as compensation for their time.

A total of 27 specialists from a range of fields of expertise, including anaesthesia, orthopaedics, urology and neurosurgery, took part ininterviews. Our study has a higher representation of female specialists (45%) compared to the number of females in the overall population of surgical specialists (12%), ²⁶ and 56% of participants had been consulting for at least 15 years. The majority (89%) of participants worked in both public and private settings. Sample characteristics are listed in Table 1.

Table 1.

Participant demographics

Attributes	n (%)
Gender
Male	15 (55)
Female	12 (45)
Age
35–44	5 (18)
45–54	14 (52)
55–64	7 (26)
64–74	1 (4)
Specialty
Anaesthesia	7 (26)
Orthopaedics	4 (16)
Urology	3 (11)
Neurosurgery	3 (11)
Other†	10 (36)
Years in practice
0–4 years	1 (4)
5–9 years	6 (22)
10–14 years	5 (18)
15–19 years	8 (29)
20–24 years	4 (16)
25+ years	3 (11)
Setting currently working
Private only	3 (11)
Public and private	24 (89)

^†Colorectal, vascular, general, cardiothoracic, endocrine, otolaryngology head and neck, oncology, more than one specialty.

Data collection

The interviews were undertaken by three female researchers (KP, PhD, Senior Research Fellow; CLB, PhD, Research Fellow and HS, MIP, MPH, Research Assistant) experienced in qualitative research with an interest in health equity. There was no prior relationship with participants. Participants were emailed a participant information sheet and provided with a link to a website with information about the researchers and their research interests prior to the interview. Interviews were conducted once with each participant via telephone and audio‐recorded with the participants' verbal consent and averaged 41 min (ranged 32–71 min). Participants were offered the opportunity to review their transcripts prior to data analysis, with eight accepting and no corrections made. No participants dropped out of the study.

Data analysis

Interviews were transcribed verbatim and imported into QSR NVivo 12. Thematic analysis was conducted using a combination of inductive and deductive coding. ²⁷ , ²⁸ First we (KP, CLB and HS) coded the same five interview transcripts to a coding tree (e.g. patient, specialist and system‐level factors) that was based on the structure of the interview guide (deductive). As more codes emerged (e.g. patient and referrer biases), these were discussed, and the coding tree was refined (inductive). HS coded the remaining transcripts and added additional codes as needed. For theme development and refinement, related codes were grouped together and then consolidated into emerging themes, which were discussed by the research team until a consensus was reached.

Results

Interviews indicated that female specialists charged less than their male colleagues and that awareness of this differential was predominantly shared among female specialists. As such, the results focus on female fee‐setting. Patient, specialist and system‐level factors influencing specialist's fee‐setting have been reported elsewhere. A range of themes were identified as to why the gap persists. The results consider the supply side, which elucidates what female specialists take into consideration when setting fees, and the demand side, which explores how they set their fees in response to perceptions of patients' and GPs' referral expectations and preferences (Table 2).

Table 2.

Themes

Market factors	Gender‐related factors	Market failure
Contextual factors	Lack of awareness	Devaluation of fees due to lack of awareness of what others (in particular men) are charging
Supply	Fee‐setting rationale	Devaluation of skills due to lack of awareness of patients' outcomes
	Ethics	Devaluation of fees due to considerations of other‐related factors such as the perception of asking for too much or deserving more
	Empathy	Discounted services and greater impetus to reduce prices to regulate for patient‐related inequalities
	Power dynamics	Devaluation of fees due to perceptions of colleagues' expectations
Demand	Assumption of skill level	Devaluation of fees due to colleagues' perceptions and assumptions of skill level and knowledge of patients' outcomes
	Patient biases	Devaluation of fees due to perceptions of patients' biases/assumptions of skill level and knowledge of patients' outcomes
	Referrer biases	Devaluation of fees, extended consultation times and procedures that may have lower risk due to colleague referral factors such as biases/assumptions of skill level and knowledge of patients' outcomes

Awareness of the gendered differential in fee setting

While most female specialists discussed the existence of differential fee setting, men were less likely to acknowledge that fee inequity exists and tended to only give importance to other factors that impacted fees (see Sabanovic et al. ²⁹ ). As one female surgeon described:

I've looked at the data and women charge less. They earn less. They spend longer with the patients. Patients are less likely to accept high fees from women. Whereas if a man charges a high fee, they'll think it's because he's better. They ask fewer questions of male doctors. They spend less time with male doctors. They're less likely to complain about male doctors. (Surgeon 10, Female)

Supply: fee‐setting rationales

On the supply side, we identified several factors influencing how female specialists set their fees which were not relevant for male specialists. For self‐related factors, female specialists value their services more conservatively and charge according to their confidence to perform a procedure. For patient‐related factors, they expressed a higher likelihood of feeling empathy for a patient, setting fees following their ethical beliefs and being more likely to be concerned about potential backlash from their colleagues.

Female specialists noted that they set more conservative fees on average to their male colleagues, not because they devalued, their services, but because male specialists tended to overinflate their skill levels and charge more. Female specialists discussed only being comfortable charging high fees for procedures they were extremely confident in performing.

I definitely think gender makes a difference […] If I divide up my surgeries into [procedure A] and [procedure B] I still don't charge a gap for [A]. All of my [A] work is no gap. Whereas my [B] work, I do charge quite a lot. I think I'd probably be above AMA [Australian Medical Association] rates to be honest for [B]. But again, I think I'm pretty good at [B]. I do charge quite a lot but saying that I still will have people that come to me for a second opinion and will say to me that I am way cheaper than [males] colleagues that they've seen down the road. (Surgeon 19, Female)

Female specialists were more likely to set their fees based on ethical considerations. Women were less willing to make a profit from others and expressed greater awareness of where they sat among the working population.

I look after a lot of patients with bad diseases, and I really find it very difficult to ask them for money above what I'm going to get [by charging Australian Medical Association rates] anyway, which to me is perfectly adequate. If you look at [surgeons'] salaries, we're probably in the top 0.1% of earners in the world. We are extraordinarily fortunate. And so, I just don't see a reason to gouge money out of sick people. (Surgeon 8, Female)

Female specialists showed greater responsiveness to patients' financial concerns but also acknowledged that patients may exploit this quality and share ‘hard luck stories’ more readily with them than with male colleagues.

I have an idea that I would charge roughly AMA [Australian Medical Association] rates, but then by the time I know them, or I feel sorry for them, or they're a little old lady who's really sick, I make a call that they're not going to be able to afford it, I might just known gap. (Surgeon 6, Female)

Female anaesthetists may take into consideration power dynamics between themselves and the surgeon when deciding how much to charge.

I think my female colleagues actually charge less than the male equivalent for the equal experience and they tend to worry more about keeping the surgeon happy. They do worry about losing the [surgical] list if they charge more than a certain amount, whereas I don't. It's a slightly different mentality in that regard. (Anaesthetist 5, Male)

Demand: setting fees according to what patients will pay

Female specialists discussed a range of implicit biases that curb their fee‐setting potential. For example, female surgeons stated that fees were set based on what they deemed patients would pay according to how they estimated their level of skill. Female surgeons perceived that patients were willing to pay more for male surgeons as they assumed their skill levels were higher.

I think there's also that preconception of female surgeons or female doctors versus male doctors that we are not as good as male doctors. If I tried to set the same fees as my male colleague, then I would probably have more patients not think that I was worth it based on my gender. (Surgeon 11, Female)

There is a lack of awareness among patients that post‐surgical outcomes for female and male surgeons are similar, if not better for patients treated by female surgeons.

Well, they're also not aware that outcomes are better for female surgeons. I'm sure you've seen that recent publication that was reported quite a bit in the popular press. (Surgeon 3, Female)

Female specialists discussed having longer consultations and spending more time communicating with their patients, which impacted their potential earnings. Because of their better communication skills, female specialists felt they were often referred more challenging patients or patients that required more time explaining their procedures.

I was getting all the referrals for patients that needed to have a bit of a chat. One of my classic referrals was for a patient that needed an operation explained to her because she really wants to stay with the surgeon who's doing the operation, but he didn't actually explain the operation to her properly. The GP [general practitioner] said, ‘I'll send you to the surgeon who'll explain the operation to you because she's a great communicator, but we'll go back to the other (male) surgeon to get the operation done’. (Surgeon 19, Female)

Discussion

Our study supports the perspective that gender norms influence remuneration for equal skills and education and that these implicit biases are shared by both men and women. ³⁰ The literature on the gender pay gap highlights factors such as occupational segregation, work experience, disproportionate domestic and care responsibilities in the home and a reluctance to negotiate salary offers. ¹⁹ , ³¹ In our study, female specialists considered gender bias, fear of retaliation and a lack of transparency as potential drivers of the gender pay gap. Female specialists setting their own fees appeared to constrain their earning potential because of a series of implicit and explicit biases, some of which constitute internalised conscious and unconscious beliefs, which ultimately stem from underlying gender norms that dictate how men and women ought to act.

These gender norms uphold the ‘care’ versus ‘cure’ dichotomy. Whereas men tend to be perceived as belonging in the ‘curing’ professions of surgeons and physicians, women are relegated to ‘caring’ professions that are considered less skilled and less worthy of pay. Caring is perceived as innate to women, so asking for remuneration for this is often met with suspicion. This dichotomy is evident in the commonly held belief that surgeons are male. ³² This presents itself in the way female specialists feel constrained by gender norms and struggle to assert themselves in situations where it is required. Potential backlash from colleagues is a concern as assertiveness is not traditionally perceived as appropriate for women. ³³

In our study, female specialists highlighted the existence of these biases in patient assumptions about skill level and the worth of their care, which in turn impacted how much they charged. This is consistent with the literature showing that patients perceive female physicians as being less skilled than male physicians and self‐regulated pricing as falling in line with perceived patient expectations. This assumption is not unfounded; female healthcare workers disproportionately experience a dynamic known as Patient Prejudice Towards Providers (PPTP). ²² PPTP refers to the prejudice patients direct towards healthcare workers when they do not conform to their idealised notion of a capable, most commonly a white male, ²² healthcare worker.

This type of bias is not only restricted to patients. GPs also exhibit biases in their referral patterns. Several studies have found that the primary factor influencing referral from a GP was surgeon sex, over and above age and experience. ³⁴ GPs are more likely to cease referring to female surgeons if patients report negative outcomes or experiences, suggesting pessimism over female surgeon skills is higher. ³⁵ However, this is contrary to evidence demonstrating equal or better outcomes for female specialists ¹⁰ , ¹² and no significant difference in the risk for surgical mortality following procedures. ³⁶ Yet female specialists are more likely to receive referrals for patients requiring longer discussions, while male specialists are more likely to see patients needing surgical procedures or technical expertise. ¹ This referral bias was evident in our study in the types of referrals female surgeons received: patients who required greater interaction (‘care’), as opposed to patients who required complex procedures (‘cure’). As a result, female specialists provide longer consultations, see fewer patients than their male counterparts and spend less time in theatre work, which has higher earning potential.

Information asymmetry with respect to fee‐setting practices amplifies these biases and reinforces false perceptions. More concerning than the false perceptions is that they appear to be internalised by women, so much so that they accordingly self‐regulate their behaviours. ³⁷ Preeminent feminist theorists like Judith Butler show how gender norms emanate from both cultural and professional spheres and are mutually reinforcing, so that females ‘perform’ an internalised conception of identity both consciously and unconsciously in everyday life. ³⁷ , ³⁸ , ³⁹ Therefore, even if female specialists consciously reject the premises of these biases, their behaviour nonetheless unconsciously reinforces the gender‐biased norms. ³⁷ Similar to women working in salaried positions, what is underlying the gender pay gap for women in private practice is the existence of a veil of secrecy arising from an information asymmetry that exists in the healthcare market between providers and patients. Patients have no information about the quality of the health care of different providers, thus relying on gendered beliefs.

Transparency, in the form of price transparency initiatives, are being promoted as an important means to achieving affordability in healthcare in countries where patients bear a portion of their healthcare costs. ⁴⁰ In 2021, the US Centers for Medicare & Medicaid Services require all hospitals to provide clear and accessible pricing information for the shoppable services they provide. ⁴¹ In Australia, the government has launched the Medical Cost Finder website, which lists the median costs for private hospital inpatient procedures by specialty, service and location. However, participation by specialists is voluntary. ⁴² While these initiatives are welcome, the information provided is incomplete. These measures focus on the demand side, with a focus on improving patient choice and cost effectiveness. In terms of the supply side and improving the gender pay gap in medicine more broadly, it has been advocated that providing greater salary transparency at an organisational level could be a solution. ⁹ , ⁴³ However, a gap exists in terms of measures focusing on ameliorating the gender pay gap for specialists, especially as they set their own prices in private settings. It is here that our research makes its novel contribution, extending the argument about greater transparency to apply it to fee‐setting practices of female specialists.

This has an additional benefit as quality measures such as clinical outcome data and patient experience surveys that can indicate quality of care are not considered by current initiatives that promote price transparency, either in Australia or internationally. We advocate that these types of initiatives should broaden their scope beyond simply price to include quality measures. It could then be beneficial for women to share their outcomes, mitigating information asymmetries and repudiating biases patients hold where they correlate capability in medicine with ‘maleness’ ²² and, in the absence of quality metrics, higher price with quality. ⁴⁴ Closing the wage gap in medicine is crucial, and while it is important for women to recognise their worth, we reject the notion that the solution lies in women simply raising their fees. Rather, the focus should be on reforming institutional structures that support greater transparency to address the information asymmetry as it pertains to outcomes, quality of care, pricing and price‐gouging activity. The government can play a greater leadership role in promoting the transparency of the private healthcare market. It could, for example, mandate the disclosure of price and quality information of common procedures subsidised by the publicly funded Medicare scheme.

Limitations

There is a chance of selection bias. The participating specialists may have been motivated because of their strong views about healthcare costs. Similarly, some specialists refused to participate because the study was funded by a private health insurance provider foundation, so their viewpoints have not been captured. The extent to which our study is generalisable to the population of specialists in Australia and worldwide is limited as we only interviewed surgical specialists, which excludes other non‐GP specialists working in Australia and elsewhere. In addition, our study did not consider ethnicity, race or other identity forms such as sexuality to explore how gender intersects with other identities to impact fee‐setting practices. We acknowledge that there is room for future research in this important area.

Conclusion

While female representation across medical specialties continues to increase, our study suggests that gender biases continue to shape the landscape in which female specialists operate. In response, female specialists constrain their earning potential. Information asymmetry in the healthcare market sustains this inequity. Price transparency initiatives, when combined with quality information, may be a potential solution to increase women's standing and earning potential in medicine.

We suggest that policy levers such as government subsidies could be used to promote specialist buy‐in to price and quality transparency initiatives. As we discuss, greater price transparency will help to close the gender pay gap, provide patients with greater choice and promote improved quality of care with the publication of patient outcomes and experiences. In addition, if patient outcomes and experiences were more transparent, government rebates could be provided for specific procedures and patient demographic groups, given the potential for greater care needs and their likely impact on consultation times, women's greater responsiveness to patients' financial concerns and mitigate referral bias from GPs, which disproportionately impacts women's relative fee‐earning potential.

If a gender pay gap persists even at the highest levels of earning potential in medicine, it sets a troubling precedent for the healthcare industry more broadly. Given the higher turnover rates among female healthcare workers, which were particularly exacerbated during the Covid‐19 pandemic, implementing strategies like ensuring gender equity in compensation is a key step in attracting and retaining women in the workforce. ⁹ This highlights the importance of addressing systemic inequality and fostering efforts to achieve genuine gender equity across all roles within the healthcare workforce. Ultimately, Australia risks undermining the quality of care provided to patients if female healthcare workers exit the sector.