How do you address a problem that is easily identified and quantified and yet remains stubbornly slow to improve despite genuine calls to do so? How do you unstuck an effort that is stuck?
Closing the Gender Gap in Medicine: A Roadmap for Healthcare Organizations and the Women Physicians Who Work for Them,1 edited by Dr. Amy Gottlieb, answers these questions by moving beyond evidential descriptions of gender-based pay inequity in medicine to presenting a comprehensive road map of guidelines, policies, and actions to ensure that equal work results in equal pay. Although there is no quick fix to the gender pay gap, a path forward is foreseeable with deeper understanding of the problem, intentionality, commitment, and planning. Such a path is elegantly laid out in this book.
Gottlieb and co-authors appropriately acknowledge and lean into the tension at the core of this problem—that we remain stuck in addressing the problem in a meaningful and long-lasting way even though most in our field agree that equal pay for equal work is consistent with our professional and personal values and makes good sense from an organizational and business perspective. Difficult problems require new ways of seeing. Threshold concepts do just that. They are commonly used in education and are likened to portals that can transform the way learners think about or understand an issue and help them to integrate seemingly dissimilar elements to gain a more comprehensive view. Threshold concepts are also troublesome, meaning they may appear counterintuitive or challenge one’s prevailing views.2
Closing the Gender Gap in Medicine begins with a foundational threshold concept describing the drivers of the gender pay gap known as second-generation gender bias. Second-generation gender bias describes the complex interplay of implicit expectations and unconscious gender stereotypes with organizational culture and structures in a way that disproportionately and negatively impacts women in the workplace. Second-generation gender bias sheds light on and refutes existing assumptions that have been used to explain differences in pay by gender. When not viewed through the threshold concept of second-generation gender bias, one might accept differences in pay and attribute these to “choices” that women make about for example specialty, number of hours worked, or how they may or may not promote their own career advancement or leadership aspirations.
Chapter 2 covers the many areas where gender stereotypes and unconscious bias may, through formal and informal channels, influence the career trajectories of women and which impact pay including specialty choice, performance evaluations, clinical productivity measures, childbearing and domestic responsibilities, role congruity and fit, and differences in sponsorship. This chapter also references studies that refute common assumptions about the career and other “choices” women make which may impact pay. Gottlieb and co-authors are correct to start with this threshold concept as one cannot plan for meaningful change and avoid unintended consequences without understanding the pervasiveness and impact of second-generation gender bias. Readers will appreciate that this lens is carried through the remaining chapters.
Chapters 3 and 4 address common physician compensation models and the legal context and considerations related to salary equity. The discussion of compensation models demonstrates the structural ways in which women physicians are disadvantaged with regard to pay equity. For example, there are more women in part-time positions and less in procedurally based specialties due to the myriad reasons listed in Chapter Two. Additionally, the majority of compensation models in the United States combine base salary (typically the largest portion of salary) with an incentive plan; the authors describe how both salary components are subject to gender bias. Base salary determination rests on several factors which are influenced by gender bias, including expected renumeration (gender norms may lead women to expect a lower salary then men), one’s prior salary, negotiation skills, leadership positions, productivity, and distribution of effort in tasks that are less likely to be remunerated (so-called housekeeping tasks that are more often assigned to women). Incentive compensation is often driven by clinical productivity. Research demonstrates that women may see fewer patients but provide higher quality care; however, this can perpetuate the gender pay gap as most current compensation models do not yet reward quality over quantity.
An important and sobering take away of this chapter is that women are at risk for lower salaries beginning immediately upon completion of training and throughout their careers, resulting in an initial pay gap that is perpetuated and potentially worsened across one’s entire career. The financial significance of this difference over a career and the importance of a comprehensive approach that recognizes the impact of second-generation gender bias, is illustrated in a study that simulated accumulated wealth based on existing gender-based pay disparities before and after institution-wide gender equity interventions. The gender equity interventions in this study,3 are similar to many that are described Chapter 6, and include: making gender equity an explicit part of the institutional mission and creating a gender equity monitoring committee, conducting regular salary reviews with mitigation of gender-based gaps, establishing efforts to recruit and retain women, ensuring transparent promotion criteria, assessing faculty satisfaction, and addressing work-life issues. The authors found a difference of $500,000 between men and women in accumulated wealth with no interventions to address second-generation gender bias versus a difference of $66,000 over a career when gender equity initiatives were instituted.3 Other studies have estimated much higher differences between men and women physicians in accumulated wealth.
It is discouraging to note that in this simulated exercise a gap remains despite extensive efforts to address gender equity, thus demonstrating the need for a broad-based and ongoing institutional approach. Chapter 5 provides a framework for doing so using a change management approach to salary equity. Change management operationalizes the difficult work of turning the statement, equal pay for equal work, into a reality. This involves a stepwise approach beginning with identifying and characterizing the problem, envisioning a solution, communicating the plan, and persuading stakeholders to buy in and finally implementing and maintaining the plan. Threshold concepts, such as second-generation gender bias, can assist in this work by engaging all stakeholders in a new way of seeing the problem and potential solutions. Strategies specific to supporting and sustaining culture change around salary equity are presented in Chapter Six. Readers will note that these strategies address the many causes of salary inequity outlined in Chapter 2 and focus on ensuring salary equity at the beginning of one’s career and across inflection points that may result in widening pay gaps such as academic promotion and leadership appointments. Specific processes related to recruitment, retention, and how leadership roles are determined are outlined. Implicit bias training is recommended, especially around the ways that gender stereotypes can influence hiring, performance evaluations, and promotion. Equitable compensation plans are critical in these processes as are routine salary reviews.
Recognizing that all culture is local and that institutions must work with local stakeholders and contexts when following a change management model, a case example is provided. From the Medical College of Wisconsin, the case example emphasizes the need for leadership at the very highest levels to commit to change, clarification of all processes and tying these to clear benchmarks and expectations, transparent and frequent communications, and accountability through reporting and annual reviews. The case highlights lessons learned at the local level and the need to anticipate unintended consequences, for example, around the challenge of salary transparency at a private institution.
Chapters 5-7 emphasize that addressing salary equity is not a women’s problem but rather an institutional imperative grounded in fairness and sound business practices. Equity in pay benefits all aspects of the healthcare mission.
Closing the Gender Gap in Medicine provides a comprehensive, detailed, evidence-based approach to addressing the gender pay gap and is a must read for all stakeholders and especially for leaders in medicine. The timing for reading this book could not be more important. The COVID-19 pandemic highlighted and exacerbated existing gender disparities and has the potential to significantly worsen the gender pay gap if not addressed now. This book provides a transformative approach to understanding the problem and an actionable plan for getting unstuck.