"Men tend to gravitate toward higher paying careers like doctor, engineer, lawyer, or CEO. Women tend to choose lower-paying careers, like female doctor, female engineer, female lawyer, or female CEO." — Jeremy McLellan, comedian
The Doximity physician compensation report came out and not surprisingly there is still a large gender pay gap. Women physicians earn a shocking 23% less than their specialty-matched male counterparts and no specialty showed equal or higher earnings for women. Looking at Doximity's graphs, it is obvious that the male-dominated specialties are on the high compensation end and the female-dominated in the middle and lower end. An argument I have heard regarding the pay gap is that women choose specialties that pay less. In other words, women have themselves to blame. While I have observed a relative gender sorting within my own specialty, I have long wondered if we are dealing with a chicken and egg phenomenon. Are women "choosing" specialties that are lower-compensated because of their "feminine characteristics" or have specialties become lower-compensated as they gain a higher percentage of women? Occupational feminization, where occupations with higher female representation have lower pay, has been recognized in many industries. I suspect that as women enter medicine in greater numbers, we are seeing a tipping point where the relative compensation, especially in female-heavy specialties, is trending downward.
The assumption that women choose specialties for their "feminine characteristics" is flawed in many ways. Certainly, it does not explain the gender pay gap within specialties. There is no argument that the female-dominated specialties are at the lower compensation end of the spectrum. The most female-dominated medical specialties according to AMA data from 2022-23 are as follows: ob/gyn (87.2%), pediatrics/psychiatry/child and adolescent psychiatry (combined 75.5%), pediatrics (73.6%), and allergy and immunology (65.8%). Some might argue that women choose these specialties because they encourage characteristics stereotypically assigned as feminine: caring for others (especially women and children), nurturing, and fostering relationships. By the same argument, some feel men are attracted to high-paying specialties like orthopaedic surgery and neurosurgery because of the stereotypically male-gendered characteristics of the job, such as physical strength, technical skill, and leadership.
The idea that a specialty attracts more men because they have stronger technical skills is as outdated as dial-up internet. My mother, a wedding cake designer, could turn sugar into a spray of orchids so detailed you believed they were brought fresh from Hawaii. Her technical skill surpassed that of many neurosurgeons I know. Possessing leadership or technical prowess is not gender specific. The specialty gender sorting is not because women only possess "feminine" skills. A recent Doximity poll demonstrated that the majority of physicians of all genders chose their specialty based on their desire to treat the patient population of the specialty. Even if women were attracted to the "feminine" specialties, do these specialties carry less value and deserve less compensation for similar work? Several disturbing questions that have been simmering as I look at gender pay issues in medicine are: Are women dragging themselves down in some way? Are women underselling their value? Are they not negotiating for fair compensation? Is medicine becoming less well-compensated because there are more women?
Here are some quotes I have heard from women in medicine regarding pay and career track:
"I don’t need to argue for a higher salary. My husband makes a good living and we don’t need the extra money."
"I am not doing this for the money."
"I would rather have more time with my kids than take the extra pay I would get by taking additional call."
"I am working part-time because my husband is also a physician and it was too much."
"I would have loved to do that specialty but I wanted to start a family."
"I didn’t choose that specialty because I didn’t like the 'bro' culture."
These quotes demonstrate not so much that women are to blame for the pay gap but that they are willing to take the blame for it. The argument that women just aren't good negotiators or choose family-friendly specialties is just masking the underlying problem of the devaluation of the work that women are doing. The concept of occupational feminization brings to light the societal devaluation of "women's work." In the article When a Specialty Becomes "Women's Work": Trends in and Implications of Specialty Gender Segregation in Medicine, Drs. Elaine Pelley and Molly Carnes showed not only the clustering of women in the lower-paid specialties but more interestingly, that as a specialty became female-dominant, the relative pay for the specialty decreased by up to 20%. In other industries, these shifts are theorized to be due to either queuing or devaluation. The queuing theory assumes that both men and women prefer higher-compensated fields, but employers prefer male candidates, leaving only the lower paying jobs to the women. The devaluation theory posits that as more women enter a field, there is a loss of prestige followed by a decline in compensation. There is a tipping point, a percentage at which the field becomes less attractive to male applicants because it is perceived as women's work. Stated bluntly, "It must be easy because anyone can do it."
Societal stereotypes play an important role in the occupational feminization phenomenon. What are the other factors? One factor that is difficult to talk about is the breadwinner status. It is possible that there are financial advantages that some women have over men in similar circumstances. I had observed that many orthopaedic surgeons in my town had wives who did not work outside the home. As the primary breadwinner, it might follow that men in this field would be motivated to high levels of productivity to support their families and lifestyle. Conversely, a female orthopaedic surgeon may have a partner who also works, maybe even in a highly compensated profession. Her motivation for high levels of productivity may be tempered by the fact that her income is important, but not the only thing sustaining her family. Her financial stability may, ironically, be the driver of her lower productivity-linked compensation. Orthopaedic surgery remains male-dominated so this individual experience may not influence ortho compensation as a whole. However, studies controlling for work hours, training, and productivity still find women to be paid less than men. So we cannot blame individual women who have more financial security to explain the gap.
On the flip side, with a working spouse, household duties split between two busy partners are more burdensome than those taken on by the person with a spouse full-time in the home. After hearing the bios of the leaders in neurosurgery whose wives facilitated their stellar careers, my husband and I remarked how we need one of those wives to take care of things for us. Whether out of need or desire, some doctors choose family time over professional success. In today's culture when two (heterosexual) parents are professionals, it is still more likely that a woman will be the one to scale back work hours to spend time with family or care for elderly parents than a man. I would argue that specialties with fewer women have been slower to adopt changing attitudes about diversity and flexible scheduling. Perhaps in fields where women have a voice, they have been more outspoken about reasonable work hours, efficient workflows, and work-life balance. Unfortunately, while these fields may have evolved philosophically, they are being penalized in compensation.
Lastly, the queuing theory, which assumes employers prefer male candidates for higher compensated jobs, still probably plays a role in occupational feminization in medicine. If the leaders selecting a candidate are male, they may have an idea of what, say, a spine surgeon looks like, and that may be a very masculine male. This may unevenly sort the women into lower-compensated subspecialties because they did not fit the profile. Fortunately, as the physician workforce becomes more diverse and implicit bias training reveals these biases, queuing may eventually disappear.
It will take a major societal attitude shift to stop devaluing work because it is "women's work." It should not take men entering a field for the compensation to increase, like we've seen in nursing. As women enter some of the more impenetrably male subspecialties, I am seeing some of the old-boys club and "bro" culture falling away. The amazing women in my field are showing that technical skill and leadership are women’s work, work with tremendous value that deserves fair compensation.
What are your thoughts on the reasoning for the gender pay gap? Share in the comments.
Dr. Lazio is a neurosurgeon in Portland, Oregon. She enjoys exploring the Pacific Northwest mountains and beaches with her three humans and two dogs.
Image by SvetaZi / Getty Images
