51: The Gender Pay Gap in Medicine with Dr. Linda Street

Welcome to The Wealthy Mom MD Podcast, a podcast for women physicians who want to learn how to live a wealthy life. In this podcast you will learn how to make money work for you, how you can have more of it and learn the tools to empower you to live a life on purpose. Get ready to up-level your money and your life. I’m your host, Dr. Bonnie Koo.

Welcome to episode 51. So, today, I have a special guest. I have Dr. Linda Street. You might recognize her name because I’ve had her on the podcast before. I had her on an earlier podcast. We’ll link that in the show notes, where we talked about negotiation.

So, Dr. Linda Street is also a certified life coach, like myself. And she’s also, I believe, maternal fetal medicine, and we decided to get together to talk about the gender wage gap that currently exists, continuing the theme of the history of women and money.

And so, a few episodes ago, I kind of laid out the big milestones in terms of the history of women and money. And today, Linda and I are going to dive deeper into some of the issues that we experience as women, specifically in medicine, and talk about some of the laws that have come into place now.

Legally, employers can’t pay a woman less than a man for the same job. But we also know that’s not reality. And so, that law started to get passed in 1963. That’s when the first legislation requiring equal pay for equal work. But it took a few more years for it to expand to, sort of, all fields.

And so, we still have a lot of work to do, and so Linda and I are going to discuss some of the issues that we face as physicians and also some literature which talks about and has proven that female physicians, even accounting for things like working part-time or taking maternity leave, we are still paid less than our male colleagues. Extremely infuriating. So, listen on as we discuss the gender pay gap in medicine.

--

Bonnie: Welcome to the show, Linda Street.

Linda: Yes, and welcome Bonnie Koo, depending on where you’re listening. I'm excited to talk to you today.

Bonnie: Yeah, so I’ve had you on the show before and we talked about negotiation, of course. And so, I thought it would be fun to have you on here so we can riff a bit on sort of the gender pay gap and what’s going on, despite the fact that legally we’re supposed to be paid the same.

Linda: Right, legal and reality are certainly not always parallel.

Bonnie: Exactly. So, I just thought we could talk about some of the – we’ll just talk about the data because I think some people think it doesn’t exist in medicine.

Linda: Oh yeah, I mean, entirely. I’ve definitely run into people who are like, “Yeah, it’s because…” insert excuses, excuses, excuses. And they can give you a laundry list of reasons as to why the gender gap’s not real.

Bonnie: Yeah, because I think people think it’s because we take maternity leave. But even accounting for maternity leave and working part-time, there still is a gender gap. So, I kind of wanted to talk about that a little bit. And so, we’ll talk about stuff particular to medicine, but I thought it would also be fun to – not fun, but interesting to talk about the gender pay gap at large in terms of women as well.

So, one thing that I found that I just wanted to say real quick on the podcast is I found this chart from 2018, just in terms of the cents on the dollar for women compared to white men. And overall, we get paid less, duh. But it’s different depending on your ethnic background as well. And so, I thought this was really interesting.

So, white women make about 79 cents on the dollar. This is all compared to white men. And then Asians are 90 cents. Oh, so we make more than white women. I don’t think I knew that. That’s interesting.

Linda: Congratulations.

Bonnie: Congratulations, right, yeah, woo-hoo.

Linda: Still less than white men.

Bonnie: Still less than white men, exactly. And then the lowest paid is Hispanic or Latino at 54 cents, which is crazy. So, they’re basically half. It’s insane. So, I just wanted to put that out there. And this data is from US Census Bureau data from 2018. So, I just wanted to put that out there that it’s just crazy, the gap.

And so, basically what I wanted to say is yeah, we make less than men and then the gap is even worse for women of color. So, let’s talk a bit about specialties. Because there are different amounts of women and men in different specialties.

So, obviously, everyone listening, this is 2021, the last time I checked there are pretty much equal amounts of women and men that enter medical school. But we’re not 50% of the physician workforce yet. Because that just takes time to percolate. So, do you want to talk a bit about that in terms of specialties that tend to be female-dominated versus not and has that changed over time as more women have entered medicine?

Linda: Right, so certainly it’s changed over time as women are becoming part of the medical community more. But what’s interesting is the pay aspect of that changes. So, most of us who spend our time in medicine can certainly see that there are some fields that are more associated with being female than others.

The first two that come to mind for me that are pretty prevalent are pediatrics and OBGYN. Those are fields that if you look at any given residency program, the vast majority of the residents are going to be female.

As an OBGYN myself, all six of us in my year were female. we had 24 residents throughout the residency and I don’t think there was ever a time point where there were more than three guys out of that 24 at any given year of time. And so, when you look at that, that’s clearly very female-predominant.

Pediatrics runs very similarly, maybe a little bit less so. But what’s really interesting is as women are getting into these fields, the pay is going down for those fields proportionally. So, not only are women being kind of pushed into certain fields because that seems more appropriate or for whatever reasons. But then, once they enter those fields and become the majority in that field, the pay for everyone in that field goes down.

So, there was actually a really great article in JAMA Peds this month that looked at the pay for men and women in specialties once they became female-predominant. And they both go down. That being said, of course, they’re not going to go down fairly. So, men’s went down half was much as the women in that field when it became a female-predominant field.

Bonnie: That’s messed up.

Linda: It’s totally screwed up.

Bonnie: I’m just so curious. I don’t know if you know the answer. How does that happen? I’m just curious what the history of the decrease, what’s behind that? We should look into that at some point. But yeah.

Linda: Yeah, and if you think about collections and things, I mean, this year was a big change because Medicare made all those changes for 2021 based on what relative value units get associated with what CPT codes, what procedures. So basically, they shifted it a little bit to favor some of the more primary care visits, like outpatient visits. And some of them were procedural things that had previously been preferred. And so, this is a group of people who sit in a room on a committee deciding, with a net neutral budget, how dollars get distributed. So, what procedures should be worth what amount of money? What value do we place on an office visit versus a procedure? This procedure versus that procedure.

So, you can imagine, over time, as these demographics change in the field, if the demographics don’t change on those committees, it’s certainly an opportunity for bias, so that’s certainly one place, kind of on a high level where what you’re compensated per procedure could change.

And even on smaller level scales, if you look at individual CPT codes, let’s go for biopsies. So, when we were starting this conversation before the recording, we were talking about how different biopsy sites, since you’re a dermatologist, may out at different levels. And obviously, it’s a lot different having a biopsy on your arm than on your genitals.

But you would think that it would be fairly equally uncomfortable to have a genital biopsy regardless of your gender. However, a penile biopsy is worth 1.9RVUs versus a vulvar biopsy or perineal biopsy is only worth 1.1.

So, already, not only are you saying that the physician who takes care of the women, that their time is worth something different, because we all know that urology tends to be more of a male-dominated versus gynecology is more of a female dominated field. But then you’re saying the value of taking care of a female patient is worth something different than the value of taking care of a male patient from a dollar standpoint.

Bonnie: Yeah, it’s like so many levels of effed up, basically.

Linda: Right, the biases are layered in there every step along the way. Like, every step along the train, there’s a whole new layer of bias.

Bonnie: Yeah, and then when you add them all up, it just leads to getting paid a lot less, basically.

Linda: Right, when you were talking about the pay data at the beginning, like, comparing to a white male, every year there’s equal pay day, and that’s the day where women have finally earned what men earned the previous year. And for women as a collective, it’s typically end of March, early April. We haven’t gotten to it yet.

But when you look at the different races, I mean, a Hispanic woman’s equal payday is going to be almost a year after it took a man to earn that same amount of money. And so, it’s just crazy when you start thinking about long-term potential, how all of these things add up to death by 1000 cuts.

It was so interesting; I was looking at something else earlier today when I was researching for our conversation. And there was an article that came out in the New England Journal of Medicine in October of 2020, so fairly recently. And it actually looked at primary care physicians, and they monitored how much time these doctors work.

So, with female physicians working 2.6% longer – so they were working more hours in this study reference – they made 10.9% less revenue from office visits and conducted 10.8% fewer visits. And then they looked at the complexity and all of those things and analyzed for that. So, basically, for the same amount of work or a little bit more, women are earning 10% less in the exact same field as men doing the exact same type of things.

Bonnie: Yeah, and this is a good segue into something else I found, is that I bet – I don’t know, there probably is a study, I just didn’t look for it specifically. But I bet female physicians on the whole don’t bill as – I don’t want to use the word aggressively, but they don’t bill for everything they do. Because I know this is the case for female lawyers, because we learn that female lawyers don’t bill for everything they do because they feel bad about, “Oh, that only took a few minutes.” Or, “This shouldn’t have taken me as long…” because they bill by time.

But I know a lot of female physicians, actually someone who took my course told me that she felt guilty about billing patients even though they had insurance. And she was telling me how she no longer feels guilty. Now she bills appropriately and her income just shot up.

But I bet there are a lot of female physicians that don’t bill for everything they’re owed. They feel bad for coding a level three or a level four visit. So, I’m curious if you have seen that or heard about that at all.

Linda: Yeah, I mean I certainly haven’t seen the data to that effect, but it makes sense, right? We’re socialized from being little tiny children that women are helpers, women are maternal. The little girls are given baby dolls to play with, like you should just be helping.

And I feel like I hear that a lot with my clients when they’re asking for raises. Like, “Oh, I feel guilty asking for more money because I really just want to help my patients.” And it’s like, they’re two separate possibilities, like you couldn’t help your patients and get paid better. Like you can’t do a good job taking care of someone and be helpful if you’re asking to be reimbursed how you should be.

And so, I think all these pervasive beliefs certainly handicap us at a different level. Like, those are interfering with our ability to earn our worth, just at a societal level, just from being trained since we were little girls to believe certain things about women.

Bonnie: Yeah, and one thing I also found was how, you know, I think everyone can agree that male physicians are perceived differently than female physicians. I feel like every female physician has a story of being mistaken for a nurse, for example. So, there’s that societal expectation of what a doctor should look like.

And then take that and one of the things I really hate about medicine, and you do too I’m sure, is now we’re like Yelp reviews, basically. People can write Yelp reviews of us. And so, Press Ganey is like the big company that does this. And some hospital employers – maybe it’s more than some. Maybe it’s many – have now tied your pay to getting a certain score, a satisfaction score.

And so, one study I found – I’m sure there’s multiple studies, and the one I found specifically was about female gynecologists was that they basically were 47% less likely to receive a top patient satisfaction score compared with their male counterparts. And this was due to gender alone.

I mean, we all know there’s gender bias in general. And so, I think it would just be interesting for every employer to kind of see how their male physicians are doing compared to their female in terms of their satisfaction. Because I think patients have different expectations if you’re a female or a male physician.

Linda: Sure, I mean not only from a what should you listen to level – I see this in my patients because I’m getting referring patients from either male OBGYNs or female OBGYNs. I see both. And it’s interesting. And I’d have to pay attention to look and see if the data jives out. But I find I get a lot more basic routine obstetric questions about discomfort and is this normal from patients who come from a male physician. Because they may or may not feel more comfortable asking that when the doctor is a female. And so, those visits take longer because I’m talking about basic routine things instead of the subspecialty information they’re seeing me to achieve.

And so, my visit all of a sudden took longer, and so that may add up to less visits you can see over a day. If you layer into that, I think the expectations are different from a woman physician versus a male physician. And so, that certainly is interesting, especially in gynecology where all these patients are female, by default. To see a gynecologist, you have two X chromosomes.

And so, for these female patients to more highly rate the male physicians just on a global scale certainly shows how deep these biases run. Women aren’t exempt from feeling these things.

Bonnie: Yeah, totally. Another thing that I learned when I had Barbara Hamilton on the show was the sort of subconscious – not subconscious, but how women are almost funneled away from higher paying specialties that are, quote unquote seen as demanding and maybe not good for women, like surgery for example is one that comes to mind.

And so, I’m wondering how many women medical students were basically deterred from pursuing certain specialties because they won’t be good for having a family because there’s that silent expectation of a woman needs to have a family and all that kind of stuff. So, we’ll link that in the show notes so you can listen to that episode.

But let’s discuss now how women in general in medicine, that the leadership is still highly male, I think across all specialties. I know for sure in dermatology it’s still mostly male, and how that affects the gender pay gap as well. Do you want to talk about that for a little bit?

Lind: Yeah, certainly I think that your governing bodies have a big role in the advocacy for your field, right? And that brings up a whole other layer that I hadn’t thought about before, is it’d be interesting to see how advocacy at a lobbyist level from a legal standpoint is different between male-dominated and female-dominated specialties.

Because oftentimes, from a societal construct, women are less focused on advocating for ourselves and doing those things. It’d be interesting to see what the topics advocated for were, whether it was patient-based versus physician benefit-based and then how that all jives out between different genders and fields. I’m making some assumptions here, but I’d be intrigued to see how that jives out.

But yeah, even in, like I said, obstetrics, which is a field where all we do is take care of women, and it is becoming a much more female-predominated field, even in our leadership, certainly it’s gotten better over the last several years, but there’s a substantial discrepancy in the rations of genders on our leadership levels versus the ratio of genders represented within the field itself.

Our leadership boards tend to be at least 50-50, if not male-predominated. And this is in a field that is very skewed towards female physicians. And so, when you have that lack of leadership at the top, certainly that’s going to trickle down and have impact on the women coming behind too.

Bonnie: Yeah, I think in general, not just medicine but in general for all professions, in general there aren’t enough women in the top leadership positions. It’s almost the exception to the rule. And people are surprised.

Linda: Right, or there’s one woman…

Bonnie: Token woman…

Linda: Yes, and the data shows that if there’s one woman in a group of men – I forget which book it was out of. One of the negotiation books that I read talked about some experiments where they looked at conversations. And if you have one woman in a group of six men, so she’s the clear minority, she often doesn’t speak up. Versus if you have a more even distribution, they’re going to feel a lot more open to sharing their thoughts, to really impacting the conversation and moving agendas forward.

So, even if you have your quote unquote token woman at the table, if she’s uncomfortable speaking up because it’s a good old boys’ club meeting, then it’s more optics than it is actual progress. And I think the same thing could probably be carried out if you start looking at ethnicities and things too. Like, if you look at the data on that, I would be surprised if it showed anything other than similar kind of data, similar results.

Bonnie: Yeah, you know, one thing I’m curious what you know about this topic is, I know that for a lot of physicians, and I know this is true of my first job at our residency, was apparently I wasn’t allowed to talk about my salary with other people. Is that even legal?

Linda: So, it’s in the contract. I have a confidentiality clause. And I actually asked, “Can we get this removed because I’m kind of morally opposed just on a principle level?” And I was told – the advice my attorney gave me was that it’s a big hill to fight on. They’re not going to want to remove it. It doesn’t actually mean a whole lot from an enforceability standpoint.

And so, yeah, but there’s that moral deterrent. There’s that, “Oh, I shouldn’t do that. I signed saying I wouldn’t.” And so, that’s in there as well. But almost every contract I see has some type of language about lack of transparency, even interestingly enough I believe the contract I signed in my first job had language saying you have to keep this contract confidential.

And the salaries were all posted on the internet. So, because we were state employees, our salary data was searchable about a year or 15 months later But despite that, there was that confidentiality clause and it certainly benefits these uneven systems because when you have transparency, it benefits more equitable distribution.

Bonnie: It’s just bizarre to me because legally – like I said, legal and reality are different. We all know it. But legally, employers can’t have gender discrimination for pay. So then, why is it legal for them to not let us talk about it, because how else are we going to know?

Linda: Right, I mean it’s something that the laws are oftentimes more about optics than actual desire for change. So, I’m sure that certainly plays a role. And oftentimes, even if things are unenforceable, we all know that unenforceable things can still be placed in a contract.

I was doing some research for a non-compete episode I’m about to record. And I have physicians in states where non-competes are not enforceable who have them in there for moral reasons, for moral persuasion, or whatever the heck that’s supposed to mean. And so, it doesn’t even have to be enforceable to show up in your contract.

There’s that barrier where most of us as physicians have been rule-followers for a really long time and that’s how we got to that position. So, even if you can add a pretend barrier, it’s often enough that most people aren’t going to jump over it.

Bonnie: Yeah, that just makes me mad.

Linda: Me too. But yeah I mean, they’re real. It’s out there.

Bonnie: Yeah, I still talked about what I made anyway. But I don’t work there anymore, so…

Linda: Right, and I think the vast majority of people, who feel the way we do, do. But there’s that person who wants to ask and just doesn’t have that confidence yet. And they’re the ones that are sitting there wondering and being paid 20, 30,000 less than their male counterpart.

Bonnie: So, I’m curious, what you do is help female physicians with their contracts. I’m sure you have worked with physicians who have found out that they were getting paid less for equal type – and I’m not talking about people who are 100% RBU-based. So, I’m just curious, you know, maybe just one or two anecdotes, how have they navigated that?

Linda: Yeah, I can think of a recent story where a gal had actually found something on a printer, like there were a couple of partners and the male in the group had printed something out for a mortgage application, or whatever it is that you needed a W-2 for, and saw that they were making more.

And they actually approached their leadership and the leadership’s comment was, “Oh, that must have been an error.” And then magically her salary was boost. And you and I both know that it’s very unlikely that that was an error. And this persona actually checked in with another female physician working in the same environment who was also making less than that gentleman.

And they were similarly ranked, similar FTE distribution, so other major variables were all comparable. And as soon as it was brough to attention and there was no real easy way to kind of bow out of it, it was corrected. But how many years was that a problem for prior to the correction, right?

So, one of the parts of the conversation here is not only how do we fix this moving forward, but is there anything you can do to recoup that lost potential? And the short answer is that pursuing that legal battle is going to cost you a whole lot more money than what you’re going to recoup. And that’s where it gets really tricky.

Because if you start looking into what you have to do to be able to file a gender discrimination claim, there are so many barriers, so many hoops that unless you can prove something really egregious and prove that the intent was based on discrimination, it’s really difficult to capture that money back.

Bonnie: Yeah, and I just want to say for everyone listening in, speaking of just gender-based discrimination and how you can sue for that, I’m sure you’ve heard of Lilly Ledbetter. She basically worked for Goodyear and found out that despite having the same sort of title compared to her male counterparts, she was making significantly less. And so, I don’t know the whole story, but in 2007 the Supreme Court actually ruled against her saying too much time had passed. Basically, if it was more than six months it was too late.

And then, thankfully a few years later, President Obama sort of signed a new law saying that you can still sue even if more than six months had passed. But like you said, even though that’s the law, it doesn’t mean that women have the resources – not just the financial resources to sue, but also want to spend the time to sue.

Linda: Right, being a plaintiff is a lot of work. It’s a lot of emotional investment. It’s a lot of time investment, a lot of financial investment. I mean, just the fact that you have to climb through those hoops when something should have been equitable to begin with is by itself a problem.

Bonnie: Yeah, and as you were talking about one of your clients, I just remembered that one of my clients actually, something similar, she sort of found out by accident that she was getting paid less than a male counterpart. And this wasn’t for her main job. This was for some sort of additional medica education type – I don’t remember the exact scenario.

And maybe this has changed, but at the time, she decided not to say anything. Now looking back I’m like, this is so messed up because she was worried about looking bad and rocking the boat and being seen as not in a good light. Because generally speaking, we both know that when women speak up for themselves, we’re not seen in a good light.

Linda: Right. I mean, I’ve experienced it. So, a lot of the things surrounding our job, so if you look at peer review structures, that’s a whole other podcast in and of itself. But the more you dig into it, peer review, if you look at the legal part and you look at the observations, it’s very skewed towards hospitals. And the physician, if they want to make you look bad, has very little ramification. So, you're almost guilty until proven innocent, not innocent until proven guilty.

And so, if you get a target on your back as a troublemaker, certainly there are a lot of things that hospitals or your department chair or your boss can do to make your life really difficult and really to potentially damage your career.

Bonnie: Okay, so now that we’ve talked about all the depressing stuff we have to face as women, let’s end with maybe, I don’t know, I don’t want to say tips, but maybe just some takeaways for our audience in terms of what they need to be aware of. I think hearing our conversation is going to be awareness in terms of what potential gender discrimination in terms of pay they’ll face, but let’s leave them with a few things they can do.

Linda: Yeah, so I think the first thing is it’s okay to ask. It is okay to ask these questions. It’s okay to ask for transparency. It’s okay to get the temperature of what’s going on around you. And then, one step further than that, it’s okay to advocate that you should be paid fairly. It’s okay to advocate if you are doing more that you should be paid more.

So, I think you need to be willing and open to advocating for your own value. We can’t change the systems overnight, but what we can do is kind of move the needle person by person until this becomes less tolerated. Because if enough of us stand up and enough of us and enough of us say this is not okay, then we can slowly move that needle. And the first step, as we learn all those cage questions back in medical school is that awareness, that being alert to the fact that yeah, this is happening. This does impact me. It does affect me. Where are places that I can improve that on a microcosm scale?

And then I think just money in general – you can certainly attest to this. I think as woman, there’s a lot of room for us to improve how we view money just at all.

Bonnie: Yeah, I really love what you said, how it starts at the individual level, woman by woman, we have to each be courageous to speak up and not be afraid to ask these questions. And since we’re both certified life coaches, one thing that came to mind as you were talking is you have to be willing to be uncomfortable to ask those questions or be uncomfortable later when you’re not paid enough.

Linda: Right, and so it’s short-term discomfort versus long-term discomfort, which goes into a lot of the money beliefs that you teach.

Bonnie: Yeah, so be uncomfortable short-term while asking these questions versus the long-term discomfort of getting paid less and how that compounds over time, not just compound interest, but opportunities and all that kind of stuff. So yeah, that’s basically what you and I do is help women advocate for themselves, basically.

Linda: Right, and help them get out of their own way so that they can do that.

Bonnie: Yeah, I’m sure for you, it’s so fun when people come back to you when they were able to get more from a negotiation. And even one lady in my program told me that she asked for a raise. And so many women are just so afraid to even ask for a raise. Even if they think they deserve it, just asking that question can be so fear-provoking. And so, she asked for a raise and they were like, “Yeah.” But you have to ask for it. You can’t assume they’re going to reach out to you and be like, “Hey, you deserve a raise.”

Linda: Right, and even being willing to say, “Hey, I’m worth this,” and if this is something that can’t happen, being willing to walk away.

Bonnie: Yeah, alright, I’m fired up now.

Linda: I know, it’s like, let’s go change the world.

Bonnie: Yeah, well thanks so much for being here. This was super-fun.

Linda: Yes, it was so great to spend some time with you. I know we both have very parallel missions so that women are doing better with money so that we can have opportunities.

Bonnie: Yeah, so tell us real quick – and this will be in the show notes – tell us how people can find you.

Linda: Yeah, I’m at simplystreetmd.com and certainly my podcast, depending on where you’re listening to this, is Simply Worth It Physician Negotiations. And for the counter office, how can my people find you so that when they negotiate their wonderful raises, they can do right by that money and make sure it’s serving them?

Bonnie: Yeah, so I am @wealthymommd. That’s all my social media handles. Really just Instagram because I’m on Twitter but not really. And then my website is also wealthymommd.com.

Linda: Perfect, so good to spend some time with you.

Bonnie: Same here.

Linda: Bye-bye.

--

Hey, if you’re a woman physician who is ready to practice medicine on your terms, then you’ve got to check out my program Money for Women Physicians. It’s part course and part coaching and 100% guaranteed to put more money in your pocket. Go to wealthymommd.com/money to learn more.