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Cover Focus | Mar/Apr '21

Equal Pay for Equal Work: Closing Ophthalmology’s Gender Gap in Compensation

Gender parity is an increasingly prioritized issue in the field of medicine.

The US Census Bureau estimated that the average full-time working woman made $0.82 for every dollar the average working man made in 2019; this was $0.25 higher than the estimate from 1973.1 Despite this slight improvement (albeit over almost 50 years), the persisting pay gap results in as much as $2 million in lost wages over the lifetime of the average woman.1 Unsurprisingly, this gap widened for single mothers and women of color.2

The medical field is not immune to this trend. A 2016 study using data from more than 10,000 physicians found an absolute pay difference of $19,878 by gender in yearly salary, even after controlling for age, experience, specialty, faculty rank, and measures of research productivity and clinical revenue. Although similar trends in ophthalmology have been reported,3 they have not been characterized with modern-day data.

INVESTIGATING THE GENDER GAP IN OPHTHALMOLOGY

In a recent publication in Ophthalmology titled, “Gender Compensation Gap for Ophthalmologists in the First Year of Clinical Practice,”4 Jia and colleagues sought to identify possible differences in starting salaries between male and female ophthalmologists and to explore the variables that may be contributing to this disparity.

In this prospective study, an anonymous, voluntary survey was sent to more than 1,500 practicing ophthalmologists and residency program directors in the United States. Between January and March 2020, 684 responses were received from early-career ophthalmologists, 56% of whom were female and 44% of whom were male. On average, female ophthalmologists earned a base salary that was $24,411.80 (10.6%) lower per year than their male colleagues’. Even after controlling for fellowship subspecialty, female ophthalmologists were found to earn $30,726.51 (11.6%) less per year than their male counterparts.

The current literature on gender theory offers various models to explain why these differences in salary exist.5 A prominent one is the nature of negotiation—that is, women may be less likely to negotiate or less interested in negotiating their initial offers. Jia et al analyzed this theory and found that, although there was no relationship between gender and the decision to negotiate, gender and successful negotiation were significantly associated. In other words, although women were equally as likely to negotiate as men, they were less successful in raising their salaries despite their efforts.

The study found that more women were employed by academic institutions than by private practices, but yearly salary at academic institutions was not significantly lower than at private practices ($208,412 vs $213,940; P = .4043). Although this difference was not significant, the analysis controlling for practice type demonstrated a persistent gender-based compensation gap of $19,843.95 per year. Additional strengths of this study included controlling for number of workdays and specifically distinguishing clinic days from OR days because the latter would likely yield greater financial productivity.

Because this study involves early-career physicians, it removes the potential for other factors (ie, work experiences, seniority, faculty rank, clinical revenue) to be at play. Thus, these findings together suggest insidious and subliminal differences in compensation for female and male ophthalmologists. Limitations of this study include self-reporting, anonymity, inability to correct errors in data reporting, selection of participating clinical sites, and self-selection of participants. Other potential factors influencing compensation (ie, the number of offers received and whether the highest offer was accepted) also were not collected in this survey. Furthermore, productivity incentives (ie, bonus) can be a substantial part of income. Given the complex and variable structures of these incentives, bonus was standardized at 20% for all individuals in this study. Finally, renegotiations that took place between the first and third years of practice were captured in the study, potentially excluding those that took place earlier or later in the course of participants’ early careers.

The findings of Jia et al were consistent with a prior retrospective study on compensation by gender in ophthalmology conducted using telephone surveys performed by the American Medical Association between 1992 and 2001.3 Even after controlling for work hours, years in medical practice, practice ownership interest, board certification, region of practice, and insurance makeup of population served, the investigators found that the income of White female ophthalmologists was 20% lower than that of White male ophthalmologists. Although there appears to be an improvement in pay disparity from the 1990s to 2020, the prior study had several limitations. The report included only White ophthalmologists, had a substantial imbalance in sample between groups (565 men vs 59 women), and did not control for the proportion of medical versus surgical clinical hours.

Although the American Medical Association study reported only disparities in compensation, the gender gap certainly extends far beyond financial inequalities. As has been well characterized in several studies,6-12 women are underrepresented in academic positions, including editorial board membership, chairperson positions, and residency program directorships in nearly every specialty, including ophthalmology. A longer publishing career, a greater number of publications, and higher academic rank may be associated with higher income. These findings can be partially attributed to the lower number of female physicians historically. The proportion of women in ophthalmology has risen in the past 2 decades (women made up 14% to 17% of board-certified ophthalmologists in the early 2000s vs 25% in 202013), and it is important that a commensurate increase in leadership by women be seen.

MITIGATING THE DISPARATIES

Although the study findings presented by Jia et al paint a picture of the gender gap in compensation that is less than satisfactory, there are potential pathways to mitigating these disparities. The standardization of employer-initiated salary transparency would create a framework for negotiation, and objective protocols for establishing pay, including experience, rank, accomplishments, market pay for the specialty, etc., might minimize unconscious bias. Such policies can increase clinical productivity, as has been reported in a study from an academic surgical practice.14 Limited health care networks, including the Veterans Health Administration system, release such data, and this may be a reason for relative equality in this government payment model as opposed to independent employers.15,16 Additionally, medical schools, training programs, and employers should be encouraged to support female achievement through negotiation workshops, mentorship, and flexible working options.

CONCLUSION

Gender parity is an increasingly prioritized issue in the field of medicine. Although this article discusses compensation, equality goals are multifactorial and include academic achievement, clinical productivity, career satisfaction, and more. The empowerment of women across all of these facets can propel the success of ophthalmology as a specialty.

1. Leisenring M. Women still have to work three months longer to equal what men earned in a year. United States Census Bureau. March 31, 2020. www.census.gov/library/stories/2020/03/equal-pay-day-is-march-31-earliest-since-1996.html. Accessed April 2, 2021.

2. Income, poverty and health insurance coverage in the United States: 2019. News release. United States Census Bureau. September 15, 2020. Accessed March 16, 2021. https://www.census.gov/newsroom/press-releases/2020/income-poverty.html

3. Weeks WB, Wallace AE. Gender differences in ophthalmologists’ annual incomes. Ophthalmology. 2007;114(9):1696-1701.

4. Jia JS, Lazzaro A, Lidder AK, et al. Gender compensation gap for ophthalmologists in the first year of clinical practice. Ophthalmology. November 26, 2020. doi:10.1016/j.ophtha.2020.11.022

5. Marks MH. Who asks and who receives in salary negotiation. J Organizational Behavior. 2011;32(3):371-394.

6. Abdellatif W, Shao M, Jalal S, et al. Novel geographic thematic study of the largest radiology societies globally: how is gender structure biased within editorial boards? AJR Am J Roentgenol. 2019:1-6.

7. Amrein K, Langmann A, Fahrleitner-Pammer A, Pieber TR, Zollner-Schwetz I. Women underrepresented on editorial boards of 60 major medical journals. Gend Med. 2011;8(6):378-387.

8. Hafeez DM, Waqas A, Majeed S, et al. Gender distribution in psychiatry journals’ editorial boards worldwide. Compr Psychiatry. 2019;94:152119.

9. Pagel PS, Freed JK, Lien CA. Gender composition and trends of Journal of Cardiothoracic and Vascular Anesthesia editorial board membership: a 33-year analysis, 1987-2019. J Cardiothorac Vasc Anesth. 2019;33(12):3229-3234.

10. Clarke Whalen E, Xu G, Cygankiewicz I, et al. Gender equity imbalance in electrocardiology: a call to action. J Electrocardiol. 2017;50(5):540-542.

11. Kloosterboer A, Yannuzzi NA, Gedde SJ, Sridhar J. Residency program directors of United States ophthalmology programs: a descriptive analysis. Am J Ophthalmol. 2020;209:71-76.

12. Dotan G, Qureshi HM, Saraf SS, Darnley-Fisch DA. Leadership of United States academic departments of ophthalmology: chairperson characteristics, accomplishments, and personal insights. Am J Ophthalmol. 2018;186:69-76.

13. AAO membership data, accessed June 1, 2020. Data voluntarily provided by AAO members.

14. Scoggins CR, Crockett T, Wafford L, Cannon RM, McMasters KM. Improving clinical productivity in an academic surgical practice through transparency. J Am Coll Surg. 2013;217(1):46-51; discussion 51-45.

15. Dermody SM, Litvack JR, Randall JA, Malekzadeh S, Maxwell JH. Compensation of otolaryngologists in the Veterans Health Administration: Is there a gender gap? Laryngoscope. 2019;129(1):113-118.

16. Maxwell JH, Randall JA, Dermody SM, et al. Gender and compensation among surgical specialties in the Veterans Health Administration. Am J Surg. 2020;220(2):256-261.

author
Lama A. Al-Aswad, MD, MPH
  • New York University Langone Health, New York
  • Financial disclosure: None
author
Sunidhi Ramesh, BS
  • Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia
  • Financial disclosure: None
author
Aakriti Garg Shukla, MD
  • Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia
  • Glaucoma Service, Wills Eye Hospital, Philadelphia
  • ashukla@willseye.org
  • Financial disclosure: None
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