Achieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians

In 2015, more than one third (34%) of the active physician workforce in the United States was female (1); an estimated 46% of all physicians-in-training and more than half of all medical students are women (2). Although women have made substantial progress in these areas, much remains to be done to improve equity and parity and increase opportunities for promotion and leadership. Several recent studies have documented the compensation inequity between male and female physicians. A 2017 survey found that male primary care physicians made $229000 annually, compared with $197000 for women, a gap of 16% (3). This gap is even wider (37%) for specialists: Men earned $345000 annually and women $251000. In academic medicine, female physicians made an average of $227783 annually, compared with $247661 for male physicians (a gap of $19878), after adjustment for factors that included faculty rank, age, years since residency, specialty, funding from the National Institutes of Health, clinical trial participation, publication count, and total Medicare payments. For internists, this difference was $16159 ($191338 vs. $207497) (4). Another study comparing faculty income at 24 medical schools longitudinally over 17 years found that female physicians in academic medicine earned 90 cents for every dollar made by their male counterparts, an annual difference of $20000 (5). In addition, although the number of women entering the medical field has steadily increased, their proportion of leadership positions continues to be small. Female physicians constitute 38% of full-time medical school faculty but only 21% of full professors, 15% of department chairs, and 16% of deans (6). This lack of female physicians in leadership positions has traditionally been believed to be a pipeline problem; however, because women have made up roughly half of medical student graduates for years, the systematic origins of this problem are becoming more apparent (7). In addition, women in medicine face other challenges, including a lack of mentors, discrimination, gender bias, cultural environment of the workplace, imposter syndrome, and the need for better worklife integration (8, 9). Many factors have been cited as causes of compensation inequity and the relative lack of career advancement for female physicians compared with male physicians, including specialty choice, years of experience, number of hours worked, choices made to balance work and family, and a dearth of mentors and senior role models (10, 11). Yet, researchers find these disparities even when controlling for age, specialty, number of hours worked, and practice characteristics (4, 12, 13). Although most data on workplace disparities come from public institutions of academic medicine, there is no reason to believe that similar inequities do not occur elsewhere in medicine. Additional research in all practice settings is necessary to determine the extent of the impact of these disparities. Even greater barriers have been found for minority female physicians (14, 15). The intersection of race and gender compounds the effects of discrimination and inequities related to compensation and career advancement. The American College of Physicians (ACP) Ethics Manual states that discrimination violates the principles of professionalism and of the College. ACP recognizes the equal importance of equity based on other characteristics of personal identity, including but not limited to race, religion, nationality, sexual orientation, and gender identity, but this paper focuses predominantly on gender equity. As the nation's largest medical specialty society, ACP has more than 152000 members, 37% of whom are women. ACP is committed not only to highlighting the obstacles that female members face but also to identifying solutions by examining and addressing the recruitment and advancement of women and other underrepresented groups. This position paper summarizes the unique challenges female physicians face over the course of their careers and identifies solutions with the goal of ensuring that medicine can realize and benefit from the full potential of these physicians. The Appendix contains the expanded background and rationale for each position. The Appendix Table gives brief case scenarios that highlight potential best-practice solutions to many common challenges that female physicians encounter. Appendix Table. Case Studies Methods ACP's Health and Public Policy Committee, which is charged with addressing issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties, drafted this position paper. A systematic literature review was not done, but the authors searched for and reviewed relevant studies, reports, and surveys related to gender equity in medicine from PubMed, Google Scholar, relevant news articles, policy documents, Web sites, and other sources. Position statements were based on this material and input from ACP's Board of Governors, Board of Regents, Council of Early Career Physicians, Council of Resident/Fellow Members, Council of Student Members, and Council of Subspecialty Societies and nonmember experts in the field. The policy paper and related recommendations were reviewed and approved by the ACP Board of Regents on 15 February 2018. Financial support for the development of this position paper came exclusively from the ACP operating budget. ACP Position Statements and Recommendations The following statements represent ACP's official positions and recommendations to achieve gender equity in physician income and career advancement. The rationale for each is provided in the Appendix. 1. ACP affirms that physician compensation (including pay; benefits; clinical and administrative support; clinical schedules; institutional responsibilities; and where appropriate, lab space and support for researchers) should be equitable; based on comparable work at each stage of physicians' professional careers in accordance with their skills, knowledge, competencies, and expertise; and not based on characteristics of personal identity, including gender. Physicians should not be penalized for working less than full-time. 2. ACP supports transparency and routine assessment of the equity of physician compensation arrangements by all organizations that employ physicians. 3. ACP supports the goal of universal access to family and medical leave policies that provide a minimum 6 weeks of paid leave and calls for legislative or regulatory action at the federal, state, or local level to advance this goal. Such legislation should include minimum paid leave standards and dedicated funding to help employers provide such leave. Paid leave policies should ensure that all employees have increased flexibility to care for family members, including children, spouses, partners, parents, parents-in-law, and grandparents. a. ACP opposes discrimination on the basis of reproductive status, for those who choose to have children biologically or via adoption and for those who choose not to have children. b. Family and medical leave and paid leave policies should be a standard part of physicians' benefit packages, regardless of gender. c. Residency and fellowship programs, academic medical centers, community hospitals, and physician practices should develop and implement paid leave policies to provide compensation to eligible male and female physicians and trainees for a minimum of 6 weeks to care for a newborn, newly adopted, or seriously ill child and to attend to other qualifying life events, such as care of seriously ill family members other than children. d. Medical schools and residency and fellowship training programs should publish and distribute their family and medical leave policies to all applicants. e. Accrediting bodies for medical education and training should establish policies regarding family and medical leave for students and trainees, supporting a minimum of 6 weeks to care for a newborn, newly adopted, or seriously ill child and to attend to other qualifying life events, such as care of seriously ill family members other than children. f. Medical specialty boards should be flexible in their requirements for board eligibility in circumstances when trainees took family or medical leave. 4. ACP supports the provision of programs in leadership development, negotiation, and career development for all physicians and physicians-in-training. 5. ACP supports the provision of regular and recurring implicit bias training by all organizations that employ physicians. Organizational policies and procedures should be implemented that address implicit bias. 6. Academic institutions, health care organizations, physician private practice groups, and professional physician membership organizations should take steps to increase the number of women in practice, faculty, and leadership positions and structure equal access to opportunities, including: a. Encouraging mentorship and sponsorship and providing training for faculty on how to be effective mentors and sponsors. b. Coaching and development programs. c. Flexibility in structuring career paths in academic medicine, health systems, and private practice and adopting flexible promotion and advancement criteria, including promotion tracks that reflect the wide range of responsibilities and unique contributions of female physicians. d. Requiring the inclusion of female physicians as job candidates and members of search committees. e. Ensuring diversity, including gender diversity, on all committees, councils, and boards through leadership development to ensure inclusion, comprehensiveness, and mechanisms for accountability. 7. Further research is needed on the reasons for and effect of gender pay inequity and barriers to career advancement and the best practices to close these gaps across all practice settings. 8. ACP opposes harassment, discrimination, and retaliation of any form based on characteristics of personal identity, incl