Otolaryngology’s Gender Wage Gap

According to Doximity’s 2020 Physician Compensation Report, the largest gap between men’s and women’s salaries in different medical specialties occurs in otolaryngology. Women made 77.9% of what men earned, a difference of 22.1%.

In addition to the difference in pay, wage gaps can result in other negative outcomes. “When someone is paid less for the same work, they feel personally devalued,” said Sujana S. Chandrasekhar, MD, a partner at ENT and Allergy Associates, LLP, in New York, N.Y. “Consequently, they aren’t likely to push themselves in terms of research projects, mentoring, sponsoring, or leadership opportunities.”

When asked what contributes to the large gap, Dana L. Crosby, MD, MPH, department chair, residency program director, and associate professor in the department of otolaryngology– head and neck surgery at Southern Illinois University School of Medicine in Springfield, said that one component of the pay gap is often attributed to gender lag, given that higher proportions of women are now in training and in the earlier stages of their careers. In 2017, women comprised 36% of active otolaryngology residents. In 2019, the Association of American Medical Colleges Physician Specialty Data Report showed that just 18% of practicing otolaryngologists were women.

Along these lines, Erin O’Brien, MD, associate professor and chair of the division of rhinology in the department of otolaryngology–head and neck surgery at Mayo Clinic in Rochester, Minn., pointed out that Medicare billing data have shown higher billings by older otolaryngologists. “Women in otolaryngology are younger on average, so the average age may be responsible for part of the gap,” she said. Secondly, female otolaryngologists are more likely to practice in urban areas than rural areas. Rural otolaryngologists bill for more services than urban otolaryngologists, so geographic differences may also play a role in the gender gap (Ann Otol Rhinol Laryngol. 2022;131:749–759).

Dr. Crosby said that gender lag alone cannot account for this significant disparity, however. A 2021 study showed that there was a significant salary gap at every career stage in academic positions, from instructor through full professor, when comparing men to women (Laryngoscope. 2021;131:989–995). “The study estimated that over the course of a 30-year career, the difference in salary by gender would amount to $3,365,000,” she said.

The study estimated that over the course of a 30-year career, the difference in salary by gender would amount to $3,365,000. —Dana L. Crosby, MD, MPH

Regarding career advancement, accelerators in pay such as promotions and leadership opportunities are often offered to those with the closest relationships to those already in leadership positions or to individuals in whom current leadership can see characteristics of themselves, Dr. Crosby continued. Because White men have historically served in those roles, persistent homogeneity in leadership roles has occurred. “Changing this culture will take time, but more importantly, intentionality is required to begin to close this gap,” she said.

Anju Patel, MD, a consultant for Mytonomy, a technology-based patient education company in Bethesda, Md., and former faculty at the Harvard Medical School Department of Otolaryngology–Head and Neck Surgery in Boston, said gender bias, harassment, and discrimination are significant in the field and may contribute to the wage gap. In fact, a 2020 survey of women in otolaryngology revealed that nearly half experienced some form of harassment at work (Laryngoscope. 2021;131:E380– E387). One in three harassment experiences were from physician colleagues or department leadership.

Other research has shown a link between harassment and the gender pay gap (Gend Soc. 2017;31:333–358). “Harassment is tied to decreased productivity, leaving an untenable workplace and subsequent drop-out from the field,” Dr. Patel said. “This leads to setbacks in compensation. Furthermore, occupational segregation or underrepresentation of women in our field hurts the specialty.” The U.S. Department of Labor has targeted occupational segregation as a significant source of the gender wage gap that must be remedied.

The gender pay gap may be even wider in certain subspecialties. “You would think that in pediatric otolaryngology, where many women practice, the pay would be equitable,” Dr. Chandrasekhar said, “but that is not the case.”

Little Progress Made

The wage gap hasn’t changed much since Jennifer R. Grandis, MD, a distinguished professor of otolaryngology–head and neck surgery at the University of California, San Francisco, and her colleagues conducted a study on compensation differences between genders (Arch Otolaryngol Head Neck Surg. 2004;130:695–702). At that time, she found that female otolaryngologists earned approximately 20% less than men for performing the same work.

“Although salaries are usually determined locally, our field hasn’t taken any steps to put systemic measures in place to mitigate inequities,” Dr. Grandis said. “We haven’t made it a priority. If we would take this issue seriously, we would have hard conversations every time decisions about compensation came up, and we don’t.”

Unlike many academic centers, which continue to keep pay and other benefits as opaque as possible, Dr. Chandrasekhar said her private practice keeps income information transparent. All 250 physicians can see what other doctors in the practice make, how many procedures they do, how many patients they see, and so forth. This information can be used within one’s subspecialty for benchmarking purposes.

Dr. Chandrasekhar maintains that poorly run or gender-biased private practices shunt pay, procedures, and consults toward men and away from women, however, ensuring that the leaders’ pre-conceived ideas that women earn less are borne out. “This is insidious and self-propagating,” she said.

Only after she left academic practice to open her private practice was she paid equitably, she said.

Historically, women tend to negotiate less than their male counterparts, which undoubtedly contributes to the gender wage gap. “Many women in medicine, especially competitive surgical specialties, continue to suffer at higher rates from impostor syndrome,” Dr. Crosby said. “I have personally entered into negotiating situations feeling lucky to have an opportunity rather than considering all of the work that I’ve done to get there. I think, ‘I’m happy to even be considered. I certainly wouldn’t want to push too hard, or they might offer the position to somebody else.’

“Simply stating that women need to be better negotiators, though, is nothing more than victim blaming,” Dr. Crosby continued. “Individuals with the power to determine salaries and incentives must hold themselves accountable for offering equal pay for equal effort.”

The Importance of Leadership Roles

Academic promotion often requires national leadership roles, so having more women in leadership may help more women achieve higher academic ranks and salary increases. “The gender salary gap starts early, including lower starting salaries for female physicians,” Dr. O’Brien said. “Waiting for women to achieve leadership roles in academic societies won’t close the gap in accumulated wealth over a career.”

A 2020 study showed that only 15.3% of leadership roles, including department chairs, residency program directors, or fellowship program directors, were held by women (Laryngoscope. 2020;130:1664–1669). When the study was published, only five of 99 otolaryngology departments nationwide had female chairs, Dr. Crosby said. The number of female chairs has grown only slightly since then.

Women who held these leadership roles tended to have fewer years in practice and were at lower ranks. “While my hope is that this is because talented young women are being identified and elevated early in their careers, I’m concerned that some of these leadership positions are being offered to women because they come with less pay and more work,” Dr. Crosby said.

Dr. Crosby currently holds the titles of both department chair and residency program director. “The latter position continues to grow in paperwork and bureaucratic requirements, but the pay is often not commensurate with the level of work required to do the job effectively,” she said. “Based on my own experiences, I worry that when offered these opportunities women are less likely to negotiate for pay that is appropriate for the level of work required, and instead simply remain thankful for the opportunity.”

Jennifer A. Villwock, MD, associate professor of otolaryngology–head and neck surgery at the University of Kansas Medical Center in Kansas City, said that increased visibility of women in leadership positions makes the path to otolaryngology and leadership more accessible to young students and trainees who are seeking mentors and role models. It also helps programming at meetings to be more inclusive in terms of speakers and panels.

“While many women who are more junior in their careers understandably seek female mentorship, there is a dearth of female leaders in our specialty,” Dr. Crosby said. “With this, it is incumbent upon not only senior women to serve as mentors and sponsors, but also for men to become familiar with the challenges specifically faced by women to serve in these roles as well.”

The Impact of Having Children

When women are being considered for leadership roles, several factors are taken into account, including a combination of clinical and research productivity.

Women in medicine often delay having children during medical school and residency and may choose to begin families early in their careers, Dr. Crosby continued. This choice results in female junior faculty being more likely to have extended time off for maternity leave, which can impact their pay and productivity, both clinically and academically.

This situation undoubtedly leads to a differential in both leadership roles and pay. Beyond the tangible impact of women taking time off for maternity leave and childcare, Dr. Crosby has heard countless times that while a certain woman might be qualified for a position, “‘She probably won’t be interested because she’s busy with her family,’” she said. “It’s frustrating that others continue to make this choice for women rather than having an open discussion with them. This phenomenon has been coined ‘the mommy track,’ and leadership needs to be careful to avoid this type of cognitive bias.”

Leveling the Playing Field

So how can the otolaryngology field close the wage gap? “As a field, we need to be committed to the goal of achieving pay equity,” Dr. Grandis said. “We need to engage both institutional and academic leaders, as well as the vast number of otolaryngologists who don’t work in university settings such as private practice and managed care. We need to routinely collect data to see how we’re faring.”

It’s critical that both men and women in leadership roles continue to identify talented young women to enter the field of otolaryngology and help them develop their careers, Dr. Crosby said. “While it’s important for women in leadership roles to take a vested interest, male counterparts need to recognize the gender tax that this creates, in which women spend a disproportionate amount of time mentoring other women,” she said.

Men should make a concerted effort to become aware of the unique challenges faced by women, such as discrimination, harassment, and childbearing decisions, to become effective mentors, Dr. Crosby continued. “I often hear that things are so much better now, and while we may have made some progress, the ongoing gender pay gap proves that we have so much more work to do,” she said. “We can’t stop this conversation, and we can’t stop improving until we have true equity.”

On another front, Dr. O’Brien said that institutions and practices need to examine the salaries and resources for male and female otolaryngologists and determine if there is equity in referrals, operating room time, support staff allocation, research support, expectations for more uncompensated work by female otolaryngologists, and leadership roles.

“Data will be necessary to find gaps in factors that affect salary, including procedures and billing, as well as academic promotion,” Dr. O’Brien said. “Transparency across academic institutions would likely drive more institutions to take active steps to close gender gaps.” For example, transparency might occur if national reputation scores included gender parity as a metric for excellence, like patient outcomes or research funding.

Transparency across academic institutions would likely drive more institutions to take active steps to close gender gaps. —Erin O’Brien, MD

Pay transparency is also key. It’s important to know what metrics are followed and how salaries, bonuses, and raises are set, Dr. Patel said. Annual wage audits have also proven helpful in industries outside of medicine.

Looking at the bigger picture, Kathleen Yaremchuk, MD, MSA, chair of Henry Ford Medical Group’s department of otolaryngology–head and neck surgery in Detroit, said the issue of gender pay equity isn’t unique to medicine, surgery, or otolaryngology. The “leaky pipeline,” “glass ceiling,” or “broken rung” are all terms used to describe the fact that women are less likely to be promoted academically or in other leadership roles in their profession. It’s a societal issue; women continue to be paid less for their work effort than men,” Dr. Yaremchuk said. The ratio of men to women who are full professors in otolaryngology is three to one, she said, and that hasn’t changed for the past 35 years.

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Karen Appold is a freelance medical writer based in San Diego, Calif.