I gained a certain notoriety last summer by suggesting in a New York Times op-ed that it isn’t a good thing for growing numbers of physicians to work part time. American-trained physicians have an obligation, it seems to me, to make full use of our professional skills because there is a shortage of doctors and because American taxpayers provide so much of the funds for our training. Now, in a new article in the Atlantic magazine–“Is Medical School a Worthwhile Investment for Women?”–two Yale professors suggest that physicians might as well work full time or more because, if we don’t, medical school is an investment of time and money that doesn’t make financial sense.
This article didn’t surprise me at all. It specifically points to the example of American primary care doctors who are less well compensated than specialists. Using a tool called net present value (NPV) calculation, Professors Keith Chen and Judith Chevalier compared the costs of earning a degree against the income earned over the likely course of a career. They compared the NPV of training as a physician assistant (PA) compared to a primary care physician, and also looked at gender differences in anticipated earnings.
Their conclusion? “We found that, for over half of woman doctors in our data, the NPV of becoming a primary-care physician was less than the NPV of becoming a physician assistant,” the authors wrote.
Was this true for men as well? No, said the authors. Most men are better off financially if they become physicians. But women physicians tend to earn less than their male counterparts, and they also tend to work less. A male physician “earns more per hour relative to the male PA than the female doctor earns relative to the female PA,” the authors noted. “However, a big part of the difference comes from an hours gap. The vast majority of male doctors under the age of 55 work substantially more than the standard 40 hour work week. In contrast, most female doctors work between 2 to 10 hours fewer than this per week.”
The professors concluded, “Even though both male and female doctors earn higher wages than their PA counterparts, most female doctors don’t work enough hours at those wages to financially justify the costs of becoming a doctor.”
After reading the Atlantic article, I don’t doubt the reasoning behind it but have other questions to raise.
First of all, why do women physicians earn less per hour than men? The work of women physicians isn’t valued less than that of men, hour for hour. But it’s been said many times before that we women aren’t tough negotiators, and tend to settle for less rather than risk being greedy or demanding. That stereotype is hard to prove, but I tend to believe it based on my own experience. Years ago, a boss told me after the fact that he had been surprised when I accepted his first salary offer, given my level of experience. He assumed it was a starting point for negotiation; I underestimated my own marketability. Modesty and a desire to be agreeable may prevent many women from bargaining effectively for promotion or pay raises.
Next query: Why do women work less than men? That may seem like a silly question, since we’re the ones who give birth. But long after children reach school-age, women physicians still tend to work less than their male counterparts. I’m curious to know how many women physicians are the major breadwinners for their families, versus how many have spouses who are equally or more successful in financial terms. What impact do those factors have on the amount that women work? Is the tendency for women to marry up, socially speaking, still prevalent? Do many women physicians have the luxury of working less because they are married to highly successful men? After all, if a primary care physician is married to an orthopedic surgeon, it makes more sense for incremental hours to be worked by the higher-earning spouse while the other manages the home front.
Here’s something else I’d like to understand–why do so many young women want to go into primary care? Is this decision made purely out of a love for the field, or are other factors in play? Certainly primary care has proved very attractive to female medical graduates. In family medicine, 54% of residents are female according to the latest statistics available, and in pediatrics that number rises to 65%. I can think of a number of reasons why these fields might be appealing:
- 1. The residency duration is typically three years, far shorter than any of the surgical specialties.
- 2. It’s relatively easy to find a position after residency with little if any night call and limited weekend responsibilities.
- 3. Office-based practice is compatible with controlled work hours and part-time work options.
- 4. There’s a sense of nobility and sacrifice in choosing primary care rather than a high-tech subspecialty.
But other than these factors, I’m hard pressed to understand why medical students choose primary care. Certainly Dr. Priscilla Chan, the wife of Facebook founder Mark Zuckerberg, doesn’t need to worry about future income in her choice of a pediatric residency. But for other medical students who may face $200,000 or more in educational debt, pragmatism alone would dictate a better compensated choice of medical specialty. Unless, of course, the medical student doesn’t really expect that she will depend on her future income alone to support her family.
Beyond the money, however, there’s the issue of professional satisfaction. We constantly read about physician resentment of the production pressure in primary care, which limits the length of patient visits to as little as seven minutes in the interests of efficiency and cost-saving. While the rewards of a close patient relationship are dwindling, the frustration of dealing with chronic diseases and social issues never ends, and at its worst, primary care becomes a toxic mix of tedium and stress.
At the end of the day, is it possible that choosing a medical field for lifestyle reasons leads to its own vicious cycle? A medical student chooses a field thinking that it will be compatible with an easier lifestyle. Working fewer hours leads to less pay and advancement, and possibly to less interesting work. The lack of satisfaction leads to diminishing interest and a desire to work even less. Is it any wonder that many of the happiest physicians I know are the ones who work hardest, get the most interesting referrals, and are the easiest to find in the hospital?
The authors of the Atlantic article never say or imply that women shouldn’t become physicians. They clearly state, however, that “correctly forecasting how much you will work later in life should influence your career choice.” While this can be hard to do when you’re young, it’s worth considering. If you really don’t want to work very hard as a physician, the cost of your medical education may not be worth it–either for you, or for the rest of society.
Fascinating article clearly written by a doctor who is willing and able to make the hard decisions about fulfilling the long hours and dedication that being a doctor requires. I wish that all young women interns would have the chance to read it.
Great article, I wish more people would be honest about the reality of this issue rather than trying to be politically correct.
I am an anesthesiologist in private practice. Depending upon ones political perspective, one may concluded that there is bias in the compensation of male versus female and old versus young physicians. Female and older physicians are paid less per year. From this statement, it would seem that there is a bias against female and older physicians.
However, all physicians are paid the same amount per hour. What makes the difference is the number of hours worked and call covered. As an older physician I am paid less on the average than younger physicians, and even less than some younger female physicians. I am not complaining of unfairness. My house is paid for, my children are grown and I have some money put away for retirement. I just do not work as much as some others.
I believe that compensation should be the same for the same service regardless of race, sex, age etc. But we do a dissservice when we simply look at overall yearly income without looking at the work needed to generate it.
Stumbled across your blog while looking for textile mills, thank you for your insights.
I wonder if our culture might be ready to shift the question from who makes more $ across the m/f divide, to instead critically examining that masculinist, capitalist, patriarchal value? Is that value system harming our culture overall? What are the costs of chronic diseases? What are the other social issues you mentioned, and what are their costs?
The question of who makes more money is a question of narcissistic aggression, paradoxical to caregiving. Could we become a hive culture that tends to the needs of the group, away from our culture of self? Are we too materialistic, too shortsighted, to envision such a shift in value?
Do you perceive the specialists as being happier because they are getting paid more, or because they work harder at work they love to do?
In answer to your last question, probably a little of both. No one will be truly happy doing work that they don’t love. But if you perceive yourself as underpaid compared to peers, that is bound to be a source of dissatisfaction. Personally, I am very happy being a specialist because I take pride in doing types of anesthetics that involve difficult technical procedures and in taking care of patients who are critically ill. This work can be extremely stressful, and certainly an argument may be made that extra compensation should accompany the assumption of higher risk. I don’t see compensation as either aggressive or patriarchal; as has been said many times, the laborer is worthy of his/her hire.
All the best, and thank you for reading–
I am a newly-boarded burned out attending physician who burned out in residency yet continues on this road because of a general lack of ideas about how to change.
Nevertheless, I still teach medical students and the one thing I tell them is to avoid primary care. See, the thing about martyrs is they’re dead. Don’t go being one of them. That’s what I say.
The good fields are ones that 1. pay well 2. allow the physician to practice autonomously 3. make a big difference for patients 4. allow for the opportunity to form meaningful doctor-patient relationships.
The only specialty that fits all four of these criteria to the letter is radiation oncology.
There is no surprise why this is the most competitive specialty. It is the only one where you can sit down and talk to patients like family doctors used to and not have to worry about going bankrupt.