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Female physicians earn about $2 million less than their male counterparts over the course of their careers, even after controlling for differences such as specialty, years of experience, hours worked, and practice type, according to a .

Over the course of a simulated 40-year physician career, men earned about $8.3 million, on average, compared with $6.3 million for women, for a gap of nearly 25%, Anupam Jena, MD, PhD, of Harvard Medical School in Boston, and colleagues reported.

Christopher Whaley, PhD, of the RAND Corporation, and the lead author of the study, told MedPage Today that past studies of the gender pay gap in medicine have concluded that female physicians see fewer patients, which leads to lower pay.

But this study, Whaley said, found that women earn less than their male peers from the day they graduate from medical school.

By the end of their first decade in practice, male physicians earned an average of $90,298 per year more than female physicians. That was up from about a $42,000 difference in their first year of practice. Those differences lessened but remained statistically significant after multivariable adjustment.

"We're finding pretty sizable pay gaps clearly in the first year of practice, before any of these differences in practice patterns [emerge]," Whaley told MedPage Today.

After that first decade, though, the pay gap remained largely stable, the researchers found.

For their study, Jena and colleagues analyzed income survey data from Doximity on 80,342 U.S. physicians in both community and academic settings from 2014 to 2019. About 75% of respondents were men and 25% were women. Mean number of years since completion of clinical training was 18.7 years; 38% worked in group-based practices and 27.6% worked in hospital-based practices; and the mean number of hours worked per week was 57.5. Mean annual income was $345,936. Ultimately, they estimated how much more, on average, a male doctor would have made than a female doctor at the end of a 40-year career.

Female respondents had fewer years of experience (16.5 vs 19.5 for men) and worked about 2.5 hours less per week. They also had lower annual income ($270,541 vs $371,370, respectively) and lower annual Medicare reimbursement ($125,807 vs $261,766).

Though female physicians are more likely to end up in like pediatrics and psychiatry for a number of reasons, the gender differences in pay seen early on remained when assessed by specialty, the researchers found. By the tenth year of practice, the adjusted gap was larger in surgical specialties than in non-surgical specialties and primary care specialties ($54,777 vs $38,611 and $30,245, respectively).

So why does the disparity in pay between male and female doctors persist, and cement itself early on?

The difference in hours worked is so small that it was "unlikely to contribute to the entirety of the observed differences in income," the authors wrote.

Traditional explanations, like structural sexism, different expectations of women, and compensation structures that favor men may not be enough, either, to explain the early-career divergence in pay, the authors noted. One theory, they said, is that female physicians may not switch jobs or practices as often as male physicians, limiting their opportunities for pay increases.

"The deck is kind of stacked, if you will, on a whole number of levels," said Susan Pories, MD, a breast surgeon at Mount Auburn Hospital, a Harvard Medical School teaching hospital, who was not involved in the study. "I don't think it's fixing one thing. I think it's fixing a lot of different things."

Pories also served as the chair of the Women in Surgery Committee for the American College of Surgeons and is currently a governor (and past president) for the Association of Women Surgeons.

Pories pointed to a lack of female positions promoted to leadership positions, where they'd be able to more easily make structural and policy changes. For example, she said, relative value units (RVUs) -- the rates used by Medicare to determine reimbursement for providers -- for procedures that are effectively the same, are often higher for male patients than they are for female patients.

"A lot of the panels -- the government panels that decide these things -- don't have women on them," Pories told MedPage Today. "It would be better if we had representation of women at every level of decision-making in terms of insurance company payment, government payments."

This lack of representation is even worse for women of color, Pories noted.

"If you look at minorities, that is another group of people that has even more difficulty," she said. "If you look at Black women in surgery, there are very, very few and they are usually compensated even worse."

Indeed, the to become the surgical chair of an academic medical center was just appointed this year.

Another explanation could be the expectations and reality of family life for women. During the crucial first 10 years when the pay gap grows, "that is when many women are starting families, and so that could be an injuring factor," Whaley said.

Women, regardless of work, still take on child-rearing and household labor. To counter the potential of a family to "injure" a woman's career, however, the authors wrote that employers could offer better paid leave and childcare options.

Pay transparency, Whaley said, is also key. "If you're a female physician, and you can see that 'a fair salary for me is actually higher than what I'm getting paid,' then having transparent benchmarks can help narrow that gap."

Although the issue is nuanced and multifactorial, Pories said the magnitude of the gender pay gap is well established.

"Papers like this just sort of underscore that, and remind us that we do still have work to do," she said. "And there's a whole number of things that could be looked at to improve the situation."

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