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Women continued to be paid less than men in academic medicine, with gender gaps in salary and representation most pronounced in cardiology and other procedural specialties, according to a cross-sectional analysis.

In 2018 and 2019, female representation approached 50% at the instructor and assistant professor ranks in internal medicine, but fell to 24% at full professor, according to Nosheen Reza, MD, of University of Pennsylvania's Perelman School of Medicine in Philadelphia, and two female colleagues.

Women's median salaries were modestly lower than those of men's in most cases -- women being paid at least 90% of what male peers got in most specialties, with an absolute difference no greater than $25,000 across lower faculty ranks -- but imbalances were worse for those in cardiology, gastroenterology and critical/intensive care.

These three specialties in particular were associated with few female faculty and the largest gender disparities in pay, as paychecks for women did not reach 90% of those of men, Reza's group .

For example, in cardiology, women accounted for only 21% of faculty, and female cardiology chiefs made about two-thirds of what males peers did at this rank.

"These findings emphasize the importance of gender diversity to achieving salary parity in IM [internal medicine] subspecialties and highlight opportunities to improve representation and salary equity in IM procedural specialties," the investigators said.

Study results may not be surprising given that women typically enter procedural specialties in lower numbers.

"Because procedures are more highly reimbursed for time spent than other medical treatments based on evaluation and management, this gender disparity may explain some of the pay gap observed in the current analysis," according to by JAMA Internal Medicine editor Rita Redberg, MD, and colleagues at University of California San Francisco.

The premium paid for procedures over evaluation and management services needs to be removed, they said.

"Recruiting and retaining women in all specialties and subspecialties should be prioritized," they added. "The issues that drive women to shun male-dominated procedural-based fields -- including lack of role models, macho 'cowboy' culture, unpredictable schedules, longer training periods, or cultural factors -- need efforts to address barriers, break down myths, and change culture."

For a trio led by Leah Marcotte, MD, of the University of Washington in Seattle, changes to the promotion process in particular are key to equality. "Too often we put the onus on women to change their behavior, but closing this [gender] gap will require institutions to make promotion systems and policies more equitable," they wrote in an .

One problem for women is the emphasis on productivity in promotion requirements: women typically get fewer and smaller grants and have to spend more time applying for grants instead of working on their research, and they are also preferentially solicited for institutional committee service, Marcotte's group said.

Institutions can combat this, they said, by funding research assistant support for junior faculty, not asking women to do low-yield committee service, and supporting women in their applications for grants and supplemental funding.

Women also shouldn't have to take extra years to juggle promotion requirements and new children. "Instead, departments could treat having a child as a major life event when trajectory is evaluated in lieu of clock adjustments. This would allow women physicians to be considered for promotion without delay," Marcotte and colleagues suggested.

For their cross-sectional analysis, Reza and colleagues probed deidentified summary survey data on academic physician salaries from the 2018 to 2019 Association of American Medical Colleges (AAMC) Faculty Salary Report. They found 21,905 faculty representing 13 IM specialties at 154 U.S. medical schools.

Women comprised 39.8% of full-time faculty across ranks and were the majority in general internal medicine, endocrinology and geriatrics.

A major limitation of the analysis was the authors' inability to adjust for other factors that may affect salary, such as professional service, academic productivity, clinical volume, and ancillary funding sources, Reva's team acknowledged.

Marcotte and colleagues speculated that the COVID-19 pandemic has also widened existing gender gaps in academic medicine.

"In leaving unrealized the full potential of female faculty, these disparities are detrimental to medicine as a whole," they said.

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