The gender pay gap in emergency medicine
A talk delivered at the ACEM Annual Scientific Meeting, Hobart, November 2019
I’ve been asked to speak about the gender pay gap. It’s a thorny topic. One that can make people feel angry or upset. I’m going to take you through it carefully and break it up with some family and social history.
I’d like to begin with some acknowledgements.
To the women. Those who have gone before, those who stand beside me now, and those yet to come. Thank you for your hard work. Seen and unseen. Public and private. Physical and emotional. Formal and informal. Paid and unpaid.
Thank you for the world you have shaped and created. A humanist world. A world in which both my daughter and my son can express their true selves. A world in which they can live authentic and connected lives.
I see you. I remember you. I acknowledge you. Thank you.
And to the men in the room today – International Men’s Day. I would like to acknowledge you too. Gender equity is a collaborative project, and you are important partners. It is not easy to stand up for something you believe in, so I would like to thank you for your support and for choosing to be here with us . We are stronger together.
My grandmother’s name was Margaret, known as Migi. She met my grandfather, a physician, at a graduation party of the Royal College of Surgeons in London, just before the outbreak of World War II. Migi built a successful career as a professional wife – wining and dining an extensive network of doctors, lawyers and academics, as well as running a household. I sometimes wonder what I could achieve with someone like her organising my life. She was a great friend of mine and I miss her.
When talking about the gender pay gap in emergency medicine, we need to remind ourselves that in the scheme of things, we are rich, powerful women. And men. And people. We’re lucky. We need to learn about how power and privilege work in order to use ours for good. Please take a moment to reflect on your own privilege. You might find it interesting to explore your prejudices. There are some excellent online tests for implicit bias. Why don’t you take one? You might be surprised by what you find.
This talk is not all about me. I’m very well paid to do a job that I love. I’m not angry. I don’t hate men. I don’t feel hard done-by. In fact, I feel very, very lucky. I am highly privileged.
I didn’t talk about gender discrimination for years. It felt like cheating. I’ve been active in medical politics and leadership roles since I was a student. I’m regularly invited to speak about ‘women in medicine’. Until about two years ago I turned these offers down. I had learned how to get ahead and play the game. I’m a good negotiator. I didn’t see it. I didn’t feel it. Until I got pregnant. Until I became the emergency department director. Until other people started to tell me their stories.
I’m senior in the professional hierarchy now. It’s time for me to speak out. It’s time to change things for those coming behind.
I grew up in a girl gang. There are three of us. I’m the big one. My middle sister, ‘Her Honour’ these days, was appointed to the bench at the age of 33, making her the youngest magistrate in modern Australian times. And my little sister is a television producer – you have probably seen some of her amazingly creative and clever work on the box. I am enormously proud of them both.
Sisterhood is my natural modus operandi. My two real-life sisters are a reliable source of support, criticism, competition and inspiration. But my sisterhood reaches far beyond this biological trio. It includes cousins, aunts, godmothers, colleagues and friends. Sponsors and mentors. Professional networks – such as the Network of Women in Emergency Medicine and Advancing Women in Emergency. The female emergency department directors of New South Wales past and present – yes, we speak to each other, and look out for each other, far more than you might suspect. And there are some wonderful men and non-binary friends in my sisterhood too.
I went to university in the nineties and took units in Women’s Studies. Here’s a potted history of feminism – to set the scene.
While feminist ideas have existed since the dawn of time, the so-called ‘first wave’ of feminism ran from the 1850s to the 1920s. The focus was on legal recognition – especially the right to vote. Women saw themselves as protectors of civilised society. The fight for suffrage was closely linked with the temperance movement. The first wave is remembered with the caricature of ‘sister suffragette’ – represented in real life by Emmeline Pankhurst in the UK, and our first Australian female politician, Catherine Helen Spence. But arguably made most famous by the mum character, Winifred Banks, in the Disney film Mary Poppins.
The ‘second wave’ of feminism ran through the 1970s and 1980s. This was a time of sociocultural evolution in the aftermath of World War II and occurred in reaction to the social conservatism of the 1950s. Women stepped out from the domestic sphere – they wanted to be more than wives and mothers. There were several brands of feminism on offer. The radical feminists – who argued there was no need for men, and liberal feminists – who strove to create a gender-neutral society. A source of ideological tension through this period was the question of whether women’s strength derived from being equal to or different from men. Nature versus nurture? The caricature of this period is the ‘bra burner’ – a term used to describe Australian academic Germaine Greer, author of The Female Eunuch, and her contemporaries. It should be noted that no actual bra-burning ever took place.
The ‘third wave’ is the feminism of my adolescence in the 1990s. It was about abolishing gender stereotypes. Women could do anything. Girl power! Inclusiveness was on the agenda – with women building bridges across race, class, culture and geography. Third wave feminists demanded freedom from male control and expectations. Naomi Wolf was the hero of the times. Her book, ‘The Beauty Myth’, told us that it was okay to wear lipstick. As long as you were doing it for yourself, not to please a man. It felt exciting at the time. But I look back at popular culture from this period and realise just how much we had to learn. And I honestly can’t believe how slowly change has occurred since.
We’re deep in the ‘fourth wave’ of feminism now. It began around 2012, with a focus on female empowerment driven by social media. It’s about intersectionality – acknowledgement of power and privilege across gradients of gender, race and sexuality. It’s about justice against assault and harassment – you have probably heard of #MeToo and #TimesUp. It’s about bodily autonomy and equity of opportunity for girls and women.
And it’s about equity of pay and work conditions – a demand made by feminists during each and every wave that has been steadily increasing in volume since the 1970s.
Which brings us to the gender pay gap.
‘The gender pay gap measures the difference between the average earnings of women and men in the workforce. It is the result of the social and economic factors that combine to reduce women’s earning capacity over their lifetime.’
Workplace Gender Equality Agency
The gender pay gap is often confused with equal pay for equal work. The gender pay gap is a much broader concept – one that looks at earnings across an entire sector or industry, not just dollar rates earned by colleagues working at the same level for the same employer. The gender pay gap is a marker of structural discrimination in employment.
My family has a black-and-white photo of an anatomy tutorial at Sydney University in about 1910 – taken in the Anderson Stuart Building, where I also learned anatomy, eighty-something years later. We’ve come some way since then. But despite women outnumbering men at medical school for the last twenty years, the old photo still reflects how medical leadership looks. There are lots of men. And the lone woman in the picture is a bit blurry. My great-grandfather, Sanny, standing six-foot eight, is at the back of the group. He became a psychiatrist.
The Australian Taxation Office collects and reports data on medical specialist incomes. In the 2015/16 financial year, male emergency physicians reported an average income of $232 595, while female emergency physicians reported an average of $165 786. That’s a big gap. Of course, these numbers don’t tell the whole story. And this is reported income, which means some accounting magic is probably in play. I posted a slide showing male and female incomes represented by choc chip cookies on Twitter over the October long weekend, so I’ve received lots of ‘feedback’. Why don’t we analyse it together? Using the comments and questions that always seem to come up.
‘It’s because women work fewer hours than men…’
The most recent round of the MABEL survey (Medicine in Australia: Balancing Employment and Life) asked participants to report their annual income and Medicare billings. Not estimates, but actual numbers from their pay summaries. The study found that male emergency specialists make $177 per hour, which is $21 per hour higher than the $156 per hour that female emergency specialists earn.
That adds up to $43 800 per year if working standard full-time hours – a 12% gender pay gap. And in emergency medicine, we’re doing much better than our colleagues in general surgery, who have a 40% gap, or general practice, with a 19% gap. But not as well as paediatricians, who have the smallest gap at 5%.
‘We’ve got the award – pay and conditions are the same for men and women…’
I’m sure you’ve heard comments like this. ‘I don’t understand – I’ve always been paid exactly the same as everyone else at my level.’ But it’s not true. In some jurisdictions, individual wage bargaining occurs. Yes, including in public sector emergency medicine.
Some variation in pay is explained by discretionary extra income – things like allowances, grants and bonuses. Mobile phones and laptops recompensed by the hospital. Business versus economy class travel to conferences.
Uneven distribution of seniority accounts for further variation – with women under-represented in management roles and at higher levels of awards. Think about the shape of the current emergency medicine workforce. Around 38% of ACEM fellows are female. A large proportion of them received their letters in the last five years, so there are far more men employed as senior staff specialists. Around 50% of current ACEM trainees are female, so I hope the structure of the workforce will look quite different in ten years.
Approximately 20% of ED directors in Australasia are women. Tasmania, with an all-female line-up, is punching well above its weight. So is New Zealand. But – I’d like you to think about where women are running the show. There aren’t many women directing tertiary departments attached to sandstone universities in the middle of town. We’re mostly on the fringe. Have you heard of ‘the glass cliff?’ Women are encouraged into leadership when a job is perceived as marginal, unwanted, precarious or undoable. Don’t believe me? Think about Julia Gillard. And Theresa May.
‘International analysis demonstrates that within specialty discrimination exists even when controlled for other observable characteristics.’
Level Medicine
Even when all factors are controlled for – age, speciality, years of practice, career seniority – a significant pay gap persists in medicine in Australia.
‘The gender pay gap just reflects women’s choices…’
Let’s contemplate women’s choices for a moment. Their choice of partner – supportive or otherwise. Whether or not to have children. Part-time work. Their choice not to apply for senior roles. Their choice not to negotiate ‘like a man’.
In a spirit of humility, I will disclose that I got married in my final year of medical school, to a gorgeous man who had everything I thought I wanted in my twenties. He wrote poetry and played the guitar. He was ridiculously good-looking. We never talked about how we might reconcile his dream of being a rural GP with my love of hospitals, universities, symphony orchestras and politics – basically, my love of big cities. It lasted 364 days. That’s respectable compared to Julia Roberts and Drew Barrymore. But not compared to my parents, who celebrated fifty years last December. I don’t want to re-write history, but I sometimes wonder how different my life would look now if that choice had worked out.
Okay then. The gender pay gap is exacerbated by women’s choices. But men make choices too, don’t they? I suspect that many men would make different choices about work, relationships and family in a more gender-equal context.
We need to dispel the myth of negotiation. The assumption that women don’t get because they don’t ask. You might be surprised to hear that research demonstrates women do ask for more money. They do ask for promotion. But they get knocked back more often than men. So, they learn to ask for less and to ask less often. They eventually stop asking.
Why do women get knocked back? It’s probably because employers assume that men need more than women. Because men have career ladders to climb. Because men have families to support. Some employers make this assumption knowingly. For many it is made unconsciously, a product of their social conditioning. Either way, the assumption is flawed and deserves to be challenged.
‘It doesn’t make sense for me to work – childcare costs nearly as much as I earn…’
This comment will resonate with almost every working mother. Most women conceptualise their professional and caring roles, and impacts on their earning capacity, as a direct trade-off.
I think this is the crux of the problem. The root cause of the gender pay gap is the deep-seated social and cultural belief that women are natural carers. At home and at work.
You’ve probably just worked out why all the stories in this talk are about my family.
‘The gap between women’s and men’s earnings is a symptom of a broader cultural problem in workplaces. It reflects the historic and systemic undervaluing of women’s workplace contributions and the significant barriers that lead to the under-representation of women in senior executive and management roles.’
Workplace Gender Equality Agency
When you discuss the gender pay gap on social media, it becomes clear that many people believe that aptitude for caring is biologically determined. The way we do child-rearing around here is as it must be. It’s a given. We’ve always done it this way.
However, other countries do things quite differently. Look to Norway, where a year of parenting leave is shared by parents, regardless of their gender, and early childhood education is provided to all families by the government, free of cost. Or Germany, where school hours align more closely with the standard working day, extra-curricular activities are included, and a professionally staffed cafeteria provides students with lunch. Fancy that!
‘Where are your kids?’
I’m asked this constantly. I suspect that most of you are too. I keep photos of the kids on my phone to remind me where I left them – my screensaver suggests they’ve been at the beach since January. Luckily, they’re very resourceful. They’ve probably been scrounging chips with the seagulls.
But seriously, every time someone asks me this at work, they undermine my self-confidence and my professional authority. I doubt this question is ever asked of a man.
‘Females and males differ with regards to the frequency of career interruptions in order to care for families or take other caring roles.’
Level Medicine
Caring happens at all stages of the life cycle, and it takes different forms. Looking after babies and children. Helping elderly parents, neighbours and friends. Canteen duty and running the uniform shop. Preparing a plate for the Father’s Day breakfast and the Mother’s Day lunch. Wrapping birthday presents. Volunteering. All of which, in our current social climate, are disproportionately done by women.
We need to broaden our thinking about who is a carer. We need to move beyond the hetero-normative, biological couple-centred notion of family. That’s not how many families work. We need to re-imagine how we might support and reward carers of all genders for doing this important and life-sustaining work, without which the economy would crumble.
‘Females with dependent children earn less than females without dependent children. Males with dependent children have higher earnings than males who do not have dependent children.’
Level Medicine
Ponder that. When measured at population level, men boost their incomes by having kids. Of course, this is not true in every individual case. But here it is again, the old-fashioned assumption that men need more because they have families to support. Implicit bias working its magic.
‘Closing the gender pay gap goes beyond just ensuring equal pay. It requires cultural change to remove the barriers to the full and equal participation of women in the workforce, including the genuine equal choice to access the same career or work opportunities as men in all occupations, industries and levels of seniority.’
Workplace Gender Equality Agency
I’m often asked, ‘how do you manage to do everything on top of having kids?’
It’s time to reveal my secret weapon. Yes – I go to bed with a middle-aged white man almost every night. I met him online ten years ago. I knew I was onto a winner when he quoted a song by Cake in his RSVP profile. ‘I want a girl with a short skirt and a looooooooooooong jacket’, he claimed. ‘Aha!’ I thought. ‘I know someone a bit like that.’ We’ve been hanging out ever since.
I knew myself better, second time around, and my priorities were different.
We are ourselves with each other. We parent and house-keep as equal partners. My career benefits from his family-friendly work conditions and he tolerates the gender pay gap in our household.
I’d like to publicly thank my wonderful partner for my extraordinary life. I couldn’t do it without him. And he makes the school lunches too.
Guess what? My dad also made my school lunches. My mum saved a clipping from the front page of the Sydney Morning Herald in 1985. A photo of me and my friends celebrating that strange and unusual fact. My dad made two varieties of sandwich – vegemite and lettuce or peanut butter and banana – neither of which I intend to eat ever again. It’s the thought that counts.
‘Studies in Australia and abroad consistently find some degree of the pay gap among doctors cannot be explained by specialisation, hours worked, seniority, training achievements or place of employment.’
Level Medicine
The gender pay gap is a strange beast. We can’t quite explain it, but it really exists.
Let’s think about how the pay gap in emergency medicine plays out over the span of an entire career. Using ATO reported incomes I referred to earlier and average superannuation interest rates, I have calculated that male emergency physicians will retire with about $657 978 to live on, while female emergency physicians will have accrued about $513 220. Is that fair?
Some of the difference is due to career breaks and periods of part-time work. When not in formal work, women are likely to be in caring roles supporting others. Mostly boosting the earning capacity of their male partner by looking after their shared children.
Relationships take all forms and they don’t always last. No-one should rely on their partner’s savings to live comfortably in retirement. It’s more of a problem for less well-off members of our society, but female poverty and homelessness in old age is growing fast. That’s an excellent reason to become a gender equity activist.
Of course, this talk is about averages. Statistics smooth over and conceal individual stories. There are single fathers, stay-at-home dads and men parenting with male partners. The vast majority of men love their children and make excellent parents. There are men looking after elderly relatives. I acknowledge their important contribution as carers. There are men doing far more than their fair share of the housework, including at my place this week – #NotAllMen. But from a structural perspective, they are currently the exception, not the norm. Most men do not set out to deliberately disadvantage women. The choices and expectations of both women and men are the product of the social conditions in which they develop.
How about New Zealand? I apologise that I have used Australian data for this talk. I did so only because it was available. The Association of Salaried Medical Specialists in New Zealand has commissioned a study into medical pay rates, but results are pending. General workforce statistics in New Zealand demonstrate similar gender pay gaps to Australia. Stats NZ reported a 16.7% gender pay gap for professional occupations in June 2019. The gender pay gap in medicine in Australia is 16.6%. It is reasonable to assume that the contributing factors explored in this talk also hold true in Aotearoa.
Don’t despair. I’ve got good news about the gender pay gap.
Research demonstrates that we can fix it. Pay equity actions make a measurable difference. Collectively, we should develop gender equity policies, review remuneration arrangements to ensure fairness, report pay gaps to executive, and introduce and evaluate corrective actions. Individually, we all need to understand and ask for our entitlements. Consider joining your union. We can also form professional and social networks, share information and support each other in calling inequity out.
There’s even more to do. We can encourage women into leadership roles – through quotas or targets, sponsorship, mentorship, coaching and reporting. We can support and encourage men in caring roles, by broadening parental leave entitlements, setting expectations and role-modelling. We should not fall into the trap of assuming that the current male way is the ‘right’ way. Instead, we should fashion new approaches to work and family that encourage equity and inclusion. Members of all genders can and should agitate for more flexible work conditions.
Health has a lot to learn from other industries. The 1987 comedy ‘Three Men and a Baby’ would still seem funny to a group of doctors. I suspect that other industry groups, with more flexible conditions and gender-neutral parenting policies, would no longer get the joke.
There are three recent Australian books you can read to learn more. I strongly recommend ‘Women, Men and the Whole Damn Thing’ by David Leser, which is a detailed exploration of fourth wave feminism. ‘The Wife Drought’, by Annabel Crabb, examines parenting and housework as barriers to female participation in the workforce. It did leave me wondering who would choose to be a wife. You might also like to read Annabel Crabb’s Quarterly Essay titled ‘Men at Work’. Jane Caro’s book ‘Accidental Feminists’ explores social and financial penalties experienced by women in caring roles across the lifespan. All three books are well written, accessible and very relevant to this talk.
I’d like to reiterate that this talk is not all about me.
It’s not all about women either. It’s about all of us – regardless of gender. It’s about humanising emergency medicine. It’s about creating health services that are flexible, diverse, equitable and inclusive. It’s about creating workplace conditions that are better for everyone. And better for patients too.
I need to thank the wonderful people I work with in the emergency department. I care for them and they care for me. In turn, we look after our community. They let me express my ideas and be myself. I wouldn’t be where I am without them. They are my work family.
I want to thank my colleagues from AWE and NoWEM from whom I have learned so much.
And to the men in the room. You are important allies in this quest. There is much you can do to promote gender equity. Please ask us how you can help. And let us know how we can help you.
I would like to thank everyone who contributed to writing this talk – in person, on the phone and via social media. Please keep talking about the gender pay gap, especially if you don’t agree with me.
I’ve got some homework for you.
I want you to think about the gender pay gap in emergency medicine. Do you think it’s real? Is it important? What should college do about it? What should hospitals do about it? What should governments do about it?
What will you do about it?
Because the gender pay gap is a socio-cultural, structural problem that affects us all.
Dr Clare Skinner is Director of Emergency Medicine at Hornsby Ku-ring-gai Hospital in Sydney, NSW, Australia. Her professional interests include health system redesign, medical education and improving hospital culture. She is on a gazillion committees. In her spare time, she writes stories, plays music, makes bad art and hangs out with her partner and kids.
References:
Project Implicit
https://implicit.harvard.edu/implicit/
Kimmorley S, ‘A look at Australia’s 50 highest paid jobs highlights a disgraceful gender pay gap’, Business Insider, December 2016
Fitzgerald G, ‘The Gender Pay Gap’, Level Medicine, 2017
‘The Gender Pay Gap’, Workplace Gender Equality Agency
‘Gender Equity Insights 2018’, Workplace Gender Equality Agency
Medicine in Australia: Balancing Employment and Life
