To the Editor:

Dr. Walter and colleagues fail to prove their startling claim with the cited sources.¹ The stated 16% difference in earnings² is based on an analysis of the 2019 American Board of Family Medicine National Graduate Survey Data.³ The article by Walter assumes respondents' employment status will not change after 3 years into their career, but the publicly available survey data does not address future career choices. That data set also highlights a wide range of employment choices without gender differentiation. Only one-half of respondents reported working in a private patient care setting, and one-fourth were employed in a government-run or government-funded work setting.³ Were adjustments made for work settings by gender in reaching their estimated 16% difference in hourly compensation? In my experience, government employment pays less but provides greater nonmonetary benefits than private sector employment, but the authors' estimates appear to be based only on total incomes, excluding benefits.

Walter and colleagues state that evidence does not support reduced work hours as a cause of lower female family physician earnings; however, the policy brief by Jabbarpour and colleagues and the study by Ganguli and colleagues document that female physicians work fewer hours than their male peers.^2,4 This disparity does not explain the entire earnings gap, but the assertion that “‘...women elect to work fewer hours’...[is] not supported by evidence” is itself lacking evidence. Using Jabbarpour's method to calculate yearly hours worked, a 3.9-hour weekly difference equates to more than 202 hours over a year, or nearly 4 work weeks. Ganguli found a smaller but statistically significant 5.3-day difference per year. This study also documents an adjusted 10.9% difference in generated revenue between male and female family physicians, which contradicts the assertion that there is no evidence of a productivity difference.

I hope the authors will clarify their assumptions and provide stronger evidence for their claims. I agree that gender pay disparities are an important issue in medicine.

In Reply:

We appreciate this reader's attention to our critical evaluation of the gender wage gap in medicine. Our analysis addresses the concerns that female physicians' choices (e.g., number of hours worked, changes in employment, diversity in employment settings) may affect their earnings.

We do not track employment changes over time for males vs. females. Our analysis is based on starting salaries, which other studies have shown predict future salaries¹ and the widening of this wage gap throughout their careers.² Therefore, we project that a lower starting salary predicts a lower salary overall, but we do not assume that salaries never change, nor do we incorporate bonuses or significant raises across one's career into our conservative estimate.¹

As the reader mentioned, work settings can affect pay disparities. However, more women work in these lower-paying settings, and the disparity persists even after controlling for work settings.³

Jabbarpour controlled for differences in hours worked by calculating the difference in hourly wage to determine wage differences,⁴ finding that females earn less than their male counterparts per hour. Ganguli found that female physicians saw fewer patients but that female family physicians also spent more time with each patient than their male counterparts.⁵

As the number of female family physicians continues to increase, advocating for wage equity in family medicine becomes ever more important.