The gender gap in physicians’ earnings is well recognized — studies have shown that female physicians earn 8% to 29% less than males — but its underlying causes are a source of ongoing investigation and often vigorous debate. Shedding new light on the subject is a study challenging conventional assumptions about women in medicine — it’s not that they work substantially fewer hours than men, as often alleged, but that they see fewer patients while spending more time with them.

The study, published recently in The New England Journal of Medicine, digs deeper than many previous efforts by comparing the work of male and female physicians within the same primary care practices. The investigators examined electronic health records (EHR) data from more than 24 million office visits of 8.5 million adults across the United States in 2017. The data encompassed visits to 8,302 internists, family physicians and general practitioners. Just over one-third (36.4%) of the physicians were women.

Fewer visits, more face time
The key finding: Over the course of one year, female primary care physicians (PCPs) generated 10.9% less revenue from office visits than did their male counterparts in the same practice, after controlling for several variables. “The revenue gap was driven entirely by differences in visit volume,” the authors note, with female doctors conducting 10.8% fewer visits per year.

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“The main takeaway,” lead author Ishani Ganguli, a physician and assistant professor of medicine at Harvard Medical School, told Medical Bag, “is that despite generating 11% less in revenue and having 11% fewer visits, female physicians spent more time in direct patient care than their male colleagues did — per visit, per day, and per year.”

Female PCPs generated similar revenue per visit but spent 15.7% more time — an average of 2.4 minutes per visit — with each patient than did male doctors. Female doctors also spent more time seeing patients with two or more chronic conditions.

The study “adds important data to our understanding of the gender pay gap in medicine,” says Connie Newman, M.D., adjunct professor of medicine at NYU School of Medicine and past president of the American Medical Women’s Association (AMWA). Newman, who was not involved with the study, notes the large number of visits in the analysis (24 million) and the fact that the time spent in each visit was precisely documented through electronic records. 

Newman was also struck by the finding that female physicians were more likely than male doctors in the same practice to miss opportunities to bill higher-paying insurance codes based on time spent with patients. Specific codes offer greater reimbursement for visits lasting more than 25 and 40 minutes, for example. “It is important that women physicians understand the value of their work. As a woman in medicine, you have to stand up for yourself,” says Newman, who adds that female physicians are more likely than male physicians to suffer from impostor syndrome, a feeling of unworthiness and a tendency to doubt one’s skills and accomplishments.

Risk of burnout
When Ganguli and her colleagues started their research, they “simply wanted to explore how the experience of work might be different for male and female physicians in primary care practice.” They found that despite working just as hard as male PCPs, females didn’t generate the same revenue because they didn’t see as many patients.

This disconnect, she suggests, may help explain why female physicians, especially those in primary care, are at greater risk of burnout than men. “Male and female physicians alike want to be able to spend more time with patients,” Ganguli explains. “We found that female physicians are currently doing this, but at a cost to themselves.”

Data from several studies on physician burnout, including some authored by NYU’s Newman, report 20% to 60% higher rates of burnout in women versus men across multiple medical specialties. In a 2020 survey of 15,000 U.S. physicians from 29 specialties, 48% of female and 37% of male physicians reported burnout. Key factors putting women physicians at risk for burnout, Newman notes, include fewer opportunities for career advancement or leadership roles, the pull of responsibilities at home, and disparaging or harassing treatment from within the profession.

Wrong productivity measure
Ganguli and her colleagues conclude that their findings support the criticism “that volume-based productivity is an imperfect measure of physician work.” While they looked only at time spent in office visits, they pointed to other research indicating that women physicians also spend more time than men in the tasks of indirect care, such as entering documentation in the EHR, handling phone calls and emails, and performing clinical reviews.

NYU’s Newman believes that the gender pay gap might decrease if the model of physician compensation “moves from a volume-based to an outcomes-based approach” that looks at clinical results of medical interventions as well as levels of patient satisfaction. Spending more time with a patient has been associated with more extensive screening and counseling, better patient outcomes (including higher patient satisfaction) and less physician burnout. Extra time in the exam room makes it possible to take a more thorough history, facilitates shared decision-making and allows more detailed explanations of diagnoses and treatment.