In recent news, some scenes in the movie All the Money in the World needed to be reshot when the actor Kevin Spacey was replaced by Christopher Plummer. Co-stars Michelle Williams and Mark Wahlberg, both represented by the same talent agency, received vastly different compensation for the reshoot: Michelle Williams received a per diem of $80 for about 10 days of work, which included Thanksgiving, while Mark Wahlberg received $1.5 million. There was some outrage when this 1000-fold gender pay gap became public, and Wahlberg and William Morris Endeavor donated $2 million to the Time’s Up organization before it was all over.

So: in medicine we are not alone.

While female doctors and surgeons earn 71% of their male colleagues’ salaries, female financial specialists are paid 66% as much as comparable men, women one year out of college earn 6.6% less than men after controlling for occupation and hours, and female MBA graduates earn $4600 less than their male classmates.

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A small difference in first salary is, furthermore, compounded over a 3-decade career, as raises and pension contributions are made on top of smaller bases, debts are paid off more slowly, and less is invested. Estimates are that a $10,000 difference in starting salary will result in a 1 million–dollar lower worth by retirement. Yet evidence suggests that women are superior providers of medical care, often yielding better outcomes including lower mortality and readmission rates in US and Canadian studies.1

Throughout medicine and the biomedical sciences, women continue to receive lower salaries and less funding, have fewer publications and first author publications — including in clinical cancer research, where they are relatively well-represented in the workforce — and be promoted at slower and lower rates. Facile explanations for these differences include differential household and child-rearing responsibilities, and different preferences on work-life balance.

These facts may contribute to sex differences in salary and promotion by reducing research productivity, but should have little independent effect on faculty rank once measures of productivity are accounted for. When, however, Jena et al controlled for age, years since residency, specialty, authored publications, National Institutes of Health (NIH) funding, and clinical trial investigation, women remained significantly less likely to attain the rank of full professor than men.2

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Faced with the evidence that these stereotypical explanations cannot fully account for the existing gender pay gap in medicine, the sources of the pay gap remain to be fully identified.

Certainly, access to the best-paying positions in medicine and academic medicine is restricted for women. In academia, Association of American Medical Colleges (AAMC) data from 2014 demonstrate that women are poorly represented among leadership positions, occupying only 15% of department chairs and 16% of deanships. Jagsi et al documented that female cardiologists are significantly less likely to practice interventional cardiology than their male peers, and are commensurately less well compensated.3

The quality of experience junior physicians have in early positions may, furthermore, influence success and compensation. Women in academics may be saddled with greater amounts of the less rewarding tasks. Guarino and Borden investigated the amount of academic service performed by female or male faculty.4 Using 2 large databases, they found that female faculty perform significantly more internal service than men, controlling for rank, race/ethnicity, and department.

Survey data demonstrate that research faculty who report having been the beneficiary of strong sponsorship by a faculty mentor are more likely to achieve academic success, and that such mentorship is reported more often by men than women.5 Indeed, discrepancies in the value placed on the work of women in academic medicine may begin even before graduation.

This article originally appeared on Cancer Therapy Advisor