SHE WORKS HARD FOR THE MONEY:

DIFFEWNCES IN THE CNCOME OF MALE

AND FEMALE CENERU PIUCTITIONERS

Karen S. Atkin

A thesis submitted in conformity with the requirements for the Degree of Master of Science

Graduate Department of Commmity Health (Health Administration) University of Toronto.

O copyright Karen S. Atkin 2000

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SHE WORKS HARD FOR THE MONEY: DIFFERENCES tN THE INCOME OF MALE AND FEMALE GENERAL PRACTITIONERS

by Karen S. Atkin

A thesis submitted in conformity with the requirements for the Degree of Master of Science Graduate Department of Community Health (Health Administration) University of Toronto.

O copyright Karen S. A t h 2000

ABSTRACT

Research studies have repeatedly demonstrated a gap between the income of male and

female physicians. This thesis examines the gendered income for farnily physicians in

Ontario based on a mailed survey conducted in 1996. The model is theoretically driven based

on variables drawn fiom two theoretical perspectives - gender stratification and hwnan

capital. The thesis demonstrates that despite a sizeable increase in the nurnber of women in

medicine and broader social trends, there remains a persistent gender gap in the eamings of

farnily physicians in Ontario, even when controlling for a large number of practice and

family characteristics. Using a model which is a synthesis of two theoretical perspectives. a

large proportion of the variance between men and women physicians can be explained.

However, different factors appear to contribute to determining the income of male and

female physicians and the importance of these factors may be different for each.

Table of Contents

Page ................................................................................................................................ Introduction 1

Li terature Review ....................................................................................................................... 4 2.1 . Practice patterns men and women physicians .............................. .... ........................... ..4

............................................................................. 2.2. Incomes of men and women physicians 6 2.3. Gender segregation & human capital theories .................................................................. 9

................................................................................................................................... Methods 14 3.1. Study design and sample .................................................................................................. 14

......................................................................................................... 3.2. Research variables 1 7 ............................................................................................. . 3.2.1 Dependent variable 1 7

........................................................................................... 3 .2.2. Independent variables -1 8 ............................................................................................................ . 3 .3 Analysis strategy -2 1

Results & Summary of Major Findings ................................................................................... 23 Discussion ............................................................................................................................... 3 1

................................................................................................................................ References 35 Appendix A - cover letter ....................................................................................................... -3 8 Appendix B - questionnaire ..................................................................................................... 39

Tables Table 1 : Women in the Canadian workforce ................................................................................... 4 Table 2: Surnmary of Canadian studies examining practice patterns .............................................. 5 Table 3: Literature review of variables commonly used ................................................................. 7 Table 4: Summary of studies examining incomes of male and female physicians ......................... 8

.................................................................. Table 5 : Sample weights adjusting for over-sampling 16 Table 6: Univariate descriptive statistics for dummy variables ..................................................... 23 Table 7: Univariate descriptive statistics for continuous variables ............................................. 23 Table 8: Unadjusted income for male and female GPs .................................................................. 24 Table 9: Means and standard deviations for family situation variables by gender ........................ 24 Table 1 0: Means and standard deviations for practice characteristic variables by gender ............ 25 Table 1 1 : Correlation matrix for variables in regression .............................................................. -25 Table 12: Regression equations for income for ail physicians ...................................................... 26 Table 1 3 : Regression for al1 GPs ................................................................................................... 27 Table 14: Correlation matrix for variables in regression for female physicians ............................ 28 Table 15: Correlation matrix for variables in regression for male physicians .......... .. ............... 28 Table 16: Regression equations for income for female physicians ............................................... 29 Table 17: Regression equations for income for male physicians .................................................. 30

........................................................ Table 1 8: Regressions nin separately for males and females 30

SHE WORKS HARD FOR THE MONEY: DIFFERENCES IN THE INCOME OF LE AND FEMALE GENERAL PRACTITIONERS

1. INTRODUCTION

"One of the most fundamental changes in Canadian society over the past several decades has been the increased labour force participation of women. An important aspect of this trend has been the growing number of women employed in professional occupations. Women have made substantial inroads into what have traditionall y k e n male-dominated professions. . . . Women in professional occupations have considerably higher employment incomes than other women. However their average incomes remain well below those of comparable men, and the gap has not closed in recent years." (Marshall, 1990b, pp. 109, 1 12).

In recent years, one of the most dramatic changes in the professions has been the

rapid influx of women into what have traditionally been male dominated professions, such as

medicine. Although there has k e n a significant increase in the number of women in

medicine, such that they now make up about half of current medical school graduates and a

quarter of active physicians, women physicians consistently earn much less than their male

peers. (Canadian Medical Association, 1996; Kay and Hagan, 1995; Kehrer, 1976; Langwell,

1982; Ohsfeldt and Culler, 1986; Mitchell, 1984; Baker, 1996; Marshall, 1 WOa; Silberger,

Marder and Willke, 1987; Uhlenberg and Cooney, 1990; Williams, Domnick-Pierre, Vayda,

et al., 1990) The literature has repeatedly found that even when differences in physician and

practice characteristics (e.g. hours of work, method of remunenition, specialty, solo/group,

age, marital status, children) are controlled for women still earn less then men. A review of

the literature shows that previous models of physicians' incomes have only been successful

She works hardfor the monqy: d~xerences in the income ofmale andfernale general practitioners by Karen Atkin

in explaining a portion of the difference in incomes. This thesis aims to M e r advance the

understanding of this gender gap in incomes.

Since 1971, Canada has had universal hedth insurance such that al1 medically

necessary services provided by physicians are reimbursed by govemment health insurance

plans. Under medicare the predominant method of physician remuneration is fee-for-service

payments whereby physicians bill the govemment a prescribed fee for each service provided

or procedure perfonned. In this system a man and woman each providing the same service or

performing the identical procedure are remunerated at the same rate. Therefore, one would

expect that a man and a woman physician working the sarne number of hours, with similar

patient volumes, would earn similar incomes; this is often not the case. Nevertheless, even

when adjusting for various factors, there appears to be a gap between the income of men and

women physicians.

The puzzle that this thesis addresses is, given the theoretically neutrai wage structure

and controlling for differences in personal, professionai and practice characteristics, why do

women physicians stiH earn less than male physicians?

This thesis uses data fiom a 1996 survey of Ontario general practitioners and family

physicians (GP/FPs) to examine differences between the incomes of male and female

GPIFPs. The primary objective is to develop a better understanding of the gap between the

eamings of male and female physicians. Two theoretical perspectives are used - gender segregation and human capital. Some previous studies of physician income have used one or

the other of these two theones, however each theory has weaknesses and on their own neither

has adequately explained the gender gap. This thesis combines the two theoretical

perspectives and builds a mode1 that incorporates variables that tap into each of them.

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She works hard for rhe money direrences in the income of male andfernale general pracritioners by Karen Atkin

Initially the model will examine the incomes of men and women physicians simultaneously.

Then the incomes of males and fernales will be examined separately to determine whether the

various variables in the model have the sarne impact for men and wornen.

Thus the objective of this thesis is to describe the income gap for this sample of

physicians and to analyze that gap. This analysis wifl be theoretically driven and the aim is to

gain a better understanding of the income gap for Canadian physicians, in the context of a

recent sample of Ontario farnify physicians.

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She w o r h hardfor the money: digerences in the income ofmale andfernale general practitioners by Karen Atkin

2. LITERATURE REVIE'W

2.1 PRACTICE PATTERNS OF MEN AND WOMEN PHYSICIANS

As with al1 historically male dominated professions, women make up an increasing

proportion of the medical profession, such that they now represent over a quarter of

practising physicians and half of medical school graduates. Statistics Canada data (Table 1)

suggests that the medical profession is sirnilar to most other occupations in that women earn

about two-thirds of the income of men. As well. the literature continues to find many

consistent differences in the personal, professional and practice characteristics, and income

of maie and female physicians. These differences have been consistently found over time by

various researchers in Canada, the United States and other countries.

Table 1: Women in the Canadian workforce

Table 2 highlights the findings of a literature review of a nurnber of major Canadian

P hysicians Females as % of profession Female income as % o f male income All occupations Fernales as % of workforce Female income as % o f male income

research studies that have examined the practice patterns of physicians. In general, maie

physicians are older and have more practice experience than female doctors. (Sanmartin and

Snidal, 1993; Williams, et al., 1990) As well, male physicians are more likely to many and

have children than women physicians. (Skelly, 1994; Uhlenberg and Cooney, 1990)

Source: Sfaristici Ca&

13.9 60.4

Research seems to Vary on the number of weeks worked each year, with some studies

finding little or no difference and others finding that men work more weeks per year.

21.0 63.1

(Bobula, 1 980; Silberger, et al., 1987; Woodward, Cohen, Ferrier, IWO) Recently in Canada,

although al1 physicians are working fewer hours per week than in the past, women still work

26.6 .. 65.7

Page 4

45.6 , 67.4

1 32.7 63.8

43.5 65.5

She works hatdJor the money: d~fferences in the income ofmale andfernale general pracritioners by Karen Atkin

fewer hours than their male colleagues. (Adams, 1989; Bobula, 1980; Martin, 1999;

Sanmartin and Snidal, 1993; Uhlenberg and Cooney, 1990; Williams, Woodward, Ferrier,

Cohen, 1997) However it is important to note that the gap in hours between men and women

is narrowing. (Canadian Medical Association, 1996; Robson, 1996)

Adams, 1989 38.308

Canadian d a Medical Association, 1996 Manin, 1999 3,100

Robson, 1996 1 3,626 Sanmartin and 38,3 13 Snidal, 1993

Domnick-Pierre,

Woodward, Ferrier, Cohen, 1997

1 Cohen, Ferrier, 1

1 Woodward. 1 395

1986 Canadian national survey 1982/86/90/93 Canadian national surveys 1999 Canadian national survey

1995 Canadian national survey 1 990 Canadian national survey

1994 - 4 country survey, Canada, US, UK, France 1 993 Canadian national survey 1987 Canadian national survey

1993 Ontario survey of recent farnily practice graduates

Survey of recent McMaster graduates 1994 Ontario

78 % 1 on the whole physicians are working fewer hours women work 90% of the hours of men

d a recently men and women are working fewer hours per week and gender gap is narrowing

1 women are more likely to have income fiom non-FFS sources

41 O h women still work less hours women with children at home work fewer hours than those with no children, however men with children work more hours than those with none men spend less time on household chores and taking primary responsibility for child care

47 % rn gap between men and wornen in hours worked narrowing

74 % rn from 1982 to 1990 average hours worked/week declined for al1 physicians men are more likely to work fùll-time women are younger

nia in ail countries women spend more time with patients

rn women less likely to be married

d a women are younger and have been practising a 1 shortertime

Page 5

68 % women physicians are younger women more Iikely to go into general, as opposed to specialty, practice women work fewer hours women more likely to work in urban areas men more Iikely to work in solo practice women see fewer patients per week

70 % women GPs have more female patients

84 %

70 %

women work fewer hours per week rn men and women share sirnilar attitudes regarding

patient care women more likely to work in groups weekdyear worked sirnilar for men and women women work less houdweek

rn women more likety than men to have career interruptions, most ofien for child-bearing

rn women spend less time on professional activities

She worh hurdfor the money: diferences in the incorne of male andfernale general practifioners by Karen Atkin

Williams, Ferrier and Cohen, 1996

when they have children, women spend more time on unwaged childcare than men

0 arnong physicians with children women spent much more time on professional and unwaged domestic work

0 when they have no children men spend slightly more time on professional and unwaged domestic work

As well, most studies find that women see a lower volume of patients each week as

they work fewer hours and they also spend more time with their patients, i.e. see fewer

patients per hou. (Skelly, 1994; Williams, et al., 1990) Men physicians are more likely to

work in traditional fee-for-service solo or group practices, while wornen have a greater

tendency to work in alternative, salaried settings, such as community health centres and

health service organizations. As well, men and women tend to enter different specialties, with

women more likely to go into generai, as opposed to speciaity, practice. (Bobula, 1980;

Canadian Medical Association, 1996; Williams, et al., 1990; Williams, et al., 1997)

Several studies have found that women with children at home work fewer hours than

those with no children; whereas, men with children work more hours than men with none.

(Baker, 1996; Martin, 1999; Mitchell, 1984; Woodward, et ai., 1996) Women physicians

spend more time on unwaged childcare and housework than their male colleagues. (Martin,

1999; Woodward, et al., 1996) Additionally, the patient characteristics of male and female

physicians differ, with women seeing more female patients and having a younger patient

population. (Williams, et al., 1997)

2.2 INCOMES OF MEN AND WOMEN PHYSICIANS

The literature has consistently identified a gap between the earnings, both adjusted

and unadjusted, of men and women physicians.

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She works hardfor the money: diflerences in the income ofmale and female general practirioners

Table 3: Review ofvariables found in lirerature

by Karen Atkn

Hourly earnings 2,4, Il , 12,23 Hourly earnings - log 1 1, 12, 17. 19 IYearly eamings Yearly earnings - log INDEPENDENT VARUBL ES

Absences ftom workforce

2.23,27,28,29 19.20

2, 1 1 Age Career cornmitment Certification Children Gender Hours of work Marital s t a t u Medical school Patient volume Physician density Professional membership RaceEthnicity So lo/group Specialty

2, 11,27,28 20 2, 11 , 12. 19-20 2, 11. 19.20.27 2,4, 11. 12, 17, 19,20,23,27,28,29 2, 1 1, 19,27,28,29 2, 11, 19.27 2. 11, 12, 17, 19,20 23,29 11, 12 2,20 2, 19-20 2,4, 17, 19,20 2, 11 , 12. 17, 19,20,23,28,29

Spouse's income Type of practice

Researchers have included a wide variety of variables in their studies when adjusting

19 2,4,11.12,17,19,20.29

Urban/rural Weeks worked per year Y ears of experience/graduation

income for persona1 and professional charactenstics. Table 3 reviews the independent and

2. 17, 19.20 1 1 2, 1 1. 12. 17, 19,20.23.29

dependent variables used in over a dozen studies examining the income of male and female

*Numbers represent the numbers in the reference section of this paper

physicians. The most cornmonly controlled for variables are: gender, hours of work, years of

experiencelage, specialty, type of practice, weeks worked per year, whether the physician has

children at home, and medical school. As well, researchers have used a number of different

dependent variables, including yearly earnings, logged yearly earnings and logged hourly

earnings.

The research studies highlighted in Table 4 al1 found that women physicians eam less

than men physicians, even when personal, workload, a d o r practice charactenstics are

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She w o r h hardfor the rnoneyr differences in the income of male andfernale generaf practitioners by Karen Arkin

controlled for. (Bobula, 1980; Mitchell, 1984; Ohsfeldt and Culler, 1986; Silberger, et ai.,

1987; Skinulis, 1993; Uhlenberg and Cooney, 1990; Williams, et al., t 990) These differences

are also found in other countries, such as the United Kingdom and France. (Skelly, 1994)

199 1 US national 70 % survey of young physicians

Baker, 1996 unadjusted eamings of men 4 1% more than women adjusted young male and female physicians earn equal incomes differences in adjusted eamings are seen among older physicians and in some specialties men have higher unadjusted incomes

1 1

1978 US national 1 d a 1 Bobula 1980 survey with over- sample of women

even if women work same number of hourdweek and weekdyear as men, mean income o f women would be 83% of mean income for males

1978 US national 70 % survey with over-

0 married women (but not men) have Mitchell. 1984 significant reduction in work hours

sampÏe of women 1982 US national 61 O h Ohsfeldt and

Culler, 1986 0 unadjusted men eamed 30% more per hour

than women afler adjusting for differences in potentially confounding variables men earned 12- 13% more than women

0 unadjusted men eamed 38% more

survey with over- sample of women

1986 US national d a Si lberger. Marder, Wiilke. 1987 survey

1994 - Int'l survev, d a women in a l Ï 4 countries likely to be in low income bracket o f physicians

Skelly, 1994 Canada US. UK. - 1 1

national survey Skinulis, 1993 0 women still make less than men

0 6 1 % of women vs. 29% of men make under $1 00,000

0 unadjusted men eam more than women marriage and children spur men to work more, reverse effect on women even after adjusting for differences in workloads, the incomes o f women werc

1980 US census lN1 hi en ber^ and Cooney, 1990 Williams, Domnick-Pierre, Vayda, et al., 1990 significantly lower than those of men

1987 Canadian national survey

The exception is Baker (1996) who found that in 1990 young male and female

68 %

physicians with similar charactenstics earned equal arnounts of money, although he did find

differences in eamings between men and women remained among older physicians and in

some specialties. It should be noted that this is an Amencan study with a much different

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She work hurdfor the money: diferences in the income ofmale andfintale general practitioners by Karen Afkin

marketplace, varying levels of physician autonomy and diffenng physician payment

methods; despite this many US studies have found practice patterns similar to Canada. Baker

hypothesized that the reasons for his finding are due to the increasing number of women

entering the medical profession, as well as broader social trends such as the attention to

issues of sexual equality and the role of women in the labour force. He also suggested that

changes in medical education may have improved the ability of women to compete for

earnings and increases in women's income in other fields may have bolstered their earnings

in medicine. Baker's study does not examine these same physicians a nurnber of years later

to determine the impact of marriage and childbearing on incomes. As well, Baker seems to

be the only researcher who has identified a complete closure of the gap in income between

physicians, young or old. Statistics Canada data shows that in medicine and other

occupations women continue to earn about two-thirds of the income of men, although the gap

has narrowed by a few points. (See Table 1)

2.3 GENDER SEGREGATION AND HUMAN CAPITAL TKEORIES

At first glance the persistent gap between male and female earnings is puzzling as the

wage structure of Canadian medicare is theoretically gender neutral- A man and woman each

providing the same service or performing an identical procedure are remunerated at the same

rate. Therefore, one would expect that a man and a woman physician working the same

nurnber of hours, with similar patient volumes, would eam similar incomes; this is usually

not the case. It might be suggested that there is a façade of neutrality, in that women have

different practice patterns than men and some things that women do are not remunerated (e-g.

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She w o r k hard for the money: d~flerences in the income ofmaie andfernale generai pracritioners by Karen Arkin

health promotion, psycho-social counselling, time spent on the phone, and more time in

generd spent with patients). (Woodward, et al., 1990)

Research on gender inequality in the professions, and medicine in particular, has

tended to look at this issue from two theoretical perspectives: human capital and gender

stratification. The human capital mode1 evaluates income economically fiom the supply side,

while gender stratification theory is more sociologically oriented and examines the

constraints and exclusions of demand side factors. While human capital stresses the attributes

of the person, gender stratification is more concerned with structural and cultural barriers that

women face in the labour market.

1 sociological focus 1 economic orientation I

A cornmon theme in the human capital literature explanations of the gender income

dernand side factors focuses on stnrctural and cultural barriers women face full participation of women difficult due to structural barriers; that is why women earn less

gap is that women are the pnmary providen of child care and so acquire less experience and

supply side factors focuses on attributes of person

women less productive then men, thetefore earn less

I

fewer job-related skills (i.e. human capital) than men. (Kay and Hagan, 1995; Wood,

Corcoran, Courant, 2993) It is suggested that women acquire less human capital than men

both because they stay at home with the children, but they also invest less capital before

having children in anticipation of future career interruptions for child bearing and rearing.

(Wood, et al., 1993) Thus human capital theorists assume that women's traditional

orientation to their families impedes their investment in education, training, and experience

and therefore women are less productive then men. (Kay and Hagan, 1995) This explains in

part why unmarried, childless women earn less than men; it is hypothesized that unmarried

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She workr hardlor the m o n q differences in the Ïncome of male andjëmale general pracritioners by Karen Atkin

women will invest less in h m a n capital in preparation for childbearing in later years.

Altematively, men are traditionally viewed as providing most of a family's income and

therefore they have a stronger incentive to invest in human capital skills, whereby this

increased investrnent would accrue immediately and over the longer career of most men.

These differences in human capital are said to account for the gendered wage gap.

Hurnan capital theory is often criticised for assuming, rather than demonstrating, that

a woman's work is a function of choice, preferences and priorities. This theory takes the

labour market entry and career paths of women as evidence of their preferences. It offers no

proof that women have real choices available to them. (Tanner, Cockerill, Barnsley and

Williams, 1999) Another challenge to human capital theory is that women persistently obtain

lower returns for their employment characteristics and investments in hurnan capital than do

men. (Kay and Hagan, 1995) As well, the process of income determination varies across

groups. For example, Ornstein (1983) has found that not only do women earn less than men

with identical characteristics, but also women receive lower r e m s for each year of

education or experience. These findings require that human capital theory be modified to

consider the reasons why women with levels of education and experience equivalent to men

really do not possess education or experience of the same "quality" or to include effects of

discrimination in their model. A final criticism is that the human capital theory views income

determination as a process between individuals with a limited set of attributes and a

homogeneous labor market. Thus, it concentrates entirely on the supply side of the labor

market process. Studies of inequality have found that earnings are not determined solely by

employee attributes, but simultaneously may be affected by a host of individual, structurai

and organizational attributes. (Kay and Hagan, 1 995)

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She works hnrd for the money: d~gerences in the incorne of male andfernale general practitioners by Karen Arkin

Gender stratification theory focuses upon the attitudes and behaviour of supervisors

and co-workers of female workers, particularly their discriminatory and exclusionary

practices. These include stereotypical assumptions about women's work cornmitment,

assumptions about their suitability for certain jobs and sexuai harassment. The effect of these

practices and asswnptions is to Iimit women, with occupational structures mediating

individual influences on earnings. (Kay and Hagan, 1995; Tanner, et al., 1 999) While hurnan

capital theonsts view women's decisions to be voluntary choices, gender stratification theory

suggests that their decisions are not based on reai choice, but such factors as inflexible work

hours. inadequate child care and unaccommodating employers such that the full participation

of women in the labour market is more dificult for women then men.

One of the main criticisms of gender segregation theory is that it is not clear whether

the various market sectors are internally homogeneous. For example, not al1 women have the

same homogeneous aspirations or interests and may have different levels of cornmitment to

their work. (Kay and Hagan, 1995; Tanner, et al. 1999) Thus this approach may conceal

important variations between industries and within sectors and between genders.

These two theoretical approaches, as well as a review of the literature, suggest a

number of variables that should be included as part of any model that attempts to explain the

income gap between male and female GPs. Since neither theory adequately explains the

differences in income between men and women, this analysis will examine regressions using

variables associated with each model separately and then both models simultaneously. Many

of the previous studies carried out have not k e n based in theory and therefore neither of

these models have been tested in the physician literature. This analysis is theoretically driven

based on the two approaches, hurnan capital and gender segregation, in an effort to more

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She works hard for the money: d~ferences in the income of male and female general practitioners by Karen Atkin

fully understand the nature of dynamics at work in determining the gap in income between

men and wornen physicians.

Typically research studies examining the income gap between men and women

physicians have only examined variables that tap into one of the two theories. Kay and

Hagan (1 995) in their study of lawyers' incomes and Tanner (1 999) in his examination of the

incomes of pharmacists are an exception in that they incorporate variables fiom both

theoretical perspectives. This thesis takes a similar approach for physicians. These two

theoretical approaches tap into both individual and systemic factors that may affect the

determination of physician incomes. The model in this thesis is based on a theoreticai

synthesis using variables that are designed to masure factors identified by both models.

Unlike rnuch of the previous research into physician incomes, it is not an atheoretical

stepwise building of a model, it is a model that is built of the basis of variables identified by

the theory. This approach should more fblly explain the gap in income between male and

female farnily physicians.

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She worki hard for rhe rnoneyr d~flerences in the income ofmale andfernale generaf pracfitioners by Karen Afkin

3 METHODS

3.1 STUDY DESIGN AND SAMPLE

The data for this paper were drawn from a larger research study of men and women

physicians and pharmacists conducted in 1996 aad used information fiom focus groups, key

informant interviews and mailed questionnaires. The study ' s objectives were:

to document and compare gender differences in the professional characteristics and

practices of physicians and pharmacists;

to examine the extent to which observed gender differences in these professions are

related to differences in underlying values and orientations toward career, family, the

provider-consumer relationship and the health system, or alternatively, workload

management considerations related to the persistence of a gendered division of labour

within the family;

to assess the extent to which gender differences in practice are a result of differences

in opportunities available to men and women; and

to identie and compare factors which influence the potential for change in medicine

and pharrnacy posed by women's increasing entry into these professions.

The first phase of the study consisted of focus groups with women and men in

medicine and pharmacy who could comment on their persona1 expenence in practice, as well

as gender similarities and differences they had observed arnong their professional colleagues.

This phase also included key informant interviews with acadernic experts and senior

professional leaders who could comment more broadly on the entry of women into the

professions and the prospects for change. The results of the focus groups and key informant

interviews were used to inform the design of the second phase of the study, mailed surveys of

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She works hardfor the moneyr d~flerences in the incorne ofmale and female general practitioners by Karen Atkin

women and men physicians and pharmacists. The mailed surveys integrated the findings of

the focus groups and key informant interviews. Survey questions explored attitudes toward

professional practice and patient care, family and the relative impact of family considerations

on professional life, sources and levels of stress and satisfaction, the influence of external

economic. political and social forces on career paths, the extent of involvement in the

organized profession, mobility prospects, income, and the perceived extent and implications

of gender differences in the professions.

All aspects of this study received full ethics approval from the University of Toronto.

As previously noted, the data in this thesis were drawn from the mailed survey. The

survey was administered using a modified version of the Dillman methodology for mailed

surveys. Initially al1 physicians in the sarnple received a survey package containing a cover

letter, the survey and a postage pre-paid retum envelop. Approxirnately ten days later the

entire sample received a reminder postcard. After about six weeks al1 non-respondents were

sent another complete survey package with a revised cover letter, the survey and pre-paid

return envelop, and a reminder postcard about two weeks later. To M e r maximize the

response rate al1 non-respondents received a personalized letter wging them to respond to the

survey at week eleven. Finally at about fourteen weeks about three-quarters of non-

respondents received a telephone cal1 requesting that they complete the survey. At this point

many of the non-respondents requested another copy of the survey.

At the time of the survey al1 physicians in Ontario were required to pay dues to the

Ontario Medical Association (OMA) under the "Rand" formula; as such they were listed on

the computerised records of the OMA, which also included physician characteristics such as

age, gender, specialty, and region of practice. Because of this, and the consequent ability to

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She works Izard for the money: dgerences in the incorne of male and fernale general practitioners by Karen Alkin

strati@ on the b a i s of gender and specialty, the OMA physicians' database was used as the

sarnpling frame for the physicians' survey.

Only active physicians under the normal age of retirement (65 years or under) were

included in the sarnpling frame. The sample was stratified to include equal numbers of men

and women such that there would be suacient nurnbers of each to be able to conduct

analyses based on gender. The sample was also stratified by specialty as follows: one half

fmily/general practitioners, one quarter surgical specialties. and one quarter medical

specialties. There were 80 1 physicians in the sample.

1 Total 1 1.000 1 1.791 1 0.403 1 Medicine Surgery

Due the stratification of the sample and the over-sampling of some groups,

particularly women from al1 three -ta, the final sample was weighted. The weights

adjusted the sample for the true proportions in the population and are outlined in the Table 5.

The initial sample included 801 physicians. A total of 87 physicians (1 1%) were

deemed ineligible (i.e. moved, deceased, no longer practising) resulting in a valid sample of

7 14. A total of 405 questionnaires were returned for an overall response rate of 56.7%

(specialists and family physicians). There were variations in the response rates by gender and

specialty; the response rate for family physicians was 55.2%, with women having a higher

response rate than men.

While the response rate was somewhat lower than originally anticipated, the final

response rate is typical for a mailed physician survey. To ver@ the representativeness of the

sample respondents and non-respondents were compared on the basis of known

Page Id

0.672 0.758

1.420 1.467

0.181 0.092

She workr hard for the moneyr dlrerences in the incorne of male and female general practitioners by Karen Atkin

characteristics. While there were some differences in the response rates between the diffèrent

speciaky groups (family medicine, surgery. medicine) there were no signifiant differences

between the respondents and non-respondents.

For the purposes of this paper oniy general practitioners and family physicians

(GPIFPs) are being examined. This strata of respondents was selected for two main reasons.

Firstly, there were not enough respondents in some of the other strata to permit analysis,

especially women surgeons. Secondly, previous research has demonstrated that the factors

that determine income differ for general practitioners and specialists and that they should

generally be examined separately when studying income. There were 263 family physicians

of whom 187 were male and 76 were female. The full questionnaire can be found in

Appendix B.

3.2 mSEARCH VARIABLES

3.2.1 DEPENDENT VARIABLE

A review of the literature reveais a split as to whether the dependent variable should

be raw income or the logarithmic form of income, with economists often using the log form,

while sociologists preferring raw income. (Omstein, 1983) There are merits to each of the

approaches. The literature review surnmarized earlier in Table 4 suggests that in studies of

physician incomes, raw income is used more fiequently than the logarithmic transformation.

Kay and Hagan (1995) suggest that a popular reauin for using logged income is that

the distribution of income may be lognormal. As well, the log transformation reduces the

skewness of income; however any skewness of income does not bias estimates of regression

coefficients or greatly increase their variance. There is also support for the logarithmic

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She w o r h hardfor rlte money: diflerences in the incorne of male and femafe generuf practirioners by Karen Arkin

transformation on a more theoreticd basis. Each proportionate increase in income might

produce approximately the same increase in utility. (Ornstein, 1983) Thus the reason for

using logged income is that the parameters can then be interpreted as rates of return.

However, there are also arguments in favor of using raw income. Ornstein (1983)

argues that without evidence as to the utility of income to earners, it is best to treat each

dollar as any other dollar in the market. Thus the focus should be on absolute amounts rather

than relative differences. As well, the statistical results of analysis of straight income are

much simpler to describe and comprehend. Finally the consequence of log anaiysis is to

dirninish the effects of large differences in income. A minute difference at the lower end of

the income range might have a coefficient equal in magnitude to that of a much greater

difference at the upper end. (Kay and Hagan, 1995) For the purposes of this paper the raw

income was used.

3.2.2 INDEPENDENT VARIABLES

In this study the variables used to understand the income of family physicians

represent a mix of variables that tap into aspects of both human capital and gender

stratification theories. Exact wording of the questions can be found in Appendix B. In

addition to gender, these variables include family situation, and professional or practice

characteristics. Variables were selected on the basis of their ability to tap into concepts

identified by the two theoretical perspectives. Many of the concepts in the two theories are

complex and represent underlying concepts that are measured by the variables in the s w e y .

The family situation factors are emphasized in the gender stratification theory while human

capital emphasizes practice characteristics.

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She w o r b hard for the m o n q diflerences in the incorne of male andfimaIe general practitioners by Karen Atkin

The family situation factors include: number of absences fiom the woridorce for

childbearing; whether the respondent is married; whether the respondent has children; an

interaction term for married and children; the hours of childcare that the physician does each

week; and the percent of the family income that the respondent contributes.

One of the main reasons that women physicians are believed to work fewer hours

than men is their household responsibilities, particularly the care of young children. Despite

the very high opportmity cost of her time, the woman physician is ofien hypothesized to be

relatively more effective and efficient in household activities, an assumption reinforced by

traditional societal attitudes. (Mitchell, 1984) However, the loss or reduction of market

earnings of mothen due to the demands on their time in child rearing also represents a

measure of family investment in human capital of their children. (Kehrer, 1976)

A physician's behaviour may be affected by hisher family situation as measured by

marital s ta tu and the presence of children. Having children may increase a physician's

income needs, which in tum may increase work incentives. Altemativeiy, some physicians

may cut back on work hours to care for their children. (Riuo and Blumenthal, 1994) Since

women are typically caregivers for children it has been hypothesized that the presence of

children will lead male physicians to work more hours in order to eam more income, whereas

women are more likely to cut back their hours of work in order to care for their children.

(Baker, 1996; Martin, 1999) These above concepts are measured by the family situation

variables.

The practice characteristic variables include: years of experience; experience squared;

percent of income from fee-for-service; non-booked hours worked per week; patient volume;

Page 19

She workr hardfor the money: diferences in rhe income of male and female general pracritioners by Karen Afkin

hours on cd1 per month; weeks worked per year; percent of patients that are women; and the

percent of patients that are seniors.

Two variables, a linear and a squared term, of the years of physician experience were

incIuded in accordance with the theory of post schooling human capital which assumes that

the amount of time devoted to human capital investment, i.e. on the job training, declines

over time from entry into practice. (Kehrer, 1976) Younger physicians generally work hard

to establish themselves in practice. whereas older physicians often display declining work

effort owing to either decreased patient demand, or the desire to work less hours. To capture

this inverted U shaped relationship, it is necessary to speciQ experience in both linear and

squared forms. (Mitchell, 1984) The expected signs on the estimated coefficients for the

linear and squared ternis are positive and negative respectively. Experience is defined as the

year of the survey (1995) minus the year of graduation fiom medical school.

The percent of income from fee-for-service was included to capture a variety of

practice types where physicians may receive a greater portion of their income fiom salary,

rather than the more traditional fee-for-service.

A nurnber of measures related to hours of work and volume were included. Weekly

patient volume is the product of the number of booked hours per week, Le. the time a

physician sees patients in the office, times the average number of patients seen in an hout.

Also inchded in the mode1 are the number of non-booked hours worked per week, which is

the total nurnber of hours worked minus booked hours (which were used in the calculation of

patient volume). Finally the nurnber of hours on cal1 per month were included. Al1 of these

variables have a direct impact on income in that the higher a physician's patient volume or

the more they work, the higher their income.

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She w o r k hardfor the money: d~rerences in the income of male and/emde general pracritioners by Karen Atkin

The finai set of practice characteristics concem the make-up of the patients in the

practice, including the percent of women patients and the percent o f patients over the age of

sixty-five. Both women and seniors have different patterns of health care consumption than

the average population, with women generally utilizing greater health care than men and both

men and women making greater use of the health care system as they get older. This variable

controls for variations in the patient characteristics of individual physicians.

3.3 ANALYSK STRATEGY

Analysis for this thesis was carried out on a personal cornputer using the statisticai

software package SPSS v8.0. A working dataset was extracted that contained only family

physicians and was weighted to correct for over-sampling.

The anaiysis began with a univariate analysis of each variable, Le. descriptive

statistics for each variable. This was followed by a bivariate ANOVA of each variable

broken down by gender. As well, an analysis of the correlations between the variables was

conducted.

Variables were then selected for the multivariate analysis based on the theoreticai

models discussed earlier, i.e. gender segregation and human capital variables. The

multivariate anaiysis consisted of a number of regression models. First a regression was run

with al1 variables against income, this was followed by partial regressions where the

independent variables were run separately in groups: gender; family characteristic variables

and practice characteristic variables. Next separate regressions were run for men and women

with the family characteristics and practice charactenstics variables.

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She w o r k Izardfor the money: diflerences in fhe income ofmale andfimale general pracritioners by Karen Affin

Many previous studies have only examined the income of men and women in a single

model. W l e this study will initially examine the income of men and women simultaneously

in the sarne model, it will also examine the income of men and wornen separately based on

the gender segregation theory that men and women do not necessarily operate in the sarne

marketplace and may experience different rates of retuni for the sarne levels of a variable.

(Kay and Hagan, 1995; Ornstein, 1993)

Of al1 the variables used in this analysis more than half of the variables had very few

missing data (1 -2%). However, about a third of the variables had missing data of 540%.

When these missing data were combined in the multivariate analysis, including the

regressions, about one quarter of cases were lost due missing data for one or more variables.

Cases with missing data values were excluded list wise rather than replacing missing data

with a value. such as means or medians.

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She w o r h hard for the money: diflerences in the income ofmale a w e m a l e general pracrifioners

4, RESULTS AND SUMMARY OF MAJOR FINDING

As discussed in the previous section, this analysis begins with an examination of the

univariate statistics associated with each of the variables. Just under a third of the sample are

women: and the majority of respondents are married and have children. (See Table 6)

IGender (female) 1 29% 1 76 1

Table 7 contains the descriptive statistics for remaining variables. The average

S pouse/partner (married) Have children fves)

income for the entire sample is $108,440. On average respondents spend about 13 hours per

week personally doing childcare and contribute about three quarters of the family income.

89 % 80 %

ANNUAL INCOME (51,000) 8 320 1 O0 108.44 53.18 FAMIL Y SI TUA TION No. absences frorn workforce for childbearing O 5 O 0.28 0.45 Hours childcare personally do per week O 112 5 13.20 18.98 Percent family income contribute 10 1 O0 80 76.4 1 23 -24

23 1 207

-

PRQ CTICE CHARACTERISTICS Years of ex~erience 4 40 18 18.22 4.83 . - Percent of income frorn fee-for-service O 1 O0 99 87.23 26.44 Non-booked hours per week O 52 17 18.50 13.19 Patient volume 13 400 139 138.97 78.03 Hours on cal1 per month O 720 60 129.49 198.17 Weeks work ~ e r vear 35 5 2 48 47.85 2.53 Percent wornen patients 15 98 50 50.25 16.57 Percent senior ~atients O 1 O0 25 28.08 17.99

The average respondent has 18 years of experience and makes the majority of their

income fiom fee-for-service. In addition to seeing about 140 patients per week during office

hours, respondents work an additional 18.5 hours each week and spend about 130 hours on

call each month.

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She workï hard for rhe money: diflerences in the income ofmale adfernale general pracritioners by Karen Arkin

In terms of patient characteristics, the average physician had a practice fairly evenly

divided between male and female patients. As well, a quater of the patients of the typical

respondent were seniors.

Med ian 1 10.00 72.00 Standard deviation

1 Number 1 187 1 76 1

Bivariate anaiysis in Table 8 reveals that male respondents earn $1 1 9,130 and

females earn $85,260. This is an unadjusted difference of $33,870, with women eaming only

72% of the income of their male colleagues. It should be noted that the variance for women is

sornewhat smaller than it is for men.

Table 9: Means and standard deviations for familv situation variables bv en der

Page 24

Proportion with spousdpartner Proportion have children Hours childcare personally do per week Percent family income contribute

p

She works hardfor the money: dwerences in rhe income of male and/emale general pracritioners by Karen Atkin

week). On average the men contribute about four-fifths of their family income while the

women contribute just under two-thirds of family income (83% vs. 60%).

Years o f experience Percent o f incorne fiom fee-for-service Non-booked hours pet week Patient volume (booked k/wk ~ts/hr)

Booked hours per week Patients wr hour

19.47 89.82 20.07

148.79

Hours on cal1 per rnonth Weeks work w r vear

The men in the sarnple have almost 5 more years of practice experience than the

29.981 13.12 4.83 1 1.81

Percent women patients Percent senior patients

women (19.5 vs. 15.1 years). The women, on average, receive less income fkom fee-for-

10.01 21.92 13.57 82.86

125.05 1 190.80 48.071 2-53

service (90% vs. 8 1%) and have fewer non-booked hours (20.0 vs. 14.8 hours). The women

25.94 4.47

L

45.65 1 14.24 30.90 f 17.75

see a lower volume of patients (148.8 vs. 116.7 patientslweek), but spend more time on cd1

15-11 81.15 14.84

116.69

140.27 47.33

(1 25.1 vs. 140.3 hours). The men work about one week per year more than the women (48.1

10.21 1.50

60.91 1 16.76 21.61 f 16.95

vs. 47.3 weeks). The n70men physicians in the study have more femaie patients (46% vs.

8.68 34.24 11.53 60.59

ns , 216.12

2-46 - - *** ***

6 1 %), while the men see more older patients (3 1% vs. 22%).

***

** **

ns

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She work hardJor the money: d1flerence.s in the income ofmale and female general practitioners by Karen A tkin

As part of the bivariate analysis of the variables a correlation matrix was run for al1

interval and ratio data. For the majority of variables the correlations are below 0.3, such that

there is little multicollinearity. The variables with the highest correlation are absences fiom

the workforce for childbearing, hours of childcare and percent family income contributed.

This is expected as these measures are al1 highly dependent on the presence of chikiren. As

well, there will be some multicollinearity in the model in that some of the variables are

almost constants, for example, married (89%) and have children (80%). However, this is

unavoidable as based on the gender segregation and human capital theones these variables

must be in the model and in the real world most physicians marry and have children.

Have children (yes) Mam'ed times have children

29.3 85 -43 -947

Hours childcare personally do per week Percent family income conmbute PUA C T K E CHARACTERISTICS Years of experience

Percent of incorne fiom fee-for-service 1 -0.330 Non-booked hours w r week 0.736

O. 180 0.489

2.346

0.237 O. 183

1 .522 0.038

The multivariate analysis begins with a regression model that includes ail respondents

22.238 23.484

Years of experience squared 1 -0.064

.449

.008*

-125 .O99

O. 129 0.286

- --

Patient volume Hours on cal! per month Weeks work per year Percent women parien ts Percent senior patients Consranr ALL VARIABLES

and utilizes the variables denved fkom the two theoretical perspectives - gender segregation

.188

.O63

.O 12*

.O1 l * * 0.048 0.0 19 1.229

- -

O. 1 73 0.069 2.395

and human capital. (Table 12) A total of 42% of the variance in income is explained by the

*p

She workr hard for the money: dlflerences in the income of male a w e r n a l e generalpracfifioners by Karen Afkin

women is still $27,581 less than men. That is, this model explains a little more than $6,000 of

the gap between men and women, but still leaves the majority of the difference unexplained.

However a review of the literature suggests that this R~ is actually very good with most

models of physician income only explaining between 10% and 25% of the variance. Using a

modei similar to this thesis, Tanner (1999), in his study of pharmacist's incomes, was only

able to explain about a third of the variance. Kay and Hagan (1 995) in their study of lawyer's

incomes came the closest, as they were able to explain about 38% of the variance in incomes.

Gender alone 1 -098 )

1 TOGI al1 variahtes 1 -415 1

Family situation only Practice characteristics onIy

Table 13 presents the results of the partial regression where portions of the model

.194 -29 1

were run with both men and women included. it can be seen that gender alone only explains

about 10% of the variation in income between family physicians. Farnily situation variables

explain about &ce as much (19%) and practice characteristic variables explain the greatest

amount of the variance (29%). An examination of Tables 12 and 13 together shows that

family situation variables tend to drop out of the equation with the addition of the other

variables, suggesting that they are mediated by practice charactenstics. Thus it may be that

gender and family characteristics determine practice patterns which in tum detemine

income.

While the regression mode1 run for men and women together explains a significant

proportion of the variation in income it may not be the most appropriate method for

examining the determination of physician incomes. Examinhg men and women in the same

model makes an assumption that they can be pooled together and that the same variables

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Slie works hardfor the money: dlflerences in the income ofmafe andfernale general practitioners by &en A tkin

determine income for both. However, as the earlier discussion of the gender segregation

theory suggests, men and women may not be operating in the same sectors of the market and

they may be receiving different rates of return for the same levels of human capital. Thus it is

may be inappropriate to include both men and women in the same mode1 of income

detemination.

Table 14: Correiaîion mafrir for variables in remession for fimale nhvsicianv

------ B. Hours childcare -279 1 .O0 C. % family income conaibute -.249 -.34 1 1.00

1

D. Years o f ex~erience .O91 -.124 -.O34 1 .O0 E. % income FFS F. Non-booked hours

-169 -.284

1.00 1 .O50 1 1-00

G. Patient volume H. Hours on cal1 per month 1. Weeks worked per year J. Percent women patients

Therefore, the next step in this analysis is to examine the models of income

determination separately for men and women. It should be noted that this is an exploratory

analysis as the sample size is not large enough to produce conclusive results, however as will

be seen the results are as expected based on the review of literature. The first step of this

K. Percent senior patients L. Incorne

Page 28

-125 -,233

-.O58 .O72

-.241 -,O45 -261 -037 -.IO5 -130

-.Il0 -.388

-.148 -250

-265 -1 18

-.O94 .O56

-.O98 -.152

-.O71 -202

-.128 -.228

.O52

.O46

-131 -.183 .O14 -359

1-00 -.389

-.Il8 .O97 .O36 -.O33

I 1.00 1

-181 .O68

. . - - . - . - - -

-.212 -.268

- 2 1 3 -.IO5 -282 .439

.264 -.O94 -.O68 -477

-206 -.O23 -.O35 -162

1.00 -.140 .130 1 -.O36 1 1-00 .13 1 1 -.177 1 -174

1.00

Sile works hard for tire money d~gerences in the income of male and female general pracririoners by Karen Afkin

separate anaiysis is to run separate correlation matrices for femde and male physicians. An

examination of Tables 14 and 15 shows that the coeffkients for men and women are quite

different.

Tables 16 and 17 show the results of the income model run separately for male and

FAMIL Y SITUA TION No. absences from workforce for childbearing Spouse/partner (married) Have children @es) Married times have children Hours childcare personally do per week Percent family income contribute P M CTICE CHA RA CTENSTICS Years of experience Years of experience squared Percent of income fiom fee-for-service Non-booked hours per week Patient volume Hours on cal1 per month Weeks work peryear Percent women patients Percent senior patients Constant ALL VARIABLES

female family physicians. The results of each equation are quite different, with the

percentage of variance explained by the model for women k i n g about a third more than the

*p

She workr hardfor the money: dlflerences in the income of male and female general practitioners by Karen Atkin

variables explain twice as much variation for women as for men. It would appear that for

women family situation is mediated by practice patterns, whereas for men family situation is

not mediated by practice characteristics. Clearly, quite different factors are operating in the

mode1 when men and women are examined separately.

No. absences fiom workforce for childbearïng , -11.702 1 37.564 -756 S~ouse/eartner (marriedl 21.752 1 24.056 -368

- -

Have chiidren (yes) 1 153.547 38.298 .o0O0** Mamed times have children - 188.248 3 8 .463 -000~ Hours chitdcare personally do per week 0.962 0.500 .O57 Percent farnily income conmbute 1 0.641 0.243 .OIOO* 1 PR4 CTICE CHARACTERISTICS 1

I -- - - -

Years of experience 2.154 2.017 -288 Years of experience squared 4.048 - 0.050 -342 Percent of income fiom fee-for-service 1 4.418 1 0.191 .030* Non-booked hours pet week 0.822 1 0.367 .027* Patient volume 0.156 1 0.056 .006** A Hours on cal1 per month 0.1 19 0.025 .OOO*** Weeks work m r vear 3.877 1.548 .O 14** - - - - - - Percent women patients 1 0.040 0.300 -894 Percent senior patients 1.055 0.277 .000*** Consram 1 -184.109 78.604 -02 1 ALL VARIABLES 1 .479***

*p

She works hardfor the moneyr diflerences in the incorne of male andfernale general practitioners by Karen Atkin

5. DISCUSSION

It has been repeatedly found that Cemale physicians earn much less than their male

colleagues, even when a range of variables, such as personal and professional characteristics,

are taken into account. This study found that this remains the case for family physicians in

Ontario. Ceteris paribus (everything else being equal), women earn more than $27,000 less

than men, even &er differences in professional characteristics, personal characteristics, and

family controlled for.

Using a model that synthesizes two theoreticai approaches this study was able to gain

a better understanding of the gendered income gap. Other physician studies have o d y been

able to explain 10-25% of the variance in incomes. And Canadian studies of pharmacists and

lawyers. using similar theoretical perspectives to that of this thesis, were able to explain 25-

38% of the income difference. Thus, this thesis was able to explain two to three times as

much of the variation in physician incomes as previous studies of physicians and somewhat

more than similar studies of other professions that were theoretically driven.

However, consistent with gender segregation theory, when the model is analysed

separately by gender, different variables emerge as more important for men and women.

Most studies examining the incomes of physicians have pooled men and women into the

same equation based on the assurnption that they are operating in the same market and that

the sarne factors determine income for both. However the magnitude and direction of many

of the coefficients are substantially different for the two groups. It is reasonable therefore to

suggest that hirther studies examining the incomes of physicians must senously question

whether a single, pooled model should be used to explain the incomes of these two groups or

whether they should be analysed separately.

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She workr hardfor the m o n q diflerences in the income of male and/emale general practitioners by Karen A t h

There are a number of limitations to this study. The sample is not large and the

response rate was only 56%. However this response rate is typical of mailed physician

surveys and there were no significant differences between the non-respondents and

respondents. As well, the results achieved are similar to those found in earlier studies. Thus

despite the sample size and response rate the results are as expected. As well, because the

analysis only examined family physicians the fmdings can not be extended to specialists.

Finally, the data in this study is based on a self-report survey and as with al1 such surveys it

may contain errors or bias in the responses due to factors such as social desirability, gaming

and simple forgethlness. Despite these limitations, the results are very consistent with many

other similar studies and therefore should not be discounted.

Therefore with the findings of this analysis, the puzzle remains given the theoretically

neutral wage structure of medicine and controlling for differences in personal, professional

and practice charactenstics, why do women physicians earn less than men physicians? One

possible explmation rnay be that men and women have different billing patterns. This study

was based on self-report data and did not have access to billing data. The results of the focus

groups and key informant interviews, conducted as part of the research study, suggest that

men may be more "aggressive" billers than women, and that money is more of an issue for

men than women. However, an Ontario study using standardized patients found that female

physicians charge more for their services than their male colleagues. (Woodward, Hutchison,

Norman, et al., 1998) As well, Chan (1998), in an examination of fee code creep, found that

women had slightly higher intermediate to minor assessment ratios than men, but in

multivariate analysis, when the age of the physician was controiled for, the gender difference

was no longer significant. Thus an avenue for hiture research may be an examination of

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She w o r k hard for the money: digerences in the income of male and/emale general practifioners by Karen Afkin

billing practices linked with data on the personal and professional and practice characteristics

of physicians to fully explore this possible explanation.

A fûrther potential area for fùture study is the impact of practice organizations and

business arrangements on the gendered income gap. Many studies have found that women

and men tend to organize their practices differently in terms of the ways they are paid and

other business arrangements (e.g. sharing of staff, income and expenses). Although this

survey asked questions about some of these factors there was a significant amount of missing

data that precluded inclusion of these variables in the analysis.

As well, this thesis was not able to confirm or refute Baker's findings in a Canadian

context. He found that among a younger cohort of physicians the gendered income gap had

completely disappeared. The sample size in the this analysis was not sufficient to be able to

examine a sub-sarnple of o d y younger physicians to determine if there has been a

convergence of incomes among these doctors. An ideal study to thoroughly examine the

income of physicians and detennine the effects of different business arrangements. billing

practices and age would have a suficiently large sample to allow the examination of a cohort

of younger physicians and would contain both survey and billing data.

In conclusion this thesis used a theoretically driven model that moved beyond

anecdotal evidence and contributes to the Canadian literature on emings differentials in a

nurnber of ways. First, it demonstrates that despite a sizeable increase in the nurnber of

women in medicine and broader social trends (e-g. the continuing attention to gender equality

and the role of women in the workforce), there remains a persistent gender gap in the

eamings of family physicians in Ontario, even when controlling for a large nurnber of

practice and family characteristics. Secondly, using a model which is a synthesis of two

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Sire worh hardfor the money: d~fferences in the incorne of male andfimale general practitioners by Karen Atkin

theoretical perspectives, a large proportion of the variance between men and women

physicians can be explained. As a matter of fact the proportion of variance explained in the

study is two to three times that of other studies of physicians. Thirdly, there are a number of

different factors that contribute to determining the income of male and female physicians and

the importance of these factors may be different for men and women. The results for men

have a higher statistical significance, but more of the variance can be explained for women.

Thus this thesis has advanced our understanding of the gendered income gap between male

and female farnily physicians and suggests some avenues for m e r research to more fully

explain the income gap.

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Shc w o r k hardfor the moneyt dflerences in the incarne of male and female general practitioners bdv Karen Atkin

Adams O (1989) Canada's doctors - who they are and what they do: lessons from the CMA's 1986 manpower survey. Canadian Medical Associarion Journal 140: 2 12-22 1.

Baker LC (1996) Differences in eaniings between male and femaie physicians. New England Journal of Medicine 334(15): 960-964.

Boardman A, Dowd B, Eisenberg JM and Williams SV (1983) A mode1 of physicians' practice attributes detemination. Journal of Health Economics 2: 259-268.

Bobula JD (1 980) Work patterns, practice characteristics, and incomes of male and female physicians. Journal of Medical Education 5 5 : 826-833.

Brown HS (1996) Physician demand for leiswe: implications for caesarean section rates. Journal of Heafth Economics 1 5: 233-242.

Canadian Medical Association (1 996) Women in medicine: the Canadian experience. Ottawa: Canadian Medical Association.

Chan B. Anderson GM, Thénauit M (1 998) Fee code creep among general practitioners and farnily physicians in Ontario: why does the ratio of intermediate to minor assessments keep climbing? Canadian Medical Associalion Journal 158(6): 749-754.

Eisenberg JM (1 985) Physician utilisation: the state of research about physicians' practice patterns. Medical Cure 23(5): 46 1 -483.

Kay RM and Hagan J (1995) The persistent glass ceiling: gendered inequalities in the earnings of lawyers. British Journal of Sociology 46(2): 279-3 10.

Keane D, Woodward CA, Ferrier BM, Cohen M and Goldsmith CH (1991) Female and male physicians: different practice profiles. Canadian Family Physician 37: 72-81.

Kehrer BH (1976) Factors affecting the incomes of men and women physicians: an exploratory analysis. Journal of Human Resources 1 l(4): 526-45.

Langwell KM (1982) Factors affecting the incomes of men and women physicians: fùrther exploration. Journal of Human Resources l7(2): 26 1 -74.

Marhsall K (1 990a) Women in male dominated professions. in Canadian social trenh (eds. McKie C and Thompson K) Toronto: Thompson Educational Publishing. pp 1 13- 117.

Marhsall K (1 99Ob) Women in professional occupations: progress in the 1980s. In Canadian social trends (eds. McKie C and Thompson K) Toronto: Thompson Educational Publishing. pp 10% 1 12.

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Martin S (1 999) "1s everyone as tired as 1 am?" The CMA's physician survey results. 1 999. Canadian Medical Association Journal. 1 6 1 : 1 020-2 1 .

Mitchell JB (1984) Why do women physicians work fewer hours than men physicians? Inquity 21 : 361-368.

Ohsfeldt RL and Culler SD (1986) Differences in income between male and fernale physicians. Journal of Health Economics 5 : 335-346.

Omstein MD (1983) Ciass. gender and job income in Canada. Research in Social Stratification and Mobility 2 : 4 1 -75.

Rizzo JA and Blumenthal D (1994) Physician labour supply: do income effects matter? JO urnal of Health Economics 1 3 : 43 3 -45 3.

Rizzo JA and Blwnenthal D (1995) Physician income targets: new evidence on an old controversy. Inquiry 3 1 : 394-404.

Robson B (1 996) Gender gaps closing, but not at the top. Taking the pulse: the CU4 Physician Resource Questionnaire 1 7-20.

Sanmartin CA and Snidal L (1 993) Profile of Canadian physicians: results of the 1990 Physician Resource Questionnaire. Canadian Medical Association Journal 149(7): 977-984,

Silberger AB, Marder WD and Willke FU (1 987) Practice characteristics of male and female physicians. Health Affairs Winter: 104- 109.

Skelly A (1994) The gender gap. Medical Post Supplement: 16, 73.

Skinulis R (1 993) A demographic silhouette: the Canadian physician in profile. Medical Post Supplement: 14- 1 5 .

Tanner J, Cockenll R, Barnsley J and Williams AP (1999) Gender and income in pharmacy: hurnan capital and farnily situation theories revisited. British Journal of Sociology SO(1): 97-1 1 7.

Uhlenberg P and Cooney TM (1990) Male and female physicians: family and career comparisons. Social Science and Medicine 30(3): 373-378.

Weeks WB, Wallace AE, Wallace MM, Welch HG (1994) A comparison of the educational costs and incomes of physicians and other professionals. New England Journal of Medicine 330(18): 1280- 1286.

Williams AP, Domnick-Pierre K, Vayda E, Stevenson HM and Burke M (1990) Women in medicine: practice patterns and attitudes. Canadian Medical Association Journal 143(3): 194-20 1 .

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Williams AP, Woodward CA, Femer B and Cohen M (1997) Cohort, gender and practice organization: examining the bounds of collaborative medicine among newly established female and male family physicians in Ontario. Health Services Management Research 10: 12 1 -13 1.

Wood RG, Corcoran ME, Courant PN (1 993) Pay differences among the highly paid: the male-female eamings gap in lawyers' salaries. Journal of Labour Economics 1 1(3):417-441.

Woodward CA, Cohen ML and Femer BM (1990) Career interruptions and hours practised: comparisons between young men and women p hysicians. Canadian Journal of Public Health 8 1 : 16-20.

Woodward CA, Hutchison B, Norman GR, Brown JA, Abelson J (1998) What factors influence primary care physicians charges for their service: an exploratory study using standardized patients. Canadian Medical Association Journal 1 58(2), 197-202.

Woodward CA, Williams AP, Femer B and Cohen M (1996) Time spend on professional activities and unwaged domestic work: is it different for male and female primary care phy sicians who have c hildren at home? Canadian Family Physician 42: 1928-1 935.

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5. APPENDIX A - COVER LETTER March 1996

Dear Dr. aNAME2)):

We are writing to invite you to participate in a major research study which examines the changing Professions of Medicine and Pharmacy.

Over the past decade, public expectations, new technologies, and economic conditions have changed how Physicians and Pharmacists are educated and how they practise. The characteristics of those entering the professions have also changed - many more women and individuals fiom diverse backgrounds are now choosing careers in Medicine and Pharmacy. Government policies aimed at '-restructuring" the health system directly affect your career choices and what you do in practice.

Although much is known about general trends in the Professions, much less is known about the experiences and views of individual practitioners like yourself who are the first to see and feel the impact of change.

How do you conduct your practice? How satisfied are you in your work? How do you balance personal and professional responsibilities? To what extent do you approve or disapprove of current or proposed governrnent policies impacting on you and the profession? What are your views on more general social issues now at the centre of political debate?

This three-year study is funded by the Social Sciences and Humanities Research CounciI of Canada. It has passed an ethics review and is being conducted by experienced researchers at the University of Toronto. Your participation is voluntary. Summary reports of the results will be sent to al1 participants who request them and more detailed reports will be provided to professional Associations and Col leges. However, al1 information given by individuals wi I l be kept strictly confidential.

Please take 15 minutes to complete and return the enclosed survey questionnaire in the prepaid envelope provided. Your responses will ensure that educators, professional leaders and policy-makers hear what you have to Say about the challenges now facing practitioners and the Profession.

If you have any questions about any aspect of this research, please cal1 us collect at (4 16) 978-2792, or fax us at (4 16) 978-7350.

Thank you for your important contribution.

S incerely,

A. Paul Williams, PhD. Associate Professor

For the smdy team: Janet Barnsley, PhD. Assistant Professor

Rhonda Cockerill, PhD. Associate Professor

Julian Tanner, PhD. Associate Professor

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6. APPENDIX B - MAILED QUESTIONNAIRE

University of Toronto

THE CHANGING PROFESSIONS OF MEDICINE AND PHARMACY

Supported by a gant fiom the Social Sciences and Humanities Research Council of Canada

ASSURANCE O F CONFIDENTIALITY

This survey has passed a full ethics review.

All information which could identiQ any individual will be kept cornplerely confidenrial. Survey results will be reported in summary form only,

PIease do not remove the identification number on this survey. It will be used only to monitor returns and save remailing of the survey to those who have already responded. The number will be removed after the survey is returned.

This questionnaire should be completed by the physician personally.

Most questions can be answered by filling in a blank, circling the appropriate response, or checking appropriate responses.

We would be most happy to answer any questions that you might have about this survey. Please write or cal1 us. The telephone number is 416-978-2792, the fax number is 416- 978-7350; Ms. Karen Atkin, Research Omcer, will be available to answer your questions. Our address is:

Professor A. Paul Williams Depamnent of Health Administration 2nd Floor, McMumch Building 12 Queen's Park Crescent West Toronto ON MSS lA8

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A. PROFESSlONAL CAREER

What best describes your route Co medical school? (Please circle only one number).

............................................ direct from an undergraduate program 1 ....................................................... direct fiom a graduate program 2

worked in another health profession before entering medical schml (please specify) 3

worked in another field before entering medical school (please specify) 4

2. From which rnedical school did you graduate as an M.D.? medicd school Y=r 19 --

3. Are ~ o u ccnified as a specialin (including thc College of Family Physicians)? no (please skrp ro Q. 5) .................................................................. 1

3 ycs. CCFP .......................... .. ...................................................... yes. cenificd in another specialty (please speci fy) 3

4. At which rncdical school did you cornpletc your specialist residency? medical school Y W 19 --

5. In addition to your M.D. dcgree. do you have any other university dcgrees or diplornas? no ............................................................................................... O ycs (please specifi) 1

6. Are you currently enrolled in. or within h e next 5 ycars do you intend to enroll in. a university degrcc or diplorna program?

no .................................................................................................. O ........................................................................................ undccided 1

... yes. currently enrollcd in (please speciS) 2

... yes. plan to enroll in (pl- specisl) 3

7. Whcn you wcre conridering medicine as a career, how important wcre cach of the fol lowing factors. (Plcase circle the appropriate numbcr to the right for each factor.)

not at al1 VC rY important c--* important

a. income potential ................................... ........... 1 ..... 2 ..... 3 ..... 4 ..... 5 b. job sccurity ...................................................... 1 ..... 2 ..... 3 ..... 4 ..... 5

..... c. a dcsire to help pcoplc ................................... 1 ..... 2 ..... 3 4 ..... 5

..... ..... ..... ..... ................................... d. control ovcr your work 1 2 3 4 5 ..... e. opportunity for flexible work schedules .......... 1 2 ..... 3 ..... 4 ..... 5

..... C family cncouragcment or cxpectations ............ 1 ..... 2 ..... 3 4 ..... 5 g. rccommendation from somconc in

..... ..*.. ...-. ..... the profession .................................................. 1 2 3 4 5 ...... ..... ..... -.... -.... h. recommendation from a school counsellor 1 2 3 4 5

..... ..... ..... ..... ........................................ i. professional prestige 1 2 3 4 5

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She works hardfor rhe money: d~gerences in the income of male and/emale general practirioners by Karen Atkin

8.

9.

1 O.

I I .

12.

B.

1.

Thinking aboutyour m e n t work as apfrysician. how satisfied or dissatisfied are you with each of the folfowing aspects?

ve'Y dissatisfied - satisfied

..... ..... ..... ..... ................................. a the ability to help people 1 2 3 4 5 ..... ..... ..... ..... ..... b. seiting in which you work ................... ... 1 2 3 4 5

..... ..... ..... ..... c. nurnber of hours worked ................................. 1 2 3 4 5

..... ..... ..... ..... d. flexibility of work schedules ................... .... 1 2 3 4 5

..... ..... ..--. ..... e. incorne ............................... ............................ 1 2 3 4 5

..... ..... ..... ..... f. rclationships with patients ..................... ..... 1 2 3 4 5 ................ ..... ..... ..... ..... g- actual ability to structure your work 1 2 3 4 5

..... ..... ..... ..... h, prestige of the profession ................................ 1 2 3 4 5

..... ..... ..... ..... i. relationships with colleagues ........................... 1 2 3 4 5

..... ..... ..... ..... j. baIance with persona1 life ................................ 1 2 3 4 5

Sorne male and fernale physicians report that they were negatively affected by gender bias at diffcrcnt points during their m e r . Did gcndcr bias by profasors, physicians. or othcr health professionals negatively affect you during the following stages of your m e r ?

definitely definitcly no - ycs

a sclcction into medical school .......................... 1 ..... 2 ..... 3 ..... 4 ..... 5 b. during undergraduate medical school .............. 1 ..... 2 ..... 3 ..... 4 ..... 5 c. choice of specialty ......................................... 1 ..... 2 ..... 3 ..... 4 ..... 5

..... d. during residcncy ............................................ 1 ..... 2 ..... 3 4 ..... 5 ..... ..... ..... ..... e. in practicc ........................................................ 1 2 3 4 5

Since you began your career in rnedicine. on how many sepante occasions have you been absent from your paid work as a physician for a period of 4 months or Ionger due to: a chi Id bearinglrearing ..................................................... -- tirnes b. persona1 enrichment (e-g. travel) .................................... -- times

............................................................... c. spouse's career -- times d. other (please specifi) -- times

What do you see yoursclf doing 5 years frorn now? ........................................................ practising rnedicine in Canada 1

3 ........................................... practising rnedicine in another country - working in another field or profasion ........................................... 3 not in the workforce (e-g. rctired) .................. .... ....... ... 4 other (please spccify) 5

Knowing what you know now. if you had to decide al1 ovcr again, would you pursue a career in medicine?

1 would decide without hcsitation to enter rnedicinc ....................... 1 1 would have somc second thoughts ......................... .... ......... 2 1 would decide definitely not to enter rncdicine .............................. 3

PRACTlCE PROFlLE

Thinking of your last typical working week as a physicim. about how many hours did you work (excluding "on-call")? hours

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She w o r h hardfor the money: diflerences in the income of male andfernale general practitioners

2. Approximately how many hours during your last typical working week did you sp