Random Thoughts from a Restless Mind

The endless debates about the “Pay Gap” between men and women in the United States drones on. Today is “Equal Pay Day”, kinda like “Tax Day”, the day when you stop paying the government and instead start paying yourself, only it’s the day when the “average” woman supposedly has to wait for before she starts to make what a man makes. It all makes for great spectacle and epic barstool arguments for the same reason that people argue about who’s greater, Michael or Elgin, Kareem or Russell, The Babe or Barry: there is no proper, standard way to measure the issue at hand. On a barstool arguing “greatest ever” you never agree on either the definition of “greatest”, nor can you account for the vast differences in historical eras.

So it is with the pay gap. No one agrees on what constitutes work, let alone equal work.

This creates the maddening situation in which we find ourselves now whenever this comes up for discussion. Absent a meaningful definition of either “work” or “equal” we are left with folks on all possible sides of the issue simply choosing whatever statistic will support their deeply held beliefs about the issue. It’s crazy, actually. I read a dozen citations today and each one was so deeply flawed that it couldn’t stand the scrutiny of the middle if you velcroed it to the  50 yard line. Work is invariably conflated with “hours worked” with no discernible effort made to investigate something like intensity, or the measurable work performed per unit of time. “Equal” work is just a quagmire of competing opinions with, again, no effort whatsoever at objective measurement. How can you have a discussion that is meant to conclude with some sort of actionable agreement when all you do is pull numbers out of the ether and throw them at each other?

While engaging in a sorta, kinda conversation about this on Twitter it struck me that I actually live and work in the perfect laboratory to investigate the issue of the Pay Gap between men and women. You see, we have reams of objective data that can be evaluated. We all, men and women, do exactly the same things if we have the same jobs. Not only that but we have a unit of measurement for that work, the RVU. If Dr. Darrell does a cataract surgery and Dr. Dora does a cataract surgery, we have both done the same job. We can even determine the “intensity” of our work, our output if you will. A simple survey of hours worked per day can generate the metric: RVU/hour. Better yet, don’t take my word for it in a survey, just look at that heretofore meaningless and useless EMR and look at the measured time Darrell and Dora took to do their work. The OR record is a precise measurement of how much work we did per unit of time.

This is powerful stuff. Work is defined. An appendectomy is an appendectomy. A Level 4 New Patient Office Encounter is a Level 4…you get the idea. You get to compare apples to apples, heck, you get to compare Honeycrisp apples to Honeycrisp apples. It doesn’t matter if you are a man or woman or transgender. White, Black, Brown, Yellow, Red (did I miss anyone?), Millennial, Boomer and everything in between, work is work and an RVU is an RVU. Heck, you could gather all of the information about the work without anyone knowing who did it until after it’s all together. We could have a big unveiling when we lift the blinders and see who did what and how much they did. Seriously, how cool is this? It would almost be like science.

Let’s do be a bit serious for a moment. Imagine what kind of information we could acquire and what kinds of questions we could ask and answer. For sure there will be very reasonable concerns about how much we will be able to extrapolate from medicine to other areas of employment (advertising, investment banking, etc.), but it’s a great place to start. The question of the Gender Gap is primary, but how about looking at work across the generations. There is a “feeling” in medicine, certainly among crusty old folks in my generation, that younger physicians of both genders work fewer hours and do less work per hour when they do work. Is that true? It sure looks like it would be easy to answer that one, too.

There are actually a number of other issues in medicine that would be clarified if we had this kind of data, at least insofar as the work done is concerned. For example, how do private practitioners stack up against salaried physicians in large groups? Is there a correlation between how those salaries are determined and the intensity of work done? We can also look at value, work done per dollar paid (again, assuming equal outcomes). Where are we getting the best bang for our buck? For that matter, with the EMR’s that never sleep we can actually look at the responsiveness of doctors to their patients in urgent or emergent circumstances. Is there one group (men vs. women, private practice vs. employed) who are more responsive?

Having a discussion that is based on hard definitions of terms and data-driven rather than belief-driven opens up a whole world of meaningful inquiry.

Once upon a time I was among the highest paid physicians in the U.S. I worked insane hours, and the intensity of my hourly output was off the charts. In a word, I earned every penny I made, and the fact that I made more than another ophthalmologist had nothing to do with the fact that I was a man. Funny thing though–I now make a fraction of what I once made because I don’t work as much as I once did. The intensity of my work is similar; I still do as much work per unit of time, and my ability to perform at this high level of intensity is still greater than 95% of my peers, I just work fewer hours. What are we to say about women who do what I do, work more hours than I do, and yet do less work? Is there a gender gap in pay if I make more money than they do? What are we to say about my ambitious female colleagues who work more hours than I and work at the same intensity? I’m firmly stating that they should make more than I do. Is that the reality on the ground?

In medicine we have the ability to answer this question in a very objective, non-ideological way. I don’t know if what we find will be something we can extrapolate to other jobs, especially if we find that pay is directly related to actual work done in a domain where work can be both defined and measured. But hey, it’s a start. And it’s way better than just playing emotional whack-a-mole with how we value what we all do.

In 2011 I wrote an essay in response to an article I read in the WSJ on the coming physician shortage. In short I agreed with a letter that pointed out the effect of physicians working fewer hours than they had traditionally worked. In that letter the effect of the changing demographics in medicine (more women physicians, generational shifts) was pointed out. My essay agreed with the points in the letter. My thesis is that you can’t “have it all”, in medicine or anywhere. Someone, somehow, always pays.

While reading about “Equal Pay Day”, the day on which the “average female wage earner” achieves the same amount of pay as the “average male wage earner” acquired in the previous 12 months, a couple of things strike me. First, the general thesis of my essay continues to be accurate, at least in medicine. Income is determined by the choice of specialty, as always, but beyond that it is driven much more so by the number of hours a physician works and how productive that physician is during those work hours. Work more hours, get paid more money. Perform more of your doctorly duties in each one of those hours, get paid more money. There are fewer and fewer physician jobs in which seniority on its own drives income, thereby negating any lack of seniority which may be caused by a career “pause” to have or care for children. Physician income is largely gender-blind. As an aside, the dirty little secret of physician pay is that production-based compensation is the norm everywhere, even at those institutions that claim otherwise.

The second thing that strikes me is the malignantly erosive effect of ineffectual, unnecessary external regulation on the practice of all medicine on effective physician work hours. In 2014, whether you are a man or a woman, the bureaucratic load associated with practicing medicine is oppressive, and hours that just 5 years ago may have been spent caring for patients is now spent caring for charts, bills, and other paperwork. These hours generate no real health benefits for patients, and do not produce any revenue that pays the doctors for working them. In a particularly cruel example of Murphy’s Law, or at least the Law of Unintended Consequences, the specialties that are hardest hit by this relentless onslaught of the unnecessary are those that tend to pay physicians the least. Fields like Family Practice and Pediatrics. On “Equal Pay Day”  it is particularly ironic to note that those hardest hit specialties tend to be staffed by the highest percentage of female doctors.

A final note as I read this post 3+ years after the initial writing: the choice of “Mommy-Track” to describe those women who graduate from medical school and work fewer hours than their male peers because of their choice to prioritize their families seems needlessly pejorative and provocative. I’ve left it in for this Epilogue because to edit it today seems dishonest in a way. Besides, I’m a little bit better at writing in 2014 than I was in 2011. I can be plenty provocative now without resorting to the pejorative.