 Yes. Hello, if you're joining us on zoom, could you let me know if you can hear us. Test, test, test, test. Do you have the number like the webinar number I could join. Oh, me. Oh, yeah, yeah. Welcome, those of you joining us on zoom. Can you just confirm you can hear me. Thanks, Myra. We haven't quite started yet. So hopefully you'll hear us better when when we do the introduction. All right, welcome everyone to those of you online and those of you joining in person. I'm really excited about today's talk. We're joined by Dr. Amy Gottlieb, and I'm going to do a quick introduction before she starts into her slides. Dr. Gottlieb is a professor of medicine and OB Guiney and the inaugural associate dean for faculty affairs at the University of Massachusetts Channing Medical Schools regional campus in Springfield, Massachusetts. As a chief faculty development officer at Bay State Health. She also holds a vice president level role in large diversified health system in Western Massachusetts. Dr. Gottlieb received her undergraduate degree in economics from Harvard worked in corporate finance prior to entering medicine. She was at the University of Chicago for her medical degree. We're excited to have her back and then she completed her residency in general internal medicine at Brown. Prior to her current role, she was on faculty at Brown for 10 years and she served in numerous educational, clinical and administrative roles there. She's currently the chair elect for the double AMC group on women in medicine and science steering committee, also known as GWIMS. And the former chair of the Society of General Internal Medicine, Women in Medicine Commission. She's the founder of the Society's career advising program, which I take part and she's an amazing mentor for that. And this sponsors initiative for women faculty and has engaged over 360 participants nationwide since 2013. And in 2020, she received the Elnora M. Rhodes Service Award, symbolizing the highest level of service to the organization. Dr. Gottlieb has led a national efforts to address workplace practices that inadvertently drives salary disparity. And she also has a book closing the gender pay gap in medicine, a roadmap for healthcare organizations and the women physicians who work for them was published in January 2021 by Springer. She also has an article in the New England Journal closing the gender pay gap in medicine, which we'll be discussing with the fellows later today. So it's with that. I welcome Dr. Gottlieb. Welcome. Good afternoon. Can you hear me? Can you hear me? Okay. So thank you so much for this really a tremendous opportunity to be back. It's the first time I've truly been back since I graduated and and I'm just really happy to be here. So I'm going to spend the next, let's see if I'm going to advance my slide here. There we go. I'm going to spend the next 20 minutes or so, 45 minutes or so talking about closing the gender pay gap in medicine. And specifically, I'm going to share some data on the gender pay gap and describe the context in which it emerges. I'll also talk a little bit about the impact of the gender pay gap on accumulated wealth and then do a very deep dive into traditional compensation methodology within academic medicine and the drivers of disparities within that calculus. I'll then talk about organizational strategies to close the gender pay gap in medicine and finish up with a few pearls of wisdom around individual advocacy. I have reserved a nice amount of time at the end for Q&A and very much look forward to that conversation. For the first time in history, the number of women exceeds the number of men in US medical schools. In fact, for 40 years, women have represented a significant proportion of med school graduates and currently account for almost half of medical students, graduate medical trainees and faculty nationwide. Despite this workforce representation, however, women continue to experience well documented disparities in opportunity and compensation within our profession. These inequities are interrelated and addressing one successfully necessarily implies understanding and mitigating the others. We can think of the gender pay gap as a crucible in which all the forces that limit women's professional value within our institutions converge. The equity of opportunity that should be flowing from numeric parity is not materializing. Women's advancement trajectory in academic medicine looks like a funnel. With fewer and fewer women, the higher one goes in seniority and leadership. Women's advancement trajectory on the corporate side of the house of health care looks the same with fewer and fewer women, the higher one climbs in the corporate ladder. In addition to disparities in achieving academic rank and senior organizational leadership roles, the data also demonstrate inequities in obtaining research support and compensation. And these disparities exist even after accounting for age, experience, specialty, productivity, and professional commitment. It's important for me to acknowledge at this juncture that the literature reveals that women of color experience even greater disparities in these domains and face considerable barriers to advancement. So now I'd like to turn to the compensation data. In this country, women physicians earn 72 cents on the dollar compared with their equally talented male counterparts. In fact, the physician gender pay gap has increased over the last several years and based on some seminal work done by Dr Aurora and her colleagues, we now understand that this pay gap amounts to an adjusted career earnings difference of over $2 million on average. Indeed, women physicians experience one of the largest gender pay gaps in the US labor market and the data consistently show that these inequities begin right out of training. Women faculty earn less than men in every specialty and at every academic rank. And as many of you are likely aware, the Association of American Medical Colleges through its annual faculty salary survey collects and publishes compensation data on about 120,000 faculty nationwide. In 2019, the double AMC published this data by gender, and then a few years later in 2021, the double AMC published this data by gender and race and ethnicity. And so we now have the opportunity to look at compensation trends and gaps through an intersectional lens in academic medicine. This 2021 analysis showed that the biggest gender pay gap occurred among physician faculty in clinical departments where women were paid between 67 and 77 cents on the dollar compared with white men. Moreover, women physicians regardless of race or ethnicity earned less than men of every race and ethnicity. Basic science and clinical science PhD faculty tended to do a little bit better with women earning between 68 cents and 89 cents on the dollar compared with white men. So when we translate these advancement and compensation disparities into the healthcare marketplace writ large, it's understandable why women comprise only a small percentage of our top earners in academic medicine despite representing a considerable portion proportion of the physician pipeline. Additionally, advancement disparities and lifetime suppression of wages have considerable impact on the cumulative wealth of women in medicine and science and carry significant implications for retirement choices and post retirement quality of life. I'd like to do a bit of a dive into this concept of accumulated wealth. And in order to do so, I'd like to share a study that was published by some colleagues at Hopkins a few years ago, in which investigators performed an accumulated wealth simulation, in which they looked at over 300 school of medicine faculty salaries about a third were women and longitudinal promotion data over about a decade. Researchers showed they attempted to show the effects of gender differences on total salary and accumulated wealth over a 30 year career, while adjusting for department rank degree and years in rank. One of the most compelling findings from this study that was even even a small gender pay gap less than 3% translated into large differences in accumulated wealth. Specifically, in this simulation, owing to the cumulative effect of salary and promotional disparities over a career, a woman faculty member would have to spend her retirement savings at a rate 40% that's 40%, slower than a male counterpart to compensate for less retirement money and longer life expectancy, or if she spent at the same rate, she would run out of money, seven years before her death. So there are multiple inflection points in women's career trajectories, where our traditional way of paying folks of valuing the work that they do disproportionately rewards the way men physicians and faculty have worked and lived for generations. Therefore, it is critical that we identify, acknowledge and address these contextual forces as we said about correcting the practice of paying equally talented women, less than their male counterparts. And so now I'd like to take some time to explore traditional compensation methodology within academic Madison, and its impact on the gender pay gap. Consider that compensation methodology typically rests on a formula of base salary determined by commercially available benchmarking data, plus additional monetary reward for rank leadership and productivity. If the goal is total cash compensation, we can see how common compensation methodology contributes structurally to gender based salary inequities because of women's diminished earning potential in each domain. For example, regarding base salary, there is often a considerable difference between the dollar amounts at the low and high ends of the benchmark ranges, allowing organizations wide birth in making compensation determinations. Salary expectations and vigorousness of negotiation during initial hire are critical to establishing where an individual faculty member falls in that range and are potentially vulnerable to gender bias. Productivity based compensation is impacted negatively by increased demands for organizational service, increased time spent with patients resulting in better outcomes, but lower volumes, and greater responsibility for domestic duties compared with male colleagues. Similarly, limited formal leadership roles and less sponsorship to access those roles decrease the compensation that attaches to those opportunities. I'd like to explore a few of these elements individually and in order to do so, I'll need to describe the phenomenon known as second generation gender bias. So second generation gender bias is different than the sexism that existed pre title seven and pre title nine in that there's not an overt intention to exclude. As I said, these biases are embedded in our unconscious stereotypes and expectations about what leaders look like, and how men and women should behave or how women's work is assigned and valued in our organizations. The descriptive societal and organizational norms are the engines behind why our talented women are failing to reach their potential and being paid less. They are the drivers of the gendered career paths we see in academic medicine, and the consistent observation that women are assigned more non promotable tasks in our organizations and experienced backlash when leading and negotiating. Research reveals that within health care on both the academic and the business sides of the house, women tend to advance in areas that are consultative and supportive, rather than those with significant operational or quantitative or managerial responsibility. In academic medicine, women who advanced to decadent roles tend to do so in faculty affairs, versus in clinical affairs or research affairs and for those of you have been around as long as I have well that's me pre COVID. But you'll recognize my husband Dr. Peter Friedman who was on faculty at University of Chicago is a physician scientist and and has allowed me to use his photo he's a research dean now. On the corporate side of health care it's also important for me to acknowledge that women's C suite leaders similarly tend to hold titles like chief HR officer and chief legal officer. And, and, and the reason these quantitative or operational or significant managerial roles are so critical. Incubators for the dean and the CEO positions but they're also the gateways to the compensation that accrues to those executive leadership opportunities. Similarly, evidence shows that women trainees continue to be directed towards certain specialties like pediatrics that require traditionally feminine attributes and away from technical or more procedural ones like orthopedics. This phenomenon as some of you may know is called occupational gender segregation and it has tremendous consequences for pay equity. In fact in the US labor market writ large a loss of prestige and a decline in earnings have been shown to occur when a large number of women enter a field or occupation. And indeed in a study published just last year in drama pediatrics investigators assessed 70,000 faculty salaries over 95 specialties and showed an $8,000 decline and mean compensation for every 10% increase in the number of women present. And here's a nice visual based on some medscape data that that compels us to consider the following. When an entire specialty loses ground in terms of relative compensation and that's reflected embedded really in our in the salary benchmarks that we use the earning potential of all women entering that field is put a considerable risk. Another manifestation of second generation gender bias that I mentioned is that women have been shown to spend more time on non promotable tasks. This is work that has little visibility or impact. It's work that benefits the organization for sure but doesn't contribute necessarily to performance evaluations or metrics for advancement. This is institutional housework and the types of work vary by industry but are readily identified. There's actually some very interesting research around volunteerism in mixed gender groups which shows that women are more likely to volunteer than men. Women receive more requests to volunteer and women are more likely to say yes when asked to volunteer so there is this shared understanding that women will raise their hands to volunteer for citizenship endeavors. Another manifestation of second generation gender bias is that women face a double bind when trying to advance in their careers and when behaving like traditional leaders. In fact, women are often expected to be directive, yet participative, decisive yet caring, executive yet approachable implicit expectations around women's behavior. Women's behavior organizationally and in society at large are often at odds with these well accepted desirable leadership traits and the question is why is that? Well, there are long standing cultural norms, unconscious stereotypes that women are to be nice and caretaking and other focused whereas leaders and high performers are decisive, assertive, and independent and there is a very well described backlash when one's behavior violates these gender stereotypes. There is a social penalty in the workplace for women who behave like traditional leaders and this impacts how they're described and evaluated and dictates how effectively they can self advocate and lead. This likability paradox was highlighted very nicely in a study that was described in Harvard Business Review a few years ago in which investigators looked at 81,000 performance evaluations at the US Naval Academy, both men and women, and showed that women were evaluated more negatively despite no gender differences in objective measures such as grades, fitness scores, or class standing. Women were judged less competent than men of equal qualification and were assigned more negative attributes. Additionally, the most commonly used positive term to describe men was analytical. For women, it was compassionate. Now you may say to me, analytical, compassionate, those are both positive, but which is more valuable from an organizational standpoint. So analytical is task oriented. It speaks to an individual's ability to reason to interpret to strategize. So when considering whom to hire whom to promote whom to compensate, which person which attribute is going to take the prize turning out a negotiation. So to acknowledge that at its essence job negotiation is really an interpersonal exchange between a job seeker and an evaluator and job seekers who violate unconscious stereotypes have been shown to experience backlash backlash in this context is defined as social and economic resistance for engaging in behavior inconsistent with what's expected of one social identity group. The data show that negotiating salary significantly decreases higher ability for women candidates and that men in particular tend to penalize women who negotiate So women and men truly do face different costs when deciding whether or not to initiate salary negotiations. In some women face a unique professional challenge of having an implicit background identity of unconscious social expectations around their behavior that they have to navigate. There's a cultural context in which women must manage the gender expectations of being feminine, while simultaneously fulfilling the requisites of advancement and leadership. And this is costly psychologically and it results in self censorship and attrition with tremendous consequences for career advancement and pay equity. It's also a sub optimal business model because we as organizations truly need to be harnessing the talents of our entire workforce. As we consider how elements of second generation gender bias can undermine the productivity element in the domain in the domain on this figure within our traditional compensation calculus we really need to look no further than the pandemic. As many folks know the pandemic has had a regressive effect on women in the workplace in general into the before 2020, all recessions depressed employment equally for men and women or depressed, depressed employment for men more. However, in the coven 19 pandemic, the job losses were much higher for women. The reason behind this is that women were heavily employed by sec infect and sectors affected by the shutdowns and had to shoulder increased childcare responsibilities because of school and daycare closures and remote learning. The economic data were clear and consistent that mothers work hours fell significantly more than that of fathers and that unfortunately working remotely did not mitigate this disparity for mothers of young children. Personally, my most compelling data point was with return to remote schooling in September of 2020 it's hard to believe it's two years ago, 80% of the individuals who left the workforce that's 80 were women that's almost a million women. The reason this is important to talk about in terms of today's topic of closing the gender pay gap in medicine is that worker historic trends tell us that workers who diminish employment during a recession experience highly persistent earnings losses and diminished career opportunities. Now we all know that the health care sector has been significantly disrupted during COVID. And when we look at our industry in particular, the data show that women in medicine and science indeed, we're doing more double shift work have been doing more double shift work during the pandemic. In the pre pandemic, there were decades of data, revealing that women, women faculty should shoulder to increase responsibilities for dependent care domestic duties and childcare disruptions, compared with male colleagues and now there's evidence of more household responsibilities and childcare reduced work hours and less academic productivity during the pandemic than men, and this labor force disengagement has tremendous implications for future productivity compensation and career advancement, and has been referred to in the literature as economic scarring. So when talking about the productivity component of traditional compensation methodology, I would be remiss if I didn't spend a few minutes talking about the RVU conundrum. Everybody's favorite topic the RVU. So the relative value unit as I'm sure you all know was adopted by CMS in the early 90s as a mechanism for physician payment. The standardized unit based on the cost of providing medical services and physician work comprises over half the valuation. Now there is considerable consternation in the literature over the questionable methodology that underlies this evaluation of physician work because it's based on surveys of physicians who perform the service. The survey response rate is low. And of course it's subjective. It's also designed to value medical services, not to measure physician performance and as such it incentivizes more, but not necessarily better work. This volume based productivity has been characterized as an imperfect measure of physician work that is inconsistent with 21st century healthcare goals, like patient centered care and teamwork and quality. What I would describe as potentially monetizing the doctor patient relationship. I would certainly offer that it penalizes women who spend more time with patients engaging in more patient centered communication who demonstrate better outcomes, but lower volumes. Women also have limited access to highly remunerative RVUs because they're over represented as I mentioned in non procedural specialties. But even for those women who do perform procedures they receive fewer referrals for them, and they perform lower value procedures. I don't know if there are any surgeons in the room, but the surgical community has been paying increased attention to how implicit gender bias is impacting the valuation of productivity. In particular, just last year late last year a large and very elegant study was published in drama surgery in which 40 in which investigators looked at 40 million referrals to surgeons over a 20 year period, and showed that male physicians were more likely to refer patients to male surgeons. Women surgeons received fewer procedural referrals, and unfortunately, these findings did not attenuate over time. This same group of investigators published a study a few years prior in which they looked at about a million and a half procedures, and revealed that women surgeons more commonly performed procedures that garnered the lowest hourly earnings. To that same and colleagues from multiple fields have been publishing about the bias valuation of female specific procedures, compared with male specific procedures, despite similar complexity about the potential impact of this disparate reimbursement on quality. And last but not least about the bias perceptions among referring physicians who have been shown to penalize women surgeons more for bad outcomes and reward men surgeons more for good outcomes that last bit of data actually comes from somebody on faculty at University of Chicago and the Department of Economics very interesting work. Last we think the silver bullet to improving productivity based compensation is incorporating alternative payment models into our salary determination processes, we need to look at a recent study that raises concerns that these new frameworks the APMs may be recapitulating existing gender biases. So just in July, the annals of internal medicine published another incredibly elegant study in which researchers looked at a micro simulation of over 1400 match primary care physicians. The investigator showed that the gender pay gap was similar under unadjusted capitation and productivity based models, however, the compelling finding was that there were larger wage gaps under capitation models use that used diagnosis based risk adjustment. Male PCPs had panels that had more men who had higher risk force and so this begs the question. Are our risk for algorithms, up waiting conditions, more prevalent and more often diagnosed in men. So now I'd like to switch tax a little bit and talk about what we can do about closing the gender pay gap in Madison we start an organizational level let's peel the onion back a little bit. What about correcting the practice of paying equally talented women, less than their male counterparts, it's critical as I hope I've communicated that we identify acknowledge and address the contextual forces that perpetuate it. In parallel, however, we must recognize that equitable compensation is a business endeavor that requires the same attention to detail and rigor afforded other operating costs. The gender pay gap in medicine will require our colleagues in finance and HR to take a good hard look at basic assumptions underlying institutional compensation methodologies to understand the expectations and the outcomes. They generate to create new approaches that better account for the unique contributions of women, and the biases facing them, and to track and report gender metrics at all compensation touch points. To argue with equal pay for equal work. It's how to achieve this goal that overwhelms institutions and their leaders organizations need a roadmap to assess how current compensation methodologies at home are perpetuating pay inequities. This is the governance structures coalitions and processes necessary to incorporate equity principles into routine business practices, and how to create the dialogue consistent messaging and cascaded information to achieve organizational transformation around gender equity. As Dr Euler mentioned about almost two years ago some colleagues of mine and I published a book that aims to help institutions with this endeavor and and I put up the link here if anybody's interested. We also must recognize the importance of culture change to this endeavor, as I'm sure everybody in the audience knows culture is defined as a set of collective norms and behaviors. And there are certain elements of culture chains that are critical, fostering organizational conversations like this is one of those elements. As is intentionally reshaping practices and patterns of interaction in our workplaces that inadvertently benefit men disadvantage women and drive the gender pay gap. What we're really talking about here is building cultures in which men and women are not limited by role expectations. This endeavor like most things in life begins with ourselves with self reflection around our own perceptions and decision makings. We need to start by being mindful of the language we use in our introductions and our evaluations implicit biases communicate in linguistically communicate stereotypes and contribute to the maintenance of gender norms that women have less standing and less expertise. The data show that women physicians and faculty are introduced with their professional titles considerably less often than men are and are evaluated with fewer standard adjectives despite similar qualifications with male colleagues. We also have to be paying attention to the processes in which unconscious biases could emerge. And last but not least, we need to be sponsoring high potential women for leadership opportunities. In the vein of paying attention we can only manage what we measure. And so if folks are not already doing so we should be tracking gender representation along the career continuum, expecting unconscious bias training of everyone involved in recruitment hiring evaluation promotion and salary setting. And we also need to be conducting regular salary audits, especially for initial hires of a folks right out of training. I'd like to talk in detail about sponsorship. Sponsorship is critical to operationalizing the value of equal opportunity within an organizational culture by helping to dismantle second generation gender biases. Women in medicine and science have a visibility gap and sponsorship facilitates access to the platforms and networks necessary for talent and merit to become visible, recognized and rewarded. Now I'm sure a lot of you understand the differences between mentorship and sponsorship so I'm just going to take a minute to review those. Sponsorship tends to center on personal and professional development. It's about skill building and goal setting a mentor is somebody who provides feedback and expertise but whose impact truly does not depend on rank or position. Sponsor, however, focuses squarely on enhancing visibility credibility and networks, a sponsor is somebody who facilitates recognition and access and whose impact depends on position and our organizational influence. There are some limitations to mentorship or traditional mentorship in terms of supporting upward career mobility because of mentorships traditionally narrow scope say for example around a research project, and it's focused on mentee behavior. Sponsorship, however, directly targets career advancement and it's anchored in a sponsor's awareness of organizational structures and opportunities, and its focus is persuading institutional decision makers to see a protege's capabilities. This is a Venn diagram from some very close colleagues at Hopkins and I love it for many reasons and how it how it describes mentorship and sponsorship I want to point out a couple in particular. So mentorship is often longitudinal and can be quite transformative, whereas sponsorship may be episodic and feel a little bit transactional. The business community has known about and published about the value of sponsorship for over a decade, specifically about how sponsorship helps folks gain promotion, it increases satisfaction with rates of advancement, facilitate stretch assignments improves gender parity and advancement and puts upward pressure on pay. Academic Medicine came to the table a little bit late, but I would argue that as early as 2014 for Sheldia Castro and her colleagues at University of Michigan published a study where they didn't use the term sponsorship but really they were describing the concept and in that work. The investigators looked at a large K cohort and showed that promoting a mentee's career through networking and advocating for the mentee influence career satisfaction. I would argue that networking and advocacy on behalf of a mentee is sponsorship. A few years later patent colleagues also from Michigan looked at another group of K awardees and showed that reported sponsorship experiences were significantly associated with academic success. Academic success in this context was defined as for achievements such as a certain number of peer reviewed pubs a certain amount of external funding and formal leadership roles. That same year Dr breeder Roy and I published some early data on a nationwide sponsorship program that I had established for the Society of General Internal Medicine. The code was that participants in the program reported promotion to the next rank and expanded job opportunities in association with their engagement with the initiative. It's very important that we are intentional about sponsoring women in medicine and science because sponsorship that happens informally, or without a mandate for inclusion, most often benefits white men. And this figure underscores very nicely how this is from patent study how men in academic medicine were reporting more sponsorship experiences than their women colleagues. What is sponsorship look like on the ground as I said intentionality is is essential structure programs on a proponent of structure programs because they can proactively link. Protegees with sponsors based on standardized criteria, they can thoughtfully match sponsors and protegees, set out clear expectations for engagement identify objectives, monitor outcomes and solicit feedback for improvement. It's critical that our top leaders are sponsors and and promote sponsorship as an organizational value. Some may say why is she going on about sponsorship we're talking about comp. Well, to bring it back to compensation and to to to underscore the importance of sponsorship and leadership opportunity, as they relate to compensation I'd like to share the Mayo Clinic experience. So some of you may be aware that the Mayo Clinic has had a salary only model for for decades. There's a target salary that's established for each specialty it's non negotiable. A few years ago some colleagues at the Mayo Clinic decided they wanted to assess how they were doing in terms of pay equity and in fact they did affirm it in 96% of cases. One of the main drivers of that remaining 4% was that there were there were more men in compensable leadership roles. So intentionally sponsoring women for formal leadership positions is meaningful work in terms of helping to close the gender pay gap. We have to remind ourselves that talent is universal, but opportunity is not and sponsorship provides that opportunity. I wholeheartedly believe that the primary responsibility for solving this gender pay equity conundrum rests on the shoulders of our organizations for all the reasons that I've elucidated. In an individual level, however, the most critical contributor to pay equity is understanding the playing field, the rules of the game. Since implicit gender bias limits, women's ability to negotiate successfully the burden of salary equity truly does lie beyond the full control of an individual candidate. However, until organizations undertake the effort to address this phenomenon systematically, it will be essential for women faculty to equip themselves with knowledge about salary benchmarks, institutional target ranges and metrics for placement in those ranges in order to support their being paid equity. Several commercially available benchmarking salary benchmarking data sets. One of the most commonly used in academic medicine is the faculty salary survey from the Association of American Medical Colleges that I've already referenced. The double amc several years ago intentionally made this data set affordable for purchase online it's actually $45 it went up. But it's, it's affordable and available, knowing that there are well described penalties for self advocacy around salary and resources I would encourage women to use appreciative inquiry and approach the exchange around compensation as a conversation rather than a negotiation and to prepare for that conversation. I would also offer that an institution or institutional leaders willingness and response to this discussion have this discussion is a good indicator around institutional culture related to equity and inclusion. Last but not least it's, it's important for me to, to mention this incredible statutory effort around this country, regarding pay equity in the last six or seven years hundreds of bills have addressing pay equity have been introduced at the state level to include more aggressive pay equity laws, wage transparency laws and bands on salary history inquiries. And this last group the salary history bands were were intentionally put in place to prevent successive employers from using past discriminatorily low compensation to justify pay disparities. You know, Illinois does have a salary a band on on asking about salary history and if you land in another state, I put up the website here you can go to and just plug in your locale it will tell you if there's a salary history band in place. To close the gender pay gap in medicine organizations will need to identify and explore factors that drive compensation calculations at home, and to develop frameworks that account for gender inequities that it when assessing experience performance and responsibilities and that also recognize and reward mission aligned pockets of productivity that are currently being ignored. I'm going to leave you all with a call to action to start somewhere to do something. If you're not already doing so start conducting regular salary audits to determine where where the salary inequities lie. If that's already happening, identify where along that career continuum the gender pay gap is the most concerning and then review compensation methodology at that inflection point and consider potential drivers of disparities and then pick a driver and tackle it. Identify salary benchmark standards if none exists, minimize the potential for that salary negotiations for junior faculty right out of training, acknowledge and account for gender inequities and biases inherent in clinical medicine. I'm often asked as you might imagine where I would begin, I would equalize starting salaries right out of training salary disparities among graduating trainees are not rationalizable. And there is very good data that closing these pay gaps will have considerable financial impact to the tune of hundreds of thousands of dollars. I would also intentionally support the academic promotion of women faculty, we also know that closing the gaps in promotion timing will have financial impact. So here are all my references. I studied under Dr. Siegler so I have a lot of them. And I'm going to leave you with one of my favorite quotes, which is from I to be wells. The way to right wrongs is to turn the light of truth upon them. Thank you so much. Wonderful. Thank you so we are going to be open for questions in the room if you have questions we also have a question from the zoom so I'm just going to start with the zoom question. And I'll read it from Jay Carlson, and he's referencing pharmacists and their approach to equity and pharmacy he said Claudia golden has argued that pharmacists have largely closed the gender pay gap in their industry by developing substitutable workers that allows for flexible hours to individuals can better balance work requirements with domestic responsibilities. What do you think about the possibility of applying these solutions to physicians. I love that question and the pharmacy literature is really interesting in this and I couldn't agree more I think there are many layers to that onion and while it is very tempting to try to solve everything at once we really do need to be focused on what pharmacy has done in terms of really a culture rating flexible work time scheduled work time has made it a lot easier for that productivity domain to be managed in terms of our compensation methodology. Any questions from the audience. Dr. I'm just going to repeat the question. Yeah, so Dr asked about strategies for women in leadership to overcome the bias. That's a great question. Thank you Dr. My answer is a little polemical I have to be honest. This is this is not going to be solved on the backs of women. This is a cultural challenge. And I think having conversations like this is real is the first step. I'm going to take this very seriously because as as my my talk implies there are far reaching implications of of this inherent bias against self advocacy and and negotiation which are part and parcel right of being a good leader. I would also say that there is data from the higher ed community that the more women we get in power in leadership, the more that it's an association it's not causation but it's associated with better outcomes around representation for women and compensation While that may not be a satisfying answer because I wish I could give a pearl of wisdom to an individual woman who is stepping on that trajectory of leadership I really do think it's on the shoulders of our organizations to have conversations like this and to make us all aware I mean we all I think could all do better at just stopping and taking a pause particularly in amongst processes like hiring like compensation setting to check in with ourselves about what are our perspectives are individually. So I'll just paraphrase quickly Dr brunette shared that as she evaluated salaries in her section that she noticed this what you mentioned about leadership, the leadership gap and wanted to ask for recommendations about how to address that. That's a really great question and I you know I don't I think we're always going to need and want leadership premiums so I think that that piece is set it's how to get more women into those roles and I think it starts with kind of the. You know democratization of opportunity and and so when our institutions and our HR folks have to be very cognizant of publicizing opportunities widely, even if they're informal. And that actually gets at the citizens since and chip tasks to and so I think, making opportunities widely known to your point, Dr brunette encouraging folks of all genders to apply for those roles. And, and then having some type of it I'm a huge proponent of checks and balance processes in terms of having some type of institutional oversight to to identify and explore when a finding like that occurs and ask why and what are some kind of on the ground local efforts that could be made. In addition to leadership development curricula like the ones that you run. There's another question from the chat with Polly Gandhi hospital administrators sometimes think that there is no productive if there is no productivity component to compensation physicians will become lazy and not perform at their best. Any advice and how to overcome this argument and also how to appease the high producers other than then that others are not being given a free ride if the compensations are not made equal. So that's a summit and actually something I've been thinking about for my next book that is really counting work. I think is we that's that's really what the Holy Grail is for academic Madison how we count work and so all your your the elements of your question are are really insightful and this is not going to be a satisfactory answer because it really is a long conversation. But I think that the belief in RV use and in terms of physician motivate as a physician motivator is not data driven. It's it's also a flawed it's both the RVU is both a flawed construct and a flawed concept and construct we talked about because the methodology is pretty weak. In terms of the concept, I would argue and you know there is some and I am not a behavioral economist but there is some nice literature in that domain about what motivates physicians and other professionals. And I would argue that we need to talk to talk and think and adapt our metrics around that a little bit better. And then last but not least I would say that you know the RVU feels good in the short term right because it's countable. It's some, it's easily countable. But in the long term and this is another calculus that needs to be looked at strategically. I would argue that it's very expensive for institutions and for our professions you know we are having a tremendous scourge of burnout and attrition, and it's costly to recruit and new physicians when folks leave and new faculty when folks leave so we need to be thinking about those costs opportunity costs as well and as I mentioned this is a longer conversation and you know I'm really sorry that that's what you're experiencing and I go all over the country talking about this and you're not you're not alone. I had one question. There was recent Harvard Business Review article saying that in business, they find that women start at the same salary but it's really this mid career where women that were the discrepancy is, and we were interviewed for that and tried to reflect on is that the same in medicine are different and I just love to hear your opinions about that. So in Madison there are, there's as I put on one of the slide there's disparities right out of the gate, which is, is, you know heartbreaking. I will say that the gender pay gap gets worse, typically, and, and for all the reasons that you've outlined, and so, so I do think that similar to what I said to in response to Dr. Burnett's question that having processes in place for those inflection points, promotion to associate professor or you know seven years in the rank of associate professor and what's happening and looking at not just academic and organizational advancement but how compensation is also being tied to that. Any other questions in the room or on zoom. So I'll try to summarize this question is about the double AMC data and could the, could the double AMC be transparent and show which institutions are high performers which are low performers, and that would then challenge institutions to be better and use the data. So, as, as Amy Gottlieb private citizen, not Amy Gottlieb who is the, got to be chair of the double AMC's group on women and medicine science I will say that I'm a huge fan of the Athena swan style of scorecarding and, and I do believe that so so for those in the room but that's a reference to essentially an enterprise that ranks organizations in the UK, based on their equity at gender equity and tie it's tied to funding and for research funding and so I am a huge, huge fan of scorecarding. And so being said, the double AMC is, you know, walks, I think a very important line and that it aims to help its member organizations move the needle in a way that is supportive and sometimes I think scorecarding is not as supportive. And so I will say that certainly in my tenure on the group on women and medicine and science which is now, I mean, a long time. There are persistent conversations about how the organization can use its data to, to, to support and achieve gender equity and this, these salary reports, 2019 2021 were directly the result of those conversations because as I'm lost in anyone in this room back in my day so when I was junior faculty to negotiate, you know, go into a salary conversation to get that double AMC data was like you had to go in the dark of night and beg an administrator and it was impossible and you can't have a fair conversation. So half the room doesn't understand what data we're talking about. So, so all that data transparency and the double AMC is actually about to come out with even more in the Dean suite this month and beginning of November. And so that's I think how they I know that's how they're trying to lead in this round. Great question. Right. So the double AMC and I unfortunately I'm embargoed so I can't talk a lot about it but there will be a lot of really nice data coming out in the, in the next couple weeks about academic medical leadership and compensation. Is there any questions in the room or over zoom. Oh, Dr. Siegler. Yeah, so Dr. see the photos on zoom Dr. Siegler is referencing his medical school graduation 1963 did I get the data right. And it was three women and 73 men and was just, you know, saying that he's seen a lot of change and hoping that'll change. I think the question for me is how fast, you know, because it's been a little slow for some of us. He asked me the differential diagnosis of respiratory alkalosis which you did ask me 25 years ago on the wards. True story. You know, so, so the arc of history is long in bed source justice right I mean that's kind of what you're getting at and I would argue to so Dr. Siegler I agree with you I also think you know there's some really good data that was published by Kim Richter out of Kansas. At this point like two and a half years ago she looked at all the med school graduates over 35 years and the advancement disparities in achieving senior academic rank and there's actually been almost no movement or even negative movement towards professor. And so I hope you're right, I do think that we, these kinds of conversations hopefully will expedite it a little bit more. I can't see the hand in the chat but I can't I can't see that I don't know if you can say your question verbally but if you want to type it in the chat that's fine. Any other questions. So, so we're going to stop the recording and then for those of you who want to say the ethics fellows will have a little bit of time with Dr. Dr. Gottlieb and perhaps to ask about her practical experience at Bay State what she does and how this equity work kind of works in practice at Bay State so