Explaining gender pay disparities in NP and PA professions

An increasing proportion of PAs and NPs are women, and old gender-based roles in healthcare are being actively challenged in educational and workplace settings.¹ But gender pay-gaps persist, several studies show.

Female NPs make 11% less than male NPs, according to one 2010 study – a median $85,000 versus $96,000.² Among PAs, a gender pay-gap has been well-documented since the early 1990s.³

Vexingly, little has changed in the intervening decades. A 2009 analysis of salaries among new PA graduates found that if anything, gender inequities in starting salaries have grown worse over time.⁴ The same is true among academic PAs, where men on PA faculties earn approximately $8,000 more each year than their female colleagues.⁵

“That such disparities persist in a profession that now comprises more than 65% women is remarkable,” Jennifer Coombs, PhD, PA-C, assistant professor in the University of Utah Physician Assistant Program, told Clinical Advisor.  “It’s not because women are having children. Everybody wants to say it’s because women chose to make less money. But the research is clear that when you compare the salaries of men and women, statistically controlling factors like working part-time, you still see a pay gap for wage.”

“It’s true that children make us very busy, but the research is very clear that we’re talking a wage gap that is independent of the very important and time-consuming work of having children,” Coombs added.

Study after study has shown that across medical — and other — professions, the gender pay-gap is a discernible and persisting inequity.

“It permeates our society,” Coombs said. “So are women working fewer hours than men, are they less productive in the clinic than men? Are women making less because they work in primary care? If you look at the research, you find it really is a wage gap independent of all those things. Women may be doing more housework, but that’s a separate issue.”

Indeed, such factors do not explain away the gap. Among physicians, for example, gender wage-gaps persist even after adjusting for factors such as full-time or part-time work, years in practice or specialty choice.⁵

The most recent study of the gender gap in pay among PAs confirms this trend in the PA profession, as well. The 2012 paper was published by a research team led by James F. Cawley, MPH, PA-C, director of the Physician Assistant/Master of Public Health Program at George Washington University in Washington, DC.⁶

“It’s hard to find good data,” Cawley said in an interview. “We asked the AAPA for their census data and the last good census data they had at that time was for 2009. They were nice enough to give us raw census data so our statistical colleague could crunch the numbers.” 

Happily, Cawley’s team found, PA wages have increased at a higher rate than the cost of living and inflation. “It’s remarkable, and NPs have taken note of that; their salaries aren’t quite as high as PAs’ salaries. For a new graduate at our program at George Washington University, a new grad commonly gets a job at $80,000 to $85,000. That’s not bad!”

Troublingly, however, the gender pay gap persists. “We found a substantial salary discrepancy by gender among PAs,” Cawley said. “We controlled for a wide number of variables and still found major differences.”

Among physicians, female family medicine MDs make approximately $17,000 less than their male colleagues, Cawley noted. Among PAs, the gap is about $12,000 overall. However, average total income for PAs is lower — around $98,000 to $99,000 a year — whereas “for family docs, the mean income is $180,000 to $190,000.”

This suggests that in terms of percentage of total income, the gender gap in salaries might actually be worse among PAs than among MDs. Like Coombs, Cawley was initially surprised to see that the gender pay gap has so clearly persisted among PAs. “But when we started looking at the wider world, we became less surprised,” he said.

Salary trends

Studies show gender salary differences not only among physicians, but many other occupations.  “A number of reports gave the figure that women make 77 cents on the dollar compared to men in a wide variety of occupations. Not only in healthcare, but a lot of occupational categories,” Cawley said.

Healthcare sociologists have discovered that as medical professions have become “feminized” during the past 50 to 70 years, salaries in the field have tended to decline. However, this has not happened among NPs and PAs, Cawley explained. As more women have entered the profession overall salaries have gone up, but gender disparities persist.

Only about 5% of male NPs are part-time employees compared with 18% of female NPs. However, when one looks only at salaries for part-time NPs, women earned on average $45.73 an hour in 2010 compared with $50.84 an hour among men.²

Exactly why that is the case remains something of a mystery. “I struggle with the word ‘discrimination,’” Coombs said. “It’s not like there’s a big conspiracy to pay women less. I don’t feel that way. PAs love our workplaces, and I never felt anybody was trying to discriminate against me.” 

Private Practice vs. Institutional Employers

Several factors have been identified that may contribute to the gender pay gap. Men tend to be underrepresented in lowest-paying NP settings — only 2% work as school nurses, for example.² However, although men represent only 8% of the NP population in the US, 19% of them own their own NP practice, which enables them to set their own salaries.²

On the other hand, PAs of either gender “almost never” own their own facilities, Cawley noted.  Among PAs and NPs compensation correlates importantly with job title, and gender gaps in salary vary between specialties. This variation could ultimately be due to differences between private practices and institutional employers.

“Surgery and orthopedics, where there doesn’t seem to be as pronounced a gender pay gap – those tend to be higher-paying specialties that are procedurally related,” he said. “Cardiothoracic surgery, for example, is almost always a hospital-based specialty.”

In hospitals, there is generally less gender disparity in pay, because salary structures are set down on paper. “If a PA or NP is being hired for cardiothoracic surgery at a hospital, there’s going to be a stated salary range that institution pays, whether you’re a man or a woman, and that should ensure there’s no gender discrimination,” Cawley explained.

Research shows that women tend to be less aggressive when it comes to salary negotiations, a skill that may be more of an asset in primary care and internal medicine. “In private practice settings, PAs’ and NPs’ salaries are often determined by the negotiation between a physician and the PA or NP, and that’s when there’s room for fluidity,” Cawley said.

Men up are up to four times more likely than women to ask employers for a raise, but being assertive can “backfire” for women, some studies suggest. “A physician may not know what the going rate really is for PA or NP, and may say to the candidate, ‘what do you want,’ and Jane Doe – because she’s a new graduate, perhaps, and doesn’t know exactly what she’s worth, may set that salary a little lower to get the job,” Cawley said.

Negotiating a fair salary

Information self-empowerment may help PAs and NPs close gender pay disparities. “It comes down to getting the data, being informed, finding out what the salary statistics show – and using all of this in your negotiations,” Cawley advised.

The American Academy of Physician Assistants is a good reference for finding accurate PA salary information. “If you’re a member, you can request the mean salary for an orthopedic surgery PA working in New Mexico in 2011, for example. This information can provide a starting point for salary negotiations,” Cawley said.

This applies to NPs as well, according to Louise Kaplan, PhD, ARNP, assistant professor at Washington State University College of Nursing in Vancouver, Washington, and Marie-Annette Brown, PhD, ARNP, FAAN, of the School of Nursing at the University of Washington in Seattle.

Salary data specific to one’s state and local area can be both practical and advantageous in negotiating fair compensation, and may depend on factors including years of experience and the role or type of practice location.

“Just as evidence-based practice promotes quality care, evidence-based negotiations could promote the quality of salaries APNs deserve,” Kaplan and Brown suggest.⁷

For women who do face workplace discrimination, there are legal protections on the books. “The National Women’s Law Center has resources about pay discrimination and the law,” Coombs advised.

Pay equity is one of the final battles of feminism, she said, adding that it’s important not to view the issue as a battle between men and women, because men also benefit from closing gender pay gaps.  “Women are increasingly breadwinners,” Coombs said. “If you lift up women, you lift up their families, too.”

Bryant Furlow is a freelance healthcare and medical research journalist based in Albuquerque, New Mexico.