Why are there so few women in the highest-paying specialties?

Every year, media outlets release the results of physician salary surveys. And every year, certain specialties and subspecialties top the list as the highest paid, including neurosurgery, plastic surgery, orthopedic surgery, cardiac surgery, cardiology, and cardiology subspecialties (particularly interventional cardiology and cardiac electrophysiology).

Is it a coincidence these are the same specialties in which women are few and far between?

Where the women are, and aren’t

According to the Physician Specialty Data Report from the Association of American Medical Colleges, in 2021 only 5.9% of orthopedic surgeons were women, compared with a high of 65% for pediatrics.^[] Only 8.3% of thoracic surgeons were women. In neurosurgery, this percentage was 9.6%. In cardiovascular disease overall, only 15.5% of active physicians were women.

In fact, in a 2022 statement on the need for greater career flexibility in the specialty, the ACC’s Solution Set Oversight Committee recognized that cardiologists at all career stages are increasingly aware of “issues that have an impact on work-life balance.”^[]

Work-life balance difficult to maintain

These specialties require some of the longest training times in all of medicine, with long hours that result in poor work-life balance during that training—and usually, during active practice as well. This has a significant influence on women’s decisions as to whether or not they are viable career options. So, while these factors contribute to placing these specialties in the highest-paid tier, they are also the very factors that discourage women from pursuing them.

The ACC statement recognized the implications for women.

The ACC committee recommended flexibility over the arc of a woman’s career, because many women are able to increase their career commitments in midlife. Given that women, on average, live longer than men, they may be able to extend their most productive years as well.

This latter point seems to have been lost on many in male-dominated specialties, as reports of ageism are anecdotally worse for women in these specialties. I have known a number of female cardiologists who, upon reaching just 50 years of age, were asked by their male colleagues or department heads when they were planning to retire! (And not a few times, these same male colleagues were 70 years of age or older themselves.)

A lack of female role models

A dearth of female role models and mentors in these fields of medicine appears to perpetuate the cycle.

In a 2016 study of female orthopedic surgeons, the authors concluded that “the relatively few women currently practicing orthopedics were attracted to the field because of their individual personal affinity for its nature despite the lack of role models and exposure.”^[] 

That has certainly been my own experience in the specialty of cardiology as well. This makes it even more important to not only encourage more women to choose these specialties, but to make the work-life situation such that they will want to stay active and mentor others.

The future looks brighter

There may well be some modest improvements on the horizon. In cardiology, for instance, the Accreditation Council for Graduate Medical Education’s residency numbers show that, during the 2021–2022 academic year, 25.5% of fellows in cardiovascular disease were women.^[] In orthopedic surgery that year, that number was 18.3%. In neurosurgery, it was 21.5%. 

As noted above, seeing other women as attending role models also effects whether or not female residents consider pursuing fellowships in these specialties and subspecialties; it can impact whether or not they feel it is worth all the extra years of training.

Making these specialties more attractive in terms of work-life balance has great benefits for both women and men, and will help ease some of the drivers of physician burnout—all of which, ultimately, is good for patients, too.