The Most “Unique, Excellent, and Promising” Episode

MALE VOICES READING WORDS FROM BAPU’S STUDY: … Excellent … Remarkable …  Innovative … 

If you’ve ever read a study in a scientific journal, you might have come across some terms like these…. 

MALE VOICES READING WORDS FROM BAPU’S STUDY: Robust … Unique … Novel

And interestingly enough, the authors that use these words tend to all have something in common…

MALE VOICES READING WORDS FROM BAPU’S STUDY: Astonishing … Unprecedented…

Can you guess what it is?

From the Freakonomics Radio Network, this is Freakonomics, M.D.

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I’m Bapu Jena. I’m a medical doctor and an economist. And this is a show where I dissect fascinating questions at the sweet spot between health and economics. 

Today on the show: Is the medical research done by men really more excellent! novel! and astonishing! than the research done by women? Well, I did a study to find out. You can probably guess what I found, but I’m going to tell you about it today and much more.

We’ll talk about gender disparities in medicine, a field that prizes objectivity, data, and outcomes. We’ll talk about what implications this has not just for doctors …

FILES: Did he just fail to call me Dr. Files, and does it matter? Am I just being super sensitive? Wow. 

… but for patients, too.

ARORA: You can’t just produce physicians very quickly.  And so when you have a departure like that, patients suffer.

Did you know that just 36 percent of doctors are female? To me, this is kind of stunning. After all, my mom’s a doctor — she just retired — and my wife is a radiologist. Now, I know that’s a pretty small sample. But, let’s keep going: female doctors, overall, are also paid less than their male counterparts. A lot less. 

These issues obviously aren’t specific to medicine. There are gender gaps in a lot of industries. But to me, it’s always been striking that this occurs on such a big scale in the medical field because there is actually an interesting reason why it should — or at least could — be less of an issue.

Hear me out. Medicine is supposed to be cut-and-dry, for the most part. It has, what we call and uh, excuse the term, an “eat what you kill” model. You may have heard it called by a different name, “fee-for-service”. This means that doctors, not all but many, typically get paid for what they do. More procedures, more money. More complex procedures, more money. More patients treated, more money. It’s often a frustrating model for both patients and doctors. And lots of people in health care think that that model — fee for service — is an important reason why America spends so much on health care.

But that model, with all its faults, could, in theory, have a benefit when it comes to gender equity. The reason why is because insurers and the government, they tend not to pay male and female doctors different prices for the services they provide. A colonoscopy gets paid the same price regardless of whether a man or a woman performs it. A visit to the doctor gets paid the same price also. So, two doctors — a man and a woman — who do the same amount and type of clinical work, paid at the same prices, should, in theory, take home similar incomes. But, as we’ll talk about today, they don’t. 

I also became interested in gender differences, for another reason as well.

In lots of industries, it’s hard to know what are the key drivers of pay. If men and women get paid differently is it because of different choices, different quality, or type of work? The economist Claudia Goldin has done some excellent work on this. But in medicine, we’re lucky. We have really detailed data on things that we know may impact income, like the number of patients a doctor sees, the types of procedures or care they perform, the amount of research funding they have, — I could go on. In most other industries, these sorts of data don’t exist. 

The richness of these data in medicine has actually allowed me and my colleagues to study rates of promotion and income between male and female physicians who are similar in terms of all these attributes I just described. And we’ve found that the differences between the earnings of men and women and their rates of job advancement aren’t simply due to differences in the specialties that they choose, their preferences for flexibility, or just more generally, the type of work they’re doing. The differences are due to something else. 

For example: in a study published just this month, we found that the lifetime difference in income between male and female physicians was nearly $2 million. That’s a lot of money! And I just want to emphasize here that in all these studies, we accounted for all of the things I just described, like the number of publications, number of patients a doctor sees, you name it.

All of this work led me to wonder: why? And what about all those glowing words you heard at the start of the show …

MALE VOICES READING WORDS FROM BAPU’S STUDY: … Excellent … Remarkable … Innovative … 

… do they have something to do with it?

There is one good thing about the gender gap in medicine.

REPORTER : There’s a new movement in the medical field. 

It’s somewhat closing, although kind of slowly. 

REPORTER: New data shows the majority of medical students in the United States are women for the first time in history.

That was 2019, when women first accounted for more than half of medical students. But in academic medicine, not much has changed in more than three decades: just a quarter of full professors today are women. That’s well below the gender divide in academia overall.

So, what’s behind these gender disparities — the promotion gap, the pay gap?

There are a lot reasons. It certainly isn’t quality of care or qualifications, and I’ll talk about that more in a bit. Women tend to spend more time with their patients. That’s good for the patients, but again, that fee-for-service model means that they could end up seeing fewer patients than men. That could be part of the issue, but there’s more to the story. Structural biases that lead to implicit and explicit discrimination are obviously important. And bias rears its head in so many different ways in the medical workplace. But a really important one is how one’s research is communicated. Research is the bread and butter of many academics and how one’s research is received by others can change a researcher’s life. So it’s any researcher’s interest to make their work seem as important as it can be.

A couple of years ago I started to wonder whether that incentive — the desire for academics to promote their work in as positive and important a light as possible — could lead to differences in how men and women promote their research. 

With my colleagues Marc Lerchenmueller and Olav Sorenson, we analyzed the titles and abstracts of almost 102,000 clinical research articles and about 6.2 million general life sciences articles published between 2002 and 2017. We wanted to see if men and women differed in how they presented their research. Specifically, we wanted to know how often they used positive terms like …

MALE VOICES READING WORDS FROM BAPU’S STUDY: Promising… Innovative … Astonishing …

Those key words can be like a bright light through the fog of millions of papers that are reviewed and published by scientists every year. If a researcher can, uh, bling up their work a little, maybe it catches the eyes of others researchers, journalists even. This means more exposure, more opportunities, maybe even better jobs.

So: what do we find? Men were more than 12 percent more likely to use at least one positive term in the title or abstract of their paper. This gender difference was even more pronounced in research published in the highest-impact journals. And these papers that were described with words like:

MALE VOICES READING WORDS FROM BAPU’S STUDY: Novel … Unique … Unprecedented …

… they weren’t necessarily more novel, or unique. I say that because we looked at articles published in the same journal, which is an important marker of an article’s actual novelty, and in the same topic area, and found that scientific teams led by men were significantly more likely to upsell their studies compared to teams led by women. That self-promotion may have paid off — studies using positive terms, like “novel” and “unique” did end up getting more citations, which means: they got more play.

Our paper on how men and women describe their work is, of course, not the only paper out there. A paper by Julian Kolev, Yuly Fuentes-Medel, and Fiona Murray looked at the review process for research grants at the Bill and Melinda Gates Foundation. They found that applications from women had lower scores from reviewers, despite the foundation having a blind application process. The reviewers didn’t know anything about the applicants. So, how could this be?

GINTHER: It was a result of the words that they used that were, you know, grandiose relative to the words that women were using . 

That’s Donna Ginther. She’s an economist at the University of Kansas who has studied the gender gap in academia. In other words, applications by women had words that led to a, quote/unquote, “significant reduction in their perceived quality.” This was even though the proposals were actually quite good!

GINTHER: One of the things I noticed about the paper is that the pool of applicants to the Gates Foundation is the same as the pool of applicants to the National Institutes of Health. And there’s no gender gap in funding at the NIH. So the question is what’s going on? If you look more carefully Gates Foundation approach, they have the reviewers read like a hundred, three-page proposals. I don’t know about you. But after proposal number five those big superlatives are going to resonate more with me than “We carefully considered and found” type language. So, I attribute some of the findings of women’s proposals being disadvantaged in the Gates foundation as an artifact of the review process at Gates.

Now in the age of the internet, self-promotion extends beyond how a researcher frames his or her papers in fancy journals or grants.

Vinny ARORA: Absolutely. Obviously, I’m a user of social media, no secret there.

That’s Dr. Vinny Arora. She’s a physician and dean of medical education at the University of Chicago.

ARORA: In fact there was a New England Journal of Medicine piece that stated that women should reap the professional benefit of social media ‘cause it could be a great way to equalize the playing field, because it’s a great way to promote your work and let people know what you’re doing.

Dr. Arora thought that this thesis was inconsistent with how some female doctors really felt about social media.

ARORA: They felt it was very self-promotional to use social media and they weren’t sure how to approach it. Would they be punished for it or would it feel awkward? 

In a pre-pandemic survey, Dr. Arora and her colleagues analyzed how doctors — men and women — use social media. All of the physicians surveyed reported using social media more or less for career advancement.

ARORA: But the professional benefits that they gain are different. Men were more likely to get research collaborations and professional invited talks from their social media use, statistically more likely than women physicians, who were on social media. 

There was another pretty big downside.

ARORA: One out of four physicians on social media of both sexes  reported that they had been personally attacked. And then, uh, one out of six women physicians reported being sexually harassed. And the harassment ranged from sort of being propositioned to lewd pictures being sent your way to threats of rape, honestly. 

This research was in line with work done by the physician-economist Dr. Rachel Werner at the University of Pennsylvania and her colleagues. They looked at Twitter use during a health policy conference and found that male health policy tweeters had a bigger following and were more likely to get retweeted than their female peers.

ARORA: So what you’re starting to see is at least that, you know, the very real sort of inequities with social media use. It’s sort of an extension of real life. And even though it’s a novel tool, if left to itself, you know, those same biases occur. 

Dr. Arora has been working for a while to undo biases in the medical field.

ARORA: How I became interested in gender equity, sort of an accidental advocate is what I call myself, in part to you, Bapu. When I had an opportunity to write an editorial for one of your early papers, looking at the gender pay gap in looking at those salaries at public universities for male and female physicians, I was struck by that $20,000 pay gap. I was in a mid-career mode, myself. I was negotiating my own salary at the time of my promotion. And I realized I was not keeping pace with my nearest peer here, who was a male. And we’d had all the same metrics and I always had trust in the system that it would work out the way that it should for people who were loyal citizens. Uh, but that might’ve been a naive approach at the time. 

JENA: There’s been a lot of interest in the field of economics for decades about gender differences in, in pay and the wage gap. And, and some of that work has populated the field of academic medicine. And one question that always came up was, well, maybe women get paid less than men on average because they are doing “different work.” Maybe they’re in different specialties? Maybe they work fewer hours per week? Maybe they write fewer papers? All those kinds of explanations and we basically accounted for all those different factors and we found, kind of to your story, that even if you look at a male and female doctor in academic medicine who are doing what we think to be the same level of work, women were still getting paid 15 percent less. So I want to ask you: why do you think that is? 

ARORA: Well, I think there’s two possible reasons. One, which is widely discussed, which is perhaps women aren’t as aggressive about asking and negotiating, for their salaries? Either at the time of their first job, or, I think actually more important is the time of retention offers. And I think that that’s very salient because as I described myself as sort of the loyal citizen of the University of Chicago at the time. I do think that there’s a lot of loyalty that comes with being a woman in medicine. At that same time, you’re having kids, dealing with family issues, partners. It’s just harder for women to see themselves as uprooting themselves, to go look for the counter offer. Unfortunately, that is the currency . You have to go get the counter offer. And then that’s how you get your new raise. 

JENA: Yeah, you have to threaten to leave. 

ARORA: Yeah. And so that’s one reason, right? The other possibility, of course, is some element of bias , when people who are looking to hire women and then also men are making judgment calls about the women they’re hiring, and thinking, okay, I can start low or I don’t need to award this salary. It’s probably a bit of both. 

JENA: One question I’ve been thinking about, and given your role as a dean, I presume that you have or will be thinking about issues related to the pipeline of physicians, again, both by gender but also by race. And there is a common refrain that you’ll hear about how representation matters. And I’m curious to get your thoughts on that, both just as an intuitive or anecdotal way, but also whether or not there’s evidence for that . I mean, you could absolutely imagine how a young woman who is thinking about a field that has historically not comprised of a lot of women spends time randomly on a clinical rotation where her attending doctor, her supervising doctor is a woman may be more likely to then enter that field than she otherwise would have. How do you think about that issue of representation? What are the things that you’ve been thinking about doing in your role at the dean level?

ARORA: Certainly gender representation is an issue, especially in those procedural fields. And I do remember being at Wash. U. and seeing, like, they had not yet — I want to say they had graduated, maybe, a number of female residents. But it was like something, like, you could count them on your hand, you know? I remember being interested in surgery, but I was like, hmm. You know, that gave me great pause. And I was like, well, this doesn’t seem like the right field for me. And at that time I had no idea what I was thinking of about my own plans for family or this or that. But it was just enough to be like —  there’s gotta be a reason. It’s so hard and there’s no representation. And so I do think representation does matter, and we’re fortunate that we’ve come a long way. I happen to be supervising an all-male team of residents right now it’s statistically random that that happened. Would have been nice to have a, a female on my team, but at the same time a positive about it is that when I round with the team, they’re like, “This is Dr. Arora. She’s the head doctor.” Like, they go out of their way to highlight that, which makes me feel very proud to see those allies in action . And so, my trainees are making it more inclusive for me to, to be seen as a physician. And so I think about this a lot for our medical students and residents, particularly from groups that are underrepresented in medicine, such as Black physicians, Hispanic physicians. One of the things we need to do is recruit and retain diverse faculty. But regardless, diversity, equity, and inclusion needs to fall upon everyone’s shoulders so that you can actually make the place better and more inclusive.

Coming up after the break: even when women are promoted to positions of leadership, and provided opportunities to share their work and expertise, what happens if they still face gender bias? And how does this all affect patient care? I’m Bapu Jena and this is Freakonomics, M.D. We’ll be right back.

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Dr. Julia Files is a doctor and researcher at the Mayo Clinic in Arizona. She speaks often about her research. And something happened at one of these talks that actually gave her an idea for a new research paper.

Julia FILES: You know, they always tell you, write about what you know, right?

Dr. Files was presenting information about medical topics to a lay audience. She was the only female presenter of four speakers. The moderator was also a man.

FILES: You know, I’m a good speaker. I’m very qualified to do what I do. And we all did our thing and the moderator stood up and said, “Wow, what a great afternoon. I’m sure you learned a lot. Please join me in thanking doctors, X, Y, Z, and Julia.” And it struck me, I thought, wait a minute, what just happened? Did, you know, did, did he just fail to call me Dr. Files and does it matter? Am I just being super sensitive? Oh, maybe my presentation wasn’t good enough? Wow. What does that mean? 

When she returned home to Arizona, she shared this story with her colleague, Dr. Anita Mayer, who agreed that the moderator hadn’t been appropriate. Then, two weeks later … 

FILES: We were at another meeting and Dr. Mayer was the speaker and I was in the audience. And at the end of it, the moderator stood up and said, “Wow, what a great evening, please join me in thanking Dr. X and Dr. Y and Anita.” He did the same thing and it was a different guy doing it. And I remember I looked across the room and we exchanged glances, Dr. Mayer and I, and we went, oh my gosh.

A lightbulb went off. Dr. Files and Dr. Mayer wanted to know if their experience was happening to other female doctors. So, they and their colleagues looked at speaker introductions during internal medicine grand rounds presentations. These are the formal, weekly lectures that doctors have. And, they’re often recorded. So … what did they find?

FILES: Yes, in fact, our anecdotal experience was representative of the greater occurrence, which was that when the introducer was female, and the speaker male, the introducer would use a formal title 95 percent of the time. So a woman would introduce the male doctor as Dr. so-and-so. But when a male was introducing a female speaker at the podium, the likelihood that her professional title would be used occurred only 49 percent of the time. 

The finding was statistically significant, meaning the behavior was unlikely to be caused by chance. But the effect was also really large.

FILES: And so we felt it was very important to publish this and to discuss it. One might say, well, who cares? Well, it does impact the speaker’s credibility in the moment, and it can be quite deflating to, to be dismissed and not addressed by your professional title. And it reinforces stereotypic expectancies and can reinforce a lack of equity in the workplace. It encourages a preconceived power differential, and it can contribute to gender stereotyping. 

But of course, this was just one study. What if it was a fluke?

FILES: We were happy to see that our findings were reproduced in another study. This was conducted by Dr. Nargust Duma and it was done at an international oncology conference. So it was confirmation that what we had discovered was actually occurring more broadly. 

Aside from being rude, misaddressing female physicians has bigger implications.

FILES: This is an example of actionable gender bias, and we know that gender bias drives gender disparity in academic advancement. So here’s one small piece of the puzzle we could address. 

That’s because these one-off, tiny bits of gender bias add up.

FILES: What we call these encounters are microaggressions. Or microinvalidations. And in the moment in and of themselves as a standalone event, it’s not that big of a deal and all of us can rise above it and move on. The problem is the cumulative nature of these microinvalidations, microaggressions, microinsults that occur across a career. And they add up over time and exhaust you and take your focus and attention and energy away from the areas that you should be focusing on, which is enhancing your medical knowledge, figuring out what’s wrong with the patient, delivering good medical care.

And speaking of delivering good medical care, research has found that female doctors tend to have better outcomes than male doctors. I’ll give you an example. A few years ago, my colleagues and I looked at the mortality rates of patients who were hospitalized and whose care was led by either a female or a male doctor. We took advantage of a natural experiment that occurs when patients are hospitalized — they don’t choose their doctors and their doctors don’t choose them. It’s random. And we found that the mortality rate of patients treated by female doctors was about 5 percent lower in relative terms.

There’s a lot of reasons we might’ve found what we did. Studies in finance have shown, for example, that men are more likely to be overconfident when it comes to investment decisions. Part of being a good doctor is maintaining a broad differential of possibilities, being deliberate, being cautious, not being overconfident, and most importantly, not closing in too fast on a diagnosis. There’s some evidence that those traits differ by gender.

Part of what we found could also reflect gender differences in the time spent with patients and the nature of those interactions. For example, using detailed electronic health record data, my colleagues Dr. Ishani Ganguli and Dr. Hannah Neprash showed that female doctors spend about 16 percent more time with patients, per visit, compared to male doctors.Another paper found that patients tend to share more information with female doctors. 

A couple of years ago, I published a paper in the New England Journal of Medicine with Dr. Lisa Rotenstein, who also is a physician at Harvard. We looked at a concept called “Lost Taussigs,” named after Dr. Helen Taussig, a physician who was underrecognized for her work in cardiovascular surgery. Our central question was: if you have a system that doesn’t adequately reward people for their contributions, will people be incentivized to invest in those areas? Or, will they underinvest? What are we losing as a field, what talent are we missing out on, and what are patients missing out on, when the incentives for women aren’t the same as the incentives for men? Here’s Dr. Vinny Arora again, from the University of Chicago.

ARORA: The great resignation and the widespread burnout that we are all facing, it’s real. Retention and burnout after, you know, 18, 20 months in a pandemic is incredibly real. And most of those people that are considering leaving are women. So let’s just play that out. So one woman physician or nurse leaves an organization. Well, that’s more work for everyone else. And you know that it takes what, 10 years to train a physician, specialized nurse, same thing. So you can’t just produce physicians very quickly. They’re highly regulated markets that have tight caps on where people work and the types of positions they have. And so when you have a departure like that, patients suffer. [00:58:01] And so that’s what’s different about the healthcare market, right? When a healthcare professional leaves their job, it’s their patients and all their future patients that suffer. So it is a justice issue, but it’s also a really important, um, issue related to making sure that we actually have the workforce we need for the work that we have at hand in healthcare. 

I couldn’t say it any better. This is a topic I’ll certainly continue to research and advocate for, not only because I think that the issues we talked about today should matter to all of us, but because I have a personal reason for things to change.

JENA: Future MGH resident right here. Anni, I have a question for you. When it’s 5 a.m. in the morning and you have two more patients to admit, what do you do?

ANNI: Focus! 

JENA: Focus! That’s right! Anni, when you’re having trouble staying awake at work, what do you say?

ANNI: Focus!

JENA: Anni, when everyone hits “reply all” to the editor, what do you say?

ANNI: Focus!

JENA: Focus, yeah!

That was my daughter back in 2017. It feels like it was a long time ago. Anyway, that’s it for this week’s episode of Freakonomics, M.D. If you have thoughts, I’d love to hear them. Send me an email at bapu@freakonomics.com. That’s B-A-P-U at freakonomics dot com. Leave us a review on Stitcher or Apple Podcasts, or wherever you get your podcasts. They help new listeners find the show. A big thank you to Drs. Donna Ginther, Vinny Arora, and Julia Files for sharing their thoughts and research, and to all of you, for listening.

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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. This show is produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. Original music composed by Luis Guerra. This episode was produced by Mary Diduch and mixed by Eleanor Osborne. The supervising producer was Tracey Samuelson. Our staff also includes Alison Craiglow, Greg Rippin, Emma Tyrrell, Jasmin Klinger, Lyric Bowditch, Jacob Clemente, and Stephen Dubner. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening. 

ARORA: I do know your wife, yeah.

JENA: You do know my wife. Exactly. She’s a smarter physician, I can say that publicly, and you better believe I, I definitely say that privately. 

ARORA: That’s — yeah, because you’re a smart guy, so that’s good.