Compensation in Academic Medicine: Progress Toward Gender Equity

Background Studies have documented substantial salary disparities between women and men in academic medicine. While various strategies have been proposed to increase equity, to our knowledge, no interventions have been evaluated. Objective This paper aims to assess the effect of an identity-conscious intervention on salary equity. Design This study shows comparison of adjusted annual salaries for women and men before and after an intervention. Participants/Setting We studied full time faculty employed in FY00 (n = 393) and FY04 (n = 462) in one College of Medicine. Intervention Compensation data were obtained from personnel databases for women and men, and adjusted for predictors. After verification of data accuracy by departments, comparable individuals within the same department who had different salaries were identified. The Dean discussed apparent disparities with department heads, and salaries were adjusted. Measurements Total adjusted annualized salaries were compared for men and women for the year the project began and the year after the intervention using multivariate models. Female faculty members’ salaries were also considered as a percent of male faculty members’ salaries. Results Twenty-one potential salary disparities were identified. Eight women received equity adjustments to their salaries, with the average increase being $17,323. Adjusted salaries for women as a percent of salary for men increased from 89.4% before the intervention to 93.5% after the intervention. Disparities in compensation were no longer significant in FY2004 in basic science departments, where women were paid 97.6% of what men were paid. Conclusions This study shows that gender disparities in compensation can be reduced through careful documentation, identification of comparable individuals paid different salaries, and commitment from leadership to hold the appropriate person accountable.     

Motivation,money and respect: A mixed-method study of Tanzanian non-physician clinicians

Poor quality of care is a major concern in low-income countries, and is in part attributed to low motivation of healthcare workers. Non-physician clinicians (mid-level cadre healthworkers) are central to healthcare delivery in half of the countries in Africa, but while much is expected from these clinicians, little is known about their expectations and motivation to perform well. Understanding what motivates these healthworkers in their work is essential to provide an empirical base for policy decisions to improve quality of healthcare. In 2006–2007, we conducted a mixed-method study to evaluate factors affecting motivation, including reasons for varying levels of motivation, amongst these clinicians in Tanzania. Using a conceptual framework of ‘internal’ and ‘environmental’ domains known to influence healthworker motivation in low-income countries, developed from existing literature, we observed over 2000 hospital consultations, interviewed clinicians to evaluate job satisfaction and morale, then designed and implemented a survey instrument to measure work motivation in clinical settings. Thematic analysis (34 interviews, one focus group) identified social status expectations as fundamental to dissatisfaction with financial remuneration, working environments and relationships between different clinical cadres. The survey included all clinicians working in routine patient care at 13 hospitals in the area; 150 returned sufficiently complete data for psychometric analysis. In regression, higher salary was associated with ‘internal’ motivation; amongst higher earners, motivation was also associated with higher qualification and salary enhancements. Salary was thus a clear prerequisite for motivation. Our results are consistent with the hypothesis that non-salary motivators will only have an effect where salary requirements are satisfied. As well as improvements to organisational management, we put forward the case for the professionalisation of non-physician clinicians.     

Modulation of the spatial attention network by incentives in healthy aging and mild cognitive impairment

Impairments of spatial attention are common in Alzheimer's disease (AD), but may develop earlier in the course of the disease, a condition referred to as mild cognitive impairment (MCI). In a previous experiment, we showed that emotional content overcame the AD-related decline in selective attention to novel events [LaBar, K. S., Mesulam, M., Gitelman, D. R., & Weintraub, S. (2000). Emotional curiosity: Modulation of visuospatial attention by arousal is preserved in aging and early-stage Alzheimer's disease. Neuropsychologia, 38(13), 1734-1740]. The current experiment examined the influence of secondary reinforcers upon selective spatial attention in MCI and healthy aging (EC). Subjects performed a covert attention task while undergoing fMRI. They won money for fast responses and lost money for slow responses. In young subjects, this task had shown that the influence of incentive upon spatial attention is mediated by the posterior cingulate (PCC) and orbitofrontal cortices (OFC) [Small, D. M., Gitelman, D., Simmons, K., Bloise, S. M., Parrish, T., & Mesulam, M. M. (2005). Monetary incentives enhance processing in brain regions mediating top-down control of attention. Cerebral Cortex, 15(12), 1855-1865]. Both groups were able to use spatial cues to generate an anticipatory attentional shift towards the cued location. The prospect of winning (but not losing) money enhanced attentional shifts in EC subjects, an effect that was mediated by OFC activation. In contrast, only the prospect of losing money enhanced attentional shifts in MCI subjects, an effect that correlated with PCC activation. Behavioral effects of incentive upon spatial attention are only partially maintained in EC and MCI with corresponding modifications in the underlying neural circuitry. These results suggest a reorganization of the relationships between the limbic system and spatial attention network in healthy aging and MCI.     

RN-BSN education: 21st century barriers and incentives

DESIGN: Qualitative using phenomenological inquiry. Methods Purposive sample of six RN-BSN students participated in focus group interviews. Data were analysed using Colaizzi's phenomenological method. FINDINGS: Incentives included: (1) being at the right time in life; (2) working with options; (3) Achieving a personal goal; (4) BSN provides a credible professional identity; (5) encouragement from contemporaries; and (6) user-friendly RN-BSN programmes. Barriers included: (1) time; (2) fear; (3) lack of recognition for past educational and life accomplishments; (4) equal treatment of BSN, ASN and diploma RNs; and (5) negative ASN or diploma school experience. CONCLUSIONS: RN-BSN educational mobility is imperative as: (a) 70% of practicing RNs (USA) are educated at the ASN or diploma level; (b) nurse academicians and leaders are retiring in large numbers; and (c) research links BSN-educated RNs with improved patient outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: RN-BSN educational mobility is imperative to nurse managers and nurse administrators because: (a) research links BSN-educated RNs with improved patient outcomes; (b) nurse leaders and academicians are retiring in large numbers; and (c) approximately 70% of practicing RNs (USA) are educated at the associate degree or diploma level with only 15% moving on to achieve a degree past the associate level. Measures to foster incentives and inhibit barriers (caring curricula and recognition of different educational levels) should be implemented at all levels of nursing practice, management and academia.     

Economic Incentives in Disability Insurance and Behavioral Responses

This paper reviews evidence that economic incentives affect the behavior of workers and their health care providers. Prior models of disability behavior have been incomplete either because these incentive responses were ignored (as in the biomedical model of disability), or they focused exclusively on the workers' incentives (the insurance model) or the providers' incentives (the managed-care model). This paper calls for the use of the more expansive, integrated approach to disability management.     

Struggle for control: General practitioners in the Swedish health care system

This paper reports on findings on the perspectives of generalpractitioners (GPs) in Sweden since the introduction of theStockholm model. The research design was exploratory with theintention of discovering several perspectives shared by doctors.The subjects were asked to describe their work, how long theyhad been working and to describe whether they were familiarwith the Stockholm model. Questions also focused on professionalautonomy, the use of diagnostic related groups (DRGs), the Isolationof work and the possible impact on patient care. While previousresearch suggests that doctors may be losing autonomy, the experiencein Sweden, in particular, as it relates to GPs, may be different.Most of the doctors interviewed reported that the Stockholmmodel had increased productivity and efficiency, that economicincentives influenced their medical decisions and that medicaltreatment appears more patient focused than before. GPs reportedan enhanced social and economic status within the medical professionsince the introduction of the Stockholm model.     

Employee and organizational factors associated with participation in an incentive-based worksite smoking cessation program

This study investigated employee and worksite characteristics prospectively predictive of participation among 474 smokers in nine different worksites taking part in a year-long incentive-based smoking cessation program. Several different ways of defining participation (e.g., joining versus level of attendance, first 6 months versus entire program) were studied. A consistent pattern of results was observed across two of the participation indices, joining the program and participating in one or more monthly follow-up meetings. Both worksite (number of employees, previous health promotion history, degree of support from management) and employee (gender, motivation, previous quit attempts) variables were predictive of participation. Logistic regression analyses revealed that each set of variables, worksite and employee characteristics, was significantly related to participation after controlling for the effects of the other set. We were less able to predict level of attendance among participants who joined the program. Implications of these findings for future studies of participation in health promotion programs are discussed.This work was supported by NCI Grant 1 PO1 CA 44648.     

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.