Negotiation: A key skill for women hospitalists

Knowing your value and preparing for an ambush are two key secret weapons.


Michele G. Cyr, MD, FACP, has firsthand evidence of the salary gap between male and female physicians. Now the director of general internal medicine at Brown University in Providence, R.I., years ago she became the interim chief of internal medicine, which gave her authority over physician salaries.

“When I looked at the spreadsheet, I was shocked and dismayed to see that the men were making more than the women. Men who had been hired at the same time as me were making more for doing the same work,” Dr. Cyr told attendees at session titled “Negotiation Skills for Women Physicians,” held at Internal Medicine 2013 in San Francisco this April.

“I said, ‘This is absolutely unacceptable.’ I went about fixing it,” she said. Then, five years later, she took another look at the spreadsheet. “Once again to my amazement and shock, the men were making more than the women.

“When I reflected on it, I realized that every time I asked one of the male faculty members to do something, he would say yes and ask for an increase in his salary,” she added. “When I asked one of the women to do something, she would say ‘Yes, and thank you.’”

This difference in approach was also uncovered by researchers at Carnegie Mellon University in Pittsburgh, she said. They found that 57% of men but only 7% of women negotiated their salary rather than just taking what was offered. And, when asked to play a game with variable pay as part of a study, nine times more men than women asked directly for higher pay.

Another study surveying physicians who had recently graduated from residency in New York State found large pay variations between the sexes. “There was almost a $17,000 salary gap that was unexplained by any of the variables they controlled for,” said Dr. Cyr.

The New York salary survey was conducted annually from 1999 to 2008. “What's most disheartening about this is that the salary gap was increasing over time,” she said. “It's not getting better. In fact it seems to be getting worse.”

The good news is that women physicians may be able to correct this inequality with more willingness and skills to negotiate. There are a number of reasons women typically avoid negotiation, including fear of failure or looking greedy, conflict avoidance, and not knowing what they deserve, said Dr. Cyr.

The last of those initially affected her when she was first promoted to chief of internal medicine. “The dean of the medical school asked me what I wanted to be paid. I was clueless,” she said.

Belief in meritocracy or “tiara syndrome” can also be a problem. Dr. Cyr explained this predominantly female misconception: “If they do their job really well, someone will notice and put a tiara on their head.”

The solution to these psychological and knowledge barriers can be simple. “Let's get over it,” said Dr. Cyr, proceeding to give her listeners a crash course in successful negotiation.

Prep for an ambush

Ambush negotiations are a common occurrence that can require skillful handling. Picture someone stopping you in the hallway to request a favor. “I think this is incredibly prevalent in medicine,” said Dr. Cyr, offering a humorous example: “I was wondering if you might be able to write a brief chapter on the complete history of internal medicine.”

A good first step is to postpone answering until you've had a chance to think about the request. “‘Sounds interesting. Could you send me an email with some specifics?’” suggested Dr. Cyr.

If your answer is no, there are a number of ways to express that effectively. “I like to keep [a list of potential] excuses. I am incredibly likely to say yes to something too quickly,” she said. “One is ‘I would love to, but I'm really overcommitted right now.’” Note that no further details are usually necessary. “Women always feel the need to explain what the previous commitment is. Men never do,” said Dr. Cyr.

Another solution is to suggest someone else for the task. “I know somebody who would be perfect for this,” Dr. Cyr said, noting that it's best not to set an ambush for the next person. “Do your colleague a favor. Call them and tell them you recommended them and they can say no, so they have time to think about it.”

But if you, like those male doctors on Dr. Cyr's service years ago, are willing to do the task in exchange for something else, get ready to negotiate. “You've got to figure out what you want. Then you have to figure out what they want. How can both of you get what you want so you can be successful?” she said.

In addition to pay, negotiable items include resources such as administrative personnel, benefits, scheduling and time off, responsibility/authority, and titles. “Don't scoff at titles,” said Dr. Cyr. “They are symbolic, but they can move you ahead in your career.”

To respond to an ambush, determining what you want in exchange and asking for it may be all that's necessary, but for bigger negotiations—a new job or an annual review, for example—more preparation is appropriate.

Know your value

Start by really knowing your own value. “It's about your work, not about how much money you need. Think about it in terms of what you're worth,” said Dr. Cyr. “One of the things that bothers me that women say is ‘I have to make enough to pay for the child care.’…That's not relevant. It's your value.”

At first, putting a number on your value may seem distasteful or difficult. “Many of us went into medicine thinking we weren't going into business,” she said. But there are many resources available for benchmarking one's salary against people in similar positions (see sidebar). “It really is powerful to have the data,” Dr. Cyr said.

When thinking about value, tally up the various ways that you contribute (or will contribute, if this is a first salary negotiation) to your employer. “Consider reimbursable work, but also nonreimbursable work,” she said, such as contribution to a hospital's mission, teaching, mentorship, downstream revenues (lab fees, for example), recruiting, research, and public relations benefits from invited presentations or media interviews.

Speaking of public relations, “Become your own PR person. It's not bragging to describe your accomplishments…Take credit, even if it was a team effort, and you led the team,” Dr. Cyr said.

Negotiation preparation also requires thinking about the other party's values and their needs. “How will they benefit if you succeed?” asked Dr. Cyr. “If you're taking a job, find out what happened to your predecessor. It may be insight into the values of the organization.”

Although you should go into the negotiation with a clear agenda, including talking points, some of the other-party research can be done early in the negotiation itself. Dr. Cyr cited a study of labor negotiators, which found that the most successful ones spent twice the average time acquiring information during negotiations.

“This is very, very similar to how we take a history from a patient. Start the negotiation with open-ended, broad questions,” she said. Listen carefully, and paraphrase what you learn back to the other person. “Don't be too quick to understand if you want to get more information,” she said.

Jumping to conclusions is a common mistake of nervous negotiators. Don't anticipate the other person's responses by saying things like “I know you can't pay me any more money” or “I know I probably shouldn't be asking.” And don't try to impress the other party with how well you understand their arguments, but do be sincere.

Get ready to bargain

After the information-gathering step of negotiation comes the bargaining. “The bargaining begins as soon as a number or a term is mentioned,” said Dr. Cyr. Before the bargaining begins, you should be certain of your bottom line. “The reservation value is the worst deal that you would accept before concluding that the negotiation has failed. It is the lowest salary you'd accept before taking another job,” she said. “The target value is your aspiration….It should be ambitious, but it should also be realistic.”

Expect the usual negative responses to your terms: “‘That just won't work with our salary structure here.’ ‘Things are really tight this year, this decade, this millennium.’ ‘You put me in a difficult situation. I'd love to do this but the big guy would never approve,’” offered Dr. Cyr.

In response, don't make the first concession. Instead, say something like, “If you can't do that, what can you do?” If you do eventually make a concession, give up something that's of lesser value to you. “Don't agree to a bad deal just to get any deal,” said Dr. Cyr, and don't talk just to fill the space. “When you're bargaining, silence is golden. Don't jump in and answer your own questions or second-guess what they might say.”

Employers may argue that the contract is standard and can't be changed, but that's not necessarily true, said Dr. Cyr. “Don't think it's one size fits all,” she said. Physicians who negotiate can often add letters or addendums to standard contracts.

Eventually, the goal is to get to a middle position between your goal and the other party's that satisfies everyone. This is a point where women can often be more successful than men. “They want all parties to come away from negotiation feeling good” and may more easily find win-win solutions, said Dr. Cyr.

To increase the good feelings, she also recommends having a definitive end to the negotiation. “A strong visible closing creates ongoing and trusting relationships,” she said. And, finally, as trusting as your relationship may be, it's always better to have a negotiation end with a signed deal. “I highly urge you to get it in writing,” Dr. Cyr said.