Jo Buyske recalls her salary negotiations to become chief of surgery at Penn Presbyterian Medical Center in 1998. A male colleague seeking the same position at Pennsylvania Hospital told her: "You shouldn't even look at it for less than 325 [thousand], and they were talking 210 to me."

Then she found the paperwork for the Presbyterian chief who preceded her. "He was making $125,000 a year more than me." When their respective job offers came, her male colleague at Pennsylvania got $150,000 more.

Buyske was furious, and also inexperienced in negotiating. It took some number-crunching to show how she'd miss $2 million over time with the proposed salary.

So, after an expert gave her a pep talk, she bluntly put the numbers to her boss. "None of this 'I feel' stuff."

"There was a 90-second pause," she recalls. "We were just staring at each other."

Eventually, she says, she got a significant raise, but not enough to bring her in line with her male peers.

Buyske, now associate executive director of the American Board of Surgery in Philadelphia, is one of many female doctors who saw themselves reflected in a recent study in the Journal of the American Medical Association.

The study observed salary differences for a group of 247 women and 553 men, all physician researchers who had won grants from the National Institutes of Health.

Women surveyed made an average of $167,669 while men got $200,433 - a difference of $32,764 overall. With controls for specialty, academic rank, leadership positions, publications and research time, women still made $12,194 less than men each year.

More women are in medicine now than ever, but they still face myriad challenges, including pay. They struggle to balance work and family with heavy schedules and unpredictable hours. Promotions are competitive and entail yet more time for work, research and networking.

Women make up 48 percent of medical students, but their numbers dwindle as they rise up the ranks of academic medicine. Nationally, women make up 35 percent of medical faculty overall but only 13 percent of department chairs and deans, according to the Association of American Medical Colleges.

At Penn, five women - about 18 percent - are slated to be department chairs, out of 28.

The Philadelphia College of Osteopathic Medicine employs five female department chairs out of 20, while four of 21 chairs listed on Drexel's site are women. There are three women out of 28 chairs at Jefferson. Temple has one woman among 24 chairs.

Several representatives say they want to do more. Temple dean Larry Kaiser last year recruited Susan E. Wiegers from Penn to improve its record. Susan Phillips, Penn's chief of staff, says that while its numbers top the average, recruiting remains a priority.

"The overarching challenge," Phillips says, "is that the candidate pool for women clinical leaders is relatively small and therefore quite competitive."

Gayatri Devi, president of the American Medical Women's Association (AMWA), notes that medicine began with men and the promotion requirements have been molded by their experiences. "It's much easier to be both a man and a physician than it is to be a woman and a physician," says Devi, a neurologist.

In Pennsylvania, women across all jobs make 77 cents for every dollar that male colleagues make, the Census found. Nationally, female physicians and surgeons earn 71 cents for every man's dollar, according to the Bureau of Labor Statistics. Neither report accounts for salary influences as strictly as the JAMA study does, but other sources document large differences between men and women's wages.

Buyske called the new JAMA study "awesome" in that it highlights that the wage discrepancy cannot be explained away by women's choices in specialty, location or work hours. "Until this paper, it was really just so soft," she says. "Every wage discrepancy had an explanation. They could defend it."

Stephanie Abbuhl, vice chair of Emergency Medicine at Penn and head of its Focus program to advance women in health, says even those who make it to leadership often lighten their load briefly by cutting hours or researching less. And then they often hide those choices.

After her first two sons were born in quick succession, Abbuhl took a radical step in 1992 and cut her hours. "I just found it incredibly difficult to be working about 60 hours a week and manage them and my home life," she says. "In that era, that was a really big deal. Nobody I knew was doing that."

She believes flexibility is increasing, not just because more women are in medicine, but because more men want balance, too.

Lisa Bellini, Penn's vice chair for education and dean of faculty, begins her day at 4:30 a.m. so she will have time for two teenage daughters at night. "The way you balance it is by not working any fewer hours per week, but you work the hours that fit your schedule."

She recalled squeezing pregnancy into her high-pressure career climb. "I pretty much went into labor at work, and then took six or eight weeks, depending; more time for the C-section."

That women undergo residency training while the biological clock ticks leads to many more complications. Buyske was proud of a policy created under her watch, allowing up to one year off during notoriously hard surgery residencies.

Residency hours have fallen dramatically since today's leaders were trained. Buyske recalls "black and gray weeks," which had 145 and 125 working hours. In 2003, those hours were restricted so residents cannot work more than 80 hours a week. And last year more restrictions were put on first-year residents, cutting maximum shifts from 30 hours to 16.

Still, AMWA's Devi says she advises female students worried about residency to "embrace technology and expand their options" by freezing their eggs. "I don't see that as radical," she says. "I see that as giving women all the choices they have to be both women and physicians."

To get true equity, "women are going to have to be migrating to the top," says Marcia Boraas, a breast surgeon at Fox Chase Cancer Center in Northeast Philadelphia. Biases may be so ingrained that leaders may not recognize them. They "are not sitting there thinking: 'Jane Smith doesn't deserve to make what Bob Smith makes,' " Penn's Abbuhl says. "It's because of unconscious bias."

Pay inequity can also be hidden. Many doctors don't know how their pay compares with that of colleagues. If they find out, as Buyske saw, the confrontation can be awkward, and in the worst cases lead to retaliation from employers.

That's a real threat, says Joanna Grossman, a Hofstra University law professor. She says the legal system puts too much pressure on the victim "to find out that she's being paid less, risk her job, file a lawsuit, probably just not win. At the end, that's a losing battle if that's the way we're fixing pay discrimination."

She thinks that employers should verify that their employees are equitably paid. None of the women interviewed considered lawsuits.

Indeed, many note how far women have come.

"When I started," said Fox Chase's Boraas, "they had the nurses' locker room and the doctors' room, and the scrub pants were in the doctors' locker room and the dresses were in the nurses' locker room, so we worked out of the nurse' locker room, and wore scrub dresses."

Boraas considers herself an early trailblazer. But close to retirement, she says that pay discrimination will be the next generation's fight.

Contact Allyn Gaestel at