When Minnesota family physician Jay-Sheree Allen begins a visit with one of her patients, she starts by turning on the faucet and washing her hands. She no longer shakes hands to minimize the risk of COVID-19 transmission, so she takes a little more time with her hand-washing routine to chat before addressing her patients' medical concerns.
Allen recently read a study published in The New England Journal of Medicine that found female primary care physicians spend more time with their patients than male doctors — an average of 2.4 minutes per visit, to be specific. But female physicians still make less money. Allen worries her hand-washing routine is contributing to the problem.
"That's my two minutes there," says Allen, who uses the time to establish a rapport with her patients. "That's the amount of time I take in the beginning, talking and having that social banter."
That 2.4 minutes may seem inconsequential. But the New England Journal study authors argue that the extra time female physicians spend with their patients adds up quickly and has profound implications for the pay gap between women and men.
The study's authors analyzed data from over 24 million primary care visits in 2017, digging deep into information from Athenahealth, an electronic medical records company that's widely used in primary care practices. The sample included about 5% of all primary care doctors in the U.S., according to senior author Hannah Neprash, an assistant professor of health policy at the University of Minnesota.
Using "timestamps" that track when patients check in and out, Neprash and her team analyzed exactly how long primary care doctors spent with their patients. They compared male and female physicians not just throughout the country, but within the same practices, which helped control for regional variations in the number of patients doctors are expected to see in a day.
Female primary care physicians spent about 15% more time with patients in each visit compared to male primary care physicians. As a result, they saw fewer patients over the course of a year.
In the U.S. healthcare system where most insurance companies pay doctors based on the number of patients they see — not how much time they spend with them — this means that women physicians generated about 11% less annual revenue for their practices than their male colleagues.
This could account for why female physicians are paid less than men, Neprash argues: They actually spend more time with patients.
The study results didn't surprise me. I'm a female primary care physician, and I often spend time asking about my patients' families and work, before we talk about their blood pressure or birth control. Often patients come in for a straightforward medical concern, and I find myself discussing how stressed out they are about child care, or how hard it's been to pay the bills on time during the COVID-19 crisis.
I love talking about these topics; I like to think it's part of what makes me a good doctor. But by not getting down to business immediately, could I end getting paid less than male doctors?
"The pay gap in medicine by gender is very well documented," Neprash says. "It's been written about for decades, but the understanding of what exactly drives that is pretty sparse."
Estimates of pay equity between men and women in medicine vary widely, since they're mostly based on what doctors themselves report. They also depend on medical specialty and the region of the country where doctors practice.
In one 2016 study, researchers found that the median salary for male physicians in the United States was almost $86,000 more per year than the median salary for female physicians in the early 2010s. Another study published earlier this year found that in their very first jobs after training, male physicians earned about $36,000 more, on average, than their female counterparts.
Some researchers hypothesize that female physicians are more likely to work part-time, which they argue could account for the difference in pay, Neprash says. But her new paper disputes that idea.
"When you look at how many minutes they are spending with their patients over a year, female physicians are spending 20 hours more — despite the fact that they're seeing fewer of them, and they're earning less money," Neprash says.
Some researchers say female doctors spend more time with their patients, because patients have higher expectations of them.
Allen says she feels it's important to ask about her patients' home lives. But that kind of small talk adds up. Many evenings she finds herself still working in the office, long after her male co-workers have gone home.
"I do wonder if some of our male colleagues second guess themselves, or go above and beyond in the ways some of us as women tend to do," Allen says.
There's evidence that Allen isn't alone in feeling like her patients expect more of her.
"Different types of topics are addressed with male and female physicians," says Dr. Katherine Gold, a family physician and associate professor at the University of Michigan. "We know that women have longer visits in general. They're twice as likely to raise emotional content in their visits, which generally takes longer to manage."
In addition to their visits generally taking longer, women also go to the doctor more than men, and female physicians are more likely to see female patients.
Research suggests that the extra time female doctors spend connecting with patients may have a positive impact.
One study found significant differences in the practice style of female and male doctors, and found the patients of female physicians tend to be more satisfied with their care. And a widely publicized 2016 study found that when elderly hospitalized patients are cared for by female physicians, they are less likely to die or return to the hospital compared to patients who have male doctors.
It's not certain that longer primary care visits translate to healthier patients, Neprash cautions. It's possible that people can get care that is just as high-quality in a shorter amount of time. But surveys show both doctors and patients of all genders prefer to have more time together.
"It is really clear that both patients and doctors want to be able to spend more time with each other. It's the most clear survey preference ever," Neprash says. "It's strange to see such a concordant preference, and see it not happening."
I became a primary care doctor because I like getting to know my patients as people, not just as a list of diseases. I truly believe it helps me provide better care. But getting to know them takes time, and that means squeezing fewer patients into each workday. That could mean less money for my practice.
It seems to be a price that many female primary care physicians are willing to pay.
Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. You can follow her on Twitter: @MaraGordonMD.