Every discussion about the gender pay gap in medicine eventually comes back to the same explanation: Women choose different specialties, different schedules, or jobs with more flexibility. Some of that is obviously true. But I’ve never thought it explained the whole picture, and the profession leans on that explanation a little too heavily.

Even when researchers account for specialty choice, hours worked, and practice setting, women physicians still tend to earn less than men. That part usually gets acknowledged and then brushed aside. After spending years in medicine and working in different practice environments, I’ve become more convinced that the structure of certain specialties matters just as much as the people entering them.

Anesthesiology is interesting because the pay gap still exists, but it often looks smaller than it does in several other high-income specialties. Not nonexistent. Just narrower.

I didn’t really notice that early on. At the beginning of my career, I assumed compensation systems across medicine were more standardized than they actually are. It was the Marit Health Physician Gender Pay Equity Report that first made me look at this more carefully. The overall gap wasn’t news, but the variation across specialties was.

The more time you spend around physician contracts, referral systems, and practice politics, the more obvious those differences become. I remember sitting down and comparing compensation structures across two similar groups in different specialties. The spread wasn’t subtle.

In anesthesiology, compensation is usually straightforward. Most groups rely heavily on RVUs, call coverage, staffing needs, and clinical work. You show up, do the cases in front of you, take call, and there’s a fairly direct relationship between the work and the paycheck. That’s a simplification, but not by much.

There’s still inequity in anesthesiology. But the compensation range is often tighter than in fields where earnings depend more heavily on referrals, procedural volume, institutional influence, or access to especially lucrative subspecialty work.

Cardiology is probably the clearest example. It’s a demanding specialty with years of additional training, and the work deserves high compensation. But the financial spread inside cardiology can become huge very quickly. Interventional cardiology, electrophysiology, general cardiology: They don’t exist on remotely the same financial plane. Women remain significantly underrepresented in the highest-earning subspecialties, and that alone shifts the overall numbers in ways that have nothing to do with hours or effort.

Once compensation structures become highly variable, small differences early in a career can widen over time. Sometimes somebody simply gets access to the better cases earlier. Another physician builds stronger referral relationships. Someone else ends up in a better-positioned system with more institutional support. Five or ten years later, the income gap is much larger than it looked at the beginning.

In specialties where compensation is clustered more tightly, those same dynamics still exist, but there’s less room for them to snowball.

And then there’s the training timeline. Cardiology training can stretch six to eight years after medical school, which overlaps directly with the years when many physicians are building families. That doesn’t affect everyone equally, but across the workforce women physicians are still more likely than men to reduce clinical hours after having children. Within six years of completing training, 22.6 percent of women physicians are not working full time compared to just 3.6 percent of men. I don’t think that reflects lower ambition. I think it reflects reality, and medicine has historically been slow to acknowledge that.

Medical training in the United States was built around a system that assumes somebody else is managing life outside the hospital. That model still shapes a lot of career trajectories, even when nobody says it out loud.

Anesthesiology isn’t immune to any of this. But the path to a high income is usually shorter and more direct, often four or five years instead of nearly a decade of post-medical-school training. That changes who stays in the pipeline, who burns out, who delays family decisions, and who reaches peak earning years earlier.

The broader pattern becomes harder to ignore the longer you’re in it: how wide the earning range is within a specialty, how dependent compensation is on referrals and institutional access, how early physicians gain access to the most profitable work, and how transparent the system actually is. Those questions matter more than we usually admit, and they don’t get asked nearly as often as “what did she choose.”

When you look at compensation through that lens, anesthesiology stands out, not because it’s perfect, but because the structure itself places some limits on how wide disparities can grow.

Medicine doesn’t need every specialty to look identical. But reducing opacity, improving transparency, and making access to high-value opportunities less dependent on informal networks would narrow some of these gaps. Not all of them. But some.

Choice matters. Of course it does. The problem is that medicine has spent decades treating “she chose this” as the complete answer, and it was never that simple.

Megan E. Paskitti is an anesthesiologist.