Female surgeons in Ontario earn less than their male counterparts in spite of the seemingly equitable fee-for-service system, according to a new study published in JAMA Surgery. The study found that, overall, women earn 24% less per hour spent operating than men.
The authors attributed the gap to two major factors: firstly, women were more likely to enter lower-paying specialities; secondly, within nearly every speciality, men had more opportunities to perform the more lucrative operations. The combination of these two issues adds up to lower hourly compensation, even though female surgeons are equally efficient at their jobs.
“Sex-based income disparities are well documented in medicine and most pronounced in surgery,” say the authors.
The findings from this paper add to the mounting evidence of a gender pay gap in the medical field. In the US, the Physician Compensation Report showed that female doctors earned 27.7% less than their male counterparts.
The more lucrative the operation, the less likely the surgeon is female
The team analyzed data from over 1.5 million surgeries performed by 3,275 surgeons in Ontario between 2014 and 2016. The gender split came down to 2,456 male and 819 female surgeons.
Even after adjusting for specialization, the pay disparity was still present. The greatest average gaps were found in orthopedic surgery ($73.66 per hour) and cardiothoracic surgery ($79.23 per hour). In gynecology, where women are much more highly represented than men, the mean difference between sexes was $22.90 per hour. Furthermore, 52% of female surgeons earned $150 or less per hour, compared to only 21% of male surgeons.
In another part of the analysis, around 200 of the most common operations were assessed according to how much they paid per hour. With the exception of plastic surgery, no significant differences in the time taken to complete common operations were observed. That means that differences in hourly compensation don’t simply come down to female surgeons taking longer to complete services.
Instead, the researchers noted that as the surgeries became more lucrative, the proportion of women performing them decreased. Of the most lucrative operations, only 6% of surgeons performing them were female.
The poor representation of women in higher-paid specializations also turned out to be a limitation of the research. With neurosurgery, there were fewer than five women to work with, so the team had to exclude this specialization from some of their analyses, said co-author Nancy Baxter in an interview with the CBC.
“In some cases, we didn’t find statistical or mathematical differences between males and females, and that’s because there were so few women in the specialty that our techniques for detecting the differences weren’t sensitive,” added Fahima Dossa, lead author, also in conversation with the CBC. “There were too few women to be able to make those assessments.”
The duo commented that their work shows there is no basis to the claim that women earn less because they work fewer hours or less efficiently. Previous research backs this up: one study found that female surgeons in Ontario are capable of performing as well as their male colleagues, and in some cases, even better.
Systematic gender bias touted as likely driver of inequality
Personal preference may influence a female trainee surgeon to specialize in a low-paying area like gynecology, but chances are this is only part of the story. The authors cite what they call the “hidden curriculum”, which involves the implicit and explicit discouragement of women from entering high-paid specializations as a key driver.
In the working world, this systematic bias would also affect the referral process, influencing type and frequency of referrals female surgeons get from other physicians.
In an invited commentary, Philadelphia-based physicians Rachel Kelz and Lindsay Kuo describe how this might look: “A senior surgeon sends a junior female surgeon ostensibly easier cases associated with lower compensation while sending a junior male surgeon more challenging cases associated with higher compensation. Although the intention behind these actions may not be malicious, the unintended consequence is downstream disparity in earnings.”
Given the difficulty of finding a surgeon willing to take on less remunerative operations, women end up taking these on due to the insufficient number of referrals they receive in the first place, according to Baxter.
Similarly, with fee setting, the lack of female representation on the boards could be another factor: “When you look at who sets the fee codes for various procedures, in general, there aren’t a lot of women at those tables. So you have men that are setting the fee codes that affect everybody,” she adds.
Kuo and Katz believe individual departments should up their accountability game. Sex-based pay gaps could be reduced if not eliminated via deliberate action and paying close attention to external and internal referrals, they say.
“Female and male surgeons work equally hard for their patients and achieve equivalent results, and they should be compensated equally.”