Physician Pay Gap Persists Even in Fee-for-Service System

Norra MacReady

October 04, 2019

Gender-specific pay gaps in medicine appear to persist even in a seemingly equitable fee-for-service system, study findings suggest.

In a comparison of female and male surgeons, women earned 24% less per hour spent operating than men, the authors write. They attribute these findings primarily to two factors: first, women tended to enter lower-paying specialties such as gynecology, and second, within any given specialty, the most lucrative procedures were more likely to be performed by men.

These findings add to a large body of research documenting a significant salary difference between male and female physicians. For example, other studies have shown that women physicians in the United States earn as much as 20% less annually than their male colleagues, the authors write.

Fahima Dossa, MD, and Nancy N. Baxter, MD, PhD, from the University of Toronto, and St. Michael's Hospital, Toronto, Ontario, Canada, published their findings online October 2 in JAMA Surgery.

The disparity suggests "that women are working in a system that is rigged against them," Dossa and Baxter told Medscape Medical News. For example, women trainees are often discouraged from entering certain disciplines while being steered toward others, and even after they enter practice, implicit gender bias may influence the nature of the referrals they receive from other physicians.

The situation is most likely the same in the United States, they explained. "The American [relative value unit; RVU] system is similar to the Ontario fee-for-service system, opening it up to the same types of biases seen in our study."

All in all, the findings demonstrate that there is a "hidden curriculum" that still often limits women from being seen as physicians, and particularly as surgeons, and affects the opportunities afforded to them in their work, they added.

In an invited commentary, Lindsay E. Kuo, MD, MBA, Lewis Katz School of Medicine, Temple University, and Rachel R. Kelz, MD, MBA, Perelman School of Medicine, University of Pennsylvania, both in Philadelphia, describe how such a hidden curriculum might work. "[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," they write.

One way to address this implicit bias would be for male and female physicians alike to do some self-reflection for any biases they might harbor, said Dossa and Baxter. As for referral bias, "a tangible step forward would be to establish centralized referral processes, whereby referrals are not sent selectively to surgeons but rather sent to a centralized unit that can then distribute referrals in a more equitable fashion."

The authors used administrative databases to conduct a cross-sectional study of surgeons' earnings for elective procedures performed in Ontario from January 1, 2014, to December 31, 2016. Within that time, 1,508,471 elective, hospital-based surgical procedures were performed by 2456 male and 819 female surgeons.

On multivariate analysis, women earned 76% of what men earned (relative rate, 0.76; 95% CI, 0.74 - 0.79), even after adjusting for surgical specialty. Unadjusted mean hourly earnings for male and female surgeons were $226.26 and $161.38, respectively, a difference of $64.88 (P < .001). "Of all male surgeons, 515 (21.0%) earned $150 per hour or less, compared with 433 female surgeons (52.9%; P < .001)," the authors write.

In a propensity matching analysis of 576 male and 576 female surgeons, male surgeons earned an hourly mean of $197.52, compared with a mean of $171.55 per hour among women (difference, $25.97; P < .001). This advantage for men persisted when the authors examined individual specialties including gynecology, otolaryngology, and cardiothoracic surgery, among others.

In a further analysis according to the most common procedures across all surgical specialties, the authors found that women performed 44,463 (27.4%) of the 162,131 least lucrative operations, but only 10,568 (5.8%) of the 182,092 most lucrative procedures. "As hourly earnings increased, the proportion of female surgeons performing the procedure decreased (β = –0.03 [standard error, 0.006]; P <. 001)," they write.

Individual departments and practices must examine their procedure mix more closely, Kuo and Katz write in their commentary. "Sex-based disparities in procedure mix can be reduced and eliminated through deliberate action and attention paid to external and internal referrals," they note.

Female surgeons work as hard as men and achieve equivalent results for their patients, "and they should be compensated equally," they conclude.

The study authors and editorialists have disclosed no relevant financial relationships.

JAMA Surg. Published online October 2, 2019. Abstract, Editorial

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