The September 2018 issue of the Dallas Medical Journal was devoted to “women in medicine.” Ahead of publication, readers were asked whether they believe there is a pay gap between male and female doctors, and if so, why, and what should be done about it. One doctor who responded said that indeed there is a gap, and it’s because female doctors choose not to work as hard as male doctors. “Nothing needs to be ‘done’ about this,” he wrote, “unless female physicians actually want to work harder and put in the hours.”
Hundreds of people tweeted to protest both the doctor’s remarks and the fact that the initial question was raised at all. “This isn’t Santa Claus,” one of them wrote. “We know a gap exists.” A position paper on gender equity in compensation put out by the American College of Physicians this past May reviewed several studies that point to a wage gap between male and female physicians in the U.S., whether in primary care, specialties, or academia, and several of these studies control for number of hours worked.
In Canada, there is very limited published data comparing earnings by gender, and many people question how a wage gap is possible in a system where the primary payment model is fee-for-service. But some physicians say the model itself contributes to a gap, by tending to reward volume over quality and complexity of care, and to value procedures over less concrete services, such as counselling and involving patients in decision-making. Some female doctors point to other factors, as well: a “pink ghetto-ization” of lower-paid specialties and even within specialties; differences between men and women when it comes to time spent in an examining room; and hiring practices for leadership positions that are both casual and opaque.
The Canadian Medical Association recently completed a discussion paper on gender equity and diversity in Canadian medicine in collaboration with the Federation of Medical Women of Canada. While the paper doesn’t compare earnings between the sexes, it does outline various barriers to women in medicine. And evidence of a pay gap does seem to be emerging: Healthy Debate has learned that the Ontario Medical Association recently compared the earnings of male and female physicians in the province, and, according to OMA president, Nadia Alam, some of the preliminary data shows that there is a gender wage difference among doctors in Ontario.
Here is more of what we learned about the differences in compensation between men and women in Canadian medicine.
More women work in lower-paying specialties
The proportion of women in medicine in Canada has grown exponentially in the past 50 years—by 500 percent in Ontario since 1968, according to research conducted by the OMA (available in the July-August issue of the Ontario Medical Review). Today, women make up just over 40 percent of the country’s doctors, and the number is growing. Among physicians under age 40, women account for 54 percent. And females are the majority in most medical school classes: In 2016–17, they comprised 58 percent of first-year students across Canada.
But when it comes to the specialties, the ratios look different. While women make up nearly half of Canada’s family doctors and psychiatrists—45.3 and 43.6 percent respectively in 2016, according to the Canadian Institute for Health Information—they are the majority in just two areas: pediatrics and obstetrics/gynecology. They take up about a third of the ranks in general surgery; according to CIHI’s data, there were 1,466 male general surgeons and 551 females. Nationally, there were 315 female and 958 male ophthalmologists in 2016; and 846 women compared with 1,835 men in diagnostic radiology.
These numbers become telling when positioned next to average remuneration for each specialty in 2016. The lowest-paid field in medicine is psychiatry, with an annual gross average clinical payment of $266,000. Third-lowest is family medicine, at $275,000, and fourth is pediatrics at $294,000. Obstetrics/gynecology lands roughly in the middle of the pack at $398,000, but is one of two specialties to see a decrease—by three percent—in pay in 2015–16. The other is family medicine, where pay decreased by almost one percent.
That same year, surgical specialists pay increased by 1.8 percent. General surgery is among the higher-paid specialties, at $435,000. Ophthalmology is the highest, at $714,000. The CIHI data for 2016 does not include an average annual income for radiology, but this has traditionally been one of the most lucrative specialties—in 2009–10, diagnostic radiologists were reported to earn an annual gross average of nearly $600,000.
Why do so many female physicians choose to specialize in lower-paying fields? “You can blame [them] if you want,” says Nancy Baxter, a colorectal surgeon at St. Michael’s Hospital in Toronto, “but basically women are encouraged to take these roles that have lower value. We’ve set up a system that allows us to take women who have been training for the same length of time as men, who work the same hours as men, and pay them less.”
Pay gaps within specialties
Even when women opt to work in surgery, one of the higher-paying specialties, they are often nudged into the lower-paying end of it, says Baxter. “You’re always encouraged to do breast surgery,” she says. And perhaps if not encouraged, expected. “When you talk to women residents and you ask, ‘What are you interested in?’ they’re quite aware that, as a woman practising in general surgery, they’re likely to preferentially get more referrals for breast issues than some of the other stuff,” says David Urbach, a general surgeon at Women’s College Hospital in Toronto. “I definitely see a lot of women general surgeons end up doing a disproportionate amount of breast surgery. And overall, breast surgery is not quite as lucrative—the time required to do the procedures, but also the consultations, which take a lot longer than the consultations to assess gall bladders and hernias.”
Female surgeons receive the majority of referrals for mastalgia, says Lesley Barron, a general surgeon who works in Georgetown, Ont., and recently wrote about the gender pay gap. Mastalgia is the medical term for breast pain, and it doesn’t usually require surgery. “It’s basically counselling patients, going over their imaging results, and spending a lot of time hand-holding,” says Barron. “I’m not saying that’s something I shouldn’t be doing, it’s just if I have to see 50 mastalgia patients to book one operative case, it gets very frustrating.”
Plus, surgeries that are often specific to women—and to female surgeons—can pay less. The procedure to correct rectal prolapse, a condition affecting primarily women in which the rectum slides out through the anus, has become something of a niche for female colorectal surgeons, says Nancy Baxter. It pays significantly less—$356—than some procedures that she says require less skill and experience, such as a laparoscopic right hemicolectomy (removal of the right side of the bowel for colon cancer), which pays $1,000. Baxter recently conducted a study that compared how much men and women are paid per hour in the OR. “We’re interrogating the fee-for-service system in operative remuneration,” she says. “Our hypothesis is that it does not result in equity.”
Cathy Faulds, a family physician in London, Ont., echoes this notion with respect to primary care. Fee-for-service, “rewards the turnstile,” she says, and points to research which shows that female family doctors spend more time with patients and deal with more issues in a single visit than males do. “When you look at those fee codes, they are directed toward the number of patients that you see. They don’t reward the quality of care—[provided by] men or women—they don’t reward the comprehensiveness of care.” Faulds’s husband also worked as a family physician, and at one point, they split a practice of 5,000 patients. “I saw the patients who had complex pain, mental health issues, marital dysfunction, child abuse, chronic pelvic pain,” she says. “My husband sutured people, looked after myocardial infarctions, fixed their broken bones. Very procedural, and higher paid items than what I saw.”
In Ontario, many primary care doctors receive a lump sum per patient per year to provide a basket of services. This system, known as capitation, is an example of the kind of alternative payment plan that Faulds says helps to take pressure off family doctors, and perhaps especially the women among them, because it means they are not paid by volume of visits. But the OMA’s research shows a gender wage difference in the capitated model of family medicine too, says Alam. And this may be a factor of women spending more time with patients as well. As David Schieck points out, capitation also rewards volume: the more patients on your roster, the higher your pay.
Schieck is a primary care doctor who works on a family health team in Guelph, Ont. He has a roster of 1,500 patients. His wife, who works in the same clinic, has about 1,000. “She spends just as much time at her job as I do,” he says. “She puts in the same amount of hours and does all the same sort of work.” What’s different, though, is the length of time they each spend with patients. While Schieck thinks he averages 15 to 20 minutes a visit, his wife spends anywhere from 20 to 30.
A 2017 study on primary care in British Columbia found that “female physicians earn less annually and have smaller practices and fewer annual patient contacts, compared to their male counterparts.” These gaps were bigger than expected, say the authors, given data from the 2014 National Physician Survey which reported “only a small difference (3.21 patient care hours) in weekly work hours between male and female primary care physicians.”
“If we had more aspects of our compensation that reflected pay for quality outcomes, a little bit better pay for time spent with patients, a little bit better pay that reflected complexity, I think you would start to address some of the areas where female physicians may do a little bit better than male physicians,” says Schieck. “And that may be a start to addressing some of the inequities in compensation that I think probably do exist between male and female physicians.”
The gender wage gap in academia
Some physicians earn income through their academic appointments, and here as well, there is some evidence of a pay gap. Sonia Anand, professor in the Department of Medicine at McMaster, led a recent study comparing the base salaries and stipends of male and female faculty members in 2017. One thing she discovered is that among the department’s full professors, men are paid significantly more—among clinical staff, the difference is about $16,000, and among non-clinical staff, the difference is almost $27,000. And at the same time, female full professors reported clocking an average of 300 more educational hours than male professors did, and earning 150 more research points (for publishing papers, for example, or winning research grants). “It kind of leaves us [asking], how does it add up?” says Anand. “Women are reporting that they’re doing more education and research—why are those [women] in the highest rank earning less?” says Anand.
Since these results have come out, the department has created a position for an associate chair of equity and diversity—which Anand applied for and was appointed to—and one of its goals is to achieve greater transparency in leadership. “When a new leadership position comes up, it has to be posted and we have to make sure that a lot of people are aware of it,” says Anand. “We also want transparency around stipends, how much people are paid to take on these leadership positions and how much people receive when they enter the department, in terms of base salary. It would be really helpful, when you enter as an assistant or associate or full professor, to know what the median salary in the department is, so at least you know what’s fair and what you should negotiate for. Right now that’s kind of grey.”
The need for more research on the gender pay gap
Why is there so little Canadian data comparing the earnings of men and women in medicine? CMA president Gigi Osler wonders if part of the reason is the sensitivity of the topic. “If you get women physicians together, we’ll quite easily talk about it,” she says, “But once you start to have a broader discussion, sometimes you have a lot of pushback. And I think that would probably be the case if you were talking about women’s issues in any group. Not just the pay gap, but inequities for women in general.”
Like others, Osler points out that the current payment system rewards volume over quality, and thinks we need more data about how different models influence everything from the gender wage gap to physician health to where physicians choose to work. “That’s a question that would be worth exploring,” she says.
OMA president Nadia Alam would likely agree. “At the end of the day, I don’t know that we can separate what differences in wage are due to gender until we have parsed out the impact of an outdated system that doesn’t pay for time, complexity, non-procedural visits, etc. There is such overlap in both issues that until we have spent time digging into both, we won’t be able to draw conclusions.”
But the digging has begun. The OMA does not yet have a planned release date for its wage-gap data; Alam says the organization is “carrying out more detailed work.” And there is more research coming—from the CMA, which will release its paper on gender equity in November, and from people like Nancy Baxter, who are studying the numbers. Once these numbers are out in the open, the work of understanding the magnitude of the wage gap between male and female doctors can begin, as can the work of fixing it.