The gender pay gap in medicine has been strongly demonstrated in the research, with medical culture and policy increasingly catching up to the notion that hiring, promotion, and payment structures need to change to close the gap. Over the past year and a half, I’ve been digging into the data in an effort to end the debate in Canadian medicine about the existence of the gap (spoiler alert: it’s just as real in Canada as elsewhere).
After publishing that work this past summer, I’ve been reflecting on what physician pay inequities say about how we approach healthcare for women and non-binary people. Ultimately, lower pay for female physicians is a surrogate marker for the underfunding of women’s health, a problem we can no longer ignore.
We know that women tend to seek healthcare more often than men and generally prefer female physicians. It’s also been well established that female physicians tend to spend more time with patients and address more issues per visit, something that has been primarily taken to represent the differences between how men and women practice medicine.
But let’s flip that perspective for a minute: what if these gendered differences originate not from innate practice style but from patient needs and expectations? What if women’s healthcare is so underfunded that simply providing essential services is financially penalized?
Gender Segregation
The gender pay gap in medicine is multifactorial, but one of its strongest elements is the disproportionate role female physicians play in delivering healthcare to women. A recent study using AMA data demonstrated the relative change in specialty income over four decades, as fields like gynecology went from 8% to 57% female.
Coincident with that change from male to female dominance was a drop in relative income of about 20%. Meanwhile, over the same four decades, urology remained nearly as male-dominated a specialty as before and its relative income didn’t change.
This data is correlative of course, but it’s hard to look at without asking what happened to funding of gynecological care over those four decades.
Canadian physician remuneration is mainly fee-for-service, so comparisons between gynecological and urological fee codes are one way to study the gender pay gap, something that has previously been done with American data. In Ontario, where my co-author and I both practice, incision and drainage of a scrotal abscess under general anesthetic pays twice what the same procedure pays for a vulvar abscess.
Certainly, the two procedures are not identical, but one would be hard-pressed to demonstrate that the scrotal procedure is twice as complex or time consuming as the vulvar procedure. In Canada, 89% of urologists are male, while 62% of gynecologists are female, and with glaring fee code disparities like this it wasn’t surprising when our analysis showed the two specialties to be wide apart in income.
Another recent Ontario-based study of surgical billings compared fee codes of the 200 most common procedures performed by eight different surgical specialties. The study found no significant differences in the volume of codes billed or the time spent per procedure, meaning that differences in income did not relate to men working more efficiently or billing higher volumes. Rather, female surgeons tended to bill less lucrative codes, resulting in an overall 24% pay gap per hour of operating time.
That female surgeons performed different procedures is partly reflective of their disproportionate tendency to operate on female patients. One of the study authors noted prior to its publication that as a female general surgeon she had developed expertise with a certain low-paying rectal procedure performed primarily on women.
In the same article another general surgeon reflected on her large volume of referrals for breast issues, which tend to be poorly remunerated. This suggests that gendered differences in procedural pay are not exclusive to gynecology/urology, which follows logically since genitalia are not the only anatomy that differ between the binary genders.
The Weight of History
Medicine has historically not been a very woman-friendly enterprise. Men have dominated in the profession until relatively recently, and many conditions and treatments were defined and studied using a default cis-male model.
One example of the problem this creates is the underdiagnosis of heart disease in women, in large part because their symptoms are viewed as “atypical.”
Major developments in medicine are often infused with misogyny and other bigotries — a disturbing example being the history of the speculum, a tool ubiquitous in modern medicine that was created by experimentation on enslaved Black women. Really, the simple fact that clitoral anatomy was not fully defined until the 21st century tells us everything we need to know about the importance of women’s health over most of medicine’s history.
How does this history still influence healthcare for women and non-binary people? The ongoing battle for reproductive justice is a clear indicator that patient autonomy is assigned lower value when the patient has a uterus.
Not only are people who can become pregnant still fighting for fair access to contraception and abortion, but the ugly practice of forced sterilization continues to happen in both Canada and the U.S. And in recent years, the rise of pseudoscience has pointed to the lingering impact of misogyny in healthcare, as it heavily targets women, who feel fed up and frustrated with medicine’s dismissive treatment of their problems.
Closing the gender pay gap in medicine is an issue of basic justice and is necessary for that reason alone. However, what research into pay inequities can reveal about funding is important as well. In healthcare, we fund what we value, so if we underpay the doctors who disproportionately care for women, that means we are underfunding — and therefore undervaluing — women’s health.
We need to study this phenomenon to better define how funding disparities impact women and non-binary people. This will mean more research into fee code disparities (particularly in Canada) and a continued call for more women in healthcare leadership, particularly in the rooms where funding and research decisions are made.
Michelle Cohen, MD, CCFP, is a family physician at the Lakeview Family Health Team and the Haliburton, Kawartha, Pine Ridge District Health Unit in Ontario. She holds a medical degree from the University of Toronto.