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Systemic Factors Influencing the Remuneration and Utilization of the Surgical Workforce in Ontario, Canada

Author: Dossa Fahima
Publication venue
Publication date: 2022
Field of study

Background: A salary gap between male and female physicians has been demonstrated in many healthcare systems. A fee-for-service system, however, should theoretically be free of biases that lead to unequal salaries. It is unknown whether sex-based inequities in pay exist within fee-for-service models and how biases in the referral process contribute to inequities. Objective: To determine the magnitude of the sex-based pay gap in surgery and explore disparities in referrals to surgeons. Additionally, this thesis evaluates whether disparities are narrowing over time as more women enter surgery. Methods: We conducted three population based studies in Ontario, Canada using linked administrative databases housed at ICES. First, we used claims for surgical procedures submitted by surgeons (January 1, 2014-December 31, 2016) to compare earnings per hour spent operating to determine whether a sex-based pay gap exists in the fee-for-service system. Second, we analyzed referrals to surgeons over 20 years to examine the existence of and drivers for sex-based inequities in referrals and the influence of physician choice on disparities. Third, we compared the number of referrals to male and female surgeons across the length of their careers to examine whether disparities improved as female surgeons acquired experience, and examined temporal patterns to determine whether inequities were narrowing over time. Results: Within Ontario’s fee-for-service system, female surgeons earned 24% less per hour spent operating than male surgeons and more commonly performed procedures with the lowest hourly earnings. Male physicians demonstrated preferences for referrals to male surgeons, even after adjustment for patient and surgeon characteristics. Disparities did not narrow over time and existed across all levels of experience of female surgeons. Conclusions: Despite assumptions that a fee-for-service system can close the sex-based pay gap and that increasing entry of women into medicine will naturally correct existing inequities, this thesis demonstrates this not to be the case. Female physicians do not receive equal pay for equal time spent working and systemic disparities, such as referral bias, continue to propagate sex-based inequities in medicine. These inequities can have significant financial and career development consequences for women in medicine and require focused efforts for their mitigation.Ph.D

TSpace (University of Toronto)